Approach

IHI partnered with MASS Design Group, the Ministries of Health in Ethiopia and Bangladesh, and local architecture partners Fasil Giorghis Consult and icddr,b to engage mothers, companions, providers, and communities to explore how the physical structure of health facilities impacts the delivery and experience of perinatal care. Through a human-centred design process, we developed designs for improving existing facilities to better meet patients’ and providers’ needs. Learn more about our process below.

Startup

  • We began by assembling a diverse team of international and local partners. First, IHI brought MASS Design Group on as a global technical partner. MASS offered experience in human-centered design, as well as a background designing and implementing maternal-newborn health projects. We issued Requests for Proposals (RFPs) in Ethiopia and Bangladesh to identify architectural and engineering firms that could contribute local expertise and resources to the process and – through the project – build experience in HCD that they could replicate in future projects throughout the country. After a competitive bid process, the team selected Fasil Giorghis Consult and International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b) as our local technical partners in Ethiopia and Bangladesh.

    In order to support global buy-in, applicability, and accessibility, IHI then convened a Global Goods Steering Committee comprising representatives from the World Health Organization, World Bank, PATH, UNICEF, Save the Children, NEST360, and the WHO Quality of Care Network.

    These individuals offered decades of experience and expertise to inform the direction of the project and the Global Goods we were tasked with producing. They were joined by representatives from the Ministry of Health in Ethiopia, the Ministry of Health and Family Welfare in Bangladesh, and from the project funders– all of whom brought unique perspectives to the project.

  • Participating sites were selected through engagement with the local Ministries of Health in Ethiopia and Bangladesh. Two hospitals and two health centres were selected in each country. The criteria for selection included: how closely the facility reflected existing standards and the condition at other facilities of a similar scale, the opportunity for replicability across the context, the amount of space available, and opportunities for expansion. After a consultation process, facilities in the Amhara and Afar regions were selected in Ethiopia, and facilities in the Jashore and Munshiganj districts were selected in Bangladesh.

  • We conducted a literature review in order to leverage existing evidence about the relationship between the built environment and quality of care. The literature review was aimed at expanding the team’s understanding of current childbirth care practices in Ethiopia and Bangladesh. We also collected lessons learned from past initiatives to improve maternal-newborn care in other LMICs, including user experience, space, and systems redesign projects.

  • We then turned our attention to planning how we would assess existing facilities in Ethiopia and Bangladesh and engage a range of stakeholders to understand the needs and opportunities for improved maternal-newborn care. We were tasked with crafting a human-centered approach to capture women’s experiences and attitudes toward perinatal care and developing a process that could be replicated by others.

    We drafted a set of tools that leveraged a broad range of engagement strategies, including interviews, focus groups, simulations, shadowing and observation, and co-design workshops. We realized that it would be important to engage a diverse group of stakeholders in the process, from mothers, family/companions, providers, and community members to facility administrators and MOH representatives. During this time, we also developed tools to conduct detailed engineering assessments at the health facilities we planned to visit. IHI submitted our protocol to secure Institutional Review Board (IRB) approval in both counties. The Engagement and Assessment Tools were then translated into Amharic and Bengali.

    MOH representatives participated in the refinement of the tools and coordinated with the selected health facilities and communities in preparation for immersion. Additionally, the MOH helped to secure and share construction documents of the existing facilities with our team as a basis for assessment and redesign.

Engagement

  • This phase focused on the engagement of end users, including mothers, companions, health care providers, facility staff, and MOH representatives. Over several months, the project team visited health facilities and communities in Ethiopia and Bangladesh to reaffirm our pre-existing understandings of maternal health care experiences, uncover new learnings and insights, and ensure that design solutions would be aligned to local contexts and reflective of stakeholder needs. In each facility, our team split into two groups. Using the Engagement Tool, the first group was responsible for carrying out interviews, focus groups, and workshops with mothers, companions, providers, and administrators. The engagement team took handwritten notes during all sessions to capture the feedback provided by the various stakeholders and completed reflection sheets at the end of each interaction to note their own observations and further questions. With the express permission of the stakeholder participants, the majority of interactions were also audio/video-recorded so that the team could revisit the conversation and ensure data quality during the analysis phase.

  • The second group – comprising engineers and architects – utilised the Assessment Tool to complete a comprehensive review of the facility’s infrastructure, including walls, roofs, and foundations, as well as water, electric, and waste disposal systems, among other elements. The group proceeded to visit and observe each space, documenting their findings in line with the Assessment Tool.

  • Between facility visits, the team debriefed and made minor adjustments to the data gathering tools in response to those experiences and lessons learned.

  • An essential part of this process was training local technical partners in human-centred design methods. In Ethiopia, MASS led the first immersion trip to two facilities in the Afar Region alongside the Fasil Giorghis Consult and IHI teams. Due to the ongoing civil unrest, MASS was unable to attend the second immersion trip in the Amhara Region; but instead coached the Fasil Giorghis Consult team to carry out the remaining facility assessments. Due to the COVID-19 pandemic and subsequent travel restrictions in Bangladesh, MASS was unable to attend the immersions in both the Jashore and Munshiganj Districts. Instead, MASS led a series of training workshops with icddr,b to prepare them for engagement and assessment on site. A pilot immersion was also conducted ahead of the first immersion to the Munshiganj District.

Analysis

  • Following the conclusion of the facility visits, MASS Design Group, Fasil Giorghis Consult and icddr,b collaborated to sort and analyze the significant quantities of data collected. All written records were scanned and saved electronically for redundancy. Interviews were transcribed and linked with observation notes. Engagement data were sorted by respondent type (e.g., mother, companion, provider, etc.) and collection instrument (e.g., interview, focus group, survey, etc.) so that the data could be analyzed and then considered in relation to other respondents.

  • In order to synthesize insights, identify priorities, and propose recommendations, MASS Design Group worked collaboratively with Fasil Giorghis Consult and icddr,b to develop one report for each country summarizing the engagement and assessment outcomes from the immersions in Ethiopia and Bangladesh. These reports included emerging thematic conclusions, assessment findings, annotated space use plans, observations and design opportunities for each care space, and care flow diagrams across different stages of the care journey.

Design & Toolkit Development

  • MASS Design Group was responsible for developing architectural concept designs for all eight facilities assessed through the project. To translate the learnings from the engagement trips, MASS developed diagrammatic plans illustrating ideas for improved user experiences. These preliminary concepts were reviewed by IHI, Fasil Giorghis Consult and icddr,b, and their feedback was incorporated. All project partners also convened at regular bi-weekly meetings to share progress and provide comments. For each facility, MASS produced a concept design presentation including an architectural design (basic plans, sections and elevations) and an engineering report. Due to the physical constraints of the facilities in Bangladesh, we produced short-, medium- and long-term options for renovation. The IHI, MASS Design Group and icddr,b teams presented our concept designs at a Ministry of Health and Family Welfare (MOHFW) stakeholder workshop in Dhaka to ensure buy-in from regional and national representatives of the Health Engineering Department (HED) and Public Works Department (PWD). Stakeholders expressed their interest in long-term planning, which signaled a commitment to investing resources in improving MNH outcomes. Following the review of concept designs, we consulted with the respective Ministries of Health to select one hospital and one health centre in each country that would be advanced to more detailed plans. MASS produced a Schematic Design (SD) drawing set including architectural, structural, mechanical & plumbing, landscape design, civil, and electrical drawings. Along with this drawing set, an SD narrative document was shared to convey full project scope and intentions for further design development for maternal-newborn units in Ethiopia and Bangladesh.

  • The local technical partners in each country (Fasil Georghis Consult and icddr,b,) were responsible for carrying the designs forward into the Design Development (DD) and Construction Drawings (CD) phases. MASS and IHI provided oversight and feedback throughout this process through bi-weekly meetings, as well as 50% and 100% design reviews in each stage.

  • In parallel with facility engagement and redesign efforts, we worked to package our learnings and approaches with the aim of allowing others to replicate our human-centred design process. We developed the ‘Delivering More Toolkit’, which includes this introductory document, as well as a 'Facility Design Guide,' 'Design Principles,' and 'Design Case Studies.' Together, these resources form a globally applicable toolkit for improving maternal and newborn facility design. The tools highlight common design principles and approaches, as well as topics that should be contextually driven and informed by local user engagement. The tools are available in both print and digital formats and are complemented by a film piece which documents our process and key insights, leveraging footage captured during the engagements in Ethiopia and Bangladesh and throughout the design process.

Key Partners

Core Project Team

The core team was responsible for planning and carrying out the user engagement and facility design initiatives, and developing the toolkit resources.

  • Global Health Partner

    The Institute for Healthcare Improvement (IHI) is a global thought leader in quality improvement that has worked with partners in over 40 countries to improve health care systems. IHI brings over a decade of experience working in LMICs and expertise in service delivery strengthening. The project built upon IHI’s existing relationships with the Ministries of Health in Ethiopia and Bangladesh and their deep knowledge of maternal-newborn care delivery needs in each country.

  • Global Technical Partner

    MASS is a nonprofit design firm that has supported partners in 20 countries with the planning, design, construction, and evaluation of transformative health care environments. MASS brings expertise in human-centred design, and experience implementing projects and design standards with MOH and NGO partners across Sub-Saharan Africa. MASS led the human centred approach, training, and tool development for the Delivering More project, as well as the conceptual redesign of facilities in Ethiopia and Bangladesh.

  • Ethiopia Technical Partner

    Fasil Giorghis Consult is an architectural design firm based in Addis Ababa with more than twenty years of experience working on health care, civic, cultural, and residential projects in Ethiopia. Fasil Giorghis Consult contributed its understanding of Ethiopian health care delivery and building industry practices and served as the local architect of record in Ethiopia. The firm strives to create community centred buildings by combining the use of local materials, indigenous knowledge, and environmental concerns in contemporary design.

  • Bangladesh Technical Partner

    International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b) is a global health research institute focused on developing, testing and assessing the implementation of evidence-based interventions designed for resource-poor settings. icddr,b contributed their understanding of Bangladeshi health care delivery and building industry practices and served as the local architect of record in Bangladesh.

Implementing Partners

Government partners in Ethiopia and Bangladesh were engaged as part of the design process at the national and regional levels.

  • The Ministry of Health and Family Welfare (MoHFW) is a Bangladesh government ministry charged with health policy in Bangladesh. It is also responsible for all government programs relating to health, health care services, and family planning in Bangladesh. The Bangladesh MoHFW is deeply involved in the planning and implementation of health facilities at all scales and will be an instrumental stakeholder in scaling improved facility designs throughout Bangladesh in the future.

  • The Ministry of Health is a federal government ministry of Ethiopia, responsible for public health care delivery. The Ethiopian MoH is deeply involved in the planning and implementation of health facilities at all scales and will be an instrumental stakeholder in scaling improved facility designs throughout Ethiopia in the future.

Funders & Advisors

This project wouldn't have been possible without the guidance of our funders and their commitment to improving maternal and newborn care.

  • Funder

    Guided by the belief that every life has equal value, the Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty. In the United States, it seeks to ensure that all people—especially those with the fewest resources—have access to the opportunities they need to succeed in school and life. Based in Seattle, Washington, the foundation is led by CEO Mark Suzman, under the direction of co-chairs Bill Gates and Melinda French Gates and the board of trustees.

  • Funder

    The Elsa & Peter Soderberg Charitable Foundation is guided by the conviction that it often takes a lead funder to initiate bold, differentiated, sustainable, and scalable programs. We seek to apply our financial and experiential resources in catalytic philanthropy through strategic project selection and grant structuring, establishing transparent and collaborative partnerships with our not-for-profit implementation partners, and active participation in project monitoring and in developing new donor collaborations. Our first question of highly experienced and credible potential partners often is, “What is the most impactful initiative you want to undertake but need a lead partner willing to invest in resources other foundations traditionally avoid?”

  • Advisory Group

    We convened representatives from a range of international NGOs with deep expertise in maternal and newborn health and health care systems improvement to guide the development and dissemination of the Global Goods. These include: the World Health Organization, World Bank, PATH, UNICEF, Save the Children, WHO Quality of Care Network, and NEST 360. The steering committee met at key project milestones to review and provide feedback on the Global Goods, with the goal of expanding the reach and impact of the tools.