October 27

Urvashi Prasad

The Psychology of Technology: Health solutions are effective only if the perspectives of all stakeholders are taken into account

Technology is increasingly being used as part of public health programs by governments and NGOs across the world. While technology can be an important enabler in strengthening implementation and scaling up, there are some prerequisites for it to be successful. Based on my experience with NGOs, social enterprises and the government in the public health space, I have highlighted some of the most important factors that influence the success of a technology and set it on the path to achieving scale and impact.

1) Acceptability – For a technology to be successful, acceptability by all stakeholders, including those who are responsible for deploying the technology as well the ultimate beneficiaries served by the program, is imperative. In addition to acceptability, stakeholders must believe that the technology actually helps them to implement the program more effectively, make more robust decisions or achieve better outcomes.

For instance, when Global Health Strategies (GHS) developed a school health database for government schools in the states of Delhi and Rajasthan in India, they had to ensure that it was acceptable to and useful for health workers as well as government officials at every level of the decision-making hierarchy.

Operation ASHA, which is among the largest tuberculosis control NGOs in India, has developed a biometric system for tracking every dose administered to a TB patient. (Note: The author works for Operation ASHA.) One of the reasons why we have been able to deploy this technology successfully for more than 9,000 patients across five countries is because patients believe that field staff who are equipped with the system are able to serve them better.

2) Ease of use – Those who are responsible for implementing technology systems in public health are very busy people, e.g. health workers in schools. It is therefore crucial that the system is relatively simple to operate. It also needs to cater to varying literacy levels in order to be scalable. For instance, Operation ASHA uses pictures instead of a text-based interface in order to make our biometric system usable by field workers who are semiliterate or illiterate.

Furthermore, in order to be easily replicable, it is important that the training process is simple and relatively fast. Operation ASHA is able to train master trainers through a video session on Skype within three to five hours and this has enabled the organization to replicate its technology solution in various parts of the world.

3) Flexibility – In order to be successful in diverse settings, flexibility is also crucial. For instance, India has 42 languages and 420 dialects. By some counts, Africa has an estimated 3,000 native languages. Also, within a region, there are considerable differences among rural, urban and tribal customs. The more flexible a particular technology solution is, the more easily it can adapt to these widely varying implementation contexts. Examples of flexibility include operability on handheld devices and laptops and, as mentioned above, an intuitive touch screen with symbols or pictures instead of text.

Simple and flexible hardware can also allow for software to be upgraded more easily. For instance, Operation ASHA’s biometric system has the potential to be used not only for monitoring drug-sensitive TB patients but also for tracking drug-resistant TB patients, vaccination rates, antenatal visits and nutritional indicators.

Moreover, after a technology is actually deployed, a number of modifications often need to be made based on inputs from field staff and patients. This also requires flexibility in the design of the technology solution.

4) Managing vested interests – Not all stakeholders are immediately comfortable with the deployment of a technology solution. Moreover, technology often brings about greater transparency with respect to measurement and tracking of outcomes as compared to a manual system, thereby creating apprehensions for some stakeholders. These concerns need to be managed proactively; otherwise, introduction of technology can have adverse or unintended consequences.

Operation ASHA’s biometric system encourages health workers to do more home visits because it sends them an SMS reminder every time a patient misses a dose at the treatment center. Hence, it is conceivable that some providers would have disabled the technology by removing the SIM cards or damaging the tablets. Our team therefore introduced an incentive system in which a health worker gets an additional 500 Indian Rupees per patient for achieving the target of 90 percent supervised doses. If the technology does not work properly, it is impossible for health workers to achieve this target. Thus, the possible vested interests of some field staff in ensuring that the technology does not work was countered by a stronger, economic incentive.

Similarly, during the development of the school health database, GHS had to ensure that it was positioned as an effort to help government officials to monitor the health of children and take appropriate corrective measures, as opposed to merely highlighting the inadequacies of the government’s school health program.

5) Collaborative development effort – Developing a technology solution for a public health initiative needs to be a collaborative exercise. A technology developed primarily by a group of technocrats is unlikely to be successful. For instance, in order to track vaccination of children, it is not adequate to put all vaccination sites and all children in need of vaccination on a Global Positioning System. Consultation with doctors and nurses is a must; these discussions will reveal that even a child who makes it to the vaccination site might not be immunized, for several reasons. For instance, a child suffering from fever will be sent home and asked to come back after a few days when he might be given two vaccinations instead of one.

During the development of the biometric system, Operation ASHA conducted a comprehensive ecosystem analysis involving consultations with patients, health workers and government officials. In order to build the picture-based system for health workers with low literacy levels, Operation ASHA also consulted with a child psychologist. This process ensured that the technology, once developed, was acceptable to and useful for all stakeholders.

While the prospect of introducing a technology solution into a public health program can be quite exciting, it is likely to be effective only if the perspectives of stakeholders who are supposed to use it and benefit from it are taken into account from the outset. Simplicity in design and adaptability to the places it will be used are also crucial for the technology to be scalable and replicable.


Urvashi Prasad is director of external affairs at Operation ASHA.


Photo courtesy of Tumisu.


Health Care, Technology
healthcare technology