This Spring quarter, while our seminar series took a break, Terry Winograd and Joshua Cohen taught a new course at the Hasso Plattner Institute of Design (the d.school): Designing Liberation Technologies.

During this class, small interdisciplinary teams focus on a term-long design project, taking advantage of the design process structures and methods that have been developed in the d.school. This year's course developed as a collaboration between Stanford, the University of Nairobi and Nokia Africa Research Center.  The focus area was finding ICT solutions to the healthcare needs of people living in Kibera slum outside Nairobi.

Under the guidance of Jussi Impiö at Nokia and the Computer Science faculty, 27 students from the University of Nairobi Computer Science department conducted need finding studies at a number of health-related sites, including clinics, hospitals, community health workers, community leaders, and government offices. They read background materials, made observations, and talked with a wide variety of stakeholders. Their reports became the basis of the Stanford teams' initial understanding of users and needs. Communication with the group in Nairobi was also maintained throughout the course, using a Facebook group to facilitate discussions, as well as several teleconference sessions.

Working in small teams, 20 Stanford students from a wide range of disciplines worked over 10 weeks to develop initial design concepts to respond to some of the needs that had been identified. Click on the title of each project to view their final presentations:

• mNote: an online archive for community health worker notes. This application empowers community health workers by preserving the flexibility and control they appreciate in their current paper notebooks, but adding digital knowledge management capabilities.
• M-MAJI ("mobile water"): an electronic information system that allows people to use their mobile phones to identify clean water sources in their community. The application seeks to decrease the time and money spent searching for water, improve water quality, and foster vendor accountability by providing a mechanism for user feedback.
• Babybank: a dedicated savings plan designed specifically for pregnant women in the slums of Nairobi. By leveraging a popular cell phone payment system, M-Pesa, the application aims to make savings easier, so that expecting mothers can afford the services that will keep themselves and their babies healthy.
• Mazanick: an application to provide support and advice to pregnant women via SMS, with the aim of helping motivate them to attend prenatal appointments.
• PillCheck (Kifaa cha Tenbe): a mobile application to help people in Kibera find information on the availability and pricing of malaria drugs quickly.
• PatientMap :a system to make the waiting process in clinics more transparent, and to increase patient trust in the medical system.

This summer, two follow up trips are planned, with Nairobi students due to spend several weeks at Stanford, while a number of students from the Stanford group will visit Nairobi to explore possibilities for developing their projects further. Building on the success and lessons learnt so far, the Designing Liberation Technologies course will be open to a new set of students next academic year. 

In early spring, historic health reform passes, extending insurance to millions of uninsured. Despite problems with workplace-based coverage, controversy over government subsidies for insurance premiums, and disparities across a large and diverse nation, dramatic shift to a single-payer system was seen as impractical.

Instead, reforms focus on expanding current social insurance programs as well as new initiatives to cover the uninsured, improve quality, and control spending. They provide a basic floor, subsidized for the poorest, but preserve consumer freedom to choose in health care. No government body dictates choice of doctor or hospital; investor-owned and private not-for-profits compete alongside government-run providers like community health centers and rural hospitals.

Left to be addressed in later phases are the difficult questions of how to slow the relentless pace of health care spending increases -- driven in part by technological change and population aging, but also perverse incentives embedded in fee-for-service payment and fragmented delivery. Pushed through despite multiple crises confronting the leadership, the final landmark health reform works in conjunction with measures enacted as part of the fiscal stimulus package to strengthen the healthcare system. Some provisions take effect immediately; others will take many years to unfold.

President Obama’s triumph on his top domestic priority? Actually, there were no votes along partisan lines, no controversy over abortion. I am describing health reform in China, which was announced almost exactly a year ago.

We do not hear much about the parallels in the US and Chinese social policy. But we cannot fully understand each other if we ignore these commonalities. We do not hear much about those who, in both societies, have been rendered destitute merely because they or a family member became sick or injured in a system with a social safety net full of gaping holes.

It will surprise many Americans to know that government financing as a share of total health spending was lower in socialist China over the last decade than in the United States. Now China has pledged about US$124 billion over 3 years to expand basic health insurance, strengthen public health and primary care, and reform public hospitals.

In China, the injustice of differential access to life-saving healthcare had sparked cases of social unrest. The April 2009 reform announcement was the culmination of years of post-SARS (2003) soul searching for a healthcare system befitting China’s dynamically transforming society. Special interests block change. (Sound familiar?) The CPC Central Committee and the State Council acknowledge that successful health reform will be “an arduous and long-term task”.  

If the US can pass sweeping health reform despite an unprecedented financial crisis, and China can envision universal health coverage for 1.3 billion while “getting old before getting rich,” then together we should be able to look past our many differences to focus on our common interests. Our two proud nations must work together to confront numerous challenges, such as upholding regional stability (e.g. on the Korean peninsula); redressing global economic imbalances (increasing health insurance can help spur China towards more domestic consumption); and investing in “green tech” for a warming planet and “grey tech” for an aging society.

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When searching for insights about how other countries deal with similar challenges, Americans often look to Europe and Canada. Rarer is the comparison to counterparts across the Pacific. Yet President Obama has clearly articulated the vision of the US as a Pacific Nation, and there are developments around the Pacific Rim that merit consideration in our debates.  

Australia pioneered cost-effectiveness in health care purchasing, while the US continues to debate whether cost should be part of comparative effectiveness research and policy decisions.

Both Japan and South Korea, like Germany, have enacted long term care insurance to smooth the transition to an aging society. Their experiences might be fruitful as we implement the first national government-run long-term care insurance program, a little-heralded component of the newly passed legislation (and a fitting legacy of Senator Edward Kennedy).

Japan and Singapore provide universal coverage to older populations than ours with health systems that, although surprisingly different from each other in terms of public financing and role of market forces, both ranked among the best in the world -- and far higher than the US -- in the World Health Organization’s ranking of health systems in the year 2000. Although one may quibble with the ranking, it is indisputable that Japan spends a much smaller share of GDP on healthcare than the US does, despite being one of the oldest and longest-lived societies in the history of the world and having (like the US) a fee-for-service payment system.

Japan and South Korea are also democracies, where health policies occasionally engender heated debates. In South Korea, physicians went on nationwide strike three times to oppose the separation of prescribing from dispensing. Although Japan’s incremental reforms rarely spur such drama, the passions aroused by end-of-life care – embodied in the bizarre “death panels” controversy in the US health reform debate of 2009 – has its counterpart in the bitter nickname for Japan’s separate insurance plan for the oldest old: “hurry-up-and-die” insurance.

Yet Japan, Singapore, and Hong Kong all offer health systems that provide reasonable risk protection and quality of care for populations older than ours, with a diverse range of government and market roles in financing and delivery, while spending far less per capita than the US.

No system has all the answers. But the US and our neighbors across the vast Pacific have a common interest in sharing what we’ve found that works for health reform. Despite divergence in our political and economic systems, we all value long, healthy lives for ourselves and our children -- and we’re united in health reforms that try to further that goal.