Where Technology Has Failed India’s Poorest Women, We’re Building Trust

By Priya Iyer 

For the past few months, our team has been visiting customers face-to-face, including a 33-year-old woman living in the slums of Chennai, India.

We’ve visited her every day in temperatures easily soaring above 100 degrees. (The locals call this peak summer season ‘agni natchathiram,’ the season of fire.) We’ve visited her in the pouring rain, when the alleys in front of her home have begun to flood. And we’ve visited her despite her mild scoldings — she’s as worried about our health, when we’re outdoors in this extreme weather, as we are about hers. It’s all worth it, though, because we’ve finally gained her trust.

Building trust, not technology, is the most challenging aspect of our work at Tulalens, the social enterprise I founded. The women we work with have been failed by markets and the government. They live off of less than $2.50 per person per day in their household. They have rarely if ever been asked for feedback on a product or service in their life. Without the foundation of trust, we found that equipping millions of women with the crucial health information they needed through technology would be impossible.

Understanding Our Customers

This realization didn’t come easily. When we started out more than a year ago, we attempted to bring women living in urban slums Yelp for healthcare. When we first launched, I carried the misconception that technology would help us quickly reach millions of women. By December of last year, we’d reached 1,000 customers. However, it was becoming apparent that we weren’t adding measurable value to their lives. I turned to social enterprises that were specifically working with the poor in emerging markets, and who were having a measurable and scalable impact. I saw a pattern — each of them had incorporated human-centered design (hcd) into their work early on and regularly. After reading more about AyzhMedic MobileNoora Health and others, I reached out to design thinking experts, and we found a generous volunteer through MIT D-Lab’s IDDS network (I lived in Boston at the time) to guide us. I flew to India, and used hcd as a tool to learn why our Yelp for healthcare system wasn’t working. Gathering customer feedback in this market segment is particularly challenging. Women are not accustomed to voicing their opinions, and most people are treated as passive recipients of services, so we had to be creative. We used +Acumen’s courses,ideo.org’s hcd resources, and the power of brainstorming. We created everything from card sorts that helped women prioritize the most important aspects of prenatal care to in-depth interviews. This taught us that government clinics had quotas to fulfill and would dictate where women went to healthcare depending on the area they lived in. Husbands and mother-in-laws also made decisions for women. In this often patriarchal society, it was common for women to have minimal autonomy around decision making and resource allocation. Households generally had one mobile phone, and husbands would usually hold onto that phone. This made women hard to reach and we had to find work arounds. Women talked to their neighbors, but rarely talked to people in other communities. Their sources of information were limited, and the information they took in on health was often inaccurate. Some of the barriers we faced were so complex that we couldn’t overcome them after lots and lots of iteration. I came to the conclusion that we could: 1) Quit; 2) Pivot. I chose #2. It was April. We had runway until July, at the time.

The Turnaround

I returned to India again, and we began determining what key problems affect women on a daily basis using hcd. We held a health camp to understand what problems women faced in their everyday health and asked women to develop collages demonstrating what health meant to them.

By beginning here, we learned about the headaches women suffer, the weakness and fatigue they feel, and how often they get sick. These setbacks make it hard for them to work outside the home and bring in extra money for their families, to care for their family and attend to the housework. Importantly, they told us these were problems in their lives that if changed could bring about drastic improvements for them.

We decided to track their diets to better understand what was going on. That’s when we discovered that the women we work with are eating 3 mg of iron on average per day. The recommended daily value is 18mg. Many are living on a diet that is made up mostly of rice, and surviving on about 600 calories a day.

Our customers had directed us to a major problem they face, but what could be done to help them? We began talking to local shopkeepers and found something surprising: Iron-rich foods are affordable and accessible to many of these women. But a knowledge gap exists. Many are not aware of the consequences of iron-deficiency anemia nor are they informed about what to eat to get the adequate amount of these iron- and calorie-dense foods.

More than 55% of women in India suffer from iron-deficiency anemia. This leads to a 30% decline in productivity due to headaches, weakness, susceptibility to infection, and to lifelong setbacks in cognitive development and stunting for the children of pregnant women.

We’re addressing this problem by recommending iron-rich ingredients that women can incorporate into their diets. We’re working with them to customize this intake to their household’s taste preferences, budget and time constraints, and by tracking and providing women with daily feedback on their iron intake. So far, we’ve been able to more than double our customers’ iron intake. We’re in the process of rapidly prototyping our service to continue to improve upon our impact. Women have also told us how empowering it is for them to be able to eat healthy, and cook healthy foods for their families. They’ve shown their commitment to their health by paying a small fee for our service.

Women certainly schooled us when we were on the wrong path, and we’ve now incorporated these learnings into our work. Our next step is to evaluate our prototype. Only after this is complete, will we start to build the technology, an app that our community advocates will use.

Our takeaways

  • Know your customer and let your customer know you: Spend as much time as possible where your customers are. When you’re straddling two countries this can be challenging. Early on, I was reluctant to spend as much time as I needed in Chennai for a long list of reasons. We ended up building something that women didn’t find useful. If I really wanted Tulalens to impact the lives of women, which I did, I realized I had to face the tradeoffs. I now spend weeks away from my partner, and know I’ll spend hours outside in the extreme weather. But, we are more convinced than ever that we are addressing a truly critical problem in the lives and under-served women, that they need the service we’re providing, and that they trust us to provide it.
  • Build trust, then tech: The technology that social enterprises build is often simple compared to the trust we have to build. I promise, I’m not saying this from a misguided perspective. I’ve worked with developers and have been learning how to code. Our example and many others I’ve seen show that investing the time to build trust first pays off.
  • Human-centered design: The resources I shared are some of our favorite hcd tools. Using hcd helped us focus on women’s needs, find creative ways to gather feedback, and come up with several out-of-the-box ideas that led to testable assumptions.
  • Test ALL of your assumptions: Break your idea up into components and ensure each component undergoes the litmus test of reality. I’d highly recommend Lean Startup for Social Change as your guide. We also use a few of the tabs in this Lean Dashboard to keep track of everything we’ve tested and learned. If you’re interested, download “Template: Lean Dashboard.”
  • Charge your users: Charge users early on. The women we work with make between $.60 to $2.50 per person per day. We were hesitant to charge them initially because we were worried about their capacity to pay. However, we dove in and tried. Charging women a minimal fee easily helps us gauge if they find utility in the service. It’s been an amazing tool that shows their willingness to invest in their health and keeps us on track. In the long run, it will help us cover all of our operational costs.