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Keywords: Design Research, Human-Centered Design, Malnutrition, Innovation

In October 2015, Quicksand was commissioned by the International Rescue Committee (IRC), one of the world’s leading humanitarian relief agencies, to provide training to its staff in design thinking and in applying design principles and approaches in developing programs. The IRC identified a need for taking a more user-centered approach and to build internal capacity in fostering innovative thinking within its ranks to achieve greater impact. Quicksand engaged with the IRC in order to address this need.

The UN estimates that nearly 3 million South Sudanese are facing “acute” food and nutrition insecurity. That translates to more than one-third of the entire country being trapped between poverty and famine on one side and debilitating internal conflict on the other. This has served to only exacerbate an already catastrophic problem.

Amey interviewing a healthcare worker at an Anganwadi in Bhopal, India

A web of factors underlying chronically high levels of acute malnutrition across the country continue to persist, with no end in sight. With nearly 40 percent of the national population in need of emergency food assistance, rates of acute malnutrition continue to rise with children at the greatest risk followed by pregnant and lactating women. Meeting the needs of these children and women has already taken concerted and considerable effort by humanitarian and development actors, with an estimated 140 NGOs preventing wider suffering through their efforts.



From personal experience, simply moving about the country is extremely challenging and hazardous. People lack the means to so much as survive, let alone avail medical facilities and treatment centers, which are few and oftentimes very far between.

The UN estimates that nearly 3 million South Sudanese are facing “acute” food and nutrition insecurity.

The engagement with the IRC kicked off with a week-long workshop in Mali where the program of the organization’s nutrition team was used as a framework for applying the human-centered design process to identify and explore opportunities in driving innovative thinking in the design of interventions. Specifically, the nutrition team’s work on developing a system for identifying and tracking severe acute malnutrition at the household level emerged as a critical opportunity. The workshop sessions enabled a collaborative articulation of a brief to develop a tangible tool or system of tools to aid in the identification and subsequent treatment of severe acute malnutrition, and which could be utilized by individuals lacking literacy and numeracy.



A team from Quicksand led IRC staff members from the United States, South Sudan, Mali, Chad, and Niger through a series of design activities. This began with a macro view of the program in order to identify challenges and opportunities therein. Throughout the course of the week, these activities became more targeted, culminating in a day-long ideation session around how the identification and tracking tool or tools could manifest.

The Quicksand team capitalized on the insights and learnings from the Mali workshop to develop a system of artefacts that when used in conjunction could:

• Monitor treatment of severe acute malnutrition from admission to discharge;
• Facilitate the accurate calculation of a child’s dosage of therapeutic food on a daily and weekly basis;
• Provide an intuitive patient register for capturing data and tracking a patient’s progress for up to 3 months. 

Efforts by the IRC to develop a Longitudinal MUAC system (i.e., a MUAC tape that would allow for the tracking of progression and regression over the course of the 12-week treatment) served as the starting point for this exploration, and was a key focal point during the workshop in Mali

Iterations of each artefact were then field tested through a series of workshops in proxy settings in India, and in conjunction with local organizations working in the malnutrition space there. Two separate Longitudinal MUAC Systems were developed, prototyped, and tested with a nutrition 
NGO in Bhopal, Madhya Pradesh, India.

 We deconstructed the malnutrition ecosystem in Bhopal through interviews with district level officials and NGO management. Workshops followed which were conducted with field level nutrition specialists to vet the systems and their component artefacts.

An IRC field staff member demonstrates the use of one of the artefacts in South Sudan (Photo: Casie Tesfai, IRC)

Participants were taken through various exercises which sought to simulate real-world settings, allowing them to interact with the artefacts and provide feedback. The field visit allowed us to understand a baseline level of protocols to facilitate comparison to the system being proposed for use in South Sudan, and beyond. Despite different protocols, this provided a fair comparison to a similar context in terms of infrastructure challenges, total catchment size of beneficiaries, and relative education levels. The feedback and observations gleaned from this testing aided in further rounds of iteration and prototyping, until a best-in-class system of artefacts emerged.

In January 2016, the Quicksand team traveled to South Sudan and spent around a month in-country, living with the IRC field and HQ team there and engaging with mothers and children in several remote villages on a daily basis. Though the toolkit needed to be designed for near universal application across all nutrition programs throughout the African continent, South Sudan was identified as the most challenging due to the severity of the crisis there and the relatively low education levels amongst those that would be using the system of tools. It was critical that the artefacts be tested with actual patients and healthcare providers to rigorously evaluate their relevance and efficacy, and with as great a number of stakeholders as possible.

The feedback and observations gleaned from this testing aided in further rounds of iteration and prototyping, until a best-in-class system of artefacts emerged

We worked closely with the IRC staff from the nutrition and iCCM team, the country staff, and Community-Based Distributors (CBDs) who provide community based treatment for malaria, diarrhea and pneumonia to children under five in the villages there. This was done through daily workshops sessions with the CBDs where we engaged with them through the IRC nutrition and iCCM country staff who played a very valuable role of interpreters and trainers for the project team. 



Through a series of activities we introduced the tools, demonstrated their use, and gathered feedback on the usability and adaptability of these tools. Another aspect of the workshop included defining local personas and placing them in a treatment scenario. To ensure an appropriateness in real world conditions, we applied an in-field iterative approach to prototyping with the idea of integrating design into the social fabric of everyday life. Based on feedback from multiple perspectives, we made refinements to the artefacts each week for further vetting until all stakeholders involved felt the artefacts had evolved to a fidelity that could ensure effectiveness in their deployment. This enabled us to not only understand sociocultural and behavioral nuances of users with regard to the tools but it also brought us closer to our end-users.

Community healthcare workers interact with the artefacts during a workshop in rural South Sudan

We also spent time observing and interviewing CBDs about their needs, constraints, and challenges in rural South Sudan. Our project required us to be in and around these health care outposts every day for several weeks in order to observe and review the use of our artefacts within the treatment protocol. Observing children as severely wasted, we got a jarring glimpse into how dire the situation was and the immediacy for change.
 Some of the key insights and takeaways from our research included:

• Understanding the challenges toward designing for the context of malnutrition, demands casting a wide net of inquiry whilst in field, and taking a macro view an ecosystem that’s deeply embedded in a continuum of existing complex issues;
• Having a design team engaged in field research/testing allows for rapid prototyping or, in the very least, explorations of additional iterations of designs, particularly with respect to tangible products but this is also applicable to service or system design;
• Synergy between design and technical teams in terms of research objectives and related activities makes engagements more efficient;
• Healthcare infrastructure is unevenly distributed which makes the journey for a caregiver to an treatment center or site at times exceptionally difficult.
• Therapeutic Foods can be perceived as a food supplements or snacks, and were often added to meals for additional nutritional value and to benefit the family as a whole and not just the child in need of treatment;
• Women’s heavy workloads and caring for large families make balancing the needs of other children a consideration when one child is malnourished and in need to treatment;
• Settlement patterns of people over villages are very sporadic, and disrupt systemic infrastructure and capacity building processes

The system of artefacts was ultimately successful and effective in identifying instances of severe acute malnutrition and documenting related readings, and only minor aesthetic adjustments were identified to further aid ease-of-use. The quality of feedback, along with the effective collaboration between the various IRC teams and Quicksand, facilitated the development and testing of additional artefact iterations. The project team emerged with a clear consensus on way forward in the development of the artefacts in preparation for the next round of field testing the IRC plans to conduct.