5| Social Care and Health Systems for Sustainable Living

Section content 

Campagnaro C., Di Prima N., Ceraolo S.
Systemic and participatory design processes in care systems

Eriksson D., Turnstedt L.
The nordics as world leaders in sustainable healthcare and why it matters to you

Gharavi N., Hozhabri M.
@HOME in transition
Encouraging asylum seekers towards more self-driven approaches to navigate the unknown they are surrounded with.

Kumar A., Wagle P., Bandarkar V., Nahar P.
Design for the taste-makers: System oriented social innovation for improving the living condition of salt pan labourers

Kumar G.N., Gupta I., Ruchatz J., Nahar P.
Ethos Design for a Good Quality Life : Building an innovation framework for individuals and organizations towards resilience and cognitive flexibility

Landa-Avila I. C., Jun Gyuchan T., Cain R., Escobar-Tello C.
Holistic outcome-based approach towards sustainable design healthcare: aligning the system purpose through system visualisation

Nie Z., Zurlo F.
Human-centered approach for flourishing: discovering the value of service ecosystem design in psychosocial career counselling service

Rygh K., Morrison A., Støren Berg M., Romm J.
Pre-fuzzy front end alignment of multiple stakeholders in healthcare service innovation – unpacking complexity through service and systems oriented design in Strategy Sandboxes

Savina A., Vrenna M., Menzardi P., Peruccio P.P.
The Impact of Food Production on Public Health:
Systemic Strategies for a Diffused and Transversal Prevention Plan

Systemic and participatory design processes in care systems

Campagnaro Cristian, Di Prima Nicolò, Ceraolo Sara
Politecnico di Torino

Social inclusion;

The paper discusses the topic of participatory design processes with systemic approach as a tool to negotiate, shape and prototype new inclusive models of citizenship and care to benefit marginal groups in society.
The topic will be addressed via three case studies from the field experience of our action research through Design and Anthropology toward social inclusion (World Bank, 2013). The two disciplines shaped a collaborative and vibrant research environment challenging the issues of participation in design processes. Since 2009, the research operates in several italian cities, entailing both methodological analysis and transformative actions that have tangible effects on social care systems: marginalized people, caregivers, services’ management organizations.

The beneficiaries involved are asylum seekers, migrants, people affected by chronic diseases, and homeless people.
They are usually intended as “fragile” people since they manifest urgent and highly impacting needs that require specific answers, usually provided by the care system, composed both by public and private sector.
Usually, beneficiaries’ needs are multilevel (housing, health, income, work, social relationships, autonomy) and interconnected. The variety of actors that contribute to meet those needs is not part of a coordinated network. From the perspective of our research a care system shouldn’t be intended as a crystallized system but as an ever-changing system that constantly needs to be transformed to better answer to social change.

All the projects described move from the stakeholders’ desire of tangible transformations in order to improve the quality of service: development of new products, redesign of spaces and processes, innovation of the service itself.
In order to support and facilitate this “desire of change”, on the basis of the complexity of the relations that shape the network of the system, it seems to be preferable to operate with a systemic design approach (Jones, 2014) and to develop projects based on participation and collaboration among all actors, in order to include the most of them in decision making processes.

Method and Tools

We developed a specific interdisciplinary method and a set of practical tools to operate into the social care system.

The fundamental elements that define our method are:

1. To observe and analyse the system in order to understand it in its complexity, focusing on the social relationships that occur among people and the stakeholders, and how they shape the system through the usage of spaces and objects. We use focus-group, in-depth interview, video-tour and participatory observation when the project has been undertaken.
2. To carry out co-design processes: all the actors are involved as expert users. We build shared decision making processes designing together a shared vision of change, and tools and procedures to achieve this change.
3. To encourage co-production of the intervention with every stakeholders. They are invited to make available resources in order to produce and manage the interventions.
4. To lead co-creation processes of the most tangible and practical stage of the project set out during the co-design process. We invite the actors to take part to the process sharing knowledge, skills, and competences.

The participatory workshop is the practical tool we adopt to materially shape the desired change. It consists of on-site interventions through creative and collaborative processes, working from within the context.
The workshop is an occasion to stimulate synergies among the actors in an informal and dialogic environment. During the workshop new connections between all the actors are found out, tried out and tightened.
The workshop is also a way to prototype solutions that can be tested, discussed and implemented with all participants.
Moreover, the workshop offers the opportunity to connect the social care system services, so often marginalized, with the society. We do so by inviting in the “outside” to take part to the processes: university students, volunteers, citizens.

CASE 1. Design for Each one _ Co-design of personalised devices for people suffering from multiple sclerosis and muscular dystrophy

The co-design process involves users, care givers, design students and researchers, promoting collaboration between Politecnico di Torino, Associazione Italiana Sclerosi Multipla and Animazione Valdocco, the social cooperative managing the care service.
In the framework of collaborative workshops, everyday life problems of sufferers are investigated by a group of designers and caregivers, through participant observation.
The group investigates on those gestures that users cannot do and they prototype small tools. Within a one-week long workshop, the product is developed and prototyped by a continuous collaborative process with the user. Than, with the same method, the product is implemented and tested for a long time until it is ready to be released.

CASE 2. Cantiere Mambretti _ Participatory renovation of shelters for migrants and homeless people in Milan

The project relies on the collaboration of homeless people and migrants in the role of expert users, workers belonging the organization managing the reception service, designers from Politecnico di Torino, young volunteers as high school students and citizens in general.
The design action places emphasis on ideal of “co-created beauty” as trigger to reshape reception services and spaces.
The co-design process is stimulated by preliminary focus groups with hosts and workers, in order to understand the needs and to define together solutions that all the actors can agree on. Than, the group of participants is engaged in the tangible transformations initiatives: furniture building, wall painting, wayfinding set up.
The project generates a sort of temporary “creative revolution” in the shelter: everybody is welcomed to participate and help with the design interventions.
The vibrant environment of the workshop challenges the reception service’s routines and fixed roles and create a positive impact, also because it involves operators and users in the actions, giving value to people’s skills and aspirations (Campagnaro, 2018).
The effects of this process are diverse in relation to each category of participant: for migrants people, participation acts as a trigger for a sense of protagonism and gratification, while, for the organization’s workers, the project offers the chance to rethink to the way the service is provided and to imagine how the spaces could contribute to improve it.

CASE 3. Costruire Bellezza _ Design Anthropology led lab based in Turin aiming at social inclusion

The group of participants of Costruire Bellezza is heterogeneous: homeless people, care givers, social workers, students and researchers in design and social sciences and creative talents.
The process is rooted in the collaboration between the Municipality services for homeless people, the social cooperative managing these services and our universities (Politecnico di Torino and Università di Torino).
The lab functioning is based on regularly held creative workshops leading to the production of co-design and co-created artifacts for the participants of the project and for the neighborhood communities.
The main outcome of the project can be traced on what the collaboration of the participants generates in terms of empowerment of the homeless people (Sen, 1992) putting in value their capabilities, development of new skills in the students (Margolin and Margolin, 2002), and in the offer of an innovative and informal occasion during which the relationships between social operators, educators and homeless people are tightened.

Design domains

The specificity of the case studies presented can be traced in the extensive use of the co-design method in order to develop all the (tangible-intangible) artifacts together with the users: either the output is a tool, a space or a new social service. However, if we analyse those processes by the “design domains” (Jones, Van Patter, 2009) a scale of incremental impact can be observed between the projects.
The ‘Design for each one’ objects represent an unseen ground for the design of innovative products based on specific needs usually unspoken by the users or not answered by the traditional market because of their specificity. Moreover the project produces an empowerment effect on the organization, fostering the participatory approach also in the educational work.
The ‘Cantiere Mambretti’ projects have an effect on a systemic dimension. They impact on how the reception service is provided in terms of both quality and functionality of spaces. Assuming the co-design model as “a new way to do things”, the stakeholders are connected systemically as agents of change. This environment activates all the participants and design enhances not only physical changes but also the strategy that lies behind the service (Campagnaro, Di Prima, 2018).
Lastly, it is possible to read ‘Costruire Bellezza’ as an example of a project operating on the highest level of the scale of the design domains. Started as an experiment (Binder, Redström, 2006) in 2014 and now recognized by the public administration as a new public service for homeless people and the development of initiative of social cohesion, Costruire Bellezza provides an example of how initiatives of co-design of objects and services can encourage new policy models that rely on the alliances fostered by the participatory design processes.

Final remarks

According to our experience, the systemic vision, thanks to a participative approach, enhances the relationships among all the stakeholders developing new visions of the services, making everybody a “beneficiary”. In order to facilitate and foster an horizontal environment of mutual exchange and collaboration, the researches need to stay within the processes. Doing so, they understand attitudes, behaviors, unspoken needs and outcomes and they can reorient the process on the basis of what the field and the people respond. Places of care can become places of innovation if the project’s system is open, flexible and sensitive to context and individuals. This fosters the cohesion and the inclusiveness of the care systems and it generates the opportunity for all those involved to flourish.


Binder, T., Redström, J. (2006) ‘Exemplary Design Research’, paper presented at the DRS Wonderground conference, 1-4. November, 2006

Campagnaro, C. (2018) ‘Projets interdisciplinaires et participatifs pour/avec les sans-abri’, in Duhem, L., Rabin, K., DESIGN ÉCOSOCIAL: convivialités, pratiques situées et nouveaux communs, it: éditions, Facougney-et-La-Mer (FR), pp. 35-52.

Campagnaro, C., Di Prima, N. (2018) ‘Empowering actions. The participatory renovation of a shelter’, in INTERVENTIONS/ADAPTIVE REUSE, vol. 9, pp.68-75, ISSN:2154-8498.

Jones, P.H., Van Patter, G.K. (2009) ‘Design 1.0, 2.0, 3.0, 4.0: The rise of visual sensemaking’, NextD Journal, Special Issue, March 2009, New York: NextDesign Leadership Institute.

Jones P.H. (2014) ‘Systemic Design Principles for Complex Social Systems’, in: Metcalf G. (eds) Social Systems and Design. Translational Systems Sciences, vol 1. Springer, Tokyo.

Margolin, V., Margolin, S. (2002) ‘A “Social Model” of Design: Issues of Practice and Research’, in Design Issues, Vol. 18, No. 4, pp. 22-30.

Sen, A. (1992) Inequality Reexamined, Oxford: Oxford University Press.

World Bank. (2013) Inclusion Matters: The Foundation for Shared Prosperity, (Advance Edition). Washington, DC: World Bank. License: Creative Commons Attribution CC BY 3.0


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The nordics as world leaders in sustainable healthcare and why it matters to you

Eriksson Daniel, Turnstedt Linnea
TEM at Lund university

Sustainable healthcare
Circular economy



Medical care in the Western world accounts for between 8% and 17% of GDP (according to the WHO), depending on the country. In Western Europe, the average is about 10% of GDP. A sector of
this size inevitably has a significant impact on the environment.
Healthcare activities, due to their specific nature, affect the environment in different ways (waste production, use of chemicals, increasing use of disposable materials etc.). These impacts often are almost exclusively due to healthcare (pharmaceuticals in the environment, infectious waste, different sources of radiation, antibacterial materials etc.).
Over the past 10 years, interest in Sustainable Healthcare has grown globally. Sweden is considered one of the world leaders in terms of Sustainable Healthcare. One of the reasons is that since the 60s, Sweden has been a forerunner in the introduction and implementation of environmental legislation as well as the concern in sustainability issues, that has also been reflected in the healthcare sector.
Sustainable Healthcare has an untapped export potential. Sweden has made great efforts in the sustainability area and is in most cases among the top players in the world, but this has not been exploited to its full potential as a lever for increased export. In this Innovation Agenda we elaborate the issue of the unrealized potential of Sustainable Healthcare.

Definition of sustainable healthcare

The concept of Sustainable Healthcare includes several aspects and spans over various disciplines and areas.

The focus of the Innovation Agenda is on the environmental impacts of healthcare buildings and on the activities that take place in them. In this Agenda, we distinguish Sustainable Healthcare from Sustainable Health which relates to prevention and public health. Disease prevention activities help reduce healthcare impacts, however they are not considered in the Agenda. A further distinction should be made between Sustainable Healthcare and Environmental Health which focuses on the effects of environmental impacts on human health.

“Sustainable healthcare concerns the care of a patient with as little negative impact on the environment.”

The model below illustrates the concept of Sustainable Healthcare and the correlations of its aspects. This model was developed within the
Swedish-Danish EU project Green Healthcare Öresund (2008). It outlines the order of priorities for tackling environmental issues in healthcare. Patient safety always comes first followed by working environment, and last but not least environmental concern. This means that environmental work should not interfere with work environment and patient safety.


Healthcare innovation

Healthcare innovation involves a wide range of stakeholders from different sectors and scientific fields. Even though they develop innovation in different ways, relatively few address sustainable development, which highlights the importance of a more comprehensive understanding of sustainability in healthcare innovation. Outside the well-established technological innovation systems, almost every Swedish hospital, county and region has been involved in national/EU projects and other activities related the environmental that aim at improving sustainability in healthcare.

Sustainable healthcare innovation

Sustainable Healthcare is an interdisciplinary cross- sectoral area. Many different stakeholders, both from public and private sectors, are interested in or affected by Sustainable Healthcare.

Public stakeholders: research centers, municipalities, regions, counties, healthcare administrations, universities, national boards etc.
Industrial stakeholders: companies working in the healthcare sector or other sectors with potential applications in healthcare. Industrial stakeholders include private healthcare, Life Science companies, Med Tech and other companies with sustainable solutions applicable to hospitals (e.g. Cleantech companies).
Networks, professional organizations and Science Parks: organizations in the healthcare sector which contribute directly or indirectly to Sustainable Healthcare innovation.
International organizations: organizations that bring together different stakeholders of Sustainable Healthcare at an international level. NGOs frequently drive forward sustainability issues in healthcare.

As the model below illustrates, Sustainable Healthcare is a horizontal framework as compared to the sector-specific approach used in industry classification. There is no Sustainable Healthcare industrial sector: different solutions, products and innovations span over a wide range of sectors.


Each of the many organizations involved in the work on the Innovation Agenda provided its own view
of the challenges and opportunities that Sweden has in the field of Sustainable Healthcare. The SWOT analysis presented below is partly based

on the experience from Sustainable Healthcare of the project management and the report authors, partly on the interviews and meetings with various stakeholders conducted within the work on the Innovation Agenda.

SwediSh beSt practiceS in SuStainable healthcare

There are many ongoing long-standing projects in the area of Sustainable Healthcare that bring together univer- sities, businesses, counties and span across borders for better efficiency. Sustainability aspects that these projects focus upon differ: energy efficiency, resource optimization, biomaterials, sustainable transportation etc.

The following three examples show the depth and width of Swedish research:

MistraPharma: the project aimed at identifying pharmaceuticals that can affect aquatic ecosystems and mana- ging the risk for growing antibiotic resistance in the environment (www.mistrapharma.se)
PVCfreeBloodBags: the purpose of this cooperation of public healthcare institutions and plastic manufacturers is to produce a PVC-free blood bag that follows the required specification and contains no hazardous substan- ces (www.pvcfreebloodbag.eu)
CLIRE – Climate Friendly Health and Care: the project includes six sub-projects that aim to demonstrate how healthcare can work with climate change in different ways, from energy efficiency in hospital buildings, to gre- enhouse gas reduction in supply chain. (www.clire.se)


Structural conclusions

The sector-specific approach which is a most widely used approach is not suitable for a cross- sectoral area such as Sustainable Healthcare. In most cases, the focus on a specific sector is an obstacle to interdisciplinary collaborations and projects.
There is a high demand for an independent platform for Sustainable Healthcare with the capacity to bring together all stakeholders, to facilitate meetings, events or other activities where companies, researchers and healthcare institutions can meet to discuss challenges and opportunities for cooperation.
Stakeholders lack coordination and often are unaware of their role in Sustainable Healthcare. Companies lack knowledge about the work and needs of the healthcare sector. The academia lacks understanding of the challenges within the area of Sustainable Healthcare. It is necessary to give all stakeholders a broader view of Sustainabl Healthcare and help them identify their own roles in the area.
Cleantech companies do not have the same opportunities to test, validate and commercialize their products/services for healthcare, as the Life Science industry. However, Cleantech industry has a significant potential for further development.
Purchasing organizations lack information on sustainability requirements that are applicable to procurement processes, as well as innovations that are available on the market.

Export-related conclusions

Sweden is well-known abroad as an expert in Sustainable Healthcare. However the export potential of the Swedish expert knowledge is not fully realized. This concerns not only Swedish environmental technology, but above all the systematic approach, management, know-how etc.
Swedish companies with innovative solutions for Sustainable Healthcare target foreign customers rather than the domestic market. The Swedish market is considered to be much more complex and difficult to access, and therefore less profitable.
Sweden has been at the forefront of promoting sustainability in healthcare for many years, but today Norway and Denmark are investing heavily in environmental technologies and green innovations in the healthcare sector. Consequently, Sweden could eventually lose its leading position.

Communication-related conclusions

Many companies do not consider healthcare as a potential customer due to lack of knowledge about how the sector operates. Therefore, better communication and simple activities (e.g. study visits and meetings with healthcare procurement) can make a significant difference.
Many domestic stakeholders are unaware of Sweden’s leading position in Sustainable Healthcare. As a result, national export policies often neglect the area that could provide high export revenues due to lack of knowledge.
According to a number of companies involved in the work with the Agenda, the healthcare sector is often sceptical about new solutions that business offers. Business needs more opportunities to communicate and test its solutions while hospitals need risk-minimizing warrants for testing an innovation.
Healthcare, industry, academia and other sectors seek meeting places at local, regional, national and international level where all Sustainable Healthcare stakeholders can meet, discuss current and future challenges and share knowledge.


The work with the Agenda highlighted the high need for an independent platform that would bring together all stakeholders in the field of Sustainable Healthcare. Following this conclusion, Vinnova extended the project and provided additional funding to start an interdisciplinary center focused on Sustainable Healthcare.

Purpose and tasks

The Nordic Center for Sustainable Healthcare (NCSH) is an intersectoral arena for stakeholders, organizations, projects and expert knowledge in the sector of Sustainable Healthcare. NCSH is an umbrella organization for existing companies, projects and competence. Our ambition is that the NCSH shall generate collaboration and ideas, and gather actors from the healthcare sector.
The NCSH shall help the healthcare sector and its suppliers of products and services to reduce their environmental impacts, while increasing export and employment in healthcare in Scandinavia. Moreover, the reputation of Scandinavia as the world’s leading region in terms of Sustainable Halthcare will be further strengthened.

A growing network

The kick-off meeting for the NCSH was held on May 28th, 2015 at Medeon in Malmö, combined with the final conference for the Innovation Agenda. Over 60 participants from business, public sector, universities and municipalities arriving from Italy, Belgium, Sweden, Norway and Denmark attended the meeting.
The interest in the NCSH is vast, and the number of members is rapidly increasing: in early September 2015, the NCSH already had over 20 members, and many national and international companies, as well as counties, regions and hospitals have expressed a strong intention to join the center. CONTRIBUTORS TO THE INNOVATION AGENDA

“More than 200 organizations have contributed to the Innovation Agenda.”

The working group for the Innovation Agenda was led by TEM Foundation in collaboration with Swecare, Lund University and a number of other partners.
The work that included many activities (interviews, workshops, meetings, conferences etc) was carried out in synergy with other initiatives and projects related to Sustainable Healthcare.

Focus areas

The work on the Innovation Agenda included three principal focus areas:

What innovations does healthcare need?
What areas are overlooked?

How do hospitals/regions, companies, and universities communicate their needs and offers?
How can expertise of the healthcare sector (the customer) be coupled with expertise of companies (the supplier) in terms of Sustainable Healthcare?
What is needed to improve collaboration between healthcare institutions with universities and companies?

How can companies get access to hospital environments for product testing and development?
What kind of support do SMEs need to scale up and reach out to foreign markets?
What needs to be done to boost export of Swedish Sustainable Healthcare solutions?


The contents of this report is a result of the work with the Innovation Agenda that involved more than 200 organizations from business, hospitals, municipalities, counties, regions, cluster organizations, NGOs and academia.
In order to make a balanced and comprehensive analysis of the state of the art in Sustainable Healthcare, these organizations participated in a series of activities where they gave answers and suggestions within the 3 focus areas of Sustainable Healthcare. The feedback from the participants provided the basis for the analytical part of the Innovation Agenda.

Different enquiry channels

8 national meetings with more than 100 organizations involved;
4 international meetings held in Norway, the United Kingdom, Germany and Sweden (with participation of foreign ambassadors);
workshops with more than 50 participants;
16 interviews with key stakeholders in the area of Sustainable Healthcare;
600 contacts in the NCSH mailing list;
more than 3000 contacts through TEM and Swecare mailing lists.

@HOME in transition
Encouraging asylum seekers towards more self-driven approaches to navigate the unknown they are surrounded with.

Gharavi Niloufar, Hozhabri Melina
AHO university

Action design research
Systems Oriented Design
Participatory Design
Asylum seekers
Refugee camps
Reception cetners
Discussion Facilitation


Welcome and feel yourself @ Home in transition.
This project is the story of tackling a common affliction today which brought 2 migrant girls from Iran to each other. They shared their backgrounds, hopes, pains and skills together, forming the project which was not only a master diploma, but a real life concern for them both.
This diploma project is meant to be the first pilot of a co-development concept in transition (elaborated inside report) which happened in Norway at the Refstad Transit reception center in Oslo, during winter-spring, 2018.
Despite the differences among reception centers around the world, they carry some similarities (Mouzourakis & Taylor, 2016) which enabled the project to extend its horizons beyond a contextualized student diploma. Consequently, the outcomes of this first pilot in Norway are both specifically designed for Refstad and also for the general context of transition around the world. The designed actions and tools are generalizable and carry general values which can be extracted as core materials to adapt to any other asylum and refugee centers around the world.

The project is following the concept of Co-designing Actions and Facilitating Discussions In Transition (Peter Checkland & John Poulter, 2006) which affords the possibility to learn through changing the system with its own foot print. It is not about a singular or multiple problem-solving project, but about working with a situation rather than defining problems to solve. (Denis Loveridge, 2008)
The project aims to create a different state of mind within the context of transition and influencing the social system with participatory approaches as a fundamental element of dignified reception. By capacity building and raising self-awareness (NORCAP, 2016), the project is meant to motivate the asylum seekers to recall their competences and wishes towards self-efficacy which affect every area of human endeavor by determining the beliefs a person holds regarding his or her power to affect situations.
Consequently, the process of recalling, planning and taking collective actions based on available resources inside the reception center, builds dignity, self-esteem and self-reliance among people. Such approaches could lift mitigating tensions and conflict in the reception facility and build bridges between different groups.
In addition, the inhabitants of each center would co-develop towards a self-initiated future based on their abilities and hopes. This achievement will also remove the false hope of necessarily ending up in the host country and enrich their abilities to bring them broader horizons regardless of the answer they will get from the authorities.

Fields of the project

With a cross-disciplinary approach, this design diploma project is being held within different design disciplines simultaneously to bring a combination of their values to the humanitarian context.
Among the involved design fields:

Systems Oriented Design: The emergence and development of a designerly approach to address complexity. (Sevaldson 2013 – www.systemsorienteddesign.net, 2009)
Participatory Design and Co-design: as an approach attempting to actively involve all stakeholders (e.g. employees, partners, customers, citizens, end users) in the design process to help ensure the result meets their needs and is usable (Simonsen & Robertson, 2013).
Service Design: as a design approach to improve the quality of different actors’ interaction and involvement by planning and organizing people, infrastructure, communication and material components of a service. (Brown & Wyatt, 2010)
Transition Design: an area of design research, practice and study which looks toward design-led societal transition toward more sustainable futures. (“Transition Design 2015,” n.d.)

Therefore, in this project, tools of Systems oriented design will provide a holistic view over the complexity of the field. “Service Design” tools and approaches help the designer to go in details and design actions based on the target groups’ needs. Co-design tools will facilitate discussions and collaborations among the designers and target groups. Together, these components benefit from the ideations within transition design field.

Theme of the project

Today, 80 million people are displaced and yet 28,300 people a day are forced to flee their home due to conflict and persecution. On the other hand, the world population is growing and this growth will not be among white and rich people. Therefore, the pressure on the borders will raise and continue over the next years. (“UNHCR – Figures at a Glance,” n.d.)
However, 2018 is considered as the down period with less arrival for most of the countries including Norway. Consequently, less resource dedication to emergency responses could lead to saving time and prioritizing development approaches/programs, enabling proper preparation for upcoming challenges. Projects with engaging development capacity management in this period could bring up different scaled local solutions which would empower self-driven approaches towards the problematics. Among them, frustration due to long waiting periods, pacification of the asylum seekers, self-loss and psychosocial health issues could be mentioned.

Followed by the context specific local solutions in countries with less emergency status, approaches and extracted materials/outcomes could be patterned and implemented as several ensuring pilots in other countries as well.
For humanitarian authorities who are engaged with providing services and resources for vulnerable people, there is the priority of encouraging solutions towards promoting self-efficacy within the reception centers to enable courses of action required to deal with prospective situations. Consequently, an individual will be empowered to exhibit coping behavior and sustained efforts in the face of obstacles. This also leads to better integration and active engagement towards the living specifications of the context of resettlement.

Context of the project

In particular, this project is focusing on the context of Transition, such as reception centers where it is even more important for refugees and asylum seekers to consider integration measures intertwined with reception, even in the early stages and with (despite of) the notion that not everybody will be granted asylum. (Bergtora Sandvik, Fladvad Nielsen, Brita Fladvad Nielsen, & Gabrielsen Jumbert, 2016)
Due to the constrains in the transit reception centers and their “military protection atmosphere”, (Balasubramaniam Venkatasamy – Refstad camp manager), as well as asylum regulations, inhabitants’ life style is limited to daily basic needs and long frustrating waiting period which provides lots of issues with psychosocial health and tension. (Based on our field studies & resources)

Design for the taste-makers: System oriented social innovation for improving the living condition of salt pan labourers

Kumar Anshuman, Wagle Prashanth, Bandarkar Vishwesh, Nahar Praveen
National Institute of Design, India

Social Innovation
Community based Design
Wicked problems
Unorganized Sector


Imagine food without salt, the taste buds falling into deep unconsciousness due to the split subconscious confusion created to identify the taste of the food we consumed. The term tastemakers fit perfectly to the labourers who work in the salt pans to produce what gives taste to our food, Salt.
The project aims to understand the ecosystem in and around the production of salt, use design thinking to flourish the living condition of the labourers working in these salt field, improve their working condition to care about their physical parts in the self-involved work culture of producing salt, understanding the socio-economic and cultural condition prevailing in it and build a self-sustainable model for the people involved in the ecosystem enabling a well-deserved return on their efforts. Using Co-design approach and participatory design approach as tools, NGO’s working in the area, the community leaders and the labourers working in the salt fields were involved in bringing design interventions.
The target of this project is to not only make the profession of salt pan labour a respectful one but also to make this profession recognisable. This would ensure cultural sustainability and justifiable remuneration pertaining to the physical and mental efforts invested in the process of producing salt looking at the psycho-social, economic and work environment conditions. The idea was:

To expose the family of the labourers to the multidimensional possibilities to identify and solve a problem
To associate with them, to improve their work and living conditions
To motivate the children of salt pan labourers to explore diverse professions for their means of livelihood
To build a co-operative self-sustainable system that would bring the community together and work towards their social inclusion in and around the community.


The entire ecosystem was understood by doing many field visits, Shadowing method and primary and secondary interviews of the academic experts working in this field, the Non-profit organisation associates working in these areas, labourers, labourer’s family members, landowners and the retailers as part of this applied design research project. 15 case studies which included literature, documentaries and blogs were explored to build a strong understanding.

The location of visit was restricted to Morbi salt production areas in Gujarat, India. Co-Design and participatory design workshops were done with the available members of the community and NGO workers working for them to understand the hierarchy of the problems and the social outlook of the residents. Exchange tools and methodologies with the NGO workers helping them to build a social to Interactive workshops were done with the kids trying to understand their mental development and interest areas. Design tools like Affinity Mapping, Break the Paradigm, Method Cards were used to synthesize the findings to get insights to bring about design interventions.

Observations & understandings

Repeated visiting of the salt pan areas, shadowing their daily routine activities and living a few days of their life at their home, gave a clear understanding of the different layers of the conditions prevailing in the area.
The caste and religious system coupled with the age- old stereotypes contributed a major role in the present condition of the labourers. The downtrodden living condition was due to a combination of socio economic and political reasons. A design intervention encompassing these factors would be necessary for bringing about a social change.
Intense interview sessions with experts from social science background, socialites, faculties from labour institutes, social innovators, designers, social reformers, policy makers were done. This helped in building the topic case study as viewed by different perspectives and understanding the interlinks between the different factors that caused the prevailing condition.

The problems that the designers figured out initially were as per the paradigm build due to their upbringing in a different context all together and be very much possible that the problems that they figured out might not be
the real problems that the labourers are facing. The participatory workshop with the labour family and other stakeholders helped us to understand the true problems that were concerning to them. A clear hierarchy of the intensity of the problem could be mapped. During the Co-Design workshops the participants facilitated by the designers could themselves bring out creative solutions to the problems faced by them, thereby bringing a positive outlook towards their life. The involvement of stakeholders and users in the design process helps in in-time validation of designs and to understand the satisfaction and influence of the new design user.

The interactive workshop with the kids living in 2 different contexts, one with the children who took formal education and other with ones who did not receive formal education, showed the difference in the perspectives of the outlook of children and gave a clear picture of the need for formal education for the children in the area, thereby facilitating us to bring about design interventions to build a sustainable future for next generations.

Design interventions

Looking at the scenario with a systemic approach helps to break the boundary of possibilities for bringing about intervention. It was understood that a single solution cannot bring a reformatory change in the condition of the salt pan labourer which was an outcome of socio-political and economical aspects with a historic background.
Different levels and kinds of intervention would be required to bring about an upliftment in the condition of the salt pan labourers.

Create a new business model: Avsar, a sustainable collaborative start-up between social reformers and the salt pan labour community. Looking at the contribution of small scale salt manufacturers against the large-scale manufacturers in the total quantity of salt production, it is necessary to look at the present scenario not from a profit-making lens but from a sustainable livelihood opportunity lens. Avsar is a business model build on these lines that would manage the systemic complexity and present a sustainable future scenario.
Redesigning the playgroup: Gamification of the learning process created an interactive learning experience for the children helping them to learn healthy living habits and acquire basic knowledge. A playgroup which would infuse motivation in children of different age group would help build an active individual with a positive and responsible outlook towards community and society.
Designing co-creation workshop models for organisations working independently in the social sectors: Co-design and participatory workshops give rich and meaningful insights into the condition and problems faced by the end-users. Methodising the process of organising a workshop and its activities would help the organisations working at grassroots levels to improve the efficiency of their efforts.
Policy design for the governing authorities: Suggesting policies that would cater to different needs of the salt pan labour community and which would align to their economic condition to sustain for a longer run.

These would contribute in the complex system to improve the living condition of the labourers working in the salt pan industry, the tastemakers, to align to Nelson Mandela’s dream in true sense “Let there be work, bread, water and salt for all”.

Ethos Design for a Good Quality Life : Building an innovation framework for individuals and organizations towards resilience and cognitive flexibility

Kumar Gonga Naveen 1, Gupta Itika 2, Ruchatz Julia 3, Nahar Praveen 4
1, 2, 4, National Institute of Design
3 Hochschule, Hannover

Social care for sustainable living
Universal wicked problem
Attributes of resilient systems
Designing for introspections
Sustainability through wellbeing
Designing for perpetual beta

The whole world is driving towards a utopia for a “faster, better, more” future. But ironically the more we have, the more discontent we’re becoming. The current epoch is probably the most complex and ambiguous time humanity has had to deal with. While we’re all designing for a better life, society, nation and world; we haven’t stopped to design and define the attributes that constitute a better quality life.
If we look at what the experts have to say about benchmarks of a utopian life: psychologists have one frame of reference to answer this question from, economists have another, spirituality yet another. The world right now is chasing quality of life through quantifiable parameters like better health, education, employment, GDP etc. and has been benchmarking nations on these parameters. But there is enough evidence to prove that these parameters have fallen short of their promise. Life in countries with the highest GDPs have problems of depression, suicides and obesity. Similarly there are poor countries with little resources resiliently fighting issues like child mortality rate and unemployment.

It’s evident that we experience life as human beings through parameters that are far more qualitative than economic indexes. Our experiences of happiness, flow, love and contentment come not from outside but from somewhere within us. So to improve quality of life of mankind, we need to reassess what Quality of Life universally means. Paraphrasing the Nobel Laureate Joseph Stiglitz: “What we measure informs what we do. And if we’re measuring the wrong thing, we’re going to do the wrong thing.”
With these dichotomies and questions about the current global narrative of a good life, we set out on a journey to define and quantify a “Good Quality Life” using the tools and methods of Systems Design.

Our research for this project started with extensive study of all global models and indexes[1] that define a good quality life, and identifying the gaps in them. We researched theories of multiple paradigms and reached out to various domain experts ranging from psychologists, economists, sociologists, environmentalists to philosophers, spiritual gurus, historians and fiction authors. We discovered a plethora of theories, some contextual and some more relevant, some old school and some contemporary. There was a lot of wisdom about man’s experience of good quality life that we got a chance to dig into.

We then started a more firsthand primary research of looking at places where no one was looking for a good quality life. As true designers, we started looking for deviant behaviors in the system, because that’s where the most relevant insights emerge. Doing this project sitting in India, we used the diversity and complexity of our nation as an advantage for the project.
We went to all sorts of places and people to understand people’s perception of life.
We went to the central jail and spoke with murderers and rapists.
We went to old age homes and heard stories of unwanted grandmothers.
We went to remote villages and immersed in their daily lifestyles.
We travelled with migrant workers to understand their daily routine and aspirations.
We spent time with experimental educationists teaching children without any curriculum; all of this to understand deviant behaviors.
And at each stage, having a culturally diverse team from Indian and Germany was a big boon. It helped us to be pragmatic and unbiased with the way we engaged with our research.

A month long process of synthesis and sense making of all these primary and secondary case studies brought us down to a list of universal insights. With numerous connections and patterns between the insights, we narrowed them down to three fundamental attributes that we believe account for a good quality life. These attributes are the lowest common denominators of what we as human beings are inherently wired to be, attributes that are at the core of who we are.
These attributes are fundamental to building a life of resilience and cognitive flexibility, and hence they are fundamental to evolution.

The three attributes of “Quality of Life” are :

• Attitude | Childlike Creative explorers, who find engagement and pleasure irrespective of what their surroundings are. Explore, learn and move ahead is the way of being. They neither hide their feelings nor hold on to them for very long.
• State of being | Love Love is a state of being where you accept yourself for who you are, accept everyone like you accept yourself, you live and care for others like you care for yourself, without expectations. You start feeling that you and others are alike. Eventually creating a feeling that we are all ONE.
• Ability to act | Creativity An ability to look at things and situations in varied perspectives, challenging rigidly formed assumptions and coming up with spontaneous acts or solutions.

These attributes are simple, holistic and universal. To make them more understandable and actionable we constructed a framework around them, which has been benchmarked and standardized using the Humantific Method by GK VanPatter [2].

The framework is intentionally designed to be simple, free of overbearing jargons or complexity and its open enough for interpretation and evolution. Our idea is to keep the framework in a state of perpetual beta, where it’s ever evolving as a model. We want to keep it dynamic enough so it can adapt as per the needs of an individuals or a culture it gets used in.
Being designers ourselves, we’re already on a journey to test and refine this framework by embedding it in our work of designing products, services and strategies.

We started with the design of an “Assumption busting toolkit” that allows people and organizations to use our framework and reassess their assumptions/hard wired beliefs that are holding them back from being more childlike-loving-creative. This toolkit has been successfully tested through a range “Designing your life” workshops with people of various ages and backgrounds. We used our learnings from the workshop to design a mobile application called Unblock, that gamifies this experience of assumption busting for people. Our application was shortlisted to be a finalist at the Global Hackathon by Aegon.

This framework played a key role in a project we took up with the national science center, to design workshops on creative leadership for school children. We’ve also used the fundamentals of the framework to reassess the current linear narrative of design thinking. Our modified approach of designing thinking 2.0 was shared in the form of a workshop at India’s biggest entrepreneurship summit. The workshop saw an overwhelming participation of 280 attendees.
It’s been quite a journey for us so far, but it’s far from complete.
One project at a time, we’re on a slow but steady journey to test and refine this framework and our approach for Quality of Life. We wish to reach a stage where we can design a world with its development paradigm aligned to childlikeness-love-creativity.
We want to use design to make this world a better place, but not through traditional prescriptive methods. Cultures are an open, adaptable and non-prescriptive tool that build societies and their value through habits and rituals. Thus, we’re now working on expanding our purview as designers from creating objects and services to creating ethos’. We’re working on using our design skills of interpreting systems, of influence behaviors; to create cultures of the future that define the spirit with which people live.
We’re a team Ethos Designers, well-armed with our framework, and all set to realign the paradigms of Quality of Life.


[1] https://s3.amazonaws.com/happiness-report/2018/WHR_web.pdf

[2] GK VanPatter, Elizabeth Pastor. (2016). Innovation Methods Mapping: De-mystifying 80+ Years of Innovation Process Design. CreateSpace Independent Publishing Platform

Holistic outcome-based approach towards sustainable design healthcare: aligning the system purpose through system visualisation

Landa-Avila I. Cecilia, Jun Gyuchan Thomas, Cain Rebecca, Escobar-Tello Carolina
Loughborough Design School

Healthcare outcomes
Systems thinking
System visualisation
Boundary object
Design method
Sustainable healthcare

Long-term conditions represent a healthcare crisis that requires a holistic and sustainable intervention. Systems thinking is fast becoming a vital and suitable approach to face the complexity of chronic care design and development. Systems thinking is considered a reasonable approach to cope with value conflicts between stakeholders and to generate consensus through the negotiation of the different healthcare systems elements. Although there are models that support the implementation of the system approach, there is still little understanding about how to assist the tension of conflict of values and purposes across the different stakeholders.

For example, even if the overarching goal of healthcare such as “achieving people’s health” seems a well-established consensus among the healthcare stakeholders, the broad interpretation of the different stakeholders could generate diverse proposals of how to address it. These discrepancies can cause processes of change towards sustainable healthcare systems to be hindered and fail in their implementation. Therefore, to negotiate the purpose of the system is a critical action that should occur in the early stages of the project and it should be carried by participatory encounters.

However, the participatory encounters in healthcare face challenges such as the lack of a common language, busy schedules, lack of empathy for the needs of others and low understanding of complex systems. Thus, strategies to trigger understanding and help to deal with value conflicts among communities of practice towards the definition of system purpose needs to be explored. Among promising strategies there are visualisations. Historically, visualisations have helped to address the discussion of complex topics and to generate models to interpret the interaction of complex systems.

Although a system visualisation facilitation method can be used to facilitate the collaboration to make sense and to co-create a common understanding of the system among different stakeholders, this technique requires support elements that guide participants during the process. A holistic outcome-based approach has been proposed in an attempt to carry out the process to facilitate a system visualisation method.
Outcomes are commonly present in healthcare systems and normally are linked with the aim and objectives of the stakeholders. However, outcomes have been barely explored as the main element to represent systems. Then, outcomes are an opportunity to negotiate the system purpose through participatory encounters; but, at the same time, outcomes will offer elements to guide and to link the stakeholders with a broader perspective of the system. This outcome negotiation process should be a participatory method able to facilitate the systemic thinking, the empathy toward the relevance of other stakeholder needs and outcomes and, finally, to allow the identification of a potential strategy to align the actions of the stakeholders towards the system purpose in a sustainable manner.

The first proposal of an outcome-based system visualisation technique was generated following a literature review. The most relevant healthcare outcomes included were traditional outcomes such as biometrics, health-related behaviours, safety and quality of care. In addition, novel meaningful outcomes such as subjective wellbeing and happiness were identified as potential leverage across the system and therefore included to complete the holistic outcome.

This paper attempts to explore how to visualise complex systems interactions using a holistic outcome-based approach.
A three-hour workshop was carried at a major design conference to generate system visualisations. The workshop was firstly adapted following recommendations from Sevaldson and Jones and Bowes. However, there were adjustments made after the pilot; the corrections were mostly to clarify the instructions of each task, adjust the time of each phase, and to remove the evaluation of an author visualisation.
Participants of the final workshop were recruited by invitation of the conference organisers. They had access to a description of the workshop prior to signing in. Although previous experience in healthcare systems was not mandatory at least 80 per cent of the participants expressed to have some type of experience in the design of healthcare services.

23 participants worked in 5 teams facing three main tasks. First, to generate an individual visualisation; second, to propose a team visualisation using outcomes, and finally, the teams produced narratives to orally explain their visualisation.
Overall, the data consist of twenty-three individual visualisations and five group visualisations with their narratives. The visualisations were analysed and compared to find relevant patterns across the teams.
The results of the visualisations suggest that there is not a clear visual pattern to make sense of systems through outcomes. Although, some outcomes, such as the psychosocial were more present in the visualisation as a link to the patient, the clinical outcomes were mostly associated with the healthcare system.
However, one of the main remarkable situations is how the visualisation technique and the use of outcomes triggered and encouraged open and meaningful discussions among the participants. Outcomes were an element to work around that guide and help participants to deal with a smaller subsystem.

These findings can suggest that outcome-based systems visualisation is a promising method to trigger meaningful discussions, increase the awareness of the systems elements through a holistic vision of what it is relevant for the different stakeholders. Nevertheless, these conclusions may be somewhat limited by the inclusion only of participants with a design knowledge. However, these findings gathered important feedback for developing further systems visualisation methods that pretend to include patients, family, and the wider interested community. A further study with a focus on the use of an outcome-based visualisation as a participatory approach that includes patients and providers is therefore suggested.


Bazzano, A. N., & Martin, J. (2017). Designing Public Health: Synergy and Discord. The Design Journal, 20(6), 735–754. https://doi.org/10.1080/14606925.2017.1372976

Comi, Alice, Nicole Bischof, and Martin J. Eppler. 2014. ‘Beyond Projection: Using Collaborative Visualization to Conduct Qualitative Interviews’. Qualitative Research in Organizations and Management: An International Journal 9 (2): 110–33. doi:10.1108/QROM-05-2012-1074.
Crilly, Nathan, Alan F. Blackwell, and P. John Clarkson. 2006. ‘Graphic Elicitation: Using Research Diagrams as Interview Stimuli’. Qualitative Research 6 (3): 341–66. doi:10.1177/1468794106065007.

Jones, P. H. (2014). Social Systems and Design. In G. Metcalf (Ed.), Social Systems and Design (Vol. 1). Springer. https://doi.org/10.1007/978-4-431-54478-4

Jones, P., & Bowes, J. (2016). Synthesis Maps : Systemic Design Pedagogy , Narrative , and Intervention. RSD5 Symposium, 1–13.

Lewis, G., & Killaspy, H. (2014). Getting the measure of outcomes in clinical practice. Advances in Psychiatric Treatment, 20(3), 165–171. https://doi.org/10.1192/apt.bp.113.01180

Sevaldson, B. (2015). Gigamaps: their role as bridging artefacts and a new Sense Sharing Model. Proceedings of Relating Systems Thinking and Design (RSD4) 2015 Symposium, Banff, Canada, September 1-3, 2015., 1–11. Retrieved from https://app.box.com/s/tsj7ewtcy9dr63knf64tvo3yrepmzdov

Wilkin, D., Hallam, L., & Doggett, M.-A. (1993). Measures of need and outcome for primary health care. Oxford: Oxford University Press.


Click here to download the working paper

Human-centered approach for flourishing: discovering the value of service ecosystem design in psychosocial career counselling service

Nie Zichao, Zurlo Francesco
Politecnico di Milano

Service Design
Human-Centered Approach
service ecosystem
Psychological Wellbeing
Career Counselling Service
First-year Student

University students are becoming more and more fragile under the new circumstances of socio- economic climate, subjective factors, increasingly diverse student population and the strong presence of their parents It is much more difficult for them to manage their campus life, containing academic performance, social support, psychological well-being, or financial pressures, in a new environment. The problem of adapting the way of university life and directing their future in a positive way is raising. The latest report from National College Health Assessment indicated that over half of students have these fragile feelings, such as hopeless (53.1%), overwhelming by all you had to do (86.9%), Exhausted (not from physical activity, 83.4%), very lonely (64.4%), very sad (68.1%), overwhelming anxiety (61.4%) and so on (ACHA,2017). Besides, Career-related Issue (24.2%) is the one of the main difficulties for undergraduates to handle within the last 12 months. These negative emotions and issues effect the students’ flourishing in life.

In this scenario, the Psychosocial Career Counselling Service (PCCS) is a corresponding solution for students to reach flourishing in the campus ecology and social ecology. The aim of this service is to improve students’ decision-making skills, communicating skills, the self-concept, and other coping strategies (Naicker,1994), It supports individuals to understand and discover themselves so as to become self-directing (Shertzer & Stone, 1981). The career trajectory has a serious impact on human flourishing, and it affects people’s every single day into varying extents, such as social circles, a marriage partner, holiday plans, retirement possibilities (Krumboltz, 1993). However, the critical weakness in career related services at university is in the absence of perception from students. The study from Engelland, Workman, & Singh (2000), was conducted in three universities and analyzed the both perspectives from undergraduate clients and career service staffs. It showed that the three of the five service quality gaps in campus were derived from the lack of understanding student expectations.

The objective of this study is to explore what are the improvements of PCCS from student perspective and how service design can contribute to this service in a cross-cultural context. It is a collaborative research and conducts with a psychologist who is in charge of PCCS at university. Therefore, it combines the knowledge from design discipline and psychology field. The methodology strategy of this research is Case Study to understand what are the service improvements from human-centered approaches, and build service maps from institution documents. Two national universities, that one is in China and another is in Italy, has been chosen and the unit of analysis is the PCCS center for each case. The research target is first-year undergraduate student from different disciplines. The reason of studying on freshmen is that they experience the transition time from high school to campus life. In this period, they suffer a stressful and anxious time while they build new psychological identities (Skahill,2002), and the common “freshman blues” can escalate into fragility, when students start their adulthood and live on their own (Ruiz,2017). The methods are in-depth interview, open- ended questionnaire, and documentation.

In China, this exploratory study collected 32 interviews that last around 40 mins to 60 mins. Besides, open-ended questionnaire elicitation resulted in 553 responses in total and 549 for the valid responses. The intent of the mixed method research was to apply the qualitative questionnaires to explore and make sense in a wider range of the qualitative findings. In Italy, there were collected 32 interviews that in the same time range from 40 mins to 60 mins. In addition, there were 487 responses in open- ended questionnaire and 267 for the valid responses. The method of data analysis is thematic analysis- 6 steps (Braun & Clarke,2006). The findings from the two countries emerged a connection between service improvements and the service ecosystem, since the institution system, education policy, culture, and social environment are different. It entails five nested social systems- microsystem, mesosystem, exosystem, macrosystem and ecosystem (Jones, 2017) to improve the service quality in a holistic vision.

With both theoretical and empirical explorations, an inter-disciplinary approach for service ecosystem design of the campus PCCS for first-year students are emerged. In addition, it puts forward a robust conceptual service design output, which demonstrates its high potential to benefit human flourishing. It discloses for the academia and practitioners both in design and health field an opportunity to see the service ecosystem design for people’s wellbeing in intercultural background, which based on human-centered design logic in order to consider PCCS improvements from new insights, which involves students in an active role for creating the service in an initial step, which is a new collaborative way in PCCS to make a common ground for service design from both design and psychology, which provides an integrated outcome for the general situation and the particular cultural diversities.


Jones, P. (2017). Soft service design outside the envelope of healthcare. Design for Health.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.

Engelland, B. T., Workman, L., & Singh, M. (2000). Ensuring service quality for campus career services centers: a modified SERVQUAL scale. Journal of marketing Education, 22(3), 236-245.

Ruiz, M. (2017, July 14). What No One Tells You About Freshman Year in College. Retrieved January 09, 2018, from http://www.seventeen.com/life/school/news/a36753/what-no-one-tells-you- about-the-first/

Skahill, M. P. (2002). The role of social support network in college persistence among freshman students. Journal of College Student Retention: Research, Theory & Practice, 4(1), 39-52.

Pre-fuzzy front end alignment of multiple stakeholders in healthcare service innovation – unpacking complexity through service and systems oriented design in Strategy Sandboxes

Rygh Karianne, Morrison Andrew, Støren Berg Marianne, Romm Jonathan
C3 – Centre for Connected Care
The Oslo School of Architecture and Design

Service-system design
Workshop facilitation
Strategy sandbox
Service design


Contemporary health systems are deeply complex, organisationally and temporally. Recently, focus has increasingly been given to patient experiences and needs (LaVela & Gallan, 2014) and to developing services that accommodate a diversity of needs within formal institutions and their extensions into society. With patient-centred recovery and well-being as a focus, the challenge arises as to how innovative and sustainable services can be developed in contexts of such systems. While Service Design (SD) has emerged as a domain of design-based inquiry and professional practice, early studies have often centred on commercial partners, service delivery, customer experience and satisfaction views. However, such approaches ought to be coupled with Systemic Design efforts, due to the socio-technological complexity and interlinked nature of healthcare service development and change management (Jones, 2013). This is crucial in the front-end of related design.

In the Nordic countries, the public healthcare sector is seeking to increase partnerships with private actors in order to reach policy goals and offer healthcare services to a wider demographic in a time of resource shortage. Ensuring a fruitful collaboration between public and private sectors becomes central as a matter of design and innovation. Such collaborations also amount to complex social systems, where actors need to understand patient journeys and medical procedures, co-create innovative solutions and distribute ownership, assignments and risks. Establishing collaborative partnerships between healthcare actors and private commercial actors can be challenging due to the deeply institutionalised ways of working and siloed expertise of the medical sector.

This calls for processes and tools that support communication and alignment of diverse actors’ views embedded in such complex social systems to be further developed and better understood systemically. This is especially crucial in the front end of related design, often referred to as the ‘fuzzy front end’. The authors have tackled these challenges facing innovative partnerships through the development and proposal of a Strategy Sandbox workshop pilot.

Developing a Strategy Sandbox for healthcare service innovation

Innovation processes are often divided in three areas: the fuzzy-front end (FFE), new product development (NPD) and commercialisation (Koen et al., 2002). The FFE determines what is to be developed on a conceptual level, but does not develop the details for a specific solution, hence the term ‘fuzzy’. In healthcare cross-sector collaborations, all actors need to gain an understanding of patient journeys and medical procedures early on, to be able to co-create innovative concepts and make a planning for the distribution of ownership, assignments and risks. This paper therefore proposes the introduction of a preliminary phase of the FFE, termed the ‘pre-fuzzy front end’ (PFFE), supporting an alignment of relationships between participating actors and the co-creation of a shared understanding of the object of development before entering the FFE.
Through defining the PFFE, the authors have questioned:How may service design support multiple actors (public and private) in aligning their expectations, needs and goals to co-envision new directions for patient-centric healthcare service innovation in the pre-fuzzy front end of a development process?
Rooted in qualitative inquiry and practice based research, the authors have made use of a blend of methods to approach this question: research by design, reflection on action and analysis of data such as sketches photographs and contextually designed facilitation tools that unpack the fuzzy front end site in wider reflexive and iterative innovation processes.

Understanding the complexity of service-system relations

The sandbox metaphor is borrowed from innovation processes and product R&D and is perceived as a conceptual workspace encouraging exploration, experimentation and interaction between diverse actors. It is informed by the Centre for Connected Care (C3) research investigating innovation labs (Carstensen & Bason, 2012) and co-design communication tools (Sanders & Stappers, 2008) that are used within the context of healthcare service design. The research draws parallels to design oriented innovation venues in health, e.g. the 100-days challenge of Nesta Health lab (UK), Experio lab (Sweden) and Mindlab (Denmark).

One of the features of complex systems is layering, meaning that different phenomena and unpredictable qualities can appear at different levels of aggregation and spatial scale (Liljenstrom & Svedin, 2005). The Strategy Sandbox has therefore set out to unpack the complexity of healthcare service development on three levels: Macro (mapping stakeholders needs), micro (mapping user needs and experiences) and meso (co-envisioning and co-developing possibility areas). Sandboxes have also been described as having four key features: connectors, framing, space and speed (Clarke, 2017). The workshops explored early phase formation of innovative partnerships within the C3 stroke project. With 47 participants in total, the concept has been run as an innovation partnership and public procurement between public sector actors and commercial vendors to innovate products and services to address unmet needs.

Workshop 1

Working on a macro level, the first workshop aimed at aligning the participating actors by creating a shared overview of their needs and perspectives, allowing them to express their opinions and views. Tailored communication tools mediated discussions between workshop participants, facilitating the sharing of perspectives on the service situation and proposals of possible public private partnerships. (Figure 1).

Actor needs were filtered via criteria derived from medical health professionals, designers and participants where a visual relational mapping clarified available resources in the actor network. By using physical tools, concepts were re-evaluated and adapted leading to concept shifts (Buur, 2012) where a proposal was presented regarding what a med-tech company might offer in developing innovative purchases following defined needs. This, we see as a systems oriented design mode of exploring service networks.

Workshop 2

On a micro level, the second workshop facilitated a detailed mapping of users’ needs and experiences and an exploration of different public-private partnerships. Here, we sought to unpack systemic complexity in two ways: 1) mapping patient needs and experiences, and 2) exploring partnership possibilities for technology, users and health service professionals. The workshop made apparent patient views through their participative engagement in patient journey experience mapping, specifically in transitional parts of the service trajectory.
Between workshops, project team meetings were held to reflect on and analyse the previously generated data, leading to plans and strategies for the next workshop. Ten possible areas of development were identified and used as a basis for workshop number three.

Workshop 3

The third workshop of the Strategy Sandbox was dedicated to co-assessment and co-development of the identified possibility areas on a meso level. Evaluations of previous mappings and explorations to develop ten possibility areas for new systemically situated service development, were evaluated and revised to: 1) strengthen patient cognitive assessment, 2) secure further and consistent treatment practices, 3) empower the patient, family and carer givers, and 4) implement distance monitoring and digital touchpoints. To facilitate the evaluation and selection of focus areas for the wider project, a holistically oriented health technology co-assessment tool was developed by the authors (Figure 2).

Future pathways

Through utilising a service systems design process and taking a ‘pre-fuzzy front end’ approach to strategy sandboxes, the stroke project managed to leverage proposals of strategies for matching the aims of technology partners with the service directions of the public healthcare actors. The workshop process facilitated an alignment of expectations and goals amongst participating actors, an identification of needs both for participating actors and end users, and co-envisioned directions for service innovation within the topic of stroke.
Service systems relations are layered and entangled and take time to be understood by a wide network of diverse actors. Our inquiry this far indicates that in order to accommodate the time needed to develop an understanding of the complex relations involved in healthcare collaborations, there is a need for a pre-fuzzy front end alignment phase within service innovation processes. Furthermore, to support the development of more sustainable and accessible healthcare services, this pre-fuzzy front end phase can greatly benefit from more systems oriented design approaches being incorporated into strategic workshop facilitation design.


Carstensen, H. V., & Bason, C. (2012). Powering Collaborative Policy Innovation: Can Innovation Labs Help? The Innovation Journal: The Public Sector Innovation Journal, 17(1), 1–26.

Jones, P. (2013). Design for Care: Innovating Healthcare Experience. New York: Rosenfeld Media.

Koen, P. A., Ajamian, G., Boyce, S., Clamen, A., Fountoulakis, S., Johnson, A., … Seibert, R. (2002). Fuzzy-Front End: Effective Methods, Tools and Techniques. In PDMA Toolbook for New Product Development (pp. 2–35). New York: John Wiley and Sons.

LaVela, S., & Gallan, A. (2014). Evaluation and Measurement of Patient Experience. Patient Experience Journal, 1(1), 28–36.

Liljenstrom, H., & Svedin, U. (2005). Micro Meso Macro: Addressing Complex Systems Couplings. World Scientific Publishing Company.

Sanders, E., & Stappers, P. J. (2008). Co-creation and the new landscapes of design. CoDesign, 4(1), 5–18. https://doi.org/10.1080/15710880701875068

The Impact of Food Production on Public Health:
Systemic Strategies for a Diffused and Transversal Prevention Plan

Savina Alessandra, Vrenna Maurizio, Menzardi Paola, Peruccio Pier Paolo
Politecnico di Torino

Public Health
Food Production
Social Care
Prevention Strategies
Patient Empowerment

Nowadays talking about industrial agro-food production also means referring to different environmental, economic and social repercussions. Although attention given to the way in which the food is produced has grown, the social costs linked to food production have been investigated with a more superficial approach. In many cases the most common mistake is to separate the quality of production processes of our food from our health, forgetting that social costs also translate into health costs if they become burdensome and prolonged over time for the majority of people. An insufficient and fragmented level of information about the strong link between food’s undeclared contaminants and chronic diseases reduces the consumer’s capability of choice in the purchase of food, further diminished by food primary selection executed by the large-scale retail trade.
While smoking is a choice, today getting sick through unreported contaminants contained in our food is not. Smoking is a bad habit, food is a necessity and as such it should not “poison” humans. In fact, diabetes and obesity are not the only disorders related to the quality of food production processes, where production processes refer to all the activities carried out along the entire production cycle, from seed to sale. In this complex scenario, the systemic approach acts as a tool for reading and analysing linear agri-food supply chains, characterized by chemical inputs such as antibiotics, hormones and pesticides (Bistagnino, 2011). However today the range of such contaminants is widening, especially if we consider all the chemical additives used during the extensive phases of food processing and all those substances released from polymeric packaging in the industrial or domestic conservation phase. In the human body they act as endocrine disruptors, interacting with other contaminants assimilated during the years (Maga, 1995).
This systemic phenomenon is deeply connected to two concepts, Chemical Body Burden, that represents the accumulation and interaction of chemical contaminants in the body and Acceptable Daily Intake (ADI), that is the quantity of pollutant legitimated to be swallowed daily without any apparent risk to health (Robin, 2012). The effects and the mutual interaction of these substances not chosen by the consumer are responsible for what the World Health Organization defines as an “epidemic” capable of perturbing the health of future generations. The list of diseases related to industrial food production is destined to longthen especially considering the current system of reproductive dysfunctions, neurodegenerative diseases and cases of teratogenesis in the fetus. In fact, most future pathologies will be of fetal origin: the transgenerational effects will gradually increase. For this reason, it is necessary to translate the concept of sustainable development and the same sense of environmental responsibility also in the field of public health. It is indispensable to start from the prevention of current generations to defend the health of future generations.
On the basis of this assumption, systemic design can lead to a behavioral change in people and in the actors involved in the health and agri-food field. In order to allow the future population to enjoy an optimal state of health a paradigm shift needs to take place within the management of public health, involving a focused and widespread prevention system, starting from the control of the pollutants included in the agri-food production system.

Since the ‘30s industry has controlled and influenced research on the toxicity of products, counterfeting the veracity of scientific results (Robin, 2012): this fast growing phenomenon has allowed higher thresholds of ADI and the legitimization of new hazardous substances. This is the reason why a multidisciplinary figure like that of the designer is essential to lead an improvement that starts from the bottom and works simultaneously on two different fronts through a shared change. This means firsly collaborating with professional figures closely linked to the epidemiological and nutritional fields and with public and private health facilities; and secondly by interacting with the patients and less aware individuals, so that a system of prevention and precaution can be put in place, extending also to those who are not affected by any diseases but who seek a balanced state of health.
The systemic designer has a responsibility in this sense, not only as a activator of relationships, but above all as a processor of a sustainable action strategy that necessarily includes a reversal of the approach to chronic diseases and the consumption/production of food.

On one hand, the doctor should keep his mentorship rebuilding it with greater awareness about the link between diseases and food production, investigating the food chemical exposure suffered by the patient, evaluating his eating habits and pursuing a systemic analysis of his disorders, interpreting the human organism as a set of strictly related organs (Capra,1997). On the other hand, it is also necessary a direct involvement of those who have not yet revealed any disturbance, so that a possibility of protection can be realized through the dissemination of information.

However, it is important that this system also involves food producers, so that they can move towards a production free from chemical contaminants, which follows the season and favors the local varieties. It is also essential to adopt recognized certifications and labels to reassure, inform and guide the user towards conscious consumption.
In this double context the systemic designer draws a dense network of relationships among different actors, within which the patient and the healthy individual to be protected represent the center, active part of the system, directly involved in the treatment and prevention process, where prevention means knowledge, conscious purchase, even self-production.
It is legitimate to ask why the designer represents the fulcrum of this network of relationships. The first answer is represented by the fact that he is simultaneously planner and user of food/health systems, consumer and health seeker (Jones, 2013). The real motivation lies instead in his transdisciplinary education, which supports him in comparison with other branches of knowledge.

Working in the perspective of sustainability and territoriality, it responds to global challenges with ethics and great intellectual honesty, always taking into consideration the peculiarities of the places and the communities in which it operates, which become an integral part of a sustainable, functional, efficient project. Nevertheless, there is another aspect that is not negligible: the systemic designer stands above all conflicts of interest, moving away from the will of the big agro-industrial and pharmaceutical corporations, planning for a sustainable well-being shared by all the collectivity involved, that does not allow tampering and disinformation. Therefore he plans a path that can become a guide towards a behavioral change, through educational projects that stimulate daily qualitative actions and choices (Wendel, 2014). Products, services and territorial strategies change their focus, moving from the profit to the health of individuals and the environment in which they live. However, in order for the connections designed between users, producers, food and health institutions to be constructive and lasting, the designer undertakes to create a dialogue between disciplines, languages and distant professions, minimizing conceptual and communicative obstacles, reconciling different cultural backgrounds. Thus its mediator role becomes fundamental for the achievement of sustainable compromises between different visions, through the objectification of critical points and possibilities. He, therefore, stands as a designer and observer of the system, avoiding imbalances in terms of costs and benefits.

Today there are many case studies developed to bring people closer to the theme of well-being achieved through food, however, most of them rarely collaborates with a team of specialized figures. The largest number of cases helps the users find local and seasonal products and meet direct producers. Some platforms aim to guide users towards a more conscious purchase through complete descriptions in terms of nutritional values, composition, etc. Almost all use tools such as apps and sites to facilitate online purchase, but the downside is the absence of a reliable source of this information and that of specialized support fugures.

Moreover, there are some very interesting isolated cases, which although they do not consider the involvement of the designer profession, they assist the interaction among patients, medical figures, food-producers and chefs for the prevention of the diseases. (an example is Diana 5 Project, conducted by the Dr. Franco Berrino and the “National Cancer Institute, based in Milan). Through this type of projects the level of awareness achieved is higher, thanks to the direct involvement of the patient in the production process of the daily meal. In addition, they represent an excellent example of design application, because it takes strength from relationships, experience and direct comparison. The aims of this research are intended to be part of the Health System for Sustainable Living sector and are not far from the approach pursued by the Medical Design frontier, but with an additional variable: the consideration of the constant chemical exposures to which man is subjected.

Nowadays a real revolution of public health is urgently necessary and this can happen only by starting from education, training and interaction, so that knowledge can become an instrument of power, while food an instrument of prevention rather than a cause of a global system of growing diseases.


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