The Shringaar Calendar- An Innovative Breakthrough for Female Reproductive Health


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

Grand Challenge Breakout Session: Toilets and Sanitation for All

The Challenge and Context

As of 2009, 74 percent of rural India still did not have or use toilets. This has implications first on health, hygiene and well-being, and then on issues of safety, convenience and privacy. The Indian government introduced the Total Sanitation Campaign (TSC) in 1999, with the aim to eradicate open defecation practices by 2017. As a part of this program, the government offers subsidies to villagers interested in building private toilets. Additionally, the TSC focuses on women and children and now has mandated that all members of local government build and use toilets in order to bring about behavioral change in the villagers. However, there is a great challenge with the translation of these policy measures into actual implementation and wide adoption of the program. The aim of this session is to brainstorm on possible solutions to this gap in implementation and to identify ways in which innovation can contribute to this effort.

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A Parable on Innovation

By Aditya Dev Sood

You are tasked with finding ways to design new kind of toilets, ones which will actually be used by those who have no experience using them. The challenge is complex because it is underdefined. Do you change the people or do you change the design? What kind of new design might work? It boggles your mind, just as it has defeated the minds of so many social workers and bureaucrats over the many years since Gandhi made toilet design an integral part of his program for the upliftment of India.

To try to bound the problem you agree to do fieldwork in rural India. Participant observation, to be precise. Early in the morning, you rise from your bedding with your host and take a walk out towards the fields. The light is still soft, the birds are singing, and the leaves rustle in the gentle breeze. You have your bottle of mineral water clutched firmly in your right hand. Your host points out a spot. It is secluded, partially hidden, and with a faint grimace you settle down to the act. It is necessary to understand the point of view that you are trying to change.

On the third morning you are walking back from the fields with a faint smile of contentment trying to remember why you are here. Toilets? Why on earth would anyone want to give up the simple and elemental pleasure of crapping in the fields? We are human mammals, evolved in riverine deltas and migrated to savannas, why do we need toilets? This is the natural way, the only way to betake oneself.

You return from the field shaken in your understandings down to your very inner core and sense of self. Everything you knew about the problem is out the window. Now you are ready to design, not one toilet, but an array of propositions and possibilities, that collectively transform the very way in which we think about what toilets are and what they are supposed to do. Innovation has begun to be possible.

The grand challenges facing our society remain unsolved because they represent an intersection between competing needs and desires for which no solution has yet been found. Once a solution is found, the challenge will become trivial, for an off-the-shelf solution for the problem will already exist: a ‘best practice.’ Until then, we will need the application of design in thought and innovation in action to discover possible, incremental solutions to these socio-technical problems.

To identify those grand challenges facing us, and to explore and articulate how innovation approaches can help us grapple with them is one of the key goals of the upcoming Design Public Conclave.

What Happens When It Rains?

It’s been pouring cats and dogs in Bombay. Roads are flooded, potholes are rapidly multiplying, and traffic has come to a standstill. Or at least been reduced to a very slow crawl. Meanwhile, Hurricane Irene continues to wind its way along the east coast of the United States, causing flash floods, destroying valuable property and necessitating evacuation.

All this begs the question: what are the design consequences of climate change? How can we design our cities to better deal with the climate? Leave alone unpredictable climate change, what about predictable, regular weather like the monsoon, which happens every year. How is it that a city which experiences the monsoons every year for four months still lacks the infrastructure to function smoothly during those soggy months?

What happens when it rains in Bombay? All kinds of hastily put together jugaad-baaz infrastructure is seen to fall apart; minor indents in roads become huge gaping puddles; standard routes get clogged as underpasses become flooded and impossible to navigate. While people are quite adaptable, and can be seen wading through knee-deep water in flooded areas, their vehicles cannot. Cars and scooters are forced to take alternate routes, and massive traffic jams are quite common during these months.

Maybe a user-centered redesign could help solve some of these issues and lead to better designed cities – not even necessarily to make them more live-able, but simply more functional. On the other hand, it could be that cities need to be designed like airports, with modern, state-of-the-art design solutions. But somehow, it doesn’t seem likely that that would work – you can design an airport to be quietly efficient and smooth-functioning using technology and high design, but not whole cities, especially not the delightfully chaotic cities of India.

Maybe solutions for such problems need to be more context-specific. They could perhaps be derived from the experiences of those living there, experiencing and dealing with those problems on a regular basis. Perhaps documenting the consequences of the monsoon in a new way could be a first step towards this: real-time videos of traffic jams due to the rain, or more visual imagery of how people navigate the flooded streets, or city-wide mapping of flooded areas to avert traffic jams.

Is such a user-centric approach at all possible and/or helpful in redesigning our cities? What kinds of approaches could we take to make this happen effectively?

On India’s Innovation Path: Where is it Leading?

Over at 3quarksdaily, our own Aditya Dev Sood wrote a thought-provoking (if somewhat rambling) article on India’s Innovation Path. He talks about how discourse around innovation in India is still at a very preliminary stage, and so far has been largely centered around jugaad and frugal innovation. Aditya argues that, while these may constitute “a first, necessary, and preliminary phase of innovation from India,” there is a need for more systematic and higher-order forms of innovation.

These require more sophisticated approaches than the ad hoc jugaad approach: they necessitate a deep understanding of human behavior, social interaction and everyday practices. Knowledge of these, he argues, can be gained through ethnographic processes, especially using visual and design oriented approaches. The information collected in this way then has to subjected to thorough design analysis, so that meaningful solutions can be designed, tested and finally implemented.

This systematic, highly-intentional approach to innovation is pretty much diametrically opposite to the adaptive, improvised jugaad approach. So what is the way forward for innovation in India? We can’t possibly disassociate ourselves from the culture of jugaad that has thrived for ages and will probably continue to flourish, but there should be a simultaneous move towards more systematic processes. These are not necessarily mutually exclusive since the creative skills and capacities needed for both methods are very similar. Maybe the answer is that we should embrace both approaches, and invite experts on jugaad and frugal engineering to collaborate with those attempting more systematic innovators. Perhaps that could be the best way to tap into the incredible creative capacities of our jugaad experts, but channel them into a more intentional innovation strategy? Comments welcome.

Collaborative Workshop for VDK Prototype Refinement

Last week, the Centre for Knowledge Societies (CKS) held a collaborative workshop in New Delhi. Organized by the team working on the Vaccine Delivery Kit (VDK) project, the purpose of the workshop was for the team to present their methods and processes, display the prototypes already created, and thereafter collaborate with the invitees to refine the colour, material and finish of the final model. There were a total of 18 participants in the workshop, including public health experts, representatives from the Bill and Melinda Gates Foundation, product designers, technical experts on medical devices, experts in colour and materials, and a sculptor. This wide array of individuals with vastly different backgrounds struck some as incongruous at first, but as CEO Aditya Dev Sood explained, innovation is most successful when a variety of minds and backgrounds come together to solve a given problem. Every person looks at any given issue with his or her unique lens, and the best solutions usually emerge when these myriad views are collected, distilled and crystallized, giving forth answers that are deeper and more meaningful than any single point of view.

The workshop began with team members delivering presentations that explained the entire process of identifying challenges, field research and ethnography, identification of use-cases and failure-cases, and developing solutions for all the challenges identified. They identified challenges in the entire vaccine delivery process, and based their designs of the kit on the idea of making the entire process more efficient and hygienic, with the maximum ease and benefit for the ANMs (Auxiliary Nurse Midwives), who are responsible for routine immunization in rural areas. Based on a design-analysis of all the data collected, the team developed three prototypes for the kit, which were tested on field. Once again, pros and cons were collated and a final design was conceptualized and presented for refinement during the workshop.

After the presentations were concluded, the collaborative segment of the workshop began, wherein participants were split up into smaller groups in order to determine the appropriate colour, material and finish for the product. The groups were made so that each one comprised a public health expert, a colour and styling specialist, and a product designer. Participants worked together to associate desired attributes (pictured above) with the visual elements that would best communicate them. The workshop, which was a day-long affair, yielded several options for colour and form, as well as a consensus on the graphic components of the kit. These will be incorporated into the final design of the kit, which will be completed over the next four to six weeks.

TEDxDelhi – Gathering Data on Malnutrition in India

Via the Bill and Melinda Gates Foundation, here’s Manoj Kumar’s talk from the recent TEDxChange @ TEDxDelhi event.

Kumar is the founding CEO Naandi Foundation, an organization devoted to the eradication of poverty in India.

In an effort to combat hunger, Naandi set out to start gathering data about the lives of people at risk for malnutrition. However, his organization found that many people didn’t even understand the concept of malnutrition:


The fundamental and the most shocking [thing we learned] was that we haven’t met any of the cases where we felt predominantly that mothers knew what malnutrition is all about… When we asked, they said they didn’t understand it. it’s not about the literal meaning of it, we tried to explain what a malnourished child could mean or look like or is. And they haven’t a clue.

The lack of awareness about how a malnourished child would look like was something that we weren’t really prepared for.

There were classic responses like she is talking, she is playing, she is eating, she is sleeping and she doesn’t have fever – so why would you say she is sick?

TEDxChange @ TEDxDelhi – Manoj Kumar on Eradicating Poverty in India

How do you make doctors wash their hands?

The New York Times blog Fixes has a pair of posts about the design challenge of getting doctors to wash their hands. Here’s part one and part two.

A health care worker’s hands are the main route infections take to move from one patient to another. One recent study of several intensive care units — where the patients most vulnerable to infection reside — showed that hands were washed on only one quarter of the necessary occasions.

It’s not that hospitals are ignoring the problem — indeed, they are implementing all kinds of strategies to promote hand-washing. Nevertheless, it is rare to find a hospital that has been able to keep the hand-washing rate above 50 percent.

Medical staff are busy, and in many circumstances they may be required to wash their hands dozens and dozens of times a day. But hand-washing is the only way to combat infection. And even though they certainly know it’s important, medical staff are simply not doing what they need to do to prevent infection.

To combat this problem, there is a whole new generation of high-tech devices aimed at making doctors wash their hands:

They work like this: every health care worker wears an electronic badge. When she washes her hands or uses alcohol rub, a sensor at the sink or dispenser or her own badge smells the alcohol and registers that she has washed her hands. Another sensor near the patient detects when her badge enters a room or the perimeter around a patient that the hospital sets. If that badge shows that her hands were recently washed, it displays a green light or something else the patient can see. If she hasn’t washed, her hands, the badge says so and emits a signal to remind her to do so. The sensor also sends this information to a central data base. Information about the hand-washing practices of a particular unit, shift or individual is instantly available.

But there may be a much lower-tech solution: the checklist. Through mandatory use of a checklist, hospitals in Michigan have been able to almost completely eradicate line infections (infections at the point of a intravenous needle). As Fixes notes, the list not only reminds medical staff of the steps they needed to take, but empowers everyone on the team to stop someone else if they skip a step.

Journalist/surgeon Atul Gawande wrote an excellent piece on the use of checklists in medicine in the New Yorker that is definitely worth reading.

Fixes is correct in noting that a checklist is overkill for a process that only has one step. But any solution to the problem of infection will likely need to take into account behavioral aspects of the problem, especially given costly, high-tech hand-washing alert systems are simply not feasible for a great many of the world’s hospitals.

Fixes – Better Hand-Washing Through Technology
Fixes – Speaking Up for Patient Safety, and Survival
New Yorker – The Checklist