Can co-design promote equity in global health?

By guest contributor Rachel Hall-Clifford

Maya Health Alliance | Wuqu’ Kawoq staff and midwives co-designing the safe+natal toolkit in Guatemala.

Several years ago, I had the opportunity to live and work as a medical anthropologist in a rural Maya village in Guatemala’s central highlands.  As I grew to know the local landscape, I became very aware of the materiality of global health and development—the bags of child nutritional supplementation powder from a UN agency kept out by the coop to feed the chickens, the latrine stall emblazoned with a bilateral aid organization logo that was used instead for bathing, the examples went on and on.  There were so many objects of global health within the community, both visible remnants and living memories of projects that had come and gone.  In fact, the community members themselves were objects of global health, treated simultaneously as vessels for pity and empowerment, their historical marginalization, poverty, and isolation checking all the boxes of a worthy target population.  I only had to look around the village at program t-shirts faded on the backs of a community still struggling to access the right to health to see our failures in global health.

We have an innovation problem in global health, always chasing the best new thing—buzzwords, frameworks, and technology alike.  We imagine new initiatives and programs as the fresh start and enduring solution that will solve a problem once and for all, but the detritus of global health left behind shows us otherwise.

Technology innovation has come a long way in global health since Paul Farmer lambasted “appropriate technology” as a fancy-sounding justification for an inferior quality of tools and services in marginalized care settings of the majority world [1].  Since the turn of the millennium, the availability of low-cost, high-quality mobile technology and specific applications of that technology for the delivery of global health has exploded, leapfrogging generations of legacy hardware and infrastructure.  Advances in low-cost hardware, microchip technology, and artificial intelligence, among other tools, mean that high-quality surveillance, diagnostics, and treatment delivery are possible beyond the limited reach of traditional health care facilities and provider networks.  The possibilities are dizzying. 

For all the potential they offer, low-cost technologies in global health walk the knife edge of equity.  The dynamics of program cycles, funding, and policy in global health favor novelty and innovation while demanding adherence to the status quo through those same program cycles, funding structures, and policy agendas.  Moreover, although low-cost technologies are intended to democratize and improve access to health care, entrenched elitism within research institutions, industry, and regulatory systems mean that who gets to “innovate” in global health continues to be dominated by those in high-income countries, a pattern aptly described by Lilly Irani as she looks at the global distribution of innovators and implementers within the technology industry [2]. There are, of course, examples to the contrary that are truly rooted in the ethos that innovation is for everyone, such as the engineering program at Carnegie Mellon University Africa, the Little Devices Lab at MIT, and the Co-Design Lab for Health Equity at Emory University, which I co-founded.  For affordable, high-quality technologies to disrupt global health inequities, we must change our approach to how they are created and implemented.

Co-design of technology offers an opportunity to reduce power asymmetries and promote equity in global health.  Co-design builds on participatory action research and agile design methods to center end-users in the development of innovation.  This begins by working with communities—both geographic communities and communities of identity—to prioritize needs, moves through asset and needs assessment, and into an iterative process of exploring existing and possible new innovations that could help solve the problem.  Often, these solutions harness low-cost technologies, but the critical and distinguishing element is that the community leads the process and its outcomes.  Co-design is both human-centered and agile, meaning that design processes prioritize rapid cycles of innovation, trial, and revision.  The co-design approach pushes against some of the received wisdom of economies of scale in global health—the assumption that technical toolkits and implementation plans can be developed centrally and delivered with minimal adaptation across the globe.  Co-design centers the ideas and strategies of the end-user communities and positions them as owners of the innovations developed, which improves sustainability because the community is invested in project outcomes.

For example, I helped facilitate the development of safe+natal, a perinatal monitoring toolkit and program to improve the continuum of maternal health care for Maya women in rural Guatemala[3].  The foreign researchers and technical experts involved were coordinated and led by a local Guatemalan health provision organization.  The team went through a deep co-design process with lay indigenous midwives to develop a user-interface that is pictogram-driven with audio instructions to support use by Kaqchikel Maya speakers, which is traditionally not a written language.  The local health organization built on existing partnerships with the government health service to develop a care navigation program enabling support for referrals to further care when the technology toolkit identified a perinatal risk.

Six years after it began as a pilot program, safe+natal has become the standard of care for midwife-led pregnancy care for the partner organization.  Beyond the reductions in maternal mortality and improved access to perinatal care, the most successful element of the safe+natal project has been the invisibility of external team members, including myself, after the co-design period.  The program is entirely led and implemented by local staff.  The technology alone has not achieved the exciting and durable outcomes we have seen, but it maximized use of existing health resources and providers.  For my part, I recognize that I am from and trained in high-income countries, and I will not be the person to lead the way toward global health equity for the global majority. My role is to support the work of thought leaders, implementers, and community members, who live the consequences of (neo)colonial relationships in global health.  Co-design is a tool that can help begin to dismantle the structures of inequity in global health.

Co-design is starting to appear regularly in global health literature and discourse, which is encouraging but potentially endangers this paradigm-shifting method as just another buzzword, another shiny new thing to be left behind in villages worldwide.  For it to work, the co-design process has to be real, not window-dressing on pre-determined intervention packages or technology developed from afar.  We cannot anticipate the exact outcomes of co-design processes—we must be open to the messiness of not knowing and shape our implementation plans and outcome metrics accordingly.  To leverage the potential of co-design for global health equity, we must not only change our work cycles to accommodate deep input from communities but also adapt our funding and reporting structures to enable cycles of creative change rather than rote replication. To make this case, those of us using co-design must show that it works by improving delivery of care, providing cost-effective solutions, and promoting sustainability. Co-design can promote equity in global health if we do the hard work it requires.

Rachel Hall-Clifford, PhD, MPH, MSc, is a medical anthropologist and global health practitioner at Emory University focused on co-design approaches and implementation in global health.  She is co-founder of the Emory Co-Design Lab for Health Equity and director of the NAPA-OT Field School Guatemala. She is at @rahallclifford on Twitter and @rachelhallclifford@med-mastodon.com on Mastodon

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