Change by Design Read online

  My own passage to India began with a visit to one of Aravind’s mobile eye camps in the “suburbs” of Madurai in the southern Indian state of Tamil Nadu. I didn’t expect neat, three-bedroom houses in planned communities. On the other hand, I was not prepared for what I saw: shantytowns cobbled together out of cardboard boxes and corrugated metal, simple houses mixed with workshops left over from the Raj, shops the size of a Wal-Mart parking space selling every imaginable necessity. But I also saw people having their eyes tested. I saw how more complex cases were transmitted via satellite back to the hospital, where experienced doctors could make the final diagnosis. I watched patients with operable cataracts boarding a bus headed for Aravind, where they would have the operation the same day.

  Aravind has its own in-house manufacturing facility that makes the intraocular lenses and sutures used in cataract operations. It is an amazing example of the use of extreme constraints as the inspiration for breakthrough innovation. Dr. David Green, who has been honored by the Ashoka Foundation, the MacArthur Foundation, and the Schwab Foundation for Social Entrepreneurship, working with Dr. P. Balakrishnan at Aravind, hypothesized that it might be possible to use small-scale computer-aided manufacturing technology to make the lenses locally rather than importing them from foreign medical suppliers at a cost of approximately $200 per pair. In 1992, through his nonprofit Project Impact, Green set up a small manufacturing unit in the basement of one of the hospitals and started making plastic lenses. Over time it expanded to make sutures as well and ultimately met all the international standards it needed to export products internationally. Aurolab (as they eventually named their basement start-up) is now the biggest exporter of lenses and sutures in the developing world. It has recently relocated to a new factory. A confessed “serial social entrepreneur,” Green has turned his attention to hearing loss and pediatric AIDS drugs—a global campaign that started as a prototype within the Aravind system.

  In the hospital itself we dressed in scrubs and toured the wards, where physicians perform more than 250,000 surgeries per year. Assembly-line operating procedures are at the core of Aravind’s productivity. As a surgeon removed the damaged lens from one patient in a quick but skillful procedure, the next patient was being prepared right alongside in the operating room. Postoperative recovery did not take place in a fancy ward with satellite TV and cut flowers but in a simple room with rush mats on the floor, where patients spent the night before returning home the next day. It was not luxurious by the standards of the West, but it was as comfortable as the beds they slept in at home. For about a third of the patients it was free; the remainder paid on a sliding scale, which began at 3,000 rupees (about $65) and for which they received exactly the same care.

  It is unlikely that a Western doctor, hospital administrator, architect, or industrial designer would have forgone expensive wards in favor of rush mats and concrete floors, even if their mission were to help the blind. This insight grew out of Dr. V’s empathy with the culture of the poor. He realized that giving his patients something consistent with what they were accustomed to in their villages but still good enough to meet acceptable medical standards, allowed him to serve the poor in an economically viable way. And he has succeeded. The Aravind Eye Hospital has served millions of patients. Aurolab operates at a 30 percent profit, which is plowed back into clinics in Nepal, Egypt, Malawi, and Central America. While the Aravind management team takes private donations to fund additional work, the operating model is self-sustaining and the clinic is no more reliant on charitable donations than the majority of Western health care facilities.

  Although many people have praised Aravind for its entrepreneurial model of “compassionate capitalism,” as a designer my experience there showed me the enormous potential of working under extreme constraints. How ironic that the holy grail of corporate America—where innovation leads to breakthrough solutions and enhanced profitability—should be realized on the straw mats of an eye clinic in rural India. Not only is Aravind providing untold benefits to the citizens of Madurai, Pondicherry, and the other cities in which its hospitals now operate, it is also exporting its ideas and approaches to other health care facilities throughout the developing world—and perhaps beyond. Indeed, there are signs that Aravind’s approach, and that of others like it, may become accepted practice in the West. Not only are young surgeons coming from the United States and Europe to train at Aravind, patients too are beginning to travel to India in search of world-class care at a fraction of the price they would pay in New York or Los Angeles.

  Dr. Venkataswamy died in 2006. To the end of his life, when he spoke about his vision for Aravind he liked to use McDonald’s as the standard of scale and efficiency that he dreamed of bringing to health care. His achievement was to use the design thinker’s tools of empathy, experimentation, and prototyping to reach McDonald’s-like efficiency in an organic, sustainable way.

  food for thought

  A thousand miles to the north, on the outskirts of New Delhi, lies the demonstration farm set up by International Development Enterprises (IDE), India. Founded by the social entrepreneur Paul Polak, IDE’s mission is to provide low-cost solutions that meet the needs of small farmers in developing countries. The narrow road that leads to the farm passes through fields of healthy crops irrigated by a variety of techniques. In one corner there are drip irrigation pipes, in another sprinklers made from very simple, low-cost materials. Amitabha Sadangi, who heads IDE (India), repeats the same message over and over: designing for the poor begins and ends with a focus on cost. Every detail must be designed to be no more expensive than necessary, and no efficiency is too small not to seize. This approach would seem sensible to most western manufacturers, but Sadangi and Polak take it one step further. In a rural twist on the quarterly bottom line, they require that any investment made by a farmer be repaid many times over in just one growing season. Whereas an American farmer may take out a loan to buy a hundred-thousand-dollar tractor and repay it over many years, farmers in the developing world cannot take the risk, nor do they have the capital to make such investments. This constraint has led to innovations that have the potential to transform agriculture in the developing world—and perhaps beyond.

  Many of IDE’s drip irrigation products are designed to last not a decade or two, as we might expect in the West, but for only one or two seasons. This seemingly shortsighted approach may seem irresponsible to a Western engineer, but by using less durable and therefore less expensive materials, IDE has brought the cost of irrigation down to approximately five dollars for a 20-meter-square (67-foot-square) plot of land. A farmer can expect to reap many times this amount in extra profit by growing fruit or vegetables, which will enable him to irrigate more land in future seasons. By driving the cost down, IDE enables farmers to reinvest the additional profits to reach economic sustainability faster and with less risk. And by thus increasing demand for its low-cost systems, IDE, like Aravind, operates on the basis of a sustainable business model.

  This approach has the potential to make a significant difference to subsistence farmers in India, Africa, and beyond, but its potential impact may be greater than that. The idea of designing products in an integrated manner such that low cost, entry-level offerings create wealth quickly for customers has applications well beyond farming. In the developing world this business model is being applied to mobile computing, communications services, clean water delivery, rural health care, and affordable housing. Why could it not apply to many of the same sectors in the West? The economic convulsions rocking the developed world as I write suggest that the prevailing model is not working. There could be no more opportune moment to imagine how we might move in the direction of a society where what we buy helps create wealth rather than just consume it. The idea of designing products, services, and business models that create a rapid return on investment seems very attractive, and it is no accident that it first appeared in places where most people have no choice.

  Organizations such as the Aravin
d Eye Hospital, International Development Enterprises, and many others like them are experimenting with approaches that measure success not by profit but by social impact, and they challenge us to think about how these lessons might be applied elsewhere. In one sense, we have seen this kind of innovation before. Toyota, Honda, and Nissan all began their meteoric rise by creating inexpensive solutions for their own markets at a time when Detroit measured the success of its cars by the height of their tailfins. They went on to demonstrate to the world that there is nothing intrinsically “Japanese” about good design, efficient manufacturing, reduced fuel consumption, and low cost. Might the Aravind model not “bounce back” to show us all the way forward? The argument for working with the most extreme users, where the constraints are unforgiving and the cost of failure high, is not just a social one. It may be how we will spot opportunities that have global relevance and how we will avoid becoming the victims of the new competitors who thrive in environments where more prudent organizations fear to tread.

  whom to work with

  Whether or not they have adopted or even heard of “design thinking,” many of these social entrepreneurs are applying its tenets. Social issues are, by definition, human-centered. The best of the world’s foundations, aid organizations, and NGOs know this, but many of them have lacked the tools to ground this commitment in ongoing, sustainable enterprises fueled not just by outside donations but by the energies and resources of the people they serve.

  In 2001 Jacqueline Novogratz created Acumen Fund, a New York-based social venture fund that invests in enterprises in East Africa and South Asia committed to serving the poor in an ongoing and sustainable way. Acumen has invested in both for profit and not-for-profit enterprises ranging from franchised health clinics to affordable housing. Its model is gaining worldwide attention. Novogratz has spoken explicitly about how her leadership team used design thinking—in addition to the standard metrics of investment “performance”—to evaluate the success of individual investments based on a balance of business sustainability and social impact. Indeed, our shared interest in using design thinking to balance business goals with philanthropic objectives has led IDEO into an ongoing partnership with Acumen Fund.

  Our collaboration began with a series of workshops in which we explored a set of critical needs that might be translated into viable projects, ranging from antimalarial bed nets to hygiene and sanitation. We decided to focus on clean water. In the developing world, some 1.2 billion people are at risk of disease from drinking unsafe water. Even when water is collected from a high-quality source, it often becomes contaminated during the lengthy trip, often by foot and usually over bad roads, to its final destination. The team drew up its own brief: how might we create safe and easy means of water storage and transportation that improve the health and living conditions of low-income communities while creating opportunities for local entrepreneurs?

  As the project progressed, we gathered as many insights into how to implement our ideas as into solutions themselves. No matter how compelling an idea might be, it is of little value if it cannot be sustained by its intended customers in India or Africa. To achieve this, the project team tapped into what the anthropologist Clifford Geertz called the “local knowledge” of NGOs and entrepreneurs in the field, which resulted in numerous culturally appropriate ideas: new types of payment using mobile phones or prepaid coupons, better branding of delivery vehicles to spread awareness, local delivery depots that could be owned and run by the community. Future steps will focus on ways to support these local groups as they bring ideas to market.

  Aravind, IDE, and Acumen Fund offer examples not just of well-designed products but of design thinking applied across the entire spectrum of a problem: the product, the service in which the product is embedded, the business model of the enterprise that provides the service, the investors behind the enterprise, and more. It is a mistake to think of them as organizations of well-intentioned, well-heeled do-gooders. These social enterprises have set out to achieve the integration of the desirability-viability-feasibility triad. This has naturally led to cross-disciplinary initiatives. In Aravind’s case most of the design thinkers involved were doctors, not designers. The design thinkers at the Acumen Fund are venture capitalists and development experts. They have learned to maneuver their way through government bureaucracies and adapt their efforts to available infrastructure because systemic problems can be addressed only through systemwide collaboration.

  what to work on

  In contrast to companies that may be struggling to extend their brands into a new subniche of a saturated market, the opportunities for socially engaged design are everywhere. Indeed, that is itself a problem, at least while there is a limited amount of design thinking talent to go around. The Rockefeller Foundation recently asked IDEO to consider how the design industry might make a greater contribution to solving social problems. After talking to dozens of NGOs, foundations, consultants, and designers, one of our most telling insights was that our efforts are in danger of being spread far too thinly. There are ten potential projects for every design thinker with the time and the talent to tackle them, and 95 percent of them are in Africa, Asia, and Latin America—which complicates the challenge of getting out into the field to gain insight or quickly and iteratively prototype our ideas.

  The solution is to find some way to aggregate the efforts of design thinkers globally so as to create a critical mass, build momentum, and begin to make real progress on some of the selected problems we want to address. One of the most promising examples of this is the charitable organization Architecture for Humanity, cofounded in 1999 by Cameron Sinclair. In its first iteration Sinclair used the Web to bring architectural talent to bear on the design of emergency housing and shelters in response to major disasters such as the 2004 tsunami that devastated Southeast Asia and Hurricane Katrina in the following year. A TED prize enabled him to create the Open Architecture Network, which provides a platform for tackling longer-range, systemic issues, not just responding to ad hoc emergencies. The network’s modest mission is to “improve the living standards of five billion people” by setting design challenges, posting design solutions so that they can be shared and improved, connecting stakeholders, and creating a participative approach to solving design problems. It seeks, in effect, to leverage the collective energies of architects and designers worldwide in a way that aggregates, focuses, and amplifies them.

  If we need to set priorities, the United Nations’ Millennium Development Goals would be a good place to start, but “eradicating extreme poverty” and “promoting gender equality” are far too broad to serve as effective design briefs. If the Millennium Development Goals are to be met, they will have to be translated into practical design briefs that recognize constraints and establish metrics for success. More promising questions might be:

  How might we enable poor farmers to increase the productivity of their land through simple, low-cost products and services?

  How might we enable adolescent girls to become empowered and productive members of their community through better education and access to services?

  How might we train and support community health workers in rural communities?

  How might we find low-cost alternatives to wood-burning and kerosene stoves in urban slums?

  How might we create an infant incubator that does not need an electrical supply?

  The key, as every designer knows, is to craft a brief with enough flexibility to release the imagination of the team, while providing enough specificity to ground its ideas in the lives of their intended beneficiaries.

  sometimes the thing to do is stay home

  Not all the most critical social design issues are to be found in the developing world. Western health care—to take what is only the most obvious example—is facing an imminent crisis. Indeed, for many millions of Americans the system has already broken down. Rising costs are threatening the stability of the system, while as a society we have committed ourselves to un
healthy lifestyles that exact a tremendous social and economic toll. Medical researchers focus their energies on cures for chronic diseases—heart disease, cancer, stroke, diabetes—and policy experts work to improve the efficiency of health care administration and delivery. In isolation, however, these efforts will never be sufficient. A sustained effort to integrate these paths and explore divergent alternatives is needed, and this is where design thinking can help.

  In medicine, once the patient has been stabilized, the larger task is to identify the source of the condition—to move as it were, from the curative to the preventive side of the problem. A case in point is obesity, which contributes to several of the leading causes of death in Western society and is now clinically described as having reached epidemic proportions. Some of the relevant factors relate to a person’s biological, cultural, demographic, and geographic circumstances, while others lie within the domain of personal choice. All of them present opportunities for design thinking.

  The incidence of childhood obesity has skyrocketed in recent decades; according to the Centers for Disease Control and Prevention, the number of overweight and obese children has tripled since 1980. What used to be called adult-onset diabetes has had to be renamed type 2 diabetes because it is no longer just adults who get it and it is no longer unusual to see kids taking insulin. At the individual level we might start by thinking about why kids develop poor eating habits early in life that are difficult to change later on. We can then begin to think about ways to address some of those issues. Some school districts have banned junk food in cafeterias and vending machines, but simply depriving kids of food they want is self-defeating. More promising are positive inducements such as that of Alice Waters, the founder of the renowned Berkeley restaurant Chez Panisse. Waters has started an initiative called Edible Schoolyard to encourage schools to grow produce to provide healthy ingredients for school lunches while educating kids about where their food comes from. In the United Kingdom, Jamie Oliver developed his School Dinners program, which works with local authorities to introduce healthier, better-tasting food. Each of these can be thought of as the response to a classic design challenge. Instead of the Millennium Development Goals’ righteous exhortation to “end childhood obesity,” they are asking the design thinker’s question: “How might we…encourage kids to eat healthier foods?”