Q&A: How human-centered design works at the world's largest foundation

SEATTLE, United States — Tracy Johnson, senior program officer for user experience and innovation at the Bill & Melinda Gates Foundation, gets mixed reactions when she makes the rounds from team to team. “I will say there are meetings I go into where people’s faces fall and they think, ‘Oh my God, she’s back. We wish she would go away. We don’t understand her,’” she told Devex at the Seattle headquarters of the largest foundation in the world. “That is changing, and more and more I’m met with smiles, and they think, ‘Okay, Tracy is going to ask about this issue and get us to think from a different perspective and perhaps come up with some different ideas as a result.’” Johnson is responsible for building capacity among Gates Foundation staff in human-centered design and identifying ways to apply it across the foundation’s portfolio of grants. Examples of her work include Lab.our Ward, an effort to rethink the maternity ward experience. Also called design thinking, human-centered design is an approach to problem solving that incorporates the wants and needs of the end users of a product or service in every stage of the design process — and Johnson is among the professionals bringing the practice from the private sector to global development. The Gates Foundation’s work on HCD, as it is often called, has included partnering with IDEO.org, the San Francisco-based firm that has brought the traditionally private sector practice to the social sector, applying these methodologies to their own work and the work of other donors and NGOs. After attending some training sessions with IDEO, Melinda Gates, co-chair of the Gates Foundation, began to see the value in learning about demand side perspectives and decided the foundation needed an in-house expert on the topic. Johnson, a social and cultural anthropologist turned human-centered design thinker, joined the foundation in 2015, leaving a global design and technology consultancy for a role that in some way took her full circle to the work she did with the U.S. Agency for International Development after getting her PhD in anthropology. She spoke with Devex about the work she is doing to integrate a human-centered design perspective into the development of new products and services to improve health outcomes. The conversation here has been edited for length and clarity. Your job title includes two buzzwords: “user experience” and “innovation.” Could you tell us a bit about this and what you do for the Gates Foundation? I think that oftentimes human-centered design is understood as UX (user experience) — whereas UX is just a part of human-centered design. I think a mistake many people make is they say, “Okay, we just need a UX designer and we’ll be fine.” I think my title is confusing because it perpetuates this idea that UX — which can limited to the interaction between a person and a screen — is the same thing as human-centered design. That’s something the field suffers from and is perpetuated somewhat within the foundation as well. In the end, the people who do seek me out and do work with me quickly begin to realize it’s not just about a screen interface. So I don’t use my title very often. Really, what I’m about is helping people understand how to start with users first — how to know, understand and experience their users. Within the foundation, our users are multiple and varied. The user can’t be seen as just one person. We have end beneficiaries, we have frontline providers, we have families and other types of caretakers, we have formal health providers, we have ministry of health officials at all different levels. I try to help people understand how they can start not with a solution first, but actually to start by asking, “How do we really understand our users and and what problems they’re facing?” If we start from there, what does the process of arriving at a solution look like? And how is that different from how we’ve been working up to this point? “My fear is we gravitate to those easy buzzwords that seem like they’re going to be faster and easy to do.” --— One of my concerns about human-centered design in this field is that people really gravitate to some of the buzzwords around it. For example, UX fails to take in the larger context that design thinking brings, but there is a rush to that immediate user experience interaction. The other is rapid prototyping. Everyone’s talking about rapid prototyping. I’ve read proposals recently where that word is thrown in, and so many times all I come away with is the thought that this person writing this proposal doesn’t know what rapid prototyping is. We can prototype until we’re blue in the face. If we’re not prototyping the right things, it’s not going to matter. So my fear is we gravitate to those easy buzzwords that seem like they’re going to be faster and easy to do, we latch onto those and don’t spend enough time with the design thinking part of the human-centered design equation. The biggest role I’ve played at the foundation is as a provocateur, to force people to ask different questions of the work that they’re doing. How does your background in anthropology inform your work? There are three ways into human-centered design: design, marketing and social science. I ended up becoming an anthropologist. I think everyone should study anthropology. You learn to look at the world in a different way. “Oftentimes, you have that catalog of what people are doing, but you don’t have the why — why are people doing that? --— There is a small group of us that have come in through the social sciences. For me, it’s really critical, because human-centered design relies on ethnography. Ethnography is a tool for observing and cataloging behavior and beginning to understand it. But oftentimes, you have that catalog of what people are doing, but you don’t have the why — why are people doing that? That is what social science brings. In this field, I feel that’s particularly important because so much of what we’re doing is rubbing up against social and cultural norms. And we can either design solutions that will be workarounds for those social and cultural norms, or design solutions that understand: okay, these are the norms, these are why they’re here, we want to slowly change behavior so we’re going to need to push and slowly change those norms, thinking about how we get people to think differently. If all we’re doing is workarounds, our solutions won’t be as successful as they could be. How did different teams take to the challenge? I sit on the Integrated Delivery Team, which has its pros and cons. Gates is a vertical organization organized by program strategy team, which is a disease state or life stage or development issue. Integrated delivery cuts across all of those — and that can be challenging because no program strategy team necessarily has to work with us. There has to be interest from select program officers who want to take a demand side perspective. There has to be that meeting of the minds. When I started, I was working initially with the HPV and TB teams. But TB doesn’t have the global budget of, say, HIV, and they didn’t feel they could devote some of that critical budget to demand side issues. It wasn’t that they didn’t recognize human-centered design could be helpful; it was more a matter of how to prioritize it within a budget they didn’t feel was large enough for everything they wanted to do. Over the course of my two years here, it’s been about finding out which teams are going to be more open to this type of work; teams such as family planning, which perhaps started experimenting even before I arrived, and were, asking how do we build on that? The global development teams — such as family planning and financial services for the poor — more naturally understood that they need to understand users. Teams such as enteric and diarrheal diseases didn’t expect the need to be thinking about demand side issues, but that is a team that has really embraced my role and asked for help in a lot of areas. Walk us through an example. The EDD team is managing a project implemented by the medical technology company Masimo to adapt the design of a combined pulse oximeter tool and evaluate its impact on diagnosis and identification of pneumonia for referral in high-burden settings. You’re working to bring a human-centered design lens to the project. Can you expand on the kinds of questions you asked the teams involved? How does the design thinking approach lead to different outcomes in projects like this one? In a lot of cases, the foundation has started with a technology. There’s a technological innovation or advancement and the feeling is: “Let’s go out there and design something with this technology and then it will just naturally be embraced by the market.” In this particular project, there were two devices involved in diagnosis. One of those devices lives in a top of the line medical facility. Another lives in the hands of a frontline health worker. There was an idea to bring these two devices together. When we develop target product profiles to send out to partners, the use case is this short paragraph that is very clinically based, like what happens when the person comes in front of the provider, and how the device is going to be used on that person in that moment. We rarely think about the larger context. For example, how is that person even going to end up in front of that facility? The idea of bringing two devices together was, “Oh yes, that would be great because we can join them!” Until I stepped in and said, “Well in fact, they live in two very different places. They have very different use cases. Why would a provider in a top of the line medical facility accept a reading from a device by a frontline health worker when they don’t think the frontline health worker has the training to use it?” The question is, how do you understand the life of a device? A device has a role in a clinical setting, and through that it takes on a great deal of importance. If you radically change the setting in which the device lives, it has to find a new role. If we’re not thinking about that when designing it then the likelihood of it actually taking on that new role becomes very diminished. Having worked for both USAID and in the private sector, what are the challenges you see in applying human-centered design thinking to the work of the Gates Foundation? I was very excited to come to the foundation when I heard they were interested in bringing the human-centered design perspective to the work that they do. I think a lot of what we try to do in the field of global development is really connected to behavior change. We’re trying to change people’s behavior to get them to better outcomes in health and well-being. The foundation really is a very special place. We have a wealth of resources that many others don’t have, which is phenomenal. We also have huge teams of experts, who have been brought in because of their deep expertise. I think one of the biggest challenges of bringing human-centered design into a setting like the foundation is that it asks you to be comfortable with ambiguity and asks you to start from a position of saying, “What is it I don’t know?” And we don’t do that well here. We want to start from what it is we do know. “There is universally a bit of discomfort with ambiguity and being able to hold complexity in your hand for a little bit.” --— Although we do have many benefits that smaller donors and other organizations working to integrate human-centered design into the way they work don’t have, I think there is universally a bit of discomfort with ambiguity and being able to hold complexity in your hand for a little bit and say, “I don’t know yet how to solve this problem and I need to do some work to figure out what it is I don’t even know, so that I can begin to apply what I do know to solving that problem.” Through my years of working at USAID, working in the private sector for Fortune 500 companies, and now being part of the foundation, that is the thing everyone struggles with. Life is messy and very complex. And we have to accept that and start from there. 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