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When you’re talking to a female population of 49 million; 88.71% of which reside in rural spaces and 46.67% of which are illiterate; it is essential to understand that service delivery strategies should not be innocent of user behavior. Through extensive field work in Bihar (India), done over a span of 18 months, it has been observed that the system and the beneficiary, speak two different languages. A simple observation was in regard to the concept of time – while the system’s understanding of time is in obvious accordance to the globally accepted Gregorian calendar, the end user remains largely oblivious to the basic understanding of the very months in the Gregorian calendar. Needless to say, the repercussions are endless.


88.71% of women in Bihar (India) live in rural spaces; 46.67% are illiterate.


Complexity within the Healthcare System:
The maternal and child health care system, depends almost entirely on the woman’s understanding of time leading to self-mobilization, further aided by the fleet of Frontline Health Workers (FLWs) acting as external triggers. The interactions begin with the woman registering for pregnancy and end with the child’s complete immunization. We start at the very beginning, understanding how women register their pregnancy – In order to register a pregnancy and generate the Expected Date of Delivery (EDD) the system requires the woman to recollect the date of her Last Menstrual Period (LMP). It is essential to understand the woman’s psychology and factors that affect her during this stage of service delivery. It has been observed that women refuse to disclose the news of their pregnancy to FLWs while in its early stage, finding it inauspicious to talk of their pregnancy publicly. Since this leads the mother to register her pregnancy later than expected, when asked about her LMP the mother must recall the said date. Now, due to the lack of perceived importance of this otherwise vital information, and a skewed sense of the Gregorian Calendar, the beneficiary is unable to accurately trace back the exact date furthermore finding it difficult to communicate it in Gregorian terms.

Time and its blurred perceptions

Time and its Blurred Perceptions:
The quickest answer to the problem, is for the system to start adhering to the beneficiary’s concept of time, abandoning an otherwise alien Gregorian system. But this local concept of time that we’re referring to is never homogenous. A few may follow the Panchang calendar, while the rest a completely independent but accurate system. While interviewing an ASHA facilitator in Sheikhpura-Bihar (India), we were told that many Muslim ASHAs have trouble understanding the paksha (shuklha paksha-krishna paksha-poornima-amaavas) concept that many Hindu women refer to. While they themselves preferred quoting the position of the moon. We realised that even though the paksha concept too referred to the position of the moon, it was primarily the mutually incomprehensible nature of mere terminologies that created a false barrier in simple communication.


The Nexus:
The visually rich lunar calendar, when mashed with the Gregorian calendar produces something that is easily comprehended by both- an illiterate beneficiary and the healthcare system. An added feature that this visual calendar boasts of is the course corrective nature of design. In a scenario, where the beneficiary is clueless about what day she stands on, she can time to time course correct herself by simply observing the actual position of the moon and recognizing it on the calendar.


Menstrual Tracking:
In practice, these calendars are distributed to eligible couples within villages by the FLWs with clear instructions of use. The system demands the woman to accurately point out her LMP, hence we get her to start tracking her period regularly. Since LMP can never be predicted, the most effective way of tracking it is by simply tracking every menstrual period. Once every period is being marked by the mother on a very visual calendar, it allows her to understand her menstrual cycle as well.

“Their understanding of their mens (menstrual cycle) is such that they feel that unless their mens (menstrual cycle) ends on the same day every month then it is irregular.” – ASHA, Samastipur


Family Planning:
The basic understanding of her menstrual cycle by the mother in an otherwise family planning depleted environment proves to be an extremely rich proposition. The understanding of the menstrual cycle allows one to employ the Standard Day Method of contraception. With the simple identification of her fertility window, the calendar allows the woman to be in control of family planning. Additionally, the Standard Days Method is 95% effective (right behind condoms, which stand at 98%). In a country that contributes to 17.1% of global unwanted pregnancies, methods such as this, which work only by understanding user behaviour, could prove to be vital interventions.

The Standard Days Method and its working.

The Standard Days Method and its working.

Once the woman’s LMP is accurately marked by the FLW, it becomes easier for the system to predict her EDD (37 weeks of foetal maturity) allowing the FLW to predict and alarm the system in case of preterm labor.

If the child is born two months before our estimated due date (EDD) (which happens often) then it completely negates whatever birth preparedness information we can possibly give to them. – Kunal, CARE BHM , Singhia PHC Samastipur


After correct identification of preterm using the calendar, measures can be taken to prevent foetal mortality. In India alone 300,000 infant deaths occur annually (the highest in the world), with 10% of India’s IMR being attributed to preterm deaths. With the simple administration of Antenatal Corticosteroids, 30% of such deaths can be averted.

The Calendar hence projects to impact issues such as period tracking, better birth preparedness, accuracy in data collection, early identification of preterm cases, and effective family planning. Monumental impact is rarely attributed to such low cost solutions. With the Calendar, as a leap towards that dream, the Lab continues to strive towards low-cost-high-impact solutions driving up public health standards globally.


Health Experts from the Bihar Innovation Lab with the CARE Samastipur, Bihar (India) team.

The Patient Health Identity Tokens team is piloting a first of its kind ‘Shringaar Card: A Menses Tracking Tool for Rural Women’ in the district of Samastipur in Bihar (India). This tool will aid married beneficiaries in accurately tracking their menstrual cycle, enabling family planning while also nudging them to register their pregnancy at the earliest and avail services currently offered by the Public Health System in Bihar. To know more about this tool do write across to Adithya Prakash at and Atishay Mathur at

Throwback Thursday!

As we are approaching the end of the week, let’s have a look at some of the interesting endeavors our teams have undertaken in the last few months. CKS teams on field work in Indonesia

CKS team on field work , working on a project for developing prototypes in order to improve the maternal health care delivery systems in Indonesia

CKS team on field work in Nepal


CKS team conducting field work for a project for assessing the use and access of technology by Nepali migrant workers in Qatar

Dr Ilkka Hämäläinen visits CKS

In Conversation with Dr. Hamalainen

CKS hosted Dr Ilkka Hämäläinen, Chairman of the Board at Oppo (Optimizing Potential, Finland) at the Chaia Innovation Campus on 16th March. Dr. Hämäläinen heads Oppo, which is dedicated to creating systemic change through integration of business, academia and the internal dynamic of societies and by promoting ‘doing good by doing business’ in BOP markets. Most recently, he has collaborated with IIT Kharagpur to take a first of its kind course on innovation management with an approach rooted in principles of , which would therefore be more widely applicable as opposed to more context-specific approaches.

Dr. Hämäläinen brought a fresh and interesting perspective on innovation and how it should be fostered by creating an enabling ecosystem. Interestingly, in his view, an effort that has not yet positively impacted the context is called a ‘hypothetical innovation’; it is only once the effort has achieved its objective that it can be called an ‘innovation’.

It has been suggested by social scientists that the role of governments in making social change will decrease, and markets will be in charge through entrepreneurship of empowered citizens driving social changes to improve their own living conditions, or happiness, if you like. –

At CKS we look forward to explore potential areas of collaboration with Dr Hämäläinen on innovation opportunities in BOP markets as well as new innovation approaches and training methods.

Innovation works best when government does least?

The question of the nature of government’s role in social issues and the market has been debated to an impasse. So too, it seems, has its role in innovation. Does government support foster innovation? Or, does innovation work best when government does least? In 2010, the Economist magazine hosted a debate between the two camps, and fleshed out the arguments for greater or lesser contributions by government to the process of innovation.

Defending the theory that innovation works best when government does least, Amar Bhide of Harvard University and author of The Venturesome Economy argues that too-involved governments inevitably muddle the innovation process; they choose the wrong winner by supporting projects that are politically popular, as opposed to those deserving of investment. [Read more…]

Nurturing Risk is Essential to Innovation

Jacob Koshy, in a recent WSJ article, wrote about how, despite the fact that India has been labelled as a nation of innovators and has embarked on a self-declared decade of innovation, this is only true in the loosest sense of the word. Most often, examples of so-called ‘Indian innovation’ are limited to improvising, tinkering, and quick-fix solutions – in other words, jugaad. Koshy observes:

…apart from the immediate, simplistic appeal that this tinkering or ‘jugaad,’ presents—of a poor, uneducated villager developing a water-bicycle that can be pedaled across a river, or a school dropout fashioning a pedal pump-powered washing machine—we rarely hear of these mavericks improving on their designs, or licensing their work to a company.

Why is there such a failure in translating these creative improvisations into successful, marketable innovations that add real value? [Read more…]

Does Innovation amount to Impatient Optimism?

The Gates Foundation is slowly growing into a powerful global force driving innovation around the world. Its health and developmental agendas have gradually be revised and realigned into a framework that increasingly blends improving the world with doing new things in order to be able to improve the world. Their motto, impatient optimism, seems to capture that sense of purpose and vision rather well.

Here at CKS we’ve been working closely with the Gates Foundation since 2009, when we began ethnographic research and design activities in Bihar around vaccine delivery services. The Foundation is a sponsor of our upcoming Design Public Conclave and we’ll have several of their key personnel at the event as well.

I sat down yesterday to talk with Ashok Alexander, the Country Head of the Gates Foundation in India. He talked to me about the need for immersive engagement, intimacy, understanding, between those who are trying to do good and those one is trying to help. In the case of Avahan, for instance, the Gates-supported HIV-AIDS program, Ashok said that learning about sex-workers and their lives, livelihoods, challenges and threats was all critical for designing the intervention. That kind of approach, and the learnings that came from understanding how to prevent violence against women in urban environments, turned out to have surprising impacts on how the Foundation was able to think about maternal and child health in rural areas, including in the state of Bihar.

Ashok Alexander will be speaking at the Design Public Conclave on how to better imagine India as an innovation society. He’s got the kind of engaged, critical and visionary perspective that we need to institutionalize in new ways to actually transform ourselves into an innovation society.

New NESTA Report on Innovation in India

Can growth of higher education keep up with India’s human potential? Can India’s low cost innovations disrupt the global economy? What effects do abstract social and creative innovations have in the Indian context? These are some of the questions that NESTA, in partnership with the UK Foreign and Commonwealth Office, UK Research Councils, and the UK-India Education and Research Initiative, are looking to answer.

NESTA’s recent publication on Innovation in India is a survey on the changing landscape of research and innovation in the Indian environment. Meant to be a resource for policymakers, higher education institutions, and innovative companies seeking partners in India, the intensive study is based on interviews with individuals in fields of policy, business, education, research and civil society. Using these interviews and the latest data, the report notes trends as well as provides insight into critical issues in India’s innovation trajectory, finally asking if India will achieve its ambitious innovation goals, and what it will mean for the rest of the world.

This NESTA report builds on the work done by the think tank Demos, in their publication Atlas of Ideas. In particular it draws from India: the uneven innovator, by Kirsten Bound, who now works with NESTA. After spending five years as a senior researcher at Demos, where she focused on democracy and innovation in India and Brazil, Bound worked for Tony Blair’s Africa Governance Initiative in Rwanda advising the Prime Minister on policy delivery. She consulted for the World Bank’s International Finance Corporation on Investment Climate Reform, and in 2009 joined NESTA as a Lead Policy Advisor on Innovation Systems. Her published works include: Brazil: the natural knowledge economy, The Everyday Democracy Index, Mapping Governance at the Local Level, and Community Participation: Who Benefits? She has also has created several series of forums designed to increase communication and learning to create spaces for new and innovative ideas in the European context. Kirsten was in Delhi earlier this week and spent lunch talking with Aditya Dev Sood about innovation in India and Design Public III. We at CKS are very hopeful for her insight and expertise at the next edition of Design Public.

Effective Technology in Education Innovation

Khan Academy, which began in 2004 as a small collection of youtube tutorials by Salman Khan, a graduate of MIT and Harvard, has become a library of free educational videos that has has earned the recognition and support of the Bill and Melinda Gates Foundation and Google. With over 3,000 mini lectures in 15 subjects, mostly in sciences, technology, and math, Khan Academy’s mission of “providing a free world class education to anyone, anywhere,” is reaching across the globe, from rural Asia to classrooms in America, and is transforming the paradigm of education with a de-centralized, student-centered approach to learning.

At, video lectures are simple, the only audio being Khan’s voice and the only visual a colorful virtual whiteboard. They are also short, each lesson about fifteen minutes long, despite covering subjects in diverse fields levels K-12. However, Khan has found that he simplicity lends accessibility. In an interview with 60 minutes he said, “I’ve got a lot of feedback from people who say it feels like I’m sitting next to them and we’re looking at the paper together…I think that’s what people like, the humanity of it.” In addition, the website also offers practice exercises and peer-to-peer tutorials, and software to track one’s own progress.
[Read more…]

How are Innovation and Excellence related?


Jeby Cherian wrote me a note the other day saying, and I quote: ‘one of my pet peeves is our “just enough is good enough” attitude.’ Jeby wants us to make a commitment to excellence in everything we do in India, from the design of transportation systems to roads and sidewalks to airports and other forms of urban infrastructure. Jeby points to the outstanding conceptualization, planning and execution of the Delhi Metro as a counter-example to the way things are normally done in India. This kind of haphazard and ill-conceived infrastructure and environmental planning is also often excused in the name of jugaad, or indovation.

What is the essential relationship between excellence and innovation? I think Jeby is on to something, and that this relationship bears more thought and discussion.

The first thing that comes to mind is that excellence may also encompass a notion of the ‘ideal fitness of things,’ which can only come about by continuing to ‘make things right’ until they achieve that state. Another name for this repetitive or iterative effort to keep making things better until they are ‘right’ and ‘fit’ and ‘excellent’ is design.

Another thought one might offer is that conceptually the word jugaad refers to a joining of unlike things, that don’t necessarily usually or naturally fit together. Continuing to work on that assemblage until the elements do naturally fit together, again, represents something more intentionally and careful, and this is one way in which we can distinguish the products of design from jugaad.

Check out our prior thoughts on jugaad and indovation here. What more can be done to help people understand the value of design and innovation in making new things possible? Your thoughts welcome below…

Lunch with Kirsten Bound of NESTA


Kirsten Bound is a Policy Researcher who has morphed into something of a specialist in innovation, particularly on how innovation relates to economies and societies. Kirsten works at NESTA, the UK’s nodal agency for innovation, which is soon transforming itself from a government agency to a private charity. Along with Ian Thornton, she’s been working on a report on India’s innovation ecology, which has mapped a number of the institutions, organizations, operations and flows that could allow India to emerge as an innovation society.

We’re very eager for Kirsten to join us for our next edition of Design Public. If not, however, watch this space for more on her interesting report.