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Thoughts on Design Improvements for COVID-19 Mass Vaccination Sites for Vulnerable Communities

Engineers often must think about the social aspects of the problems they are solving, and a mass vaccination site is a great example of a problem that combines process engineering, medicine, and social science. I volunteered at one such site in a low-income area last weekend as part of a program to support pop-up clinics in vulnerable communities, and although my individual responsibilities were rather simple (welcoming guests, handing out vaccination cards, and cleaning seats), I couldn’t help but think that there were improvements to the design of the clinic that could make the process more efficient and comfortable for the patients.

Many patients come from vulnerable communities who don’t regularly interact with the healthcare system, and some design improvements could better accommodate the familial support which many of these patients rely on in anxious circumstances. Furthermore, although the United States is well on its way to vaccinating much of its population, many other countries still have a long way to go, and I believe that a spirit of design thinking could both improve throughput in these facilities and reduce vaccine hesitancy.

Translation/interpretation for non-English speakers represents a critical constraint and efficiency could be improved with a more patient-centric usher model

Most non-English speakers showed up at the clinic with younger English-speaking family members who were also patients. This slowed the process because the family member serving as an interpreter had to wait for their other family members to be vaccinated before they themselves could get their shot. This also caused our patients anxiety because many didn’t know what was going on – and if their other family member was preoccupied with their own vaccination and couldn’t interpret, they couldn’t get answers right away. Our clinic had consent forms available in several different languages with interpreters available to help, but those resources were not always available during the later steps of the process.

I think this process could be improved with a more patient-centric usher model. If families were met by a trained volunteer who accompanied them from intake through discharge, the process would operate more smoothly and quickly, and the vaccination process would be decoupled from the critical rapport-building, anxiety-reducing process where patients are asking questions. Community members who haven’t had as much exposure to the healthcare system are certainly going to be more anxious about the process than patients who are familiar with healthcare settings, and a friendly face may be exactly what’s needed to make the process more effective and comfortable for everyone.

Identification of critical paths and required resources for vaccination process could improve throughput and reduce nurse time per patient

The entire patient journey requires quite a lot of unique steps, and a detailed identification of those steps and required resources can help improve throughput and reduce waiting times. Consider the vaccination step – where the nurse actually injects the patient with the medication. This process consists of multiple steps, including:

  • Initial introduction to patient and rapport building while moving to patient location and putting on new gloves (~30 sec)
  • Asking patient which arm they want to receive the shot, and explaining that they (the nurse) don’t have a preference (~15 sec)
  • Helping patient roll up sleeves or otherwise expose arm to get vaccinated (~5 sec)
  • Opening bandage and setting aside so it can be applied to patient when ready (~5 sec)
  • Opening alcohol pad and wiping arm (~5 sec)
  • Helping the patient relax their arm, injecting the medicine, throwing away the syringe, and applying the bandage (~10 sec)
  • Instructing the patient about the rest of the process, informing them they have to wait for 15 minutes, and answering further questions (~30 sec)

By my estimates, it takes a nurse approximately 100 seconds to vaccinate a patient from beginning to end, but many of these steps (especially regarding the introductions, rapport building, and followup instructions at the end) could be performed by other people under a more patient-centric model, thus reducing nurse time per patient and improving the number of vaccinations that each individual nurse can provide in a given time period. Nurses at our facility also had to manage their own inventories of vaccines and PPE, which caused delays when nurses had to pause vaccination to obtain more equipment.

Speed up vaccine thawing and preparation process

Another critical path is the vaccine thawing and preparation process. This part of the process was not visible to me so I can’t comment on the details, but both at our clinic and at a different site in San Francisco (where I was accompanying a family member for their appointment), the long lead time required to remove a vaccine from storage, thaw it, and prepare the syringe caused extra wait times as volunteers had to count and manage the people in line to ensure no vaccines were wasted. If vaccines could be thawed more quickly from deep-freeze storage, they could be thawed on a just-in-time basis and given to patients immediately as new allocations arrive, thus improving the patient experience and reducing administrative burden.

Improve the waiting experience for patients under supervision

Patients who receive a COVID vaccine are generally required to wait 15 minutes under supervision to check for adverse effects of the vaccine – and those with a confirmed history of allergies or other risk factors have to wait even longer. This caused problems for many of our patients, who were forced to sit silently in socially-distanced chairs after receiving a new vaccine. We were forced to separate parents from their children, and families often couldn’t sit together too. Although this makes sense from a strictly public-health perspective, some flexibility should be given to better accommodate those patients who are nervous about the process and who are accompanied by loved ones.

These are just some examples of design improvements that could be implemented quickly for vaccination sites for vulnerable communities – further observation will certainly uncover more. I hope that this sparks some ideas among the wider medical and engineering communities and results in more efficient and effective vaccination efforts.

Impact Investing Priorities from World Water Week

World Water Week is a global water conference held annually in August which convenes stakeholders across the private sector, the nonprofit space, and governmental agencies to discuss many issues related to water. New technologies are highlighted, new policies are debated, and case studies from all around the world are analyzed.  This conference provides an interesting snapshot of future trends in the water space, and impact investors should be following these developments closely to help focus their investment decisions. The 2020 conference just ended, and in this post, I’ve outlined some of the key trends that impact investors should take away from this conference.

Resilience

Resilience is a huge priority within the water world at all levels, and it was the most frequent theme discussed at World Water Week. The ongoing global crises around climate change, COVID-19, and political disputes related to cross-border water usage are encouraging innovation in humanitarian aid delivery, policymaking, public works, and private projects. Stakeholders are encouraged to consider the broad risk profile of their water usage and to account for potential vulnerabilities within water sources that may impact their operations or programming. There is significant demand for investment in technologies that will reduce water usage, improve information around water reporting, and facilitate a dynamic response to changing climate conditions in business operations.

Quantitative Sensing and Data Tools

This is the age of big data and the water sector is no exception. Several sessions were held regarding the importance of providing data to decision makers, including discussions of mapping technology, emissions detection systems, and hydrological models. The perception within the sector is that there is significant data scarcity in many areas, and the development and deployment of sensing, modeling, and other quantitative tools for analysis could meet many immediate needs. The sector is quite conservative – there aren’t many moonshots here – and it will likely take more time to drive adaptation of these new technologies than would be required elsewhere. There is an upside: many of the implementations will be quite “sticky” and could lead to significant account growth over time. An impact investor with a long enough time horizon could develop a robust portfolio of investments covering different geographies and market sectors.

Decentralized Solutions

Local problems require local solutions, and the sector is starting to recognize and invest in smaller-scale utility systems. Different kinds of businesses which focus on localized service provision, including water delivery networks and local water kiosks, were emphasized as lower-cost alternatives to the expensive capital investments of centralized utility networks. These solutions can be applied in different geographies and at different scope based on local conditions, which means that attractive investment opportunities can be found for a wide range of impact investors. In addition to financing, these businesses have various crosscutting needs where impact investors could add value beyond providing financial resources, including capacity development, provision of technical assistance, and implementation of other forms of best practices in the organization.

IoT and Digitization

Digitization of sensing technologies is a big area of focus, especially as sensors are developed with lower power requirements, longer battery life, and a more affordable cost. The sector is learning the value of connectivity to identify water loss in utility networks, to distribute water more accurately and effectively for agriculture, and to handle payments for utility providers in the developed world, among other applications. An impact investor could have a significant impact by bridging the gap between water utilities and the high-tech world of IoT.

Consider Responsible Water Use When Investing in Water-Heavy Sectors

The final takeaway for impact investors from World Water Week is that responsible water use is a key factor in the success of other kinds of investments, especially in water-heavy sectors like agriculture and mining. Investors in those sectors must consider incorporating responsible water stewardship frameworks, like the AWS Standard 2.0, into their programs. A proper site vulnerability assessment should be done to identify risks to water supplies before money is spent on expensive capital projects. Impact investors should also consider the broader social impact of the project on the wider community’s water needs, especially the needs of immunocompromised or otherwise vulnerable people. A longer-term focus on the sustainability of water resources is a key aspect of due diligence and must be at the core of an investment committee’s decision-making process.

CoI disclosure: My company’s partners in Inogen Alliance perform AWS certification and site vulnerability assessments for private clients.

In summary, World Water Week was a great opportunity for impact investors to learn about trends and opportunities in the water sector. There are many potential intersections of other innovative spaces, like IoT, with the more conservative water sector which could be explored and developed to have significant impact. The sector is ready for new ideas and is ripe for investment across a wide range of deal sizes, geographies, and focus areas.

5 Tips To Ensure Business Continuity and Resilience During A Dangerous Political Crisis

Last week, soldiers in Mali seized power from President Ibrahim Boubacar Keita, setting off a regional crisis that sent shockwaves through African political circles. As of this writing, only a few lives have been lost, but the country has been suspended from the African Union and significant security restrictions have been imposed. This is just the latest example of the dangerous crises that so often impact business owners and entrepreneurs in the developing world. Succeeding despite these setbacks requires a deep understanding of the importance of business continuity and resilience when doing business in emerging markets.

The typical advice for most expats in these situations isn’t particularly helpful for business owners – it’s usually just to avoid demonstrations, shelter in place, or leave the country. Although this may be sufficient when only considering your physical safety, it says nothing about the continuity of your business or the safety of your local team. In this post, I’m going to outline five tips I’ve learned for keeping your business going during a dangerous crisis.

1. Develop as much flexibility with your cost structure as possible.

When working in a potentially unstable location, you should think hard about the exact modalities of your cost structure. Consider if it makes sense to rent a business location where you can pay rent month-to-month rather than committing to a long commercial lease with an extended notice period, even if the total cost of the longer lease would be less than a monthly arrangement. If local law allows, include a suspension clause in your employee contracts allowing you to reduce pay or furlough the employee in case of an emergency – remember that clauses like this should only be invoked when absolutely necessary for the survival of the company. Ensure that you can suspend SLAs or other ongoing commitments in case of civil unrest. It may sound silly and overcautious at the time, but these kinds of precautions can prevent your business from entering a death spiral when something bad happens.

2. Cross-train employees on basic critical business tasks.

As your company grows, your headcount will expand and team members will specialize. In a crisis, some team members may not be able to perform their duties as needed, so you should ensure that those remaining can keep things running and ensure business continuity. Multiple employees should understand the business’ overall needs related to regulatory filings, rent and other financial obligations, and any other important tasks which are necessary to keep the business in good standing.

3. Maintain an accessible stash of hard currency.

A lot of business involving larger amounts of money or cross-border trade is done in hard currency like the US Dollar or Euro, and you need to ensure you have the uninterrupted ability to meet your payment obligations. During a crisis, foreign exchange in-country may be restricted or the local supply of hard currency may run out, so it’s important to keep some emergency funds in an accessible place. Depending on your circumstances and the amount required, you can store the cash in a foreign bank account or even just a secure cash box in your local office. Consider how you can access the cash and pay your vendors if you can’t get to the bank in person – then develop your contingency plan.

4. Develop detailed security, evacuation, and continuity plans for local and foreign staff.

You should keep your local and international team members safe by developing comprehensive plans that may involve local or international restrictions or relocation of team members. Many international organizations and companies operating in unstable environments have security plans including different levels of restrictions that are implemented based on a location-specific risk assessment. A simple example could look something like this:

Level 1: No special restrictions, life continues as normal with basic common-sense precautions

Level 2: Nighttime curfew is implemented for all staff, specific no-go zones are set and specified

Level 3: Non-essential personnel are ordered to depart immediately; remaining staff are relocated into temporary accommodations in areas protected by security forces

Level 4: All essential personnel are evacuated using all available methods Monitor the political situation, including local and international media and other social media channels like Facebook, Whatsapp, and Twitter. It will often be challenging to find accurate information, so you need to be willing to go with your gut and act decisively before it’s too late. Remember that your first priority is to ensure the safety of your team and their families, and you need to be a leader and take charge. In a crisis, you can’t rely on anyone else, including diplomatic representation, to take care of you, so think about what kinds of circumstances should trigger certain responses.

Consider ways to get your staff out of country, including using unofficial routes if borders are closed. Note that formal evacuations using military assets are often only for the most extreme circumstances; and if such an option is available, you may be required to sign a promissory note promising to reimburse the cost.

5. Communicate early and often with international partners, clients, and other stakeholders.

The international media will often fail to report situations until they have escalated to an extreme level, so it is extremely important that you communicate with your international partners, clients, and other stakeholders early and often if you sense that problems could start to develop. It’s better to be too cautious and overcommunicate than to cause surprise and alarm when a situation appears to come out of nowhere. By communicating early, you will develop trust and understanding and will make it easier to readjust or renegotiate agreements and commitments if needed.

I hope you found these business continuity tips insightful and I would love to hear your thoughts in the comment section below. If you want to learn how I can help you implement these concepts in your company, advise you on other topics related to business in emerging markets, or solve Grand Challenges; or if you want to contact me for any other reason, please reach out via the contact form on this website.

What an Angry Mob Taught Me About Social Entrepreneurship

Sometimes you have to learn things the hard way, especially when you’re a so-called “social entrepreneur”. On the surface, social entrepreneurship is a laudable concept – the idea is that one can build a company or organization that solves a community problem while also being financially sustainable, and it seems like a win-win. After all, you’re making money and you’re helping people. You’re changing lives! No more donors will be throwing money away on useless projects! This is the future!

As I would come to learn firsthand, the issues surrounding social entrepreneurship are a lot more complex than they on the surface. As an aspiring social entrepreneur, if you’re not really careful about where you fall – more on the “social” side or more on the “entrepreneurship” side – you can have some serious issues.

Let me tell you a story that made me see things differently. Soon after starting my work in Africa, I sat for hours in a dusty Land Cruiser with my colleagues and a client as we sped down dirt roads in a remote part of rural Uganda. We drove past rolling hills covered in vibrant green trees, banana plantations, and cattle. Children stopped on the side of the road as we drove by and stared and shouted – after all, white people didn’t come by very often. Families of monkeys darted across the road in front of us, reminding me of the deer I saw growing up in Minnesota. We were the only car for several kilometers in any direction, and the journey was exhausting because of the poor conditions of the bumpy roads. The car was filling with dust, the sun beat down, and we were tired.

We had left Kampala earlier that day on a mission – to visit several remote rural sites where our client was constructing churches. The client had an ambitious program to construct hundreds of churches in rural East Africa, and they planned to provide water and energy services to support the community as part of their investment. We were their strategic partners who advised them on different kinds of technical solutions, and they partnered with local contractors to carry out much of the work. Their project was moving quickly; they had already met with government officials in most countries in the region, several of the churches were under construction, and funding had been secured from donors in Latin America. The project seemed to be moving fast compared to local norms, but we did our due diligence and independently confirmed that these activities were really going on. As a New Yorker frustrated by the slower pace of business on the continent, it was exciting to be on a project where things were finally moving!

After more driving, we arrived at our destination, a small remote village. We examined the worksite, where the foundation had already been poured and construction of the walls was ongoing. Great progress! We then met with the village leader who was incredibly happy to see us. Upon speaking with him, he told us about the local orphanage, where children who have lost one or both parents can get additional support, help with schoolwork, and other kinds of services. It seemed like a great opportunity for us to make an impact.

We went to the orphanage and met the kids. These children were extremely poor, even by local standards; they wore tattered clothes that were dirty and worn out, not like the new school uniforms at the fancy private schools in Kampala. Their English was poor and my attempts to communicate in my horribly broken Luganda didn’t go well either. Some of the children had hygiene problems, and there were several dozens of children with only a few staff. The whole situation was sad and overwhelming.

After we mingled with the staff and introduced ourselves, we were given the chance to address all the children at once, at which point one of the most infuriating moments of my entire professional life happened.

The client looked the children in the eye and told the crowd that I was going to bring them safe drinking water.

At the time, the idea was exciting. The kids cheered, clapped, and all started hugging me. I would later realize that he had made a promise on my behalf that I would fail to keep, and my overly-optimistic disposition became a liability.

Fast forward a few months later. Their construction work had been ongoing for a few months and the donors had all arrived to see the progress of the project. A large event was arranged at the national stadium to introduce the project to the world, and I was invited to be a VIP. Community members filled the stands as we took our respective seats under a canopy shading us from the brutal equatorial sun. I was wearing an Italian suit, sitting in a leather armchair in the middle of the stadium with the other VIPs. Officials surrounding me included the donors (who were wealthy entrepreneurs from Latin America), several local government officials, and a few Ministers. The local news media was present and was filming the event – they seemed to like using my face for their camera tests. The project was formally presented to the stakeholders, refreshments were served, and a crazy dance party broke out in that true Ugandan way that you can really only understand once you’ve spent time over there.

And then the mob showed up and demanded justice. No, seriously.

I learned later that our client had failed to pay about a hundred contractors in the region, so they decided to band together and fight for their money. They showed up en masse at the stadium and tried to force their way past the armed police guarding the place. The situation was tense – at first, our client unsuccessfully tried to calm them down, and then the police got involved…for the record, Ugandan police have no qualms about using force. It wasn’t clear what was happening at first, but once we realized something was wrong, we escaped through a side door, made our way to our car, and drove home before things got worse. It became clear that this project, despite our optimism, truly wasn’t going to work out after all.

I realized at that point that I had made a huge mistake: I spent too much time listening to people around me and “drinking the Kool-Aid”. When you’re a social entrepreneur, you are surrounded by people who are motivated by changing the world in different ways. SOme people volunteer, they go into politics, they start nonprofits, or they work in the private sector, but the vast majority of the ecosystem you build around you naturally consists of people whose main focus is on the social impact of their work. There are a lot of dreamers, not enough cynics, and too little institutional focus on core business concepts like lead qualification, unit economics, sales cycles, pipeline development, and cashflow management. I’ve always felt that the ecosystem surrounding social entrepreneurship is more accurately described as a nonprofit ecosystem dipping its toes into the world of business rather than the inverse, and my failure as a first-time entrepreneur to recognize my lack of experience in certain areas led me to be too excited about this project.

It also doesn’t help that everyone around you tells you that you’re awesome. I’ve attended formal dinners with heads of state and other government leaders where I was twenty years younger than everyone else, friends have introduced me at parties as ‘that guy who’s doing something amazing and changing the world’, and I could get an audience with just about anyone who was remotely interested in helping out poor or vulnerable people simply by introducing myself and sharing a little bit about my background. In terms of directional signals, it really seemed like things were going well and everyone was excited about my work. I was optimistic that everything would work out, and I wasn’t skeptical enough of what was happening in front of me. If I had been a bit more careful and spoken with more of the other partners involved in the project, maybe I would have realized that trouble was on the horizon.

But I didn’t. And I got chased out of a stadium by a mob.

It’s easy to get swept up in grand visions of changing the world, making an impact, and doing something about the problems you see around you. But until you really understand the core fundamentals of developing a company – all the way from the high-level, strategic vision down to the nuts and bolts of cash management, contract negotiations, and everything else – consider whether you’re doing more harm than good. Years later, I still think about those poor kids that never got water because I was too optimistic that things would work out and didn’t act quickly enough to prevent promises being made that I couldn’t keep.

Next time, I’ll be more careful.

This post is also available on Medium.

Welcome!

My name is Andrew Mang, and I’m a social entrepreneur, engineer, and consultant. I started this blog to share some of experiences and thoughts. I’m sharing my stories to entertain, to instruct, and to start discussions, and I hope you enjoy them. If you want to chat with me, please reach out via the contact link and we can set up a time to talk.