REVIEW

The model used by Design That Matters and KSE Medical seems to have a common pattern. Other social enterprises in sustainable technology use a similar model of collaborative partnership, such as:

IDE, a social enterprise that design farm technologies and services to improve small farmer productivity and income around the world, again with a mix of ethnography and engineering to design technologies and services for developing country farmers so that they are robust enough to cope with those climates and are sustainable in the materials they use and maintenance.

CATAPULT DESIGN, who work in many different sectors, also claim to use ethnography to assess client needs, by visiting the field to spend time with technology end-users, observing their lives and conducting interviews. With this research in mind, existing technology solutions are evaluated and a range of concepts explored with the goal of proposing a workable technical solution and taking it to market. So their design cycle would be

                                 DESIGN --------- MARKET -------- ASSESS

But who are the actual organisations involved here?

·         The client - which could be a social enterprise or a charity

·         The engineers - seems to be donated time from profit businesses and/or academics

·         The marketers - manufacturing and logistics companies, for-or-not-for profit

·         The social enterprise - who acts as “piggy in the middle” juggling all these interests

Such partnerships seem to be essentially targeting a ‘(not) fit for purpose’ problem.

Technology is often not fit for the environment in which it must work so is easily broken; broken parts cannot be easily fixed or manufactured locally and often require an expensive part to be bought from overseas; equipment is trashed or sits unused rather than repaired; health facilities petition charities or individuals to donate more equipment; equipment that can’t be used constitutes rubbish so the rubbish piles up.

On the other hand, manufacturing and maintaining medical equipment have socio economic outcomes - educating technicians and engineers (expanding skills base); employing local people; using and recycling locally available materials (jobs and innovation creation) as well as reducing waste during the life cycle of equipment as well as at the end of its life.

Overview of a Movement....

Slideshare has an overview of the design for social impact "movement"... featuring not only Design That Matters but numerous other designers who seek to solve health, environmental, social and political problems in the developing world...

Design That Matters

Design That Matters is an American NGO that creates new products for improved service delivery in developing countries. Some of their designs include a non-electric incubator for premature infants in rural areas, a children's talking toy for Native American language preservation, "smart canes" for the blind, hand-powered electricity generation for rural computing and communication tools for handicapped children.

But what do they actually DO?

Identify a design problem – through client prospecting, due diligence, contract development, prior research, needs assessment, development of a "design challenge portfolio."

Design a product through collaboration between students and industry volunteers, gain MIT evaluation of the design, and carry out field testing through client’s fieldsite networks.

Make it! DtM pursues the shortest path to getting a product to life. For clients who are themselves manufacturers, this would involve DtM handing off design drawings or a “works-like” prototype to the client for further development. For clients needing only a small volume of the finished product, implementation would involve DtM managing manufacture. For clients needing large product volumes, DtM would license the project intellectual property to a third party for manufacture.

So for example, - for Breath of Life program in particular, EMW set the design problem for DtM to solve. DtM works with MTTS to manufacture technology and with EMW who distribute the technology.

And HOW are they doing it?

From their website it seems that their modus operandi is to bring MIT students, MIT staff and industry alumini together to donate their engineering skills and time to create low cost design products - using the infrastructure available at the host institutions.

They do design, engineering and ethnography, that is, they focus on how technology is actually USED. DtM first carry out a series of on-site interviews and observations, to develop an understanding of client needs and the context in which they work. Based on these insights, DtM generates a design problem (as above).  Clients also distribute the new products and services that result from collaboration.

Originator Timothy Prostero  makes the key point that technology should look good, not cheap and cheerful. Users (doctors / Ministry of Health officials) then believe it will actually work.

And I like his point that there are no dumb users, just dumb devices.

The mix of design, engineering and ethnography is intriguing – more information is definitely required!!

Medical Technology - Policy Perspective

World Health Organization (WHO), of course, see medical technology from a policy perspective, imagining Ministry or Department of Health officials sitting in their offices, or perhaps hospital directors and medical consultants looking at their budgets … and asking, how can we manage technology commissioning?

For WHO, technology commissioning for healthcare has phases…

·         Assessment – Do we really need this?

·         Selection – If so, what’s best for us, given our situation?

·         Procurement – Where do we get it from? At what cost?

·         Management – Can we maintain it? What cycles of maintenance are necessary?

·         Training – Does anyone in our facility actually know how to use it?

·         Use – Even if we do know how to use it, do we actually make use of it?

Irreversible breakdown and disposal are missing from this list.

Underlying WHO thinking is a belief that technology is a relationship between medical experts (such as doctors, consultants, midwives, nurses and so on) and medical engineers and technicians. You can see an example of this thinking on youtube WHO The Power and Potential of Medical Devices.

WHO seem to be assuming that the patient is passive – acted upon by various medical expert and devices, and perpetuating a common medical myth, I would say, that patients are not active in their own care. We have to see patients as active participants in their own care – plenty evidence from medical anthropology supports this conclusion.

However, my interest is not in policy rather design and use of technology, so let’s return to the Breath of Life story…

ANALYSIS

            Let’s dock on our journey for a moment and think about what we are seeing…

The PROBLEM about medical technology (medical devices) is…

Almost 95% of medics (World Health Organization) practicing in less developed countries are reliant on medical technology that has been imported. More than half of this technology is not used by healthcare staff because they either don’t know how to use it or have insufficient means to maintain the equipment - leading to inadequate healthcare provision in the developing world ...

The SOLUTION is sustainable/appropriate medical technologies/devices...

But when we say technology what do we mean?

            CPAP machines and CT are accepted high tech medical devices but what about spectacles, mosquito nets, syringes, measuring taps and weight scales… that are used at different times in medical intervention (diagnosis, treatment, prevention).

Sustainable/appropriate medical technologies/devices – what does that mean?

·         Using existing medical technologies in new ways e.g. mobile phones in health promotion anywhere in the world?

·         Making sure that imported medical technologies actually get used in developing countries? So ensuring training, manuals in local languages, and wider locally available engineers and parts possibly leading to wholesale redesign…

·         Imported technologies are designed to cope with developing country conditions? So making sure that a device is robust enough to cope with developing country conditions – notice this in itself doesn’t meant that devices get used….

WHO would agree with the last and argue that appropriate devices are those technologies that can work in the CONTEXT  in which they will ultimately be used . For WHO, this also includes being affordable…

And sustainable - when thinking about sustainable medical technologies, at what point in the technology development and uptake cycle is sustainability an issue?  

Uptake of technology can have serious social consequences. Import, use and patient demand for ultrasound in pregnancy has powered increasing sex ration imbalance in Asia, with early termination of female fetus reported in Vietnam, India and China (HESVIC In addition, it is known that the growing private sector in Asia has over prescribed pharmaceuticals and medical procedures (academic press). Should sustainability be extended to human behavior – not only ensuring medical experts prescribe necessary treatment but also to modifying the demands of patients and their families?

Since WHO also believe there is a critical shortage of medical engineers, I imagine that WHO sees wholesale training of engineers as part of the solution also that is, not just a short demonstration of training or donated engineering time (usually from western countries) undertaking very short charitable missions to repair equipment in the developing world, rather a longer term ambition to influence education systems. So for WHO sustainable is before, during and after a short term need for a particular medical device has been identified....

Conference

I missed a very interesting conference in London recently...


Appropriate Healthcare Technologies for Developing Countries by the Institution of Engineering and Technology.

18 - 19 September 2012 | Dexter House, London, UK

The IET also run an Appropriate Technology network, with lots of fascinating goodies....

KSE Medical

KSE Medicalare also based in Hanoi and work in “appropriate technology medicine”.

Like MTTS, they focus on newborns and infants, are based in Vietnam but looking to expand in the region. And like MTTS they produce the following equipment:

1.    CPAP

2.    Phototherapy

3.    Infant Warmer

4.    OPTIMA Hand Sanitizer

5.    Infant bed

In addition, they also manufacture hand dryers.

KSE Medical provides “technical services” such as custom design and installation at “low cost”. They offer preventive maintenance and a full service contract (1 year +). All products have a one year warranty and replacement parts are available. Teaching and training are also provided but no more details on this from their website.

They have delivered CPAP, warmers and phototherapy all over Vietnam for the BOL program.

The site interestingly has a 2003 endorsement from the National Hosptial of Paediatrics in Hanoi who stated that the “working mechanism is safe, simple with high reliability (such as temperature, pressure.. etc). We have not seen any case of complication (side-effect) after using this system such as pneumothorax, heamodymic disaster...etc)… (also the design was) neat, orderly… portable and easy to transport. It is designed for low pressure oxygen, and is easily used at clinics which do not have standard oxygen and air pressure system. … the material to make (the CPAP) is mostly local so it´s price  (US$1,500)  is much cheaper than the imported CPAP system  (about US$8,000), and it is also easy to fix, repair and do maintenance as well.”

Other endorsements are from 2004 - Harvard Business School and University of California.

It sounds like Kirk Evans did the R&D on the original CPAP now used by BOL – can anyone correct me on that?

When KSE say they ‘delivered’ CPAP, does that mean put it in a lorry and take it there or something else?

• Sustainability for KSE Medical, MTTS and BOL is in creating a piece of equipment that is as safe and effective as more expensive counterparts but at a fraction of the price.
• Sustainability fpr these three are in equipment being durable, having easily accessible parts and a long shelf life in the tropics.
• Sustainabilty also seems to be in training personnel to use equipment and in ongoing support. However, this kind of support needs to be as long as the equipment is working because staff come and go and don't always cascade their understanding to others...