Design for the developing world
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A large number of our projects focus on the needs of low and middle income countries (developing world). The success of these products depends on a deep understanding of the environment. A product designed for the developed world often fail in these environments in unexpected ways. This page tells a few stories of how designing for the developing world is quite different than designing for the developed world.
Loss to follow-up
Patients come from long distances, often on foot, to access health care. When tests are performed that need to be sent to a central lab, patients do not get results immediately. One common test that is sent out is infant HIV testing. The current test requires large, expensive equipment that may be located in only one or two locations in a country. The samples need to be carried via bus, motorcycle or mail to the central lab. The test run and the results sent to the requesting clinic. The time required for results varies from two weeks to several months and is not predictable. The image below shows a pile of test results for infant HIV testing that were never delivered to the mother.
This represents approximately half of all tests conducted at this clinic. The results are not delivered for a variety of reasons including mothers not returning to the clinic, mothers returning multiple times but the results are not there, samples are lost, and mothers simply can not get back to the clinic. Loss to follow up is a problem for both diagnostics and therapy. Given that roughly half of infants with HIV die before age 2, rapid diagnosis and treatment is essential.
Poor power quality
When people think of power in the developing world, they think "are the lights on?". In the developed world, people are concerned about power outages or spikes due to lighting strikes. These happen in the developing world also but other problems like neutral-to-ground voltages, high nominal voltages for minutes, or very low voltages happen frequently. This causes power supply failures and motor failures in many types of equipment including diagnostic and surgical equipment. We conducted a study to monitor voltages across sub-Saharan Africa and were suprised at the extent of the problem . The graph shows 1,421 hours of data and the data points represent an instance that was more than 10% more or less than the nominal voltage.
Proper use of test kits
Clinics conduct HIV testing every day in Africa. The image shows a number of these tests being conducted in a lab in an African clinic. Rapid diagnostic tests (RDTs) like these enable a broad range of testing in the most remote locations including HIV, syphilis and malaria. When I took this image, I asked the laboratory technician what should be changed in these types of tests to make them more convenient or more accurate. The answer surprised me: add more running buffer in the kits. I doubted that the manufacturer did not add the correct amount of buffer routinely so I asked a few more questions. When they have an unusually large number of tests (happens often), they used double the amount of running buffer. This provided a result much faster, but unknown to them, it also reduced the accuracy of results. Anecdotally, I understand that when they run out of buffer, they substitute other buffers from other tests or simply use water. The people conducting these tests are smart, dedicated people, but they are simply acting upon the knowledge they have. Due to the training and quality control measures present, these kinds of errors are inevitable if the test allows them to happen.
I went into a small clinic lab and was very surprised to see a nearly new biosafety cabinet to handle TB suspect sputum samples. In the developed world, this is an absolute requirement for handling similar samples but is quite rare in sub-Saharan Africa. As we talked, I realized that the fan was not running on the cabinet. The cabinet was donated about a year earlier, but the filters clogged quickly due the the large amounts of dust present in the dry season. The filters were not cleanable, affordable, or available in Africa. Donating the equipment was done with the best intentions, but the equipment was not designed with the environment or logistics infrastructure considered. This is a common problem with a range of equipment from diagnostics to surgical equipment.
When visiting a clinic outside of town in Sub-Saharan Africa, I was suprised to see a pharmacy right across the street. I thought that the medications and other supplies were provided by the public clinic. I asked the health care workers about how the pharmacy could possibly survive being so far out of town. The answer surprised me. For many reasons, supplies are often out of stock at the clinic and are stocked-out in local warehouses. The pharmacy serves to fill gaps. If a syringes or medications are not available at the clinic, patients can purchase them at the pharmacy for their treatment. This is not a problem unique to this particular area or country, but is common in many places. We opted to include everything required for testing in our test kit so that our test can always be completed even if gloves or lancets are otherwise not available.