Q&A with Margot Fahnestock: A teen-centered approach to contraception in Zambia and Kenya

Can a creative teen-centered design process help increase young women’s access to contraception? We thought it might when we funded a new partnership between IDEO.org and Marie Stopes International in Zambia and Kenya in 2013. An independent evaluation that we commissioned from Itad provides new insights about the human-centered design approach to adolescent reproductive health. Hewlett Foundation Program Officer Margot Fahnestock tells us what donors, designers, and reproductive health leaders can learn from the evaluation and approach.

What is human-centered design and how did you think it could help adolescent reproductive health programs in sub-Saharan Africa?

Global reproductive health programs have helped many women learn about, access, and use reproductive health products like contraceptives. They’ve been less successful reaching adolescents and young people, even though more than one-third of women in Zambia, for example, give birth by age 18. It’s an area we felt could benefit from a new approach like human-centered design.

Typically, reproductive health projects start with a predetermined idea of the intervention or program design, like community-based delivery or using mass media. Human-centered design starts with a completely open question: How might we increase the number of young people who use birth control?

The human-centered design process is rooted in empathy and curiosity about what people like, what makes them tick, what motivates them. Designers take these insights to design a product or service that will really resonate with the people being served. Human-centered design, in this case, gives us a tool to listen to young women to design products and services that they like and might even inspire them.

What did the evaluation tell you about the difference human-centered design made?

The evaluators said the Divine Diva model in Zambia and Future Fab in Kenya are desirable for the young women they’re trying to reach. Future Fab and the Diva Centers show real promise for increasing awareness, knowledge, access and use of birth control among 15-19 year-old girls. In Zambia, for example, 15-19 year-olds used to account for fewer than seven percent of Marie Stopes’ services; after the launch of the Diva Program, that number rose to 12 percent and Marie Stopes Zambia saw an increase in the number of unmarried women who had never given birth coming to their clinics. In Kenya, the average number of services provided to adolescents per Marie Stopes center per month increased six-fold, from nine to 54 and the total number of contraception services increased from 225 to over 1000.

We also hoped an independent evaluation would tell us whether human-centered design improved the quality and number of services young women receive. This turned out to be more challenging than we expected, primarily because the evaluators found few adolescent programs for comparison.

Given that human-centered design is closely associated with innovations in the private sector – particularly the technology sector – we and our partners expected that the approach would result in something completely new and different. But we learned that creativity isn’t always about coming up with something entirely new: it’s finding the connections between things that already exist. The evaluators agreed. They found that the components of the interventions themselves weren’t necessarily innovative (peer counseling, youth-friendly space). What is innovative about the solutions that IDEO.org helped create is the way in which the interventions are implemented – the Divine Divas and Future Fab are a “coherent ecosystem of solutions that give primacy to adolescent girls and their desires.”  By listening to the girls and including girls and boys meaningfully in an iterative design process, IDEO.org succeeded in designing solutions that resonated with girls and show the potential to be “transformative.”

Were there surprises about the approach?

We were most surprised by the contribution design craft and quality seem to be making to the popularity and effectiveness of the models in Zambia and Kenya. The evaluators had difficulty determining how much design quality matters, but our hunch is that designing delightful places for young women to get birth control is a marked improvement over traditional public health approaches and contributes to how girls react to the services. One leader of a community-based organization in Homa Bay, Kenya said even the quality of the paper used to print the Future Fab magazine was important; the quality, he said, made the community and girls feel valued.

We were also surprised about how expensive the models were to operate compared with Marie Stopes’ other service delivery channels. We do know that birth control services for adolescents will inevitably cost more than services for women 25 and older. First, Marie Stopes is offering the adolescent services for free. And second, reaching 15-19 year-olds requires intensive outreach and communication with young people to increase knowledge and awareness of contraceptives. But the biggest factor that the evaluators found is that IDEO.org and Marie Stopes (particularly in Zambia) didn’t have a shared set of expectations about how much a solution would cost, whether it should operate within Marie Stopes’ current model, or how quickly a solution should scale.

What can donors learn from the evaluation?

Invest in innovative approaches such as human-centered design, but don’t expect results immediately and be prepared to be as flexible as possible to let success emerge. The best thing we did to support these types of partnerships was to provide flexible support. We didn’t enter these projects with an end in mind in terms of when our funding would stop. We understood that the essence of design thinking and human-centered design meant starting with an open question (“How might we..?”), and that meant that we didn’t know how the process would play out and we needed to be flexible and patient. The evaluation team found “clear evidence that the support provided by the foundation, as a broker, counselor and flexible funding partner, helped overcome challenges.”

You can structure the funding as we’re doing now – providing enough funding to our implementing partners to allow them to bring on design consultants. Parallel funding turned out to be a murky approach in terms of who was responsible for what, and whether decisions were the funder’s to make, or one of the other parties. But most of all, be curious… and be patient!

What can human-centered designers learn from the evaluation?

Invest the time required to really understand your client and the client’s operating model and constraints (e.g., cost). It’s important to establish right up front a shared expectation of what success will look like, how you will measure it, who will be involved in the design process from the implementing partner, and whether the length of the engagement you have agreed on is an adequate time period in which to show results.

What can organizations like Marie Stopes International learn about the potential for human-centered design in their programs?

Human-centered design holds real promise for tackling persistent challenges in reproductive health, like reaching vulnerable adolescents with contraception. Be clear with design firms about your expectations for how you will assess success, how this approach fits with your overall strategies and goals as an organization, what level of resources you have to support the design phase and, most importantly, scaling any resulting solution.

Organizations should also enter any human-centered design experiment with the mindset that the initial design process may take longer than they think, and that there will inevitably be moments where the design thinking mindset and public health mindset will clash. Human-centered design uses rapid prototyping and iteration to test different ideas, and that process often clashes with public health protocols and practices designed to keep confidentiality and ensure clients’ safety. When those moments arise, it’s very important to communicate with the design partner in a timely manner.

But most of all, be curious to learn from people who come from disciplines outside of public health… and be patient!

For more information, read Itad’s full evaluation and recommendations below.