NOVEMBER 2016

The Use of Design Thinking in MNCH Programs: A

Case Study of the Care Community Hub (CCH)
Pilot, Ghana

Anne LaFond
Nikki Davis
The Care Community Hub (CCH) pilot was implemented by Concern Worldwide and Grameen
Foundation in collaboration with the Ghana Health Service as part of the Innovations for Maternal,
Newborn and Child Health Initiative (Innovations) funded by the Bill & Melinda Gates Foundation. JSI
served as the global research partner for Innovations (Phase II) and conducted this case study in
collaboration with ILC Africa. Ledia Andrawes provided technical guidance and framing to interpret the
design process. This case study is one of four in a series that reports on the application of design
thinking in MNCH programming in Africa.

Suggested citation:
LaFond, Anne and Davis, Nicole (2016). The Use of Design Thinking in MNCH Programs: A Case Study of
the Care Community Hub (CCH) pilot, Ghana. JSI Research & Training Institute, Inc. Arlington, VA.

Cover photo:
Community health nurses participating in a design workshop (Volta region, Ghana).
Photo courtesy of Ledia Andrawes.

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Table of Contents
Executive Summary....................................................................................................................................... 5
1 Introduction ............................................................................................................................................... 8
2 Design Thinking Defined ............................................................................................................................ 9
3 Mapping the Influence of Design Thinking in MNCH Programs .............................................................. 11
3.1 Research Propositions and Focus................................................................................................ 11
3.2 Methods ...................................................................................................................................... 12
3.3 Data Sources................................................................................................................................ 12
3.4 Analysis........................................................................................................................................ 13
3.5 Strengths and Limitations ........................................................................................................... 14
3.6 Ethical Approval .......................................................................................................................... 14
4 Care Community Hub Pilot Description ................................................................................................... 15
5 Description of the Application of Design Thinking in CCH ....................................................................... 18
5.1 Intent ........................................................................................................................................... 22
5.2 Enquiry & Insights ....................................................................................................................... 22
5.3 Explore & Innovate ...................................................................................................................... 25
5.4 Formulate & Evaluate.................................................................................................................. 27
6 The Experience of Using Design Thinking ................................................................................................ 28
6.1 Essential Framing and Practical Insights ..................................................................................... 29
6.2 The Role of Empathy ................................................................................................................... 30
6.3 Comparing Design Thinking with Traditional Planning ............................................................... 31
6.4 Value and Drawbacks of Design .................................................................................................. 33
7 Influence of Design Thinking in CCH ........................................................................................................ 34
7.1 Grounded Theory ........................................................................................................................ 34
7.2 CCH Outcomes ............................................................................................................................ 35
7.3 Uptake and Use of CHN on the Go .............................................................................................. 38
7.4 Lasting Change: Buy-in and Ownership....................................................................................... 43
8 Design Thinking Influence Beyond CHN on the Go .................................................................................. 45
9 Reflection on Design Thinking in CCH ...................................................................................................... 46
ANNEXES ..................................................................................................................................................... 49
Annex A: References ........................................................................................................................ 49
Annex B: Detailed Description of Design Thinking Methodologies and Visual Products ................. 52

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List of Tables and Figures
Figure 1: Overlapping lenses in design thinking ......................................................................................... 10
Figure 2: CCH pilot development and implementation timeline ................................................................ 17
Figure 3: Timeline of application of design thinking in CCH ....................................................................... 19
Table 1: Summary of application of design thinking tools and methods in the CCH pilot ......................... 20
Figure 4: Main findings from the formative design research ..................................................................... 23
Figure 5: Process map for routine home visits conducted by CHNs ........................................................... 25
Figure 6: Three CHN user personas ............................................................................................................ 25
Figure 7: 10 opportunity spaces ................................................................................................................. 26
Figure 8: Final opportunity spaces ............................................................................................................. 27
Figure 9: Theoretical pathway of the influence of design thinking on MNCH programs ........................... 35
Figure 10: Six opportunity spaces from design thinking mapped to concept of fit .................................... 41

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Executive Summary
Responding to growing interest among designers, global health practitioners, and funders in
understanding the potential benefits of applying design thinking methods and tools to solving complex
social problems, the Innovations for Maternal, Newborn, and Child Health (MNCH) Initiative
(Innovations) developed and piloted innovative interventions to address common barriers to improving
the effectiveness of basic MNCH health services in low-resource settings. Central to the initiative’s
overall strategy was experimentation and learning related to the application of “design thinking,” a form
of inquiry that is applied in the conceptual stages of a planning process and subsequent stages of
program or product development. In spite of increased reports of the use of design thinking in
developing-country settings, there is little systematically documented evidence of the value of these
approaches in the form of in-depth documentation or formal evaluations that link design thinking to
health program performance or health outcomes. Moreover, there are few validated metrics to assess
the effect of design thinking.

A fundamental rationale for the use of design thinking is that it provides important insights into user
experience, needs, and desires and helps to translate these insights into tailored interventions or
products, increasing the likelihood of user adoption and reducing the risk of intervention failure. This
case study focuses on the use of design thinking in the Care Community Hub (CCH) pilot project that
introduced CHN on the Go, a mobile phone application, to improve health worker motivation and job
satisfaction among community health nurses (CHN) and their supervisors in Ghana. The research design
used a mixed-methods, comparative case-study approach. We constructed research propositions to
describe and explain the application and influence of design thinking in the CCH pilot and focused our
research using the constructs of fit, uptake, buy-in, and ownership and the effectiveness of the CHN on
the Go mobile phone app. We refined these propositions over time and, as data emerged, constructed a
theoretical pathway to illustrate the influence of design thinking on this MNCH intervention. The in-
depth study methodology was intentionally designed to be exploratory and analytical but not evaluative.

Description of Design Thinking in CCH

From October to December 2013, the CCH team introduced design thinking techniques to facilitate the
development and refinement of the CCH pilot design. During this period, a professional designer from
ThinkPlace, working with Grameen Foundation and Concern Worldwide team members, conducted
formative design research and interactive workshops in Ghana that utilized design thinking methods
(e.g., formative design research, nurse profiles, user personas, journey maps, and convergent and
divergent thinking) to understand better the context in which CHNs lived and worked, gain insights into
their workplace challenges, and highlight areas that could be addressed through the CCH intervention.
The application of design thinking occurred in four phases: Intent, Enquiry & Insights, Explore &
Innovate, and Formulate & Evaluate. The CCH team synthesized insights into CHN values, desires and
needs into six opportunity spaces which became the six modules that comprised the CHN on the Go
mobile app (Learning Center, Point of Care, Event Planner, Achievement Center, and Staying Well and
WhatsApp). The pilot team tested and then adapted the modules based on user feedback and inspired
by the empathy with CHNs. In the case of CCH, adaptation of the design of CHN on the Go continued
beyond the initial planning phase with a smaller group of users through user testing and feedback
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sessions. We describe the different steps and approaches applied during the design phase and
document in detail program managers and designers experience with design thinking in CCH focusing
the way in which design thinking provided essential framing and practical insights of the end users’
experience; its role in developing empathy for end users among program staff; how it compares with
other forms of program planning; and program staff’s perceptions of the value and drawbacks of design.

The Influence of Design Thinking

To understand the influence of design thinking in CCH we constructed a theoretical pathway or
grounded theory during the course of our analysis. In this pathway, we hypothesized that that through
the application of design thinking, CCH achieved fit, meaning the pilot created an essential match
between key strategies—mainly the focus and content of the mobile application—and many of the
CHNs’ needs, desires, and aspirations that related to job satisfaction and motivation. Fit then played a
role in catalyzing uptake or adoption of the CHN on the Go app among CHNs – a critical program
outcome. As the intervention was further refined with users through feedback loops and adaptation, it
achieved an even tighter fit, which influenced continued acceptance of and increased commitment to
using the CHN on the Go app. Throughout the pilot and during the endline study, CHNs described in
detail the ways in which the app addressed many of the barriers to health worker motivation and job
satisfaction uncovered during the design phase. Based on these observations, we conclude that design
thinking worked alongside other program elements to contribute positively to the realization of pilot
outcomes related to job satisfaction and health worker motivation. In the case study report we discuss
and illustrate this pathway and provide a critical analysis of the added value and limitations of design
thinking in the context of CCH.

Findings
Findings from the endline study of the effectiveness of CCH indicate high levels of adoption, sustained
use, and satisfaction related to the CHN on the GO application among CHNs. The CHN on the Go app
gained remarkable traction among the majority of the CHNs and supervisors over only an 18-month
implementation period and became widely used. Among those surveyed, 94 percent of CHNs reported
that the CHN on the Go app met their needs and half the CHNs reported using the app more than five
times per week by the end of the pilot. The majority of CHNs interviewed for the endline survey noted
that they would continue to use the phone and the app once the project finished.

With respect to reported health work motivation and job satisfaction among CHNs, direct reports from
survey data indicated limited change from baseline values. Younger CHNs (< 30 years) reported only a 5
percent increase in job satisfaction, whereas older CHNs reported no change. Low levels of self-reported
job satisfaction in the survey may stem from the challenge of conceptualizing the concepts of
satisfaction and motivation among CHNs or the variety of workplace challenges or frustrations reported
by the nurses that could not be addressed by a mobile phone application, including health worker
compensation, opportunity for professional advancement, and access to resources. In contrast to the
survey results, qualitative interviews with CHNs, indicate that CHN on the Go helped address many of
the intrinsic and some extrinsic elements of health worker motivation assessed in the baseline survey
and targeted in the pilot theory of change. Those included feelings about workload; CHN self-

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confidence; CHN perceived respect and recognition by the community, supervisors, and peers; CHN
feelings of connectedness, and job security. The link between use of CHN on the Go and reported
changes in aspects of health worker job satisfaction and motivation were documented in both the
process documentation conducted over the course of the pilot and in the qualitative data collected at
the end of the pilot, providing a more complete picture of pilot performance than emerged from the
endline survey of CHNs alone.

We observed that the high levels of uptake, appreciation, and use of CHN on the Go found in the endline
survey and consistently reported in interviews with key informants were clearly linked to the learning
and empathy that emerged from the initial design phase and the translation of this learning to an app
that facilitated work tasks, enabled continued learning, provided a resource for service delivery, and
built a supportive network for the CHNs. The design thinking experience also had a notable influence on
the program staff who took part in the design phase and then went on to manage the pilot. Their
continued commitment to the use of CHN- and supervisor-centered reflection and feedback loops to
inform iteration of the content of the modules also helped the app gain a tighter and tighter fit with
CHN needs and desires. Although user testing is common in software development, the Grameen team
was especially dedicated to extending the design thinking ethos of codesign and iteration beyond the
design phase, so that it became one of their major program strategies.

Design thinking influenced the CCH pilot in many positive ways, but we cannot conclude that design
thinking was the sole driver of positive processes and outcomes of CCH. Other critical practices or
strategies worked with design thinking to lay the foundation for an effective pilot intervention and for
sustained interest and commitment among the nurses and supervisors for continuing to develop,
extend, and support CHN on the Go. These included engaging GHS in the introduction and adaptation of
the app, working closely with the GHS to make the app compatible with the GHS community health care
protocols, linking the Learning Center module to the continuing education system and opportunities for
CHN professional advancement, and taking important steps to get the smart phone hardware and
software functioning effectively. In this sense, design thinking was a positive addition to the package of
other equally important program implementation strategies.

Design thinking in the context of CCH was an effective strategy for gaining meaningful insights into the
problem of health worker satisfaction and motivation, effectively tailoring interventions to address
those needs, and promoting a culture of adaptation and learning with end users that contributed to a
strong fit between the intervention and the end user needs, early and sustained uptake of the
intervention, and program effectiveness.

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 “If you really do not understand the person, it is difficult
for you to build something that works for that person”
 CCH program officer

1 Introduction
The Innovations for Maternal, Newborn, and Child Health (MNCH) Initiative (Innovations) developed and
tested innovative interventions and strategies to address common barriers to improving the
effectiveness of basic MNCH health services in low-resource settings. Central to the initiative’s overall
strategy was experimentation and learning related to the application of “design thinking” in MNCH
programs. Design thinking is a methodology that designers use to solve complex problems and find
desirable solutions for clients.1 The Innovations Initiative responded to growing interest among
designers, global health practitioners, and funders in understanding the potential benefits of applying
design thinking methods and tools—normally reserved for developing and marketing products—to
solving complex social problems, such as improving access to life-saving health services among women
and children in the developing world (Brown and Wyatt 2010). In this social innovation space,2 it is
assumed that design thinking can enhance traditional public health planning and implementation
strategies and thereby improve their effectiveness and the pace at which improvement takes place.
Although there is a growing collection of experience in applying design thinking in global health in
countries such as India (IDEO 2009), Uganda, Senegal (Fabricant, Milestone, and Qureshi 2014), and
Nicaragua (Villa and Hammer 2013), there is a need for focused documentation and analysis of the
practical challenges and benefits of the approach and evidence of its influence. In spite of increased
reports of the use of design thinking in developing-country settings, there is little systematically
documented evidence of the value of these approaches in the form of in-depth documentation or
formal evaluations that link design thinking to health program performance or health outcomes.
Moreover, there are few validated metrics to assess the effect of design thinking.

This case study focuses on the use of design thinking in the Care Community Hub (CCH) pilot project that
designed and introduced a mobile phone application to improve health worker motivation and job
satisfaction in community health services in Ghana. It documents and analyzes the application of design
thinking methods and tools within the CCH pilot and its influence on problem definition, pilot design,
implementation, and outcomes. Specifically, the case study examines the pathways through which the
CCH intervention has succeeded or failed in achieving its objectives, focusing on the role that design
thinking played at the different stages of the development and implementation of the intervention. This
document presents one of four case studies of the Innovation Initiative’s experience with design
thinking. A companion document—a comparison of all four cases—analyzes the evolution of design
thinking concepts in the Innovations Initiative and compares experience across all four cases to generate
learning and stimulate discussion on the use of design thinking methods and tools in MNCH programs in

1
http://www.tonchevassociates.com/blog-bedford/2015/6/24/what-is-design-thinking
2
For the purpose of this protocol, we define social innovation as: “The process of inventing, securing support for,
and implementing novel solutions to social needs and problems.”(Phillis et al. 2008)

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different settings and for different purposes. The findings of the individual and comparative case studies
are intended to inform future investment in design thinking in global health in developing country
settings.

2 Design Thinking Defined

Design thinking is a form of inquiry that is applied in the conceptual stages of a planning process and
subsequent stages of program or product development (Box 1). The process of design thinking is
described as open-minded,3 iterative, and human-centered and is intended to result in new, innovative,
and groundbreaking solutions. It is used to help define problems from the user perspective, explore user
needs and desires with respect to a particular issue or problem, and identify solutions to address those
needs and desires. In the context of global health, design
thinking is emerging as an approach to enhance the Box 1: Design thinking described
effectiveness of health program interventions. It helps to
 “…an analytic and creative process that
tailor program interventions to user needs and desires in engages a person in opportunities to
order to improve the uptake and sustained use of health experiment, create and prototype
models, gather feedback and
products, services, and behaviors. The application of design redesign…”(Razzouk and Shute 2012)
thinking methods and techniques is often referred to as  “ …a human-centered approach to
innovation that draws from the
human-centered design (HCD). For the purpose of this case
designer's toolkit to integrate the needs
study, we will use the term “design thinking” to describe the of people, the possibilities of
application of design thinking methods and tools in the CCH technology, and the requirements for
business success” (Brown 2009)
pilot.  “Design thinking is a powerful approach
to innovation that can be used to
Central to the design thinking approach is that designers generate breakthrough ideas.” (Brown
2009)
gain insights into the lives of end users and other key actors
to develop empathy for them. In CCH, end users were Characteristics of design thinking
community health nurses (CHNs) in most cases; other key
 A human centered approach
actors were mainly their supervisors. Empathy is defined in  A process of inquiry that involves
various ways,4 including the image of “standing in the shoes divergent and convergent thinking
of others.” In the context of design thinking, it allows  Iteration of ideas or designs to refine
them before widespread use
designers to “connect with people on a fundamental level”
(Brown 2009). Empathy, Brown notes, is “the most important distinction between academic thinking [or
modes of inquiry] and design thinking.” Design thinking introduces techniques that build empathy in
order to create emotional as well as practical links between designers and users and generate ideas or
solutions that are readily taken up by users.

3
i.e., receptive to new and different ideas or the opinions of others. (The American Heritage Dictionary of the
English Language 2009)
4
Cognitive empathy is understanding someone's thoughts and emotions, in a very rational, rather than emotional
sense. Emotional empathy is also known as emotional contagion, and is 'catching' someone else's feelings, so that
you literally feel them too.( http://www.skillsyouneed.com/ips/empathy.html)
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Empathic understanding goes beyond knowledge: when empathising you do not judge, you “relate to [the user] and
understand the situations and why certain experiences are meaningful to these people” (Battarbee 2004), a
relation that involves an emotional connection (Battarbee and Koskinen 2005).

A second element of design thinking is the use of facilitation techniques to stimulate divergent thinking
where possible by multidisciplinary teams to generate a wide range of possible ideas for addressing a
particular challenge or complex problem, followed by convergent thinking to gradually eliminate options
and integrate concepts such as viability and feasibility into the process of refining solutions.

Finally, design thinking often integrates the iteration of ideas and solutions on a small scale to test ideas
and refine them with end users before introducing them on a wider scale. Iterative approaches, using
co-creation or codesign techniques, often take the Figure 1: Overlapping lenses in design thinking
form of visualization and prototyping.5 They are
nonlinear and cyclical processes of design in which
designers test designs, assess effectiveness, define
lessons learned, and apply these lessons to refine the
design and/or implementation over time. Feedback
from stakeholders is used to create further iterations
of the product/solution and to make designs more
compelling for end users and programs more
effective within their target populations (IDEO 2009),
increasing the pace of uptake and reducing the risk of
program failure.

The use of design thinking at the early stages of programs represents a different approach to
conceptualization and planning than is traditionally used in public health programming. Design theory,
for example, notes that the design process often starts by using a “desirability lens” to examine the
needs, desires, and behaviors of the people that designers want to affect with solutions. The desirability
lens is used throughout the process and is critical to designers’ developing and maintaining empathy for
end users, which increases the likelihood of creating a solution that is responsive to unmet or latent user
needs and desires. During the later phases of the process, designers bring in the “feasibility lens” and
“viability lens” to refine their solutions based on financial, capacity, and other considerations. Figure 1
presents a conceptualization of the overlapping lenses of design thinking. For additional information on
the practice of design thinking see Annex A.

5
Prototyping is the act of turning ideas into actual products, services, and systems that are then tested, iterated,
and refined. It is an iterative technique for quickly testing a rough and low-cost version of a solution and using the
test data to make improvements (Kasper and Clohesy 2008). Prototypes are disposable tools used throughout the
concept development process to validate ideas, to help generate more ideas, and to help designers to think in
realistic terms about how users would interact with the concept (IDEO 2009). Prototypes go through stages of
testing, learning, and refining, inspired by a notion that it is acceptable to fail because failure moves one closer to a
better design. As the project nears completion and heads toward real-world implementation, prototypes tend to
increase from low fidelity to high fidelity.

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3 Mapping the Influence of Design Thinking in MNCH Programs
The use of design thinking in MNCH programming is a new phenomenon with limited evidence or
documentation of the way in which it is intended to affect the shape, execution, and outcome of MNCH
programs. Thus, we found it necessary to construct research propositions (e.g., hypotheses) to describe
and explain the application and influence of design thinking in the CCH pilot and to focus our research.
We refined these propositions over time and, as data emerged, constructed a theoretical pathway to
illustrate the influence of design thinking on MNCH programs. Below, we present our original research
propositions and research focus. The pathway of the influence of design thinking in CCH is discussed in
Section 7.

3.1 Research Propositions and Focus

The case study was guided by the following general research propositions (i.e. hypotheses) that focus on
the application and influence of design thinking in MNCH programs. The concepts in these propositions
were then adapted for specific use in the CCH case study (see Box 2, Section 7.2).

Research propositions

The application of design thinking methods and tools will:

 Create designer empathy for end users/target population
 Result in fit6 of problem definition with target population/user desires, needs, and barriers
related to MNCH programming
 Result in fit of MNCH intervention/pilot with target population/user desires, needs, and barriers
related to MNCH programming
 Result in end user buy-in and sense of ownership of the MNCH intervention
 Increase the pace of uptake of the MNCH intervention
 Play an enabling/driving role in the achievement of pilot outcomes

These propositions translated into the following foci for data collection:
 Application of design thinking concepts, processes, methods, and tools to:
o Problem definition
o Solution identification
o Intervention design
o Implementation
o Evaluation

6
For the purpose of this case study, “fit” is defined as: Program design addresses a need or desire of the CHN or
supervisor identified through the application of design thinking to the program development. General definition of
fit: of a suitable quality, standard, or type to meet the required purpose. Synonyms include reflects, corresponds
to, mirrors, is tailored to, is responsive to, takes into account.

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  Translation of results of application of design thinking concepts, processes, methods, and tools
to:
o Problem definition
o Solution identification
o Intervention design
o Implementation

 Effect of applying design thinking with respect to:

o Designer empathy for end user/target population
o Fit of problem definition and intervention design with end user desires and needs and
barriers to MNCH programming
o Uptake of the intervention and pace of uptake
o End user buy-in and sense of ownership of intervention/behavior
o Achievement of pilot outcomes

 Role of contextual factors on the process and influence of design thinking

 Lessons from applying design thinking methods and tools

3.2 Methods
The research design for the design thinking exploration used a mixed-methods, comparative case-study
approach, which enabled investigators to explore the application of design thinking in MNCH
programming during the Innovations Initiative and its influences on MNCH programs in different
settings. The CCH pilot intervention in Ghana constitutes a single case of applying design thinking in the
context of MNCH programming. The CCH case was selected as one of four pilots implemented in the
second phase of the Innovations Initiative (2012-2016).

3.3 Data Sources

To complete the case study on design thinking, the research team relied on several sources of primary
and secondary data. We drew on 1. the primary data collected for routine pilot monitoring; 2. a rigorous
program evaluation (baseline and endline studies) to measure the effectiveness of this innovative
program model in improving health worker job satisfaction and motivation and in overcoming barriers
that contribute to demotivation; and 3. process documentation, consisting of in-depth qualitative
interviews during implementation to document and assess the proposed and actual pathways between
program intervention and program effectiveness as proposed in the pilot’s theory of change, and
document, prospectively, the drivers of change. We also conducted separate and focused primary data
collection at the same time as process documentation to document and explore the application and
influence of design thinking methods and tools. In all cases, primary data on design thinking were
collected using in-depth semistructured interviews, group discussion, and observation. Data collection
included three rounds of interviews and observations beginning approximately six months after the
initial design thinking activities took place (focusing on the application of design thinking), continuing
one year into program implementation (focusing on the influence of design thinking), and ending 18
12
months into program implementation. In the first round, respondents included program managers,
research advisors, and program and research implementers from all partner organizations (Concern
Worldwide, JSI, Grameen Foundation, ILC Africa, and Ghana Health Service). In subsequent rounds, we
interviewed the same respondents, as well as CHNs and supervisors participating in CCH. In some cases,
repeat interviews were conducted with particular key informants to explore the effect of design thinking
over time and the evolution of the perceptions of program managers and implementers on the role of
design thinking. The team conducted 155 interviews, focus group discussions, and observations. The
case study team also reviewed program-related documents, program monitoring data, and the findings
of the final evaluation of CCH. The study teams consisted of Ghanaian and international researchers, the
majority of whom collected data and conducted analysis in all three rounds of data collection.

3.4 Analysis
The case-study method derives its analytical power from sequential development of themes and theory
that are generated from an immersion in the data. Thus, data analysis to describe and explore the
application of design thinking in CCH took place in stages. After the first round of document review and
data collection, researchers reviewed and synthesized interviews, reports, and graphic summaries of the
design thinking activities; constructed a timeline of events; and produced a brief description of each
activity. These detailed descriptions of the content and process of the design thinking activities helped
define and bound the specific focus of this study of design thinking in CCH. The descriptions were shared
with program staff and design professionals who were involved in the activities and who then verified
their accuracy. These verified descriptions then constituted the key design thinking activities whose
influence was explored through subsequent rounds of data collection.

As the data collection progressed (process documentation as well as case study–specific data collection),
researchers employed NVivo 10 and 11 software (QSR International 2014) to code and sort qualitative
data. Codes captured the perceptions of design thinking and the influence of design thinking on
designers’/program managers’ perceptions of the end users and their program design and management
choices. Codes were also used to capture concepts such as the fit between end user needs and desires
and program design elements and the extent to which the program as designed had its intended effect
(end user uptake, buy-in, ownership). To ensure coding quality, in each round two team members coded
the same 10 transcripts. Coders held frequent meetings to discuss coding patterns and used NVivo to
check intercoder reliability coefficients.

To synthesize findings, we first identified common themes, forming initial theories and findings and
generating additional questions, which were incorporated into the next round of data collection.
Researchers refined codes with each iteration of the analysis. These codes were applied at each stage to
identify the emergence of or absence of evidence of fit, uptake, buy-in, and ownership and changes in
these variables over time and among intervention groups. We also continued to construct program
timelines, define thematic grouping and classification of the data, and triangulate primary data with
other sources noted above.

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Following the second round of data collection, researchers used the emerging themes to begin to
construct a grounded theory about the way in which design thinking was applied in CCH and influenced
the pilot. This theoretical pathway helped the research team explore the relationship between the five
elements of design thinking that were assessed in each round of data collection. The pathway was
further refined with each subsequent round of data collection and completed once all the data were
analyzed. We validated case study findings through discussions with CCH program managers and
evaluation team members and by engaging the original design professional involved in CCH to reflect on
and interpret the theoretical pathway, analysis, and conclusions.

3.5 Strengths and Limitations

Many reviews and evaluations of program experience in the health sector in low-resource settings use
mixed methods to assess program outcomes and effectiveness, combining objective quantitative
measures with qualitative exploration of implementation pathways to explain and explore aspects of
program success or failure. The Innovations CCH case study is unique for the volume of data collected
over time to understand the influence of design thinking in the pilot through a range of data sources.
The mixed-methods approach enabled triangulation of results, and the extended time frame allowed
researchers to explore nascent themes with key respondents and program managers as they emerged,
confirming or adapting them as needed and integrating new questions into subsequent rounds of data
collection. The second methodological strength of the study design was its focus on description and
reflection of pilot experience with the use of design thinking across four programs. The ability to make
explicit comparisons and contrasts among different experiences of design thinking found in each of the
four Innovations’ pilot during the research offered a strong methodological advantage over the use of a
single case to reflect on experience.

There were limitations as well. The in-depth study methodology was intentionally designed to be
exploratory and analytical but not evaluative. The findings should not be interpreted as a statement on
the impact of design thinking, since we did not include a counterfactual or comparison case that
implemented the same program without the use of design thinking. Still, the case-study methodology
has uncovered information about the opportunities and challenges of applying design thinking in MNCH
programming that may be relevant to other teams considering its use.

Finally, we were unable to sufficiently address a key research proposition—the influence of design
thinking on the pace of uptake of the CHN on the Go application—because of the lack of reliable mobile
phone application usage data. We were also limited in our ability to conduct in-depth analysis of all key
contextual factors because of the sheer number and complexity of relationships, timing of events, and
limited access to data.

3.6 Ethical Approval

Approval for this study was granted by the Ghana Ethics Review Committee (ID No. GHS-ERC: 07/09/13).

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4 Care Community Hub Pilot Description
The Care Community Hub (CCH) was a pilot project that aimed to provide the government of Ghana with
an innovative solution to address barriers to health worker motivation through the use of information
and communications technology (ICT), specifically, through the development of a mobile phone
application called CHN on the Go. In general, CCH sought to use a mobile technology application to
provide knowledge, learning, decision support, and motivational and communication tools to
community health nurses (CHNs) and community health officers (CHOs) who work in the Community-
based Health Planning and Services (CHPS) system and subdistrict health centers in Ghana in order to
improve health workers’ well-being and connectedness and to decrease their feelings of demotivation.
There was an unwritten desire that this intervention would in turn contribute to improved quality of
care; however, no explicit steps were taken to focus the intervention beyond the improved job
satisfaction and health worker motivation.

The initial CCH concept was defined in 2012 by the Innovations for MNCH project team, and in 2013 the
implementing partner and intervention sites were chosen in collaboration with the funder and
representatives of the Ghana Health Service (GHS). Project planning took place in early 2013 resulting in
an inception report and a research monitoring and evaluation (RME) plan to guide the project
management team and partners. To refine the project plan and in the spirit of innovation that defined
the Innovations for MNCH Initiative, the project engaged a professional designer from ThinkPlace who
worked with CHNs, supervisors, Grameen Foundation and Concern Worldwide program and technical
staff, and district and regional health managers to apply human centered design and with digital
technology staff to help shape the various aspects of the CCH intervention and specifically the mobile
application that stood at the center of the pilot theory of change. The learning and experience that
emerged from this four-month design phase were incorporated into the official project plan. Following
the initial design phase, the Grameen Foundation team conducted 15 additional workshops between
January and June 2014 to further refine and adapt the design with end user inputs. Through this process
software developers built the CHN on the Go app and the app went through a series of adaptations and
iterations drawing on data and information collected through feedback sessions with the CHNs. This
additional engagement with CHNs and supervisors included a visual interaction design workshop with
CHNs and supervisors to assist the software developers to define the user interface of the app. This
workshop explored how the end user would move through each of the mobile application’s five modules
while using the application. Through the process of refining the Point of Care module, CHNs expressed
that they wanted to be able to more easily move through the diagnostic protocols in this module
without having to go step by step. They wanted to be able to jump to a particular point in the protocol in
instances where the beginning portions were unnecessary. From this feedback, the team modified the
module to allow CHNs to navigate the module more easily when dealing with their clients.

The mobile application CHN on the Go was launched in June 2014 in five rural districts in Ghana: Ada
East, Ada West, and Ningo Pram districts in Greater Accra Region and South Tongu and South Dayi
districts in Volta Region. The application consisted of five independent modules (Learning Center, Point
of Care, Event Planner, Achievement Center, and Staying Well) and WhatsApp, a free Internet-based
mobile messaging tool. The Learning Center enabled CHNs access to e-learning courses for various
15
topics such as newborn and infant care and family planning. Point of Care was designed to be an
interactive diagnostic tool to help CHNs determine the best course of action for sick patients. It further
provides CHNs with visual aids to show clients during counseling. The Event Planner helped CHNs plan
their home visits, clinic outreach, etc., while the Achievement Center was created to help CHNs track
their progress with individual targets related to their daily work. The Staying Well module was
constructed to be the “stress relief” module, providing CHNs with inspirational material, personal
wellness tips, and other nutrition and fitness recommendations. Lastly, WhatsApp, including the various
groups that were formed, was used as a platform for CNHs to share ideas, thoughts, and challenges with
peers, colleagues, and supervisors, facilitating easy communication with staff across each district.

There were five iterations of the CHN on the Go app over the course of the CCH pilot between the
launch in June 2014 and the end of the pilot in May 2016. Version 1 included all six modules that
emerged from the design thinking process with the basic content. In version 2, the team introduced
target setting in the Event Planner module, updated graphics, added postnatal care quick reference
content to the Point of Care module, and bolstered the content in the Staying Well module. Version 3
included a rebuilt Staying Well module that contained additional activities and content tailored to the
user’s personality. Version 4 included a revised Achievement Center module that added a feature
focusing on target setting at the facility level. It also improved user ability to update events and added
content and topics to the Learning Center. The fifth and final version of the app removed the Target
Setting module and introduced a content management system for the Point of Care module that made
the content dynamic and downloadable.

As the CHN on the Go app went through a series of iterations, drawing on data and information
collected through feedback sessions with the CHNs as well as Magpi surveys, in-depth process
documentation, and monitoring data to inform each adaptation and the program strategy. The pilot was
completed in May 2016, after 23 months of implementation. Figure 2 maps the pilot timeline including
changes made in the design of the pilot and the mobile application.

16
Figure 2: CCH pilot development and implementation timeline

17
5 Description of the Application of Design Thinking in CCH
From October to December 2013, the CCH team introduced design thinking techniques to facilitate the
development and refinement of the CCH pilot design (Figure 3). At various stages, this process engaged
a range of pilot stakeholders from different teams and representing different disciplines: technology and
public health experts from the Grameen Foundation, health program experts from Concern Worldwide,
M&E experts from John Snow Inc., design experts from ThinkPlace, and the various beneficiaries,
including CHNs, their supervisors, and staff from the district and regional levels of the GHS. During this
period, a professional designer from ThinkPlace, working with Grameen Foundation and Concern
Worldwide team members, conducted formative design research and interactive workshops in Ghana
that utilized design thinking methods specifically to better understand the context in which CHNs live
and work, gain insights into their workplace challenges, and highlight areas that could be addressed
through the CCH intervention. In addition to the formative design research and exploration of CHN and
supervisor needs, desires, and experiences, the team conducted a series of synthesis and ideation
activities involving multiple stakeholders to refine the program design and to co-design7 and test a
mobile application to support health care workers by addressing barriers in their everyday work. Over
110 people took part in the research, design, testing, and build phases, including 60 CHNs, 12 nurse
supervisors, 18 pregnant women and nursing mothers, and more than 20 stakeholders from the partner
organizations (Alva, 2016). In all stages, the design thinking techniques aimed to generate empathy
among program managers and software designers to engender deep understanding of the CHNs’
situation and experience related to workplace motivation and job satisfaction. We describe below the
specific activities that constituted the design thinking process in CCH and report the experience through
the observations and perspective of the program managers and designers during this period.

The application of design thinking occurred in four phases: Intent, Enquiry & Insights, Explore &
Innovate, and Formulate & Evaluate. Table 1 summarizes the design thinking activities, mapping out the
purpose of each, the tools and methods used, intermediate findings, and the resulting design decisions.
Each decision represents an adaptation or addition to the original program model. Annex B provides
more details and visual outputs of the design thinking process at different stages, illustrating the ways in
which design thinking helped program staff gain insights into user needs, desires, and experiences and
shape these insights into design decisions.

7
Scrivener stresses that the term ‘co-design’ manages to set out a framework for debate, without constraining
thinking into too narrow a mold: it is an ‘umbrella term’ covering both ‘community design’ and ‘participatory
design’.19 As such, co-design broadly refers to the effort to combine the views, input and skills of people with
many different perspectives to address a specific problem.

18
Figure 3: Timeline of application of design thinking in CCH

19
Table 1: Summary of application of design thinking tools and methods in the CCH pilot

Participant
Time-
Activity Location Roles/ Purpose/ Goals Tools/ Methods Findings Design Decisions
line
Organization
A short project initiation document was
 Intent statement tool:

Intent
Determine the current state and delivered to key stakeholders outlining
describe current and Intent Statement incorporating desired
Grameen Offices- ThinkPlace, define the desired future state and the project activities, deliverables, and
Intent Workshop Accra Grameen, Concern reach a shared understanding of the
intended future state and
intent statement with the following
end state from all stakeholder
hypotheses to accomplish perspectives
project’s intent outputs: Project intent statement, project
desired outcomes
timeline, project Scope
There were 12 key areas of interest:
 One-on-one interviews respect, monitoring & supervision, clinical Used the information to map out the
with supervisors targets & performance, data & reporting, system, the relationships between
Facilities: Greater  Focus groups (clients & career progression, nurse training & different players, segment users, and
Formative ThinkPlace, Gain an understanding of the “users”
Accra & Volta CHNs) mentoring, supervisor training & capture their lived experiences of the
Research Grameen and their experiences of the system
Regions, Ghana  Process mapping (with mentoring, recognition & appreciation, system.
CHNs) being connected, resource limitations,
 Health worker profiles client & community relations, nurse
drivers & roadblocks
Synthesize field research and
Grameen Offices ThinkPlace,
Analysis and summarize key themes that emerged

Enquiry & Insights

Accra Grameen  Post-it note synthesis Top 5: drivers, barriers, most important
from the research.
Synthesis  Clustering things to nurses; identified 10-12 themes
Bring all parties that didn’t participate
La Villa Boutique ThinkPlace,  Harvesting that emerged from the field research.
Workshops (2) in field research up to speed on
Hotel Accra Grameen, Concern
findings and empathy.
Understanding Utilize the process and experience Brainstormed dozens of questions around
ThinkPlace,  Brainstorming
La Villa Boutique maps to understand the system from how to improve the relationship between
the System Grameen, Concern,  Process map review Developed challenge questions
Hotel Accra different perspectives of the supervisors and nurses during supervisory
nurses  Persona development
Workshop generated personas visits

 Empathy building
Understanding ThinkPlace,  Brainstorming Health worker personas finalized to be
La Villa Boutique Work with nurses to see if they Determined motivating factors for
the User Grameen, Concern,  Storyboards used in ideation and concept
Hotel Accra identified with the personas different health worker personalities
nurses  Persona validation development
Workshop
 Process mapping

Utilize challenge questions to  Idea sheets

Explore & Innovate

ThinkPlace, generate solutions to challenges  Iteration Determined guiding principles and design Identified 10 opportunity spaces, which
Ideation La Villa Boutique
Grameen, Concern, identified in formative research.  Clustering criteria, refined emerging concepts, could potentially be developed into
Workshop Hotel Accra
mHealth expert Review and discuss potential mHealth  Harvesting refined opportunity spaces application modules.
solutions that exist  Score cards (for ranking)
Nurses and supervisors validated
 Roleplaying
ThinkPlace, Utilize the nurses and supervisors to personas and which of the 10
Codesign La Villa Boutique  Scoring
Grameen, nurses, help further develop, refine, and Refined the 10 opportunity spaces to six opportunity spaces to take forward, as
Workshops (2) Hotel Accra  Voting
supervisors identify opportunity spaces well as providing input into ways to
 Process mapping
improve the ideas.

20
 ThinkPlace, Further develop the six opportunity
Concept Grameen, Concern, spaces by utilizing the various Ultimately determined the modules
Mindindi Hotel  Storytelling
Development Accra
ILC, tech developers, perspectives brought to the table in
 Concept templates
that would be created for the
mHealth NGOs, non- order to assess the viability of the application and outlined their content
Workshop

Explore & Innovate

mHealth NGOs options
Decisions such as using the work
planning calendar instead of a GPS
List out all activities needed for each
component to track nurses’ clients
ThinkPlace, of the opportunity spaces to happen Modules needed to be scaled based on
Prototyping Mindindi Hotel Developed a roadmap for developing
Grameen, Concern, and get a sense of what will be  User stories template nurses’ capacity to utilize them, as well as
Workshops Accra the code, training, and deployment of
ILC, tech developers realistic to build, technically and cost and resources required to build them
the tool
organizationally.
High-level work plan to move the
project forward
Develop User
Stories,
Grameen Offices, ThinkPlace, Synthesize information and outcomes
Pathways, and  Visualization
Accra Grameen, Concern from all of the workshops.
Interaction
Models
Validate proposed intervention with

Formulate & Evaluate

ThinkPlace, GHS district and regional Supervisors need to be involved in this
Grameen, Concern, representatives. Ensure that they feel program as well. Animosity if nurses are Creation of a computer-based
Validation Mindindi Hotel
Ghana Health the intervention will work as proposed  Storyboards getting smart phones and supervisors are supervisory dashboard to accompany
Workshops (2) Accra
Service District and and they support the use of the CCH not. Supervisors are older and generally the CCH application
Regional Directors application among CHNs and less tech savvy.
supervisors.
Flesh out details of application
content so that document could be
ThinkPlace,
Refine Blueprint Nairobi, Kenya
Grameen
used by Grameen to start building the
application to incorporate information
generated by the design process

21
5.1 Intent
At the beginning of the design process, the designer facilitated an Intent Workshop to frame the main
objective for the project focusing on assessing the current state, formulating a shared understanding of
the future desired state, and hypothesizing the desired outcomes. At this workshop, the participants
created an “Intent Statement”8 that served as an anchor to ensure that the pilot remained on track to
achieve the intended goals through the course of the design process. The Intent Statement was further
refined through the design process and the final statement and guided programmatic decisions through
the course of the pilot.

Intent Statement: To enable a more motivated frontline health workforce, resulting in better
quality of maternal and child health care for rural women in Ghana through a mobile technology
innovation

5.2 Enquiry & Insights

Following the Intent phase, insights were gleaned and empathy was evoked through a process of
formative design research. This step helped the design team put themselves in the shoes of the nurses
when they are providing care at the community level. The team collected nurses’ personal stories
prompted by a storyboard template they could fill out, completing phrases such as: “A time I felt most
satisfied in my work was when …” or “A time I felt most frustrated in my work was when ….” The team
then used these stories as a launching pad for discussions in focus group discussions and individual
interviews. They also provided the nurses with a “nurse profile” template asking them to list their
professional goals, personal aspirations, and the roadblocks or barriers they faced to achieving their
goals. These stories, which captured the language of the nurses, kept the project team grounded in the
words of the CHNs during the subsequent steps of analysis and decisionmaking.

Several design decisions for the CCH intervention emerged from the following key areas of interest that
became the focus of the Explore & Innovate phase of the intervention development: respect, monitoring
and supervision, clinical targets and performance, data and reporting, mentoring, supervisor training
and mentoring, recognition and appreciation, being connected, resource limitations, client and
community relations, and nurse drivers and barriers. Figure 4 illustrates the consolidated areas of
interest related to CHNs that emerged from the formative design research.

Based on the learning during the formative design research, it became clear that CHNs faced challenges
with career advancement and desired opportunities to advance their skills through further education
and training. CHNs also expressed a desire to receive feedback and encouragement on their
performance and to connect and collaborate with other health care providers. Additionally, because
many of the CHNs were posted to communities where they did not have social connections, they
indicated the need to relax and decompress from their work life to reduce stress. CHNs were also
concerned about interacting productively with their communities and clients. They expressed a need for

8
An Intent Statement is a term coined by ThinkPlace and is akin to a purpose/outcome statement

22
help in planning their daily interactions and ensuring that clients are available when they make home
visits.

Finally, CHNs expressed a strong desire to provide good care to their clients and for tools that could aid
them in diagnostics, treatment, and counseling.

Figure 4: Main findings from the formative design research

RESPECT ME
•Enabling nurses to feel respected by their peers, supervisors and in their communities
•Setting appropriate and achievable targets that are reflective of what is happening on the ground in communities

REWARD ME
•Using data-based evidence for appreciating nurses and supervisors rather than enabling favouritism
•Showcasing the extent of nurse efforts, not just their clinical results, by tracking their movements and daily
activities.

TEACH ME
•More in-depth, one-on-one supportive and facilitated supervision time for nurses
•More helpful feedback mechanisms for nurses following supervisory interactions
•Minimizing the wait time between supervisory interactions and feedback for nurses to improve themselves

INFORM ME
•Strengthening nurse knowledge and capacity at the frontline with easy access to relevant information and clinical
support
•Stronger emphasis on data accuracy and integrity

CONNECT ME
•Building close, authentic and trusting relationships between nurses and clients
•Improving communication channels between nurses and supervisors
•More cooperative and less adversarial relationships between nurses and supervisors
•More peer-to-peer learning, sharing and collaboration among nurses
•Stronger engagement with communities and their volunteers

EQUIP ME
•Minimizing the time and human resources involved in data collection and analysis processes
•More strategic approach in identifying and caring for high priority cases
•More effective scheduling and coordination between nurses, their clients, community volunteers and supervisors
•Aiding supervisors in making informed decisions regarding the allocation of limited resources

INSPIRE ME
•Stronger resilience in the face of trouble and system challenges

BELIEVE IN ME
•Greater empathy and understanding among supervisors toward nurses and their challenges

23
Analysis and Synthesis Workshops followed the formative design research phase, during which the CCH
team empathized with the end users by analyzing and summarizing the information from the stories and
profiles, field interviews, and focus group discussions. The workshops were highly collaborative and
interactive, designed to push boundaries and challenge participants in their thinking. From those
workshops, the design team identified the main themes and key findings that would guide the
development of the CCH intervention and CHN on the Go application. They also identified the top five
motivators and demotivators for the CHNs. The team decided that they should not only focus on
eliminating demotivating factors but should build upon and amplify existing motivating factors in order
to produce a successful intervention.

Through Understanding the System and Understanding the User Workshops, the program staff and
software developers took a deeper dive into nurses’ stories, process maps (Figure 5) created during the
formative design research, and other information gathered during the formative design research to
better understand the barriers and enablers to CHN job satisfaction and motivation, as well as their
pathways through different CHN tasks (home visits, supervision, group outreach). They immersed
themselves in the findings and were prompted to experience the nurses’ stories as “I” rather than
“they,” as they walked through the raw data posted on workshop walls, all of which helped them build
empathy for the CHNs.

The team then created CHN personas to depict the intrinsic motivating factors that influenced the way
in which CHNs approached their work. Personas are hypothetical archetypal users that represent the
needs, goals, values, and behaviors of larger groups of users in a system.9 By identifying human drivers
of motivation, personas bring users to life by giving each one a name, personality, and face. To develop
personas, the group started with five or six distinctive common character traits of a CHN and clustered
them based on the patterns that emerged from the CHN stories. This clustering resulted in three main
CHN personas: Purpose-driven & Resilient (Naana), Purpose-driven & Dispirited (Mary), and Paycheck-
driven & Dispirited (Michael) (Figure 6). In a later phase, the team walked several CHNs through each of
the personas, and they validated them because they were able to identify with the resulting
personalities. The team also developed personas for supervisors (see Annex B).

From reflecting on the experience maps and personas, the design team produced several “challenge
questions” (i.e., posting questions such as “How might we…?”) that were later used in the Explore &
Innovate phase to provoke and generate ideas and steps for addressing the workplace challenges faced
by CHNs.

9
Cooper, A. (1999) The inmates are running the asylum. Sams, Indianapolis. p124

24
Figure 5: Process map for routine home visits conducted by CHNs

Source: ThinkPlace 2014

5.3 Explore & Innovate Figure 6: Three CHN user personas

In the next phase, the designer facilitated an Ideation
Workshop to generate as many ideas as possible that
were specifically focused on the use of mobile
technology to address the desires, gaps, and barriers
identified in the formative design research. These
activities allowed the team to use the emerging themes
that arose from the early stages as a launch pad. From
a place of empathy, they were coached to think
expansively (diverging) about the different approaches
that fit with/determine the guiding principles and
design criteria for the mobile technology intervention.
Bounded by these parameters, the team then refined a
list of 10 opportunity spaces (converging) (Figure 7),
representing potential modules that could be taken
forward to form the final CHN on the Go mobile Source: ThinkPlace 2014
application.

25
Figure 7: 10 opportunity spaces

Source: ThinkPlace 2014

In order to incorporate design input from end users into the mobile app, the team held two Co-Design
Workshops with CHNs and their supervisors. During these workshops the facilitators validated the CHN
personas and used insights gleaned from these conversations to further consolidate the 10 opportunity
spaces into six opportunity spaces: “learning and growing,” “providing good care,” “knowing how I am
doing and feeling appreciated,” “connecting with others,” “managing my work,” and “keeping well.”
Using the desirable, viable, possible model (an adaptation of Figure 1 above), the team zeroed in on the
specific areas that could be addressed through the use of mobile technology. Three additional areas that
they felt were instrumental to achieving the desired outcomes were considered beyond the scope of
CCH and a mobile technology solution because they involved system-level interventions by the GHS.

During the Concept Development Workshop, the team then iterated on these six opportunity spaces and
developed them into more robust concepts through small-group work to answer questions such as:
What is the aim of each concept? How would each concept work in practice from the perspective of
supervisor, client, GHS, nurse? How would each concept be experienced differently by the three distinct
nurse personas? What are the technical functions required to make each concept work for the three
personas?

Figure 8 illustrates the opportunities identified through the design thinking process. The final six
opportunity spaces are depicted in color in the upper half of the circle. The spaces in gray in the lower
half of the graphic represent areas that were important to CHN motivation but were beyond the scope
of the CCH project.

26
As a next step, the designer facilitated a Prototyping Workshop to further assess the viability of the app
by mapping out the technical requirements to build each module. From there the team began to assess
the viability of each of the six opportunity spaces through using the agile software development method
to create user stories.10 These stories ultimately determined the various business requirements that sit
within each module as part of the mobile app. This stage further helped the Grameen Foundation
technology team create a framework for the application complete with the resources that would be
required to build it.
Figure 8: Final opportunity spaces
This workshop also enabled the software
developers to refine aspects of the mobile app
such as language, look, and feel to reflect CHN
and supervisor experience and perceptions.
During this workshop, the team developed a
high-level work plan for implementing the
project. The work plan involved steps to
further test and iterate on the design, develop
and test the content, develop and test the
software, develop and train the
CHNs/supervisors, and introduce the
application into existing GHS processes. This
road-mapping activity allowed the team to
cascade and prioritize certain activities or
functions for app development. Additionally,
the initial prototyping provided a foundation
that helped developers to build the app
infrastructure through wireframes that
visualize the flow and process of engaging Source: ThinkPlace 2014
within the app from the perspective of the end
users (CHNs).

5.4 Formulate & Evaluate

To integrate ideas and gain support from the GHS, the team then held Validation Workshops at both the
district and regional levels. At these workshops the GHS participants verified that the initiative would be
valuable and provided suggestions on ways to improve aspects of the app design and pilot execution.
For example, the GHS participants felt that supervisors should be more involved in the pilot to reduce

10
In software development and product management, a user story is a description consisting of one or more
sentences in the everyday or business language of the end user or user of a system that captures what a user does
or needs to do as part of his or her job function. User stories are used with agile software development
methodologies as the basis for defining the functions a business system must provide and to facilitate
requirements management. It captures the "who", "what," and "why" of a requirement in a simple concise way,
often limited in detail by what can be handwritten on a small paper notecard.
(https://en.wikipedia.org/wiki/Userstory).

27
potential animosity among supervisors if they did not also receive smartphones. They also noted that
the supervisors tended to be less technology savvy than the younger CHNs, which could pose problems
related to uptake and consistent use of a mobile application. As a result, the Grameen Foundation team
decided to include a computer-based supervisory dashboard to accompany the CHN on the Go app,
enabling supervisors to monitor some of the CHN activities and become embedded in the process of
solution identification.

Finally, the designer created a visual and written blueprint to synthesize all of the findings and decisions
that were made throughout the CCH design process. The blueprint fleshed out the details of the app
purpose and content, documenting the design inputs and decisions and establishing a road map to build
the app and introduce and support it over the course of the CCH pilot. Ultimately, the findings from the
design thinking phase were integrated into decisions on the final choice of modules and the
development of their content, resulting in the CHN on the Go app containing the Learning Module,
Achievement Module, Staying Well Module, Hangout Module (WhatsApp), Work Planning Module, and
Point of Care Module.

6 The Experience of Using Design Thinking

The team that engaged in the design thinking phase at the early stages of the pilot included a
multidisciplinary group consisting of public health, technology, development, and innovation
professionals, local cultural experts, and, at times, the CHNs and supervisors and staff from the district
and regional level of the GHS. As noted by Dandonoli (2013) in Andrawes et. al. 2016, “a deliberate
attempt was made to seek input from the unconventional voices usually excluded from health system
planning and decision-making in this context.” A core group from this range of stakeholders engaged in
the design thinking process throughout, from formative design research to validation of the findings
with the GHS. Others joined the process at different points, depending on their availability and their role
in the design process.

As part of our exploration of design thinking in CCH, we conducted interviews with 11 respondents who
participated in the design thinking phase of the pilot (October 2014 to January 2015) or were integrated
into the team following the design phase but were familiar with the role that design thinking played in
the life of CCH. Respondents ranged from end users (CHNs and supervisors) who were present at the co-
design workshops to program managers and software developers who were directly involved in shaping
the CCH pilot and the CHN on the Go app. In many cases, the same respondent was interviewed twice,
once following the design phase and next at the end of the pilot to reflect on the influence of design
thinking. The respondents’ experience with design thinking in CCH fell into four broad categories:
essential framing and practical insights; empathy for end users; comparison with other forms of program
planning; and observations of the overall value and drawbacks of design.

28
6.1 Essential Framing and Practical Insights
Respondents came away from the design process with a greater sense of understanding of the situation
of CHNs, their working environment, and typical frustrations in the work place. These insights were
framed through the formative design research and the series of synthesis and co-design workshops led
by the design professional. It was described as “a journey” by some and “torture” by another. But there
was general agreement among participants that the design process helped to elucidate the concept of
health worker motivation in concrete and personal terms and to translate the concept into design
choices for the mobile application that could effectively address the needs of the CHNs and the
supervisors. As a senior technical manager noted:

My understanding of design process was number one: try to figure out what motivation meant for this
group of people. And then try and figure out what could be addressed by a technology solution. So, going
from this very abstract thing of addressing motivation with technology and being able to come to this very
complete place where we identified specific modules that would help to address specific issues that have
been raised.

A senior technology advisor reported:

So the main purpose [of the design thinking] was trying to really get to… well there were two things. One
was making sure that we can really understand the problem of motivation or demotivation for the nurses
and the reasons why that was a problem ... the actual ball game was the focus groups, individual
interviews, and exercises we put them through which really helps you to get a very holistic view in terms of
answering the question. And the second part was to make sure whatever we were developing was actually
something they could use and actually address their problems. And for that we needed to both involve the
nurses and the supervisors in the process of development.

Participants in this early design thinking phase gained a deep understanding of the CHNs and learned a
great deal about their work life. A Concern Worldwide manager noted: “There was really an insane level
of detail and that was useful later on.” The technology advisor reported: “The biggest advantage [of the
design phase] was knowing who the app was for and developing it for their use.”

Steps such as constructing user personas and capturing the nurses’ value statements made it easy for
program staff and software designers to envision the kind of mobile application that might be needed.
As a program manager noted:

Identifying various personas was very important. Some [CHNs] are really passionate about their job
regardless of challenges. Others are there because they need to be there, and others are there because
“my daddy wanted me to become a community health nurse.” Persona development helped develop an
app so it addressed all the personalities and not just those who are passionate about their work. The
various kinds of people in the system should be reflected in the design of the app.

Some participants learned new things, as a program manager noted: “Understanding the system around
frontline health workers was new to me: the complexity of the supervisor role and that the level of trust

29
is low.” Others gained depth of understanding: “A lot of the information [we learned] we had heard
through other channels, so that wasn’t surprising. What was interesting was the nurses getting into
details of how they work and why they are frustrated” (technology advisor).

As the design phase advanced, a program manager noted:

Key themes emerged: issues around respect, not feeling appreciated, not having the right information or
resources to do their job well, not having good avenues of career progression, not feeling support of
supervisors, and two giant system-level issues that trickled down to how nurses feel about doing their job.
These were the foundation on which the six big ideas (opportunity spaces) were built and helped to frame
the overall strategy of the CCH pilot.

6.2 The Role of Empathy

One of the research propositions we explored was the use of design thinking to build empathy with the
end user as part of the problem mapping and solution identification process. In addition to gaining
detailed understanding of the CHNs’ workplace experience and job satisfaction, participants in the
design phase reported a strong affinity for the CHNs’ situation, which further influenced, along with
their own professional skills and experience, the design of the mobile application. A program lead
described his observations of the team that had just returned from conducting the fieldwork for the
formative design research:

They were tired but extremely energized. I think they went through a process they had never gone through
before, but I think they felt reconnected to the work and had a much deeper understanding of the nurses’
and supervisors’ experiences and the health system in general. They were talking about the nurses and
supervisors on a first-name basis and it seemed like their hearts had opened from the experience. For
example, when we were developing personas, they were able to talk about the women they had met and
they got really animated about it. They felt that some of these people were really special and in a really
tough environment. And there was a sense that they wanted to do the best job they could to help those
people.

As the participants synthesized the field-level learning about the CHNs, they built off their perceptions
of the nurses’ experience in the work place. A participant reported:

So we started to familiarize ourselves with the information, then looked at the personas of the different
nurses and supervisors with the intention of using the persons to help with the design, and to mentally
have these people in the room as we designed the mobile application. We looked at the process maps. We
did exercises to get ourselves into that space. It was great. It gave us an awareness that we needed to
design the app for this broad base of nurses. It led us to realize that we were not designing a cookie cutter
approach.

Through the design experience, respondents had personal revelations about CHNs that later influenced
their approach to their work on CCH. A Concern program manager stated: “I can relate to all the
frustrations and desires that the nurses expressed. I want to be respected. I want to be inspired.

30
Everything they said definitely resonated with me in the roles I have played.” The technology advisor
reported:

A surprising number of nurses had a sense of resilience about their environment. They have few resources
and knowledge to execute what they need to do. When I asked them about it, they feel like this is expected
[normal]. So despite all the issues they faced, they were willing to sacrifice to provide care. There was a lot
of empathizing with them and being in their shoes. So in deciding about the technology, it helped us decide
how to do it. For example, we had a huge discussion around enabling their social environment on the app.
After speaking to them, you realize that in their down time there is really little for them to relax. So that is
something we wanted to build; something that would help them escape from their day-to-day work. I
fought hard to keep that in [the mobile application]. I am interested in making sure that the things that go
in there are really useful.

Several respondents reported that the design thinking inspired their interest in continuing engagement
with the CHNs and the integration of regular consultation and feedback loops into the project. The
empathy for the nurses engendered through the design phase infiltrated the project team as a sense of
commitment to involving the CHNs and supervisors in every step of application development. It changed
the way in which many team members approached their work and perceived their roles. For example,
the decision to integrate WhatsApp groups into CHN on the Go rather than build their own Hang Out
module was a direct response to staff commitment to improve communication among nurses and
between nurses and their supervisors quickly. A software programmer noted:

We could have decided to build our own messaging tool and wait forever to do it. But we saw this
[communication] problem as a human problem that is affecting [the CHNs] now. So I would say the way
[design thinking] has changed us is that it has helped us to understand how we will put the person first or
what the person says first in what we are doing.

The powerful effect of participating in the design phase was noted by the technology director when he
compared team members with this experience to those that arrived in the project later:

[With new staff] there was a lack of nuanced understanding of what had been experienced, and that made
it difficult. Because we had gone through the [design] process we knew that even though [someone
suggests] a logical explanation or option, we had these gut feelings about how we needed to go about
[determining our next step], and it was hard to articulate. But being able to slip into the nurses’ shoes or
the supervisors’ shoes was easy for us in the process, but not so much for the newer staff.

6.3 Comparing Design Thinking with Traditional Planning

Program staff and stakeholders who engaged in the design process often described it as transformative
and unique. Many felt the process was considerably different from the typical process used to develop
public health interventions, because the planners or designers returned frequently to end users and to
their voices which were captured during the design phase, to inform and refine program strategies. The
CHNs were always present in person or in spirit as information was synthesized and decisions were

31
made surrounding the design of the mobile app. The design leader described the process as follows,
invoking the use of the desirability lens to frame the approach:

So we brought back all of our material and post-it noted the hell out of it. We synthesized as much as we
could without losing the words that the nurses and the supervisors used themselves. We used quotes that
they used and then based our insights and clustered our insights around their words. We [mapped] their
words to our interpretations, reflections, and observations. So it was all rooted in the voice of the user.

Participants compared this approach with their previous experiences with program design. A program
manager noted:

When I have done things like this before, you aren’t doing the same level of research and that kind of data
collection (like with the CHNs) as intensely as we did. You are kind of using the beneficiary of the program
as the framework for what you are doing. In my experience you are normally given a framework, and you
kind of have to fit into it.

The M&E advisor observed: “I thought this approach was very user-centric, very beneficiary focused.
Instead of focusing on what the donor wants it cares about making sure those results happen, it really
focused on the nurses’ experience.”

A second aspect of design thinking that differs from typical planning is the commitment to shaping an
intervention in collaboration with end users. A program manager stated:

The difference is the co-designing. A lot of projects involve the end user but they ask questions and then do
the analysis away from the end user, and then tell the end user what they need. In design thinking [the
designer] sets up the framework and the template for data collection and analysis for you so you are
collecting it and analyzing it with them, you are designing [the program] already.

A third difference is the testing of ideas and solutions by implementers and end users through modeling,
role playing, and visualizing over several cycles. “It was iterative—not a simple leap, but an iterative
process that included workshops with the two teams. It was for hearing the voices of the nurses and the
supervisors in our heads. I am trying to get as much mileage out of these voices as possible,” reported a
program manager.

Finally, the process is also reflective, as noted by the M&E advisor: “I think a lot of time organizations
jump straight into carrying out activities, but this was really trying to get people to dig deeper as to why
you were carrying out the activities. This process has people stop and think at that early stage instead of
using a retrospective [approach such as evaluation].”

Overall, respondents described the process as “challenging and different,” “creative,” “rigorous,” and
“deep.” “I would say the HCD process was more rigorous and in-depth [than planning in other

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development programs I have been involved in]. Comparing the CCH experience with Motech,11 the
technology advisor said:

….we did speak with some people about the design. We did some qualitative studies on how people would
view the application but it really never went this far. We [talked] with pregnant women, but I don’t know
the different types of pregnant women and the different types of help they will need. So the content [of
the application] had to just fit everyone. For CCH, I now know that there are three different types of
nurses. I now know how they will each potentially use the different types of modules in the application,
and how it will address different types of needs of these nurses.

6.4 Value and Drawbacks of Design

Positive feelings surrounding the design thinking process were expressed by the majority of participants.
However, they also acknowledged that they had to endure a rigorous, challenging, and sometimes
taxing process.

The workshops were extremely interactive and collaborative; the process was designed to push
boundaries and challenge participants in their thinking. It forced participants to think more deeply about
the “problem” and even to hone in on details, addressing head on the complexities of the CHNs’
situation and building a mobile application that fully addressed the frustrations and aspirations of the
CHNs in their workplace. An M&E advisor noted: “A lot of the time [the designer] would mention ‘Oh
this is a journey, trust me, I know this is frustrating but at the end you will be happy.’” One respondent
reported clear frustration with the apparent lack of structure of the design process: “This is a very
different way to do programming; for things to be constantly changing for the first 6 months of the
project. You really don’t know where to go because your starting point always changes.”

In spite of the challenges, on balance, the majority of respondents felt the design process was effective.
The M&E advisor noted:

I think there was a much deeper appreciation for what the [mobile] device should look like and it was well
thought out. What I appreciated about it was in the end, when you get to the end of the road it’s an
exceptionally well-thought-out process. So when somebody asks you ‘Why did you design this module?’
you feel highly confident talking about why you designed a program in such as way. It really adds to the
thinking.

The Concern program manager concurred:

I think that some of it I could have guessed from my office in New York. But what was of deeper value was
that it left no sense of doubt. Whilst I know nurses are demotivated and have harsh work environments, I
think [design] gave a deeper insight into their experience, which was special. It was a collective and
personal insight instead of one-off kind of thing. That was powerful.

11
A mobile technology health intervention in Ghana.

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Finally, we observed through interview data that the experience of using design thinking established a
shared sense of ownership for the mobile application and its purpose not only among program staff but
also among end users. A field officer reported:

I think the purpose of design thinking was to make something in a way that the end users felt part of the
process. It wasn’t as if we wanted to design something and push it on them. We wanted them to tell us
what they needed, what will suit them. We had to bring in some of the supervisors and some of the nurses
to actually tell us what the application should look like. At the end of the day, they were the ones that
were going to use it. So if you design something for them that doesn’t suit their needs or what they have in
mind, I think usage isn’t going to be as high.

The director of technology observed that use of a different process other than design thinking to
construct the mobile application might have resulted in a very different and inferior product:

I think the question really is would it be possible to get these insights in some other way? It is sort of likely
that doing it another way we would have probably gotten only one or two of those insights. If we had
done a needs assessment to address this problem of demotivation… if we had not done it with design
thinking we would have identified some changes needed in issues like transportation, and maybe some
frustrations from the nurses that could not be addressed in an app. We might have come up with a
transportation app, like pick-ups and making sure buses get there for the nurse. So maybe that would have
been all that we had for [the CHNs].

7 Influence of Design Thinking in CCH

7.1 Grounded Theory
A fundamental rationale for the use of design thinking is that it provides important insights into user
experience, needs, and desires and helps to translate these insights into tailored interventions or
products, increasing the likelihood of user adoption and reducing the risk of intervention failure.
Following our documentation of program staff experience with design thinking and working from the
original research propositions noted in Section 3.1, we describe below our findings related to the
contribution of design thinking in CCH using the constructs of fit, uptake, buy-in, and ownership and the
effectiveness of the CHN on the Go mobile phone app. Specifically, we explore the potential contribution
of design thinking to improved health worker job satisfaction and motivation among CHNs using a
theoretical pathway or grounded theory constructed in the course of our analysis of the role of design
thinking in CCH (Figure 9).

In Figure 9, we hypothesize that that through the application of design thinking, CCH achieved fit,
meaning the pilot created an essential match between key strategies—mainly the focus and content of
the mobile application—and many of the CHNs’ needs, desires, and aspirations that related to job
satisfaction and motivation. Fit then played a role in catalyzing uptake or adoption of the CHN on the Go
app among CHNs. As the intervention was further refined with users through feedback loops and
adaptation, it achieved an even tighter fit, which influenced continued acceptance and use of the CHN

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on the Go app. In CCH, we defined this lasting influence of design as buy-in, or continued use of CHN on
the Go, and ownership, or demonstrated commitment to ensuring continued availability and use of the
app over time. Based on these observations, we propose that design thinking worked alongside other
program elements to contribute positively to the realization of pilot outcomes. We discuss and illustrate
this pathway below and provide a critical analysis of the added value and limitations of design thinking
in the context of CCH. Specific definitions for each construct in the pathway are found in Box 2.

Figure 9: Theoretical pathway of the influence of design thinking on MNCH programs

7.2 CCH Outcomes Box 2: Definitions of Design Thinking

As described above, design thinking in CCH began with a Pathway Elements
stated intent or desired outcome. In this case, the intent
of CCH was improved motivation and job satisfaction Empathy: Empathy of the pilot designers
among CHNs in Ghana through the introduction of a for CHN and supervisor’s needs and
desires, generated during the design phase
mobile technology application. Design thinking
of the pilot.
approaches were used to gain insight into the factors
that affect health worker motivation by generating Fit: Program design addresses a need or
empathy for the end users among the program designers desire of the CHN or supervisor that was
and managers through their participation in the design identified through the application of design
process. The design process also involved various steps thinking during pilot development that
and techniques (e.g., formative design research, nurse facilitates adoption and acceptance among
users.
profiles, user personas, journey maps, and convergent
and divergent thinking) to translate understanding of Uptake: Utilization of the CHN on the Go or
user needs and desires into intervention design (CHN on supervisory dashboard/app. Encompasses
the Go), including prioritizing key opportunity spaces for concepts of how the app is used, frequency
addressing barriers to or facilitating drivers of health of use, ease of use.
worker motivation and defining practical aspects of the
Buy-in: Demonstrates a CHN’s positive,
application such as the content and the look and feel of
emotional, or behavior reaction to the app.
each module. Iteration of the mobile application design
with end users (e.g., through persona validation and Ownership: A stage beyond buy-In.
Emotional or behavioral acceptance of the
app/dashboard and an indication that it is
35
something that CHNs and supervisors
would fight to keep.
process and experience mapping) was used in the early planning stages. The pilot team tested and then
adapted modules based on user feedback and inspired by the empathy with CHNs. In the case of CCH,
adaptation of the design of CHN on the Go continued beyond the initial planning phase with a smaller
group of users through user testing and feedback sessions.

Findings from the endline survey of the effectiveness of CCH indicate high levels of adoption, sustained
use, and satisfaction related to the CHN on the Go application among CHNs. Among those surveyed, 94
percent of CHNs reported that the CHN on the Go app met their needs and half the CHNs reported using
the app more than five times per week by the end of the pilot. The majority of CHNs interviewed for the
endline survey noted that they would continue to use the phone and the app once the project finished.
In addition, most CHNs reported that they would pay for their own airtime credit if needed to support
their use of the app; however, only a few CHNs were willing to pay for the phone if they had to purchase
it themselves (Alva, 2016). With respect to the intended effect of the pilot on health worker motivation
and job satisfaction, results are more guarded. Younger CHNs (< 30 years) reported only a 5 percent
increase in job satisfaction from baseline values, whereas older CHNs reported no change in job
satisfaction. Low levels of self-reported overall job satisfaction may stem from the challenge of
conceptualizing the concepts of satisfaction and motivation among CHNs or the variety of workplace
challenges or frustrations reported by the nurses that could not be addressed by a mobile phone
application, including health worker compensation, opportunity for professional advancement, and
access to resources.

In spite of cautious self-reports of overall influence of the pilot on health worker motivation and job
satisfaction, the CHN on the Go app gained remarkable traction among the majority of the CHNs and
supervisors over only an 18-month implementation period and became widely used among CHNs and
their supervisors. In addition, the pilot effectively addressed many of the intrinsic and some extrinsic
elements of health worker motivation targeted in the pilot theory of change and assessed in the
baseline survey. Those included feelings about workload; CHN self-confidence; CHN perceived respect
and recognition by the community, supervisors, and peers; CHN feelings of connectedness, and job
security. The link between use of CHN on the Go and reported changes in aspects of health worker job
satisfaction and motivation were documented in both the process documentation conducted over the
course of the pilot and in the qualitative data collected at the end of the pilot, providing a more
complete picture of pilot performance than emerged from the endline survey of CHNs alone. Several
examples are presented below.

7.2.1 Addressing Elements of Job Satisfaction and CHN Motivation

 CHNs and their supervisors reported that CHN on the Go is an effective job aid that facilitates
the work of the CHN, particularly in delivery of community-level health care. CHNs indicated
that the Event Planner module helped them schedule their work, improving efficiency and their
ability to reach more clients. The Event Planner module specifically helped them improve their
time management through use of the calendar and calendar alerts. The Learning Center module
was a tool used for professional development where CHNs gained new knowledge through

36
 courses and took refresher training on topics they covered in their original training. With the
Point of Care module, CHNs had diagnostic algorithms at their fingertips and visual aids to help
communicate with their patients. The phone itself was a convenient field resource that was easy
to transport while conducting outreach and home visits, eliminating the need to transport heavy
reference and health communication materials. It also enabled CHNs to communicate easily
with both professional and personal contacts using WhatsApp while in remote areas or when
they needed to contact their supervisors or peers for support and advice.

As one CHN explained about her role in the community and her use of the app, “You are
everything: the doctor, the accountant, the statistician. You are everything. So the phone is
good for all of them.”

A program manager explained: “CHNs’ perceptions of the app have changed over time. After
[updating] the phones and putting more things into the app that make their work easier and
faster, they have grown to love it so much.”

On CHNs use of the app for planning, a district director noted: “Before we planned outreach for
them, but the app has come for them to plan, and I think it is a form of motivation. So you see,
nobody plans for you but you look at your particular situation and you plan today.”

 CHNs equated the use of the phone with increased confidence in their ability to be effective
caregivers. For example, they used the calculator to calculate dosages for different clients, give
advice on family planning, and estimate delivery dates. With the phone, they carried with them
all required reference materials and were able to phone a friend if they needed support when
serving clients. As noted by a district director,

Before they did not have anything like the Learning Center, something that will give them the
confidence that when they meet their clients and they want to give care, they can follow it. They
have the Learning Center and can go there and increase their skills and their knowledge of service
delivery. They have the opportunity to read because the Family Health Unit has put all the
protocols [on the app]. So it has really boosted morale.

 CHN on the Go also created a digital network of peers and colleagues that did not exist prior to
the pilot. During the pilot, CHNs reported that they routinely contacted each other through
WhatsApp for professional and social purposes, noting that this easy method of communication
allowed for the quick exchange of information, facilitated learning, and informed their care
practices. For example, CHNs reported that when they could not find an answer to a question in
the Point of Care module while working with clients, they contacted their peers and supervisors
through group or individual chats and received immediate support during service delivery.
CHNs, supervisors, and field officers noted the importance of ease of access to information,
support, and even humor and comradery through the CHN on the Go platform, linking it to
feelings of confidence among CHNs. CHNs noted that they trusted the information they received
and came to rely on their vast network of support and information sources to address work and

37
 personal challenges A CHN noted: “The app has created some kind of friendly atmosphere that
CHNs are supervised and whenever we need something, we can easily talk to [the supervisors]
using the WhatsApp.” A program coordinator reported: “We have enhanced the communication
within the districts, among district-level users in terms of communicating with WhatsApp.”

 CHNs indicated that through CHN on the Go they gained an increased sense of professional
security that stemmed from easy communication with peers and supervisors and access to
learning and reference materials. They used the app to look up treatment protocols and explain
concepts to their patients through visual materials contained in the phone. In explaining how
she used the Point of Care module, a CHN explained: “So you just open [the module], take a
quick glance at what you are saying, be sure you are sure about what you are doing, and you are
done with the person.” CHNs also reported that clients appreciated their use of the phone
during home visits or in clinics and linked its used to perceived quality care. In addition,
supervisors could view each CHN’s Event Planner, and through this planning tool CHNs
demonstrated to their supervisors how they managed their schedules and completed their
assigned duties. CHNs and their supervisors reported a direct benefit from taking refresher
courses through the Learning Center that translated to day-to-day service delivery. As noted by
a program coordinator: “Nurses are reading the courses; it is enhancing their knowledge and
enhancing their services.”

 CHNs appreciated the CHN on the Go application because it provided increased opportunities
for recognition and career advancement. CHNs valued their access to learning tools and the link
between completion of Learning Center courses and renewal of their nursing licenses. A
program coordinator noted: “In terms of their knowledge and skills assessments, the certificates
[earned through course completion] are something that even supervisors and non-CHNs are
fighting for so that they can also renew their licenses easily.”

7.3 Uptake and Use of CHN on the Go

Throughout the pilot, researchers assessed use of the application by module using interviews and
tracking software in the phone. Program staff reported that uptake of the app was negatively influenced
in the beginning of the pilot because some phones malfunctioned and had to be replaced, and the initial
version of the computer-based supervisor dashboard was plagued with functionality issues, leading to
slow and limited uptake directly following the first roll-out. The dashboard was eventually converted
into an app based on supervisors’ feedback. Due to challenges with the digital technology and
programming, the phone-based tracking data were not sufficiently reliable for assessing precisely the
pace at which users initially adopted different modules.

In spite of technical hiccups, within six months of introduction self-reported frequency of CHN on the Go
use was high among the majority of respondents, and at subsequent stages of data collection CHNs
continued to report use over time and engaged in feedback sessions at the request of program staff to
refine different modules. In the successive points of data collection through in-depth interviews, CHNs
also reported increased familiarity with the application. CHNs spoke, in detail, about the way in which

38
they were using specific modules, explaining their likes and dislikes, and the advantages they gained
from using individual aspects of CHN on the Go. For example, they reported that certain modules were
more useful and appealing than others. Those modules used most often included Learning Center, Point
of Care, Event Planner, and WhatsApp. The least popular modules were the Achievement Center and
Staying Well. Toward the end of the pilot, some CHNs indicated that they did not use the smartphone as
often as they did in the beginning, but they still felt it was important to their daily work. Additionally,
many CHNs interviewed indicated that they would continue to use the app in the future after the CCH
pilot ended.

Since the pilot team and the GHS did not require CHNs to use the mobile application in their work,
reported and documented uptake of the app represents self-directed use rather than conformity with a
workplace directive. Instead of mandating its use, the CCH team introduced the app, trained nurses and
supervisors, continued to engage with them to gather feedback, and monitored usage to assess
satisfaction. Uptake and frequency of application use clearly varied among the CHNs interviewed
throughout the pilot. However, all CHNs interviewed reported that they used the modules to some
degree, and all had a solid understanding of the purpose and content of the modules and an
appreciation of the way in which it had changed their working and personal lives. Where CHNs reported
a decline in use, it was often because they had absorbed the content of a learning module. Over time,
some CHNs asked for additional topics to be added to the Learning Center because they felt they had
already mastered the existing content. With the Point of Care module, some CHNs reported that they no
longer needed the phone to interact with their clients on certain topics because they had internalized
the content through frequent use.

7.3.1 Fit and Uptake

We observed that the high levels of uptake, appreciation, and use of CHN on the Go found in the endline
survey and consistently reported in interviews with key informants were clearly linked to the learning
and empathy that emerged from the initial design phase and the codesign processes used to shape the
choice and content of the CNH on the Go modules. This link between the use of design thinking and
uptake is expressed as the concept of fit as depicted in the pathway graphic (Figure 9). The influence of
design thinking on fit and uptake emerges in several aspects of the CCH pilot but is best illustrated in the
way in which the words and value statements used by the nurses to explain their needs, desires, and
frustrations in the workplace correlate to the modules that program staff designed and built for CHN on
the Go. As noted by a senior technical manager: “There were motivational value statements from the
nurses—respect me, inform me, teach me—and then there are the modules, and you can just point to
each statement through the module. Those statements that match to the modules for me show the
outcome of what happened [through design thinking.]” A senior program manager added:

[In the design blueprint], there was a set of 8 to 10 nurses’ statements like ‘Respect me,’ ‘Reward me.’
These statements grabbed me because you know exactly what [the CHNs] were concerned about. Right off
the bat everyone knows who the end users are and what it is they want …’Believe in me.’ ‘Connect me.’
‘Equip me.’ ‘Inform me.’ When we built the modules, we had a slide with the nurses’ statements alongside,
and it was very clear where the modules came from.

39
Through additional exploration of fit and its link to uptake (as well as buy-in and ownership below), the
influence of design thinking continues to emerge from the data. The application of design thinking
approaches in the initial mapping of user experiences, persona development, and the definition of six
opportunity spaces shaped the initial choice and content of each module built. In addition, the
continued commitment among the program staff to the use of CHN- and supervisor-centered reflection
and feedback loops to inform iteration of the content of the modules helped refine the intervention to
gain a tighter and tighter fit. As explained by a program manager and a program officer respectively
when considering their experience with the use of design thinking and CHN on the Go:

When you [plan] you are trying to fix a problem. But with design thinking it went through a lot of
processes, and barriers were identified. It provided us with more information about what is motivating the
different types of CHNs to do their jobs. It covers all the different levels, whether [the CHN is] there
because [she] wants to help people or [she] is there because [she] needs money. By segmenting that
information and going through those processes and coming up with the blueprint, it went a long way in
helping to design the modules that they would use.

I think that sometimes [CHNs] just want people who will listen. It is easier for you to present something to
the person and for the person to accept it [when you have been listening.] So I think design thinking made
acceptance [of the app] easy and then it also made people say how much the project was helping them.
Other nurses who were not even in the project district requested the application.

A technology advisor with experience implementing similar mobile phone–based interventions in Ghana
observed that use of design thinking might have increased the pace of uptake of CHN on the Go.

Compared to other health programs, CHN on the Go was taken up faster. In terms of coordinating the
details of what is to be done and all that, and the actual terms of usage, I think that it was much faster
than other health programs we have done … Because users were engaged in CCH, the outcome was quite
different. Motech (another mobile health phone application in Ghana) was not so easily accepted like CHN
on the Go. It took time for nurses to accept what we were presenting and it took time for them to see the
benefit. With CHN on the Go you have already discussed [with the CHNs] how [the app] will look, so
acceptance is very easy and you really don’t have to do much work in getting it to be used.

As noted above, the ideas generated during the design thinking process converged into six opportunity
spaces that reflected CHN challenges and barriers in the workplace and their aspirations for overcoming
these challenges (Figure 10). The modules did not map one-to-one to each of these opportunity areas.
For the most part content overlapped, cutting across opportunity spaces to address several barriers or
needs simultaneously and increasing their effect. To illustrate different concepts of fit in CCH we present
below six brief examples of the link between the CHN on the Go modules that were designed in
response to the opportunity spaces and the use and appreciation of the modules by CHNs.

40
Figure 10: Six opportunity spaces from design thinking mapped to concept of fit

Adapted from ThinkPlace 2014

 Opportunity Spaces: Learning and Growing & Connecting With Others

CHNs reported that CHN on the Go met their desire to continue learning new skills “on the job.” The
Learning Center, one of the most popular elements of CHN on the Go, provided refresher training and
references on health conditions, prevention, and treatment protocols. It was used to push out new
protocols and policies so CHNs did not have to leave their posts for training. Moreover, once completing
learning topics on the app, CHNs were able to renew their nursing licenses and were beginning to use
the training as the basis for career advancement. As a program manager reported: “Recently a nurse
told me she passed an exam at the university. A lot of people failed the exams but with the help of the
[CHN on the Go] course in the Learning Center she was able to pass.”

With this module and the Point of Care module, CHNs assessed and addressed knowledge gaps and used
the modules to prepare for outreach and home visits in the course of providing care to mothers and
children. WhatsApp connected the CHNs with peers and supervisors to pose questions and receive
support. Supervisors also reported that they were able to track progress of the CHNs as they moved
through each topic, increasing supervisor appreciation for the commitment of CHNs to self-led learning.

The WhatsApp group provides regular links to colleagues and supervisors, and through regular use
CHNs felt more connected to their networks for professional and personal support. CHNs used the
WhatsApp group to pose questions about diagnoses and treatments and share ideas about providing
care. The app also facilitated the transfer of information from the district level to CHNs, including
guidelines (Point of Care) and meeting schedules (Event Planner), allowing quicker roll-out of new
practices and coordination of schedules. As a CHN noted, “The app has created some kind of friendly

41
atmosphere that CHNs are supervised, and whenever we need something, we can easily talk to
[supervisors] using the WhatsApp to do the communication.”

 Opportunity Space: Providing Good Care

CHNs reported that the Point of Care module is a reference that facilitates diagnosis and treatment
while serving clients, enabling them to work more independently and efficiently. It provided easy
references to technical guidelines and protocols and contained diagrams and photos to educate clients.
A CHN reported: “[CHN on the Go] helps me to know more about what family planning is. Maybe I can
educate somebody by using the application. I do not have difficulty finding the words to present [to
clients] because the application is there.”

The module responded directly to the nurses’ desire to have a quick reference when seeing clients. A
CHN reported on her experience using the Point of Care module: “So when you open the application and
you show it to [the client] and explain that this phone is for work, they become happy and then they are
ready to listen to you whatever you are telling them.”

In building and testing the Point of Care modules, a program manager reported how CHN feedback was
incorporated into the design:

The Point of Care [module] was created for nurses to quickly have some learning material they can refer to
and engage the clients. However, there was a fear that using a phone might make them look incompetent
in front of the patients because it is like opening a book and then the clients says ‘You don’t know what
you are doing.’ The design of the Point of Care module was done in a way that it could be interactive with
the client. Through role play [with CHNs] we learned that it would be important to train the nurses on how
to use the app and use it to interact with the clients.

Finally, the app also addressed CHNs’ desire for easier communication and rapid responses when
providing care. CHNs reported that they used WhatsApp to receive alerts when a woman delivered a
baby, and they could reach her within 24 hours to follow up. The calculator contained in the app also
enabled faster and accurate calculations of dosages, delivery dates, and other care steps. As explained
by a district director about how the app was used in his areas:

There was a malnourished child identified by a CHN. She just took a picture of it. After using the
application to talk to her supervisor she sent her the picture. The supervisor reported it to me, we
mobilized resources, a vehicle, and the child was rescued. She was kept with her grandmother who
neglected the child. The child was taken to the health facility, treated, and recovered.

 Opportunity Spaces: Managing My Work & Feeling Appreciated

CHNs reported that the Event Planner was accessible any time to the nurses and their supervisors. It
eased work planning, provided reminders, and verified CHN work programs to supervisors. This module

42
responded to CHNs’ expressed anxiety about supervisors’ dissatisfaction with their performance and a
desire to demonstrate their commitment to their job. A program manager noted:

We learned in the design thinking that the CHNs felt that supervisors thought they were lazy and not
diligent in following up with their clients. We decided to have a digital Event Planning module where
nurses can enter the plans and targets, comment on what happened with regard to the targets, and this
information would be visible to the supervisors so they would be aware of the challenges that the nurses
face and would know what is going on.

The supervisor dashboard and the CHN Event Planner also allowed the supervisors to communicate
easily with CHNs and join CHNs for critical events, increasing transparency and building trust between
the supervisor and the CHN. CHNs reported that with clear documentation of their workdays through
the app, they felt increasingly recognized for their efforts and found they could share their work
program, increasing efficiency and facilitating work life. From the supervisor perspective, the app also
helped increase accountability, an element that was more appealing to the supervisors than to the
CHNs. As a CHN reported: “You set the targets. Because you know it is going to your supervisors, you
know you are forced to achieve them. If you don’t and it gets to them, they will come and question
you.”

 Opportunity Space: Knowing How I am Doing

In the words of a program manager, the Learning Center and Point of Care modules have also “helped
some of the CHNs to have more recognition for their work and more respect. When they are informed,
it makes the person more confident. It is easier for the CHNs to answer questions when she is asked and
that gives her respect from the community members, because she seems to know her stuff well and she
doesn’t fumble to answer.”

 Opportunity Spaces: Staying Well and Connecting With Others

CHNs reported that the Staying Well module, social networking through WhatsApp, and the ease of
accessing technical information and learning opportunities reduced the stress associated with their
work and with living away from their relatives and friends.

7.4 Lasting Change: Buy-in and Ownership

Our analysis went on to explore the influence of design thinking on two concepts related to fit: buy-in
and ownership of the CHN on the Go app. We posed this question: Did the use of design thinking in this
pilot sow the seeds for long-term and sustained changes in behavior or practice? In other words, was
there an indication that design thinking also influenced the integration of CHN on the Go into CHNs’ and
supervisors’ work life so that they came to rely on it and became vested in its continued use, adaptation,
and improvement?

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At the final stage of data collection, CHNs and key stakeholders reflected on the extent to which CHNs
had integrated the application into their work. A district director noted: “With the CHN on the Go, when
you ask [the CHNs] they say ‘We’ve gone high tech.’ It is very popular with the CHNs.” Examples of their
commitment included interest in continued improvement of the app. CHNs continued to engage when
asked in feedback sessions and surveys on their perceptions of the app to improve its functionality and
content. Several respondents linked CHN commitment to the initial and continued engagement of the
nurses in designing, reviewing, and improving the application as important to the sustained use of CHN
on the Go. A program manager noted:

If they had not been involved and we had just gone at any point in time and [suggested changes in the
app], I don’t think the involvement [of the nurses] would have been as it is now. We sit with them and ask
“What do you think should change or what do you think should be included or should be taken out to make
things better?”

Respondents also requested additional content for the Learning Center and the Point of Care modules
throughout the course of the project, as they exhausted the existing information and raised questions
about other areas of care that were not included in the initial design. As noted by the technology
director: “I think using the Learning Center tool and learning the courses, and I think the fact that they
keep using those tools and taking the courses, is the way they have shown their commitment to the
app.”

When discussing the likelihood of continuing to use the app once the pilot ended, some CHNs reported
that they had become used to having CHN on the Go and without it their work life would be more
difficult. Other respondents felt that without the app, things would go back to the way things were
before the pilot, making it more difficult to communicate with supervisors and peers and forcing them
to revert to the use of large text books as references and long periods without receiving support. In
addition, the nurses reported that they would miss the opportunity to advance their learning. As a
senior technical manager reported: “They use the Learning Center. They will do an exam 10 times
because they want a correct score. They do the pretest and the posttest until they get 100 percent.
When they run out of [phone] credit, they buy credit themselves.”

Some observers noted that commitment to CHN on the Go could be linked to the opportunity to possess
a smartphone for professional and personal use at no cost to the CHN. However, the data depict a
growing sense of reliance on the app as well as personal commitment among CHNs to ensuring its
continuity beyond the CCH pilot. CHN respondents had strong reactions to the idea of losing access to
the phone app and reported that they would miss out on opportunities without access to the Learning
Center, Event Planner, and Point of Care modules in particular. Some nurses expressed concerns about
being transferred outside the district and losing access to the phone. Others reported that they paid for
additional phone credit out of pocket to ensure they could use the app throughout the month after
project-funded data were exhausted. As a program officer reported:

44
 I think that the best is people wanting to have the application on their personal phones or people willing to
pay for the phones in order to have the application. We have people who have damaged devices but they
are still using the application on their personal phones. That shows how committed they are to the
application. Because really, if they didn’t want to use it, once the device was damaged they wouldn’t use it
anymore.

At the final round of data collection near the end of the project, nurses indicated that they wanted to
continue to have access to the app beyond the CCH pilot. Some asked to have it loaded on their
personal phones. Other CHNs expressed willingness to purchase the app and, in some cases, the phone,
in order to facilitate continued use of the application once the CCH project ends. The sentiment of three
CHNs is found below:

It will be helpful, I will be happy if we will continue using the app and if there are new things in the system,
they put it or they update on the phone so we will continue learning.

I will buy it; we buy malt and drink, so I will sacrifice because I get something out of the phone, so why
shouldn’t I buy it. Maybe 4 cedis a month is nothing, so I will buy it.

I’m so much interested in [keeping the app]… I love it, it makes my work quite easier. So please don’t take
it away.

8 Design Thinking Influence Beyond CHN on the Go

The design thinking experience, while directly influencing the shape and feel of CHN on the Go, also had
a notable influence on the people who took part in the design phase and then went on to manage the
pilot. For example, the Grameen Foundation team introduced the first iteration of CHN on the Go in
June 2014 and over the course of the pilot’s implementation demonstrated extensive commitment to
iterating and improving the app through engagement and user testing with CHNs and supervisors. They
conducted five major updates of the application before the end of the pilot in May 2016. Prior to each
update, the team gathered information from the CHNs and the supervisors on their experience with the
app and fed that information into the next design phase. Although user testing is common in software
development, the Grameen team seemed especially dedicated to extending the design thinking ethos of
codesign and iteration beyond the design phase, so that it became one of their major program
strategies. Senior managers, technology professionals, and field managers professed their appreciation
of the value of codesigning with the nurses and supervisors, as summed up by a program manager and a
program coordinator:

We can draw insights from design thinking for public health; everything that followed [from the design
research] involved going back to nurses on a consistent basis under the umbrella of user testing from the
content side, involving the GHS every step of the way. This may not feel like design but the way we have
these conversations has a design feel about it. … The way we got feedback is design, like using role play
and process mapping. We would stay with the user personas as possible. We try to take a step back and
say ‘Are we forgetting the voices of the nurses?

45
 In a typical project, we do the design and we push it to them; whether it’s going to make an impact on
their lives, we just do it. But this particular project has not followed this trend; it’s like we are constantly in
touch with our end users because we don’t want to design something or don’t want to put something
together that won’t be used or that won’t have a positive impact on them.

Even the technical director who had used design thinking approaches to develop software applications
in other settings noted that the CCH experience went further than he had imagined one could go and, in
his opinion, transformed the way the team approached their work in the CCH pilot:

It occurred to me that the app is going to have a lot of the elements of the design [thinking process], but
that is going to be an imprecise way to look at what the process meant for getting to the final app design.
In the sense that for me, doing that design research and going through that whole process basically
created a whole new world with a whole new language for those of us who were in the process; it created
a worldview in which we were working and a language that we could use to communicate. I feel like even
talking to you now, I am not sure that it came across well, but that is where I see the strength in design
thinking. It would be really hard to look at the app and look at the [design] process we did and capture
fully that [whole] process that has been brought into making the app.

9 Reflection on Design Thinking in CCH

Prior to introducing the CHN on the Go mobile application, CHNs expressed to program staff a range of
frustrations related to their work life and defined needs and aspirations for improving their situation
working and living at the community level in Ghana. Following the 18-month pilot phase that introduced
and refined the CHN on the Go application, it is clear that some of these frustrations remain. However, it
is also clear that nurses readily used CHN on the Go in their work and personal lives and appreciated
many elements of the application for transforming the way in which they work. They consistently
provided examples of how the application made their work easier, improved their ability to serve
clients, and linked them through digital networks to people and knowledge.

At the outset of the CCH pilot, a design thinking approach helped program managers and software
developers gain a profound understanding of the expressed and latent desires of CHNs related to work
life satisfaction and motivation. These insights and the process of codesigning the pilot with the nurses
and supervisors influenced their choice of program strategies and design elements in the smart phone
application, sowing the seeds for high levels of uptake of CHN on the Go and a solid sense of
appreciation and ownership for the app among CHNs. As noted by a program coordinator: “If you
constantly engage the CHNs you make them feel a part of the process, they are always there to support
you. They feel they own it, they feel that the ownership of that project belongs to them and they push
things and you just stay behind and follow. So I think this is what has led, from where I am seated, to the
success of this project.”

46
As such, design thinking introduced to the pilot a powerful needs assessment and intervention mapping
process that helped the pilot team design an effective intervention. The program managers and
software developers themselves highly valued the insights they gained through the design process and
the empathy gained for the nurses’ working conditions and aspirations. The design experience also
inspired them to continue to test and iterate the application with the end users well beyond the design
stage to further refine the way in which the application and the pilot fit with the nurses’ aspirations and
improve both the practical functions and personal rewards nurses experienced in the workplace. The
intensive and powerful experience with the design process at the beginning left a pilot culture that
valued and maintained a commitment to prioritizing user input and gaining user acceptance, which was
expressed in frequent and multifaceted feedback steps and consultations with CHNs and other
stakeholders. In the view of some respondents, this cultural shift might have extended too far, noting
that the extensive use of codesign and feedback processes with the nurses and supervisors, while
effective, took a considerable amount of time and would be difficult to sustain for a long period in a
post-pilot stage. However, the overall consensus among respondents pointed to a net positive influence
of design thinking.

From our analysis of this case study we conclude that design thinking influenced the pilot in many
positive ways, but we cannot conclude that design thinking was the sole driver of positive processes and
outcomes of CCH. Through review of program documentation and analysis of interview data we learned
that the pilot team implemented several equally critical practices or strategies that together with design
thinking have laid the foundation for an effective pilot intervention and for sustained interest and
commitment among the nurses and supervisors and GHS officials for continuing to develop, extend, and
support CHN on the Go. These included engaging GHS in the introduction and adaptation of the app,
working closely with the GHS to make the app compatible with the GHS community health care
protocols, linking the Learning Center module to the continuing education system and opportunities for
CHN professional advancement, and taking important steps to get the smart phone hardware and
software functioning effectively. In this sense, design thinking was a positive addition to the package of
other equally important program implementation strategies.

With design thinking, the CCH experience went beyond traditional health program planning, allowing
space for user-led program design, iteration, and adaptation. Successful uptake and acceptance of CHN
on the Go emerged not only from use of design thinking techniques to focus the pilot on CHN needs and
aspirations but also because the project team embraced the ethos of design thinking, creating an
enabling environment for adaptation and codesign that tightened the fit between the intervention and
end user interests and desires. They also built a strong working partnership with all stakeholders,
including supervisors and district and regional managers, integrating health system requirements (such
as use of approved health care protocols and standardized training curricula) into the mobile application
while ensuring the relevance and accessibility of the app to the CHNs. Design thinking in the context of
CCH was an effective strategy for gaining meaningful insights into the problem of health worker
satisfaction and motivation, effectively tailoring interventions to address those needs, and promoting a
culture of adaptation and learning with end users that contributed to a strong fit between the

47
intervention and the end user needs, early and sustained uptake of the intervention, and program
effectiveness.

48
ANNEXES
Annex A: References

Alva, S. and Magalona, S. 2016. Care Community Hub Project Evaluation Findings. JSI Research &
Training Institute, Inc. Arlington, VA.

Andrawes, L., Moorthy, A., & McMurray, A. (2016). ‘Disrupting conventions in development: From
Beneficiaries to Co-designers’ in Alison Rieple, Patrik Wikstrom, and Robert DeFillippi (Eds), Business
Innovation and Disruption by Design Book Series. Edward Elgar Publishing. p112American Heritage
Dictionary of the English Language, Fourth Edition. 2000. Boston: Houghton Mifflin Company. Updated
in 2009.

ThinkPlace. 2014. Care Community Hub Service Blueprint. ThinkPlace. Australia.

Further Reading on Design Thinking/Human Centered Design

Battarbee K, Suri JF, and Howard DG. Empathy on the Edge: Scaling and Sustaining a Human-Centered
Approach in the Evaluating Practice of Design. IDEO. Posted January 2014.

Boyatzis R. Transforming qualitative information. Thousand Oaks: Sage Publications; 1998

Brown T. 2011. “Why Social Innovators Need Design Thinking.” Stanford Social Innovation Review.
November 15. http://www.ssireview.org/blog/entry/why_social_innovators_need_design_thinking,
accessed Dec 22, 2013.

Brown T. 2009. Change By Design: How Design Thinking Transforms Organization and Inspires
Innovation. Harper Collins. New York, New York.

Brown T. 2008. http://designthinking.ideo.com/?p=512011).

Brown T and Wyatt J. 2010. “Design Thinking for Social Innovation.” Stanford Social Innovation Review.
Leland Stanford Jr. University. Winter 2010, p 31-35.

CDC/ATSDR Committee on Community Engagement. 1997. Atlanta: Centers for Disease Control and
Prevention. http://www.cdc.gov/phppo/pce/d.school, 2014. bootcamp bootleg. Institute of Design at
Stanford, https://dschool.stanford.edu/use-our-methods/accessed on Marc 31, 2014.

Dandonoli, P. (2013), ‘Open innovation as a new paradigm for global collaborations in health’,
Globalalization and Health, 9, 41.

Denend, L, Lockwood A and Barry M, et. al. 2014. “Meeting the Challenges of Global Health,” Stanford
Social Innovation Review. Leland Stanford Jr. University. Spring 2014.

49
Fabricant, Robert, David Milestone, and Claire Qureshi. 2014. “Human-Centered Design and the Last
Mile.” Stanford Social Innovation Review.
http://www.ssireview.org/blog/entry/human_centered_design_and_the_last_mile.

Fast Company. 2006. “Design thinking…What is That?” http://www.fastcompany.com/919258/design-

thinking-what, Accessed on March 15, 2014

Goldschmidesign thinking, Gabriela, and Paul A. Rodgers. 2013. “The Design Thinking Approaches of
Three Different Groups of Designers Based on Self-Reports.” Design Studies 34 (4). Special Issue:
Articulating Design Thinking: 454–71. doi:10.1016/j.destud.2013.01.004.

IDEO. 2009. “Human-Centered Design Toolkit”. 2nd Edition. http://www.ideo.com/work/human-

centered-design-toolkit/. Accessed Dec 23, 2013.

Investopedia 2009. http://www.investopedia.com/terms/e/end-user.asp. Accessed April 5, 2014.

Kasper, G and Clohesy, S. 2008. “Intentional Innovation: How Getting More Systematic About Innovation
Could Improve Philanthropy and Increase Social Impact”. W. K. Kellogg Foundation.
http://www.monitorinstitute.com/downloads/what-we-think/intentional-
innovation/Intentional_Innovation_Exec_Summary.pdf.

King, Alison, email to the DesignX community, Center for Design Research at Stanford] in
Goldschmidesign thinking G and Rogers P. 2013. “The design thinking approaches of three different
groups of designers based on self-reports,” Design Studies Vol 34 No. 4 July 2013.

Norman C. 2013. “Design Thinking, Design Making, Design Thinking Foundations.

www.designfoundations. ca/tag/developmental-evaluation. Accessed on Mar 30, 2014

Phillis, J., Deiglemeier, K. & Miller, D. 2008. Rediscovering Social Innovation. Stanford Social Innovation
Review. http://www.ssireview.org/articles/entry/rediscovering_social_innovation. Accessed April 1,
2014.

Preskill, H and Beer, T. 2012. Evaluating Social Innovation. FCG: Center for Evaluation Innovation.

Razzouk, R and Shute, V. 2012. “What is Design Thinking and Why Is It Important?”, Review of Education
Research, Vol 82, No 3, pp330-348. DOI: 1.3102/0034654312457429.

Spreng, R, McKinnon M, Mar R, and Levine B. 2009. “The Toronto Empathy Questionnaire.” Journal of
Personality Assessment 91 (1): 62–71. doi:10.1080/00223890802484381.

Technology Strategy Board and Design Council. N.d. An introduction to service design and a selection of
service design tools: Design methods for developing services.

USAID, Bill & Melinda Gates Foundation, and Grand Challenges Canada. 2013. Saving Lives at Birth: A
Grand Challenge For Development (Round III); Request for Application; RFA Number: RFA:-OAA-13-
000004

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Villa, Rafael, and Samantha Hammer. 2013. “A Promise to Every Child: Developing a Regional Policy for
Children in Nicaragua’s Northern Atlantic Autonomous Region”. New York: UNICEF and Reboot.
https://www.dropbox.com/s/g0jz7oph7qt99qd/UNICEF_Nicaragua_FinalReport_%C6%92_web_singles.
pdf

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Annex B: Detailed Description of Design Thinking Methodologies and Visual Products

Phase I: Intent

Intent Workshop

Activity Purpose

The goal of the Intent workshop was to frame the main objective for the project by assessing the current
state, formulating the desired future state, and hypothesizing steps to produce the desired outcomes.

Activity Description and Methods

This process was facilitated to develop an intent statement tool which allowed participants to determine
what ‘’success” looked like for different groups of people that would be involved or impacted by the
project. The output was a one page intent statement,12 which included a clear description of the current
state and barriers to health worker motivation and hypotheses on how a change could be achieved. The
statement was shared with all of the project stakeholders.

Findings and Decisions

The intent statement served as an anchor for the project that was used for reference throughout the
formative design research process to ensure that the project remained on track for achieving its
intended goals. It was further refined through the course of the design phases and resulted in a final
intent statement that incorporated the desired end state as defined by the project stakeholders. It was
then used to guide programmatic decisions throughout the life of the project.

Phase II: Enquiry & Insights

Formative Design Research

Activity Purpose

The aim of the Formative Design Research was to collect detailed information on the supervisory
structure, general workflow for routine tasks performed by the CHNs, and situational context in order to
identify opportunities for the CCH intervention to improve health worker motivation and support the
CHN’s ability to provide quality services. Through this exploration, the design teams gained a better
understanding of the process of providing community-level care and mapped the existing supervision
processes from the perspective of both the CHNs and their supervisors.

Activity Description and Methods

12
An Intent Statement is a term coined by ThinkPlace and is akin to a purpose/outcome statement

52
The design team used a series of tools to facilitate the formative design research. They conducted
interviews and focus groups of CHNs, supervisors, and clients to understand the context of the CHNs’
working environment. These interviews and focus groups aimed to identifying the facilitators and
barriers to heath worker motivation and job satisfaction and to understand, in detail, elements of
routine tasks performed by the CHNs and their supervisors. They also served to highlight potential areas
for improving health worker motivation.

Information gleaned from the interviews and focus groups was further refined through the use of
process mapping (Figure A1) related to CHNs and supervisors. The process maps explored the steps
involved in different routine CHN tasks such as group outreach, home visits, data collection and
reporting. The mapping exercise allowed the designers to understand CHN experience in detail, to
identify frustrations and potential starting points for ideating solutions to improve CHN motivation and
job satisfaction. The team further explored and refined the process maps during the Understanding the
System and the Understanding the User workshops.

Figure A1: CHN process maps

Source: ThinkPlace 2014

The team constructed CHN profiles using information collected from interviews and the process
mapping exercises. They answered questions about health care workers, such as what matters most to
them at work? what makes them happy at work? and what frustrates them at work?.

53
Findings and Decisions

Reflection and learning during the formative design research influenced several design decisions for the
CCH intervention. Based on the interviews and focus groups conducted, the design teams identified the
following key focus areas for the ideation phase: respect, monitoring and supervision, clinical targets
and performance, data and reporting, mentoring, supervisor training and mentoring, recognition and
appreciation, being connected, resource limitations, client and community relations, nurse drivers and
barriers.

Through the formative design research it was clear that CHNs faced challenges with career advancement
and desired opportunities to advance their skills through education. They also expressed a desire to
receive feedback and encouragement on their performance and the ability to connect and collaborate
with other healthcare providers. Additionally, nurses indicated the need to relax and step away from
their work life because many of the CHNs were posted to communities where they lack social
connections.

CHNs were also concerned about interacting with their communities and clients. They asked for help in
planning community interactions and ways to ensure that clients are available when they make home
visits. CHNs indicated their desire to provide good care and for tools that could aid them in diagnostics
and treatment. These findings influenced the development of the modules comprising the CHN on the
Go app: Learning Center, Point of Care, Event Planner, Achievement Center, and Staying Well and
WhatsApp.

Analysis and Synthesis Workshops

Activity Purpose

The purpose of the Analysis and Synthesis workshops was to consult and engage participants who were
not able to participate in the formative design research and accelerate the emergence of findings and
decisions. It aimed to build empathy for the CHNs and supervisors among participants and engage the
whole group in synthesizing the information collected during fieldwork.

Activity Description and Methods

The workshops included Post-it note synthesis, whereby quotes or insights from the formative design
research were written on individual Post-it notes and posted and grouped on the wall. The process was
described as “rough and messy” but allowed the group to cluster ideas on the notes based on the
emerging themes of the design research. From there, the group was able to harvest 10-12 main themes.

Findings and Decisions

The themes generated from the Analysis and Synthesis workshops guided the development of the CCH
intervention. The team also identified the top five motivators and roadblocks for the CHNs and
determined that the program design would should not only focus on removing the demotivating factors
but also build upon the existing motivating factors to achieve success.

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Figure A2: Main Findings from the formative design research

RESPECT ME
•Enabling nurses to feel respected by their peers, supervisors and in their communities
•Setting appropriate and achievable targets that are reflective of what is happening on the ground in
communities

REWARD ME
•Using data-based evidence for appreciating nurses and supervisors rather than enabling favouritism
•Showcasing the extent of nurse efforts, not just their clinical results, by tracking their movements and daily
activities.

TEACH ME
•More in-depth, one-on-one supportive and facilitated supervision time for nurses
•More helpful feedback mechanisms for nurses following supervisory interactions
•Minimizing the wait time between supervisory interactions and feedback for nurses to improve themselves

INFORM ME
•Strengthening nurse knowledge and capacity at the frontline with easy access to relevant information and
clinical support
•Stronger emphasis on data accuracy and integrity

CONNECT ME
•Building close, authentic and trusting relationships between nurses and clients
•Improving communication channels between nurses and supervisors
•More cooperative and less adversarial relationships between nurses and supervisors
•More peer-to-peer learning, sharing and collaboration among nurses
•Stronger engagement with communities and their volunteers

EQUIP ME
•Minimizing the time and human resources involved in data collection and analysis processes
•More strategic approach in identifying and caring for high priority cases
•More effective scheduling and coordination between nurses, their clients, community volunteers and
supervisors
•Aiding supervisors in making informed decisions regarding the allocation of limited resources

INSPIRE ME
•Stronger resilience in the face of trouble and system challenges

BELIEVE IN ME
•Greater empathy and understanding among supervisors toward nurses and their challenges

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Understanding the System Workshop

Activity Purpose

The Understanding the System workshop utilized the process maps and health worker profiles
generated during the formative design research to describe and understand the health system from the
point of view of the various health workers personas.

Activity Description and Methods

The group further took steps to refine health worker profiles and develop personas of different health
care workers based drivers of motivation. They created personas collaboratively by immersing team
members in the CHNs’ stories of satisfaction and frustration gathered during the research phase and
then brainstormed what emerged as the differentiating motivators.

The team also reviewed the process maps created in the previous steps to allow participants to “step
into the shoes” of the user and understand CHN work activities from different perspectives based on the
health worker personas. They grouped Post-it notes by major themes, allowing participants to engage
with the raw data and form insights while they worked in groups during brainstorming. During this
process, as participants walked through each of the process map pathways, they could see the
frustrations and the joys experienced by the CHNs and identified a challenge question to focus the
ideation process and define an appropriate solution. In particular, the group generated dozens of ideas
on how to improve the relationship between nurses and supervisors.

Findings and Decisions

This workshop produced several challenge questions that focused on issues related to the relationship
of the CHNs and their supervisors as well on barriers that CHNs face in their daily work. These findings
were applied to the Explore & Innovate phase of the design process.

Understanding the User Workshop

Activity Purpose

The design team used the Understanding the User Workshop to dive deeper into the health worker
personas and to elicit feedback from CHNs.

Activity Description and Methods

The team reviewed and validated the process maps with the CHNs to continue to build empathy among
the designers for CHN experience. They used storyboards to present findings from previous workshops.

For the process of persona development, the team started with about five to six personalities and
grouped them based on the patterns that emerged from the CHN stories. The result was three main
personas for CHNs (Figure A3): Purpose-driven and Resilient (Naana), Purpose-driven and Dispirited

56
(Mary), and Paycheck-driven and Dispirited (Michael). They then walked the CHNs through each of the
personas to determine whether they could identify with the personas.

As secondary users to the system, the team also created personas for supervisors: Empathetic and
Highly engaged (Madeline) and Apathetic and Disengaged (Jeanette).

Findings and Decisions

Insights gleaned from the feedback provided by the CHNs Figure A3: Three CHN user personas
allowed the team to refine the motivating factors for
each of the different health worker personas. With this
refinement and validation, the team finalized the
personas and used them in subsequent ideation and
concept development activities.

Phase III: Explore & Innovate

Ideation Workshop

Activity Purpose

The purpose of the Ideation workshop was to utilize the

challenge questions that were developed in the Enquiry &
Insights phase and generate potential mhealth solutions
to address the barriers to motivation and job satisfaction
Source: ThinkPlace 2014
identified in the formative design research.

Activity Description and Methods

The team broke into small groups and began to ideate and refine the challenge questions. Each person
on the team was given a set of challenge questions and idea sheets which they used to help organize the
ideation process. Participants were asked to become familiar with the mindset of each persona and
generate as many solutions as possible related to each challenge question.

Solutions were then clustered into emerging themes. Once the main themes were established, the
team was asked to generate ideas would be considered impossible to implement, based on their
understanding of the constraints in the health system. This strategy allowed them to push the
boundaries of possible solutions, and generate ultra-creative ideas.

Findings and Decisions

Through the Ideation workshop, the team was able to refine the themes that emerged from the
formative design research. They determined the guiding principles and design criteria for the CHN
intervention and refined a list of opportunity spaces. The 10 opportunity spaces (Figure A4) that were
identified represented potential modules for development in the CHN on the Go mobile application.

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Figure A4: 10 Identified opportunity spaces

Source: ThinkPlace 2014

Codesign Workshops

Activity Purpose

The Codesign workshops aimed to utilize the insights gained from the supervisors and nurses to refine
and develop the 10 opportunity spaces generated in previous workshops. One Codesign workshop was
held with CHNs and the other was held with a supervisor.

Activity Description and Methods

The design team engaged in process mapping exercises with both the supervisor and CHNs which
allowed validation of the processes depicted in the maps. When it was clear that this approach was not
yielding the desired insights, the program team used role playing with the CHNs and the supervisor
which helped the team understand more clearly the interaction between CHNs and their supervisors,
including areas of frustration and discomfort. They also asked the CHNs and supervisor to score different
potential interventions and then vote on the most appealing ones.

Findings and Decisions

The Codesign workshop validated the process maps and personas and helped the design team to reduce
the 10 opportunity spaces to 6 opportunity spaces: “learning and growing,” “providing good care,”
“knowing how I am doing and feeling appreciated,” “connecting with others,” “managing my work,” and
“keeping well.” (Figure A5)

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Concept Development Workshop

Activity Purpose

The Concept Development workshop was used to further refine the six opportunity spaces and assess
the viability of each of the options presented.

Activity Description and Methods

Participants of the workshop were split into small groups and applied a concept template which asked
questions such as “How would this work in practice?” “What are the implications of implementation?”,
and “What is the flow of the system?” These steps helped the group assess the proposed model for
CHN on the Go and consider how and if it would work in the health system context. The group also
explored avenues for building each module through collaboration with health system partners. The
team added this information to the concept templates and synthesized learning around project-level
complexity, potential partners, and resources needs from all participants.

Next the facilitator used storytelling, asking participants to take on each of the personas that had been
developed and walk through the health system tasks reflecting the views of each type of health worker.
The process was difficult for the participants, but the stories they created were recorded and used by
the software developers to define the requirements for the mobile application (Figure A6).

Findings and Decisions

Learning from this workshop ultimately determined the type of modules that would be built as part of
the CHN on the Go mobile application and framed the application for the technology team which
allowed them to define resources requirements.

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Figure A5: Six refined opportunity spaces

Source: ThinkPlace 2014

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Figure A6: User stories for the learn and grow module

Source: ThinkPlace 2014

Prototyping Workshops

Activity Purpose

The Prototyping workshops were used to determine how CHNs’ expressed user needs could be
translated into a mobile app, assess resources required to build the mobile application, and determine
the viability of moving forward with each proposed module.

Activity Description and Methods

The team was split up into groups; each group was assigned to a particular work streams. The groups
employed user stories to outline the steps for implementing the mobile application including design,
technology requirements, training, implementation, and sustainability. The goal was to develop a high
level work plan. Preliminary plans were synthesized and shared with the GHS to assess the viability of
the intervention.

Findings and Decisions

The findings From the Prototyping workshop were used to write the work plan, specifying next steps for
implementing the project. The work plan involved steps related to developing the code, training, and
introducing the application, helping the team frame the scope and scale of the pilot and the application.

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The team decided that each of modules should work at scale, and made adjustments to the plan to add
a calendar and remove a GPS component.

Develop User Stories, Pathways, and Interaction Models

Activity Purpose

The program developers at Grameen Foundation worked with the ThinkPlace web designer to visualize
the user and technical requirements for building the application. This visualization enabled the
developers to further define the language, look, and feel of the application.

Activity Description and Methods

The web designer worked with the Grameen developers to review the findings and products from the
Enquiry & Insights and Explore & Innovate workshops, and they were able to specify technical
requirements for the application.

Findings and Decisions

The web designer assisted the developers to build the application infrastructure through wire frames,
visualizing the flow of the internal processes contained in each module.

Phase IV: Formulate & Evaluate

Validation Workshops

Activity Purpose

Validation workshops were conducted to confirm that the GHS would support the use of the CHN on the
Go. They were held at both the district and regional levels in order to test whether the initiative would
function as proposed and to receive feedback on aspects of the project.

Activity Description and Methods

The team used storyboards to present the project to the GHS. The storyboards introduced the CHN and
supervisor personas and the process mapping that was created. They also demonstrated how each
module would work and how it would benefit the CHNS

Findings and Decisions

The GHS confirmed their support for the program. However, they felt that supervisors should increase
their involvement in the pilot. They sought to avoid any animosity between supervisors and CHNs and
recommended that both receive the smartphones. They also noted that the supervisors tended to be
less tech savvy, which could be challenging in terms of adoption of a mobile app. Consequently, the

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design team decided to create a computer-based supervisory dashboard to accompany the CHN on the
Go app allowing supervisors to monitor CHN activities.

Refine Blueprint

Activity Purpose

ThinkPlace created a blueprint to synthesize all of the findings and decisions made throughout the
design process. The blueprint fleshed out the details of the application purpose and content and
created a roadmap for the development of the application as well as the implementation of the CCH
initiative.

Visual Interaction Design

Activity Purpose

Visual Interaction Design was used to help the app design team at Grameen explore the user interface of
the app. It explored how the user would move through and between each of the modules.

Activity Description and Methods

No particular method was used for this activity. The process incorporated feedback from the CHNs on
improvements they felt could be made to facilitate use of the app.

Findings and Decisions

Through the process of refining the Point of Care module, CHNs expressed the desire to move more
easily through the diagnostic protocols without having to follow the same steps each time. They wanted
to be able to jump to a particular point in the protocol as required. Based on this feedback, the team
modified the module and enabled the CHNs to easily navigate the module when dealing with their
clients.

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