Human Centered Design at Work in Somaliland: Lessons Learned

Posted January 31, 2018

Plagued by chronic drought, prolonged violence and complex population movements, Somalia has sometimes been referred to as “the most difficult context in the world.”

Unsurprisingly, many health interventions in the country have failed and there is little evidence for what works. PSI was recently funded by the UK Department for International Development (DFID) to address access to skilled delivery, modern family planning methods and maternal nutrition in a new way – by applying human centered design (HCD) in Somalia/Somaliland.

Piloting this new approach, along with tight deadlines, resource and security challenges, as well as difficulties in generating support for the new HCD process, was an immense challenge. However, the PSI Somaliland team navigated the space and found success in solid prototypes that resonate not only with users, but also the Health Ministry.

Here are some of the key learnings, as shared by Rachel James, Social Behavior Change Advisor, East Africa at PSI for the project:

High levels of adaptability and flexibility were required to undertake HCD in Somaliland, taking a pragmatic approach to HCD in a context with low literacy, reliance on oral formats, sensitive cultural issues and limitations in both deadlines and locations that the design firm could go to.
It is difficult for users (particularly low-income women) to think innovatively of interventions beyond those which they have already experienced. Expecting users to drive the prototyping process and invent new and innovative solutions is unrealistic.
Prototyping was found to be an excellent way of gaining genuine user insights. As users contributed to the development and testing of prototypes, their reactions could be observed, providing new insights beyond those previously gathered through more structured research methods.
Prototyping is a highly labor-intensive process, requiring significant commitment from both PSI staff and design teams. It can also be challenging to the social norms and deeply held beliefs of staff as well as users, which requires sensitivity in navigating on the part of the design firm. Embracing “fast failure” and no-fault learning was critical to enable the process to advance.

For more insights and details on the program, visit PSI’s Somaliland country page.

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For example, in Mali, access to formal health services remains challenging, with four in ten people living several miles from the nearest health center, all without reliable transportation or access. In 2009, the Ministry of Health adopted a community health strategy to reach this population. The U.S. President’s Malaria Initiative (PMI) Impact Malaria project, funded by USAID and led by PSI, supports the Ministry with CHW training and supervision to localize health services.

In 2022, 328 thousand malaria cases were recorded by CHWs); 6.5 thousand severe malaria cases were referred to health centers, according to the national health information system.

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Supervisors directly observed how CHWs performed malaria rapid diagnostic tests (RDTs) and administered artemisinin-based combination therapy (ACT). They recorded CHW performance using the digitized checklist, interviewed community members, reviewed records, and provided on-the-spot coaching. They also interviewed the CHWs and tried to resolve challenges they expressed, including with resupply of commodities or equipment immediately or soon afterwards.

Beyond the observed interactions with patients, supervisors heard from community members that they were pleased that CHWs were able to provide essential malaria services in the community. And the data shows the impact.

In IM-supported areas of Mali, 36% of CHWs in the first round were competent in performing the RDT, which rose to 53% in the second. 24% of CHWs in the first round compared to 38% in the second were competent in the treatment of fever cases and pre-referral counseling. Between both rounds, availability of ACT increased from 80 percent to 90 percent.

Supportive supervision with interviews and observations at sites improved the basic competencies of CHWs between the first and second rounds, and additional rounds will help to understand the longer-term programmatic benefits.

Taking a market-based approach to scale sanitation in Ethiopia

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“Rather than relying on traditional aid models that often distribute free or heavily subsidized sanitation products, market-based sanitation creates sustainable and affordable solutions, integrating market forces and supporting businesses to grow.”

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Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities. The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

Human Centered Design at Work in Somaliland: Lessons Learned

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The Consumer as CEO

Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

Building community health worker capacity to deliver malaria care

Taking a market-based approach to scale sanitation in Ethiopia

Promoting self-managed care like Self-testing and Self-Sampling

Using peer coaches to counter HIV stigma in South Africa

simplifying consumers’ journey to care in Vietnam

Engaging the private sector for disease surveillance in Myanmar

Training health workers in Angola

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