Frictions

Using the Strand Approach, inflection points in health seeking journeys were analyzed to better understand the sources of frustrations (and at times, satisfaction) of health seekers, which could just as easily emerge from stresses in their financial health, social health, spiritual health as their physical health. These frustrations and failures were identified, categorized and clustered. These clusters were then labeled and connections between them were explored. What emerged was essentially a set of Frictions – gaps between health seeker expectations from the healthcare system, and what providers (primarily public health but even other types of providers such as private healthcare providers or traditional practitioners) were willing and able to provide them. Apart from being barriers, these frictions, perhaps more importantly, are also opportunities for interventions and innovations. These frictions fall within two broad and interrelated buckets of the typical health journey and the [lack of] enabling factors that contribute to the success [failure] of the health journey. They are briefly described below.

• The health journey:
  • Awareness & Knowledge
    The health system is often equipped to recognise a patient only after a successful diagnosis and patients are left to navigate the initial stages of their journey with minimal formal guidance.
  • Accessing the system
    Through a healthcare journey, a health seeker has to make important financial, emotional, social, and spiritual decisions and sacrifices that have consequences on their health and the health of their families. These decisions take the form of ‘tradeoffs’, where certain strands are prioritized over others. While seekers are expected to make multiple trade-offs in favor of their physical health, they may perceive risk differently than their health providers.
  • Adherence & Maintenance
    Upon diagnosis, seekers with serious ailments embark on an emotional transition from seeker to long-term patient, which is often a daunting experience for the seeker because of the trauma they experience from the diagnosis. Despite this, they are required to make this transition swiftly and without time and support.
• [Lack of] enabling factors:
  • Dialogue/Trust/Understanding
    The absence of dialogue can lead to an understanding gap, which over time can result in reduced trust in the health system. This becomes a vicious cycle that compounds over time. As a consequence, seekers may be left feeling confused, disempowered, ill-equipped in managing their own health journey, and unable to deal with their side effects.
  • Social Networks
    Patients are part of an expansive social network, which includes family, friends, neighbors and non-formal health providers among others. By failing to leverage this network of care in a patient’s treatment, the system does not equip existing care-givers with information and skills that could improve a seeker’s health journey.
  • Intermediaries
    Seekers need various forms of support to physically, emotionally and financially navigate a complex, at times bureaucratic public health system. While there is a large demand for this, the lack of formalized roles or solutions means that this support is provided largely by unregulated actors, such as touts or pharmacists, who are accountable neither to the seekers nor the system.

Design Principles

Design Principles are a set of fundamental positions used to guide the design process; they are not mere suggestions of activities but assertions that guide the designer to more effective outcomes (Mattson & Wood, 2014). Some scholars have added that “principles are not simply a listing of goals but rather a set of methodologies to accomplish the goals” (Anastas & Zimmerman, 2003). For ARC it is important that principles help provide a pathway for public health systems actors and other stakeholders in global health to arrive at better, more user centered health systems in the future.

The ARC team framed design principles ostensibly to address the frictions. However, as is discussed below, these principles were also aligned with objectives of public health systems. In this exercise the ARC team relied on an extensive literature review of existing innovations both within public health systems as well as those outside of it. Further, the team also sought inspirations from hacks that communities and individuals themselves arrive at to overcome frictions they face in accessing and receiving healthcare.

Digital strategies will play a critical role in strengthening health systems and they have been formally recognized as a strategy to help meet the Sustainable Development Goals and universal health coverage targets. However, our principles also reflect the limitations of digital strategies and the crucial role of in-person efforts in healthcare, particularly for the vulnerable. This recognition was formalized by the WHO in its 2019 guidelines and recommendations on digital interventions for health system strengthening (Recommendations on digital interventions, 2019). The guidelines, “urges readers to recognize that digital health interventions are not a substitute for functioning health systems, and that there are significant limitations to what digital health is able to address.” Research evidence from ARC underscores this, and our principles provide a necessary provocation for developing a hybrid phygital approach to health systems in the future; striking the right balance between digital and in-person efforts will be key in road mapping the health systems of the future. As such, the diagram below presents “Everything is Physical; Everything is Digital” as the central provocation.

Figure 11. Design principles, patient needs, and health system outcomes. Illustration © Project ARC.

The innermost arc around this provocation presents a distilled version of the learnings from Project ARC regarding health seekers’ needs and expectations from health systems. Briefly these include:

1. I understand more and better, which reflects the needs of health seekers to better comprehend and evaluate diagnosis, prognosis and treatment regimens when seeking care. It also reflects their need to understand their options for keeping healthy and preventing disease.
2. I make fewer trade-offs while seeking care, which reflects the need of health seekers to consider and address stresses in all their health strands and their expectations of healthcare options that seek to minimize conflicts between their physical health and their other strands of health.
3. I am a partner in my care, which reflects the need of health seekers to actively engage in their own health journey and feel a sense of agency. This also reflects the need that many health seekers express to involve their informal care networks in their health journey, which may include their friends and family but can also include neighbors and other members of their community.
4. I know I can get the care I need, which reflects the need of health seekers to be aware of and trust the healthcare options that the healthcare system (particularly public healthcare) makes available to them.