#designresearch

Field notes are messy. Voices overlap. Contradictions appear. Patterns hide in plain sight.

After days of interviews, system mapping, and stakeholder conversations around e-Sanjeevani in Meghalaya, we reached the stage where everything needed to slow down.

The next step was about capture sheets.

For every interaction, we created structured capture sheets, not just to record what was said, but to decode what was meant. Each sheet helped us extract:

Who was involved

What their role in the system really is (not just on paper)

Pain points vs workarounds

Emotional signals (frustration, pride, hesitation, indifference)

Gaps between policy and practice

Some categories we focused on, for organising our data were:

Verbatim quotes

One month from now, we’d like to remember: 

Unusual / interesting observations we made

Initial thoughts/ inspirations for concepts

Patterns started emerging: • Repeated bottlenecks across different districts • Invisible labor carried by frontline workers • Digital constraints masquerading as “user error” • System-level delays that get absorbed at the human level

The most interesting part? The contradictions.

What the system assumes versus what the dashboard shows versus what the ground reality actually is.

Analysis, in this phase, wasn’t about numbers alone. It was about triangulation — aligning interview narratives, journey maps, consultation data patterns, and stakeholder structures to see where friction accumulates.

Putting the pieces together is less like solving a puzzle and more like tuning an instrument. You adjust one layer, and the whole system resonates differently. Design decisions are not made from empathy alone they are made from structured empathy. And tools like these are where structure begins.

If you’ve worked within layered public systems, especially in rural or resource-constrained contexts, we would love to hear your perspective. You can write to us at [email protected]. Until next time!

On day 5, we left early in the morning to meet one of the most widely known Khasi health providers, the traditional healers. For many Khasi people, they are the first point of care, especially for bones and teeth. Fractures, body aches, persistent pains, even something like gastritis, there’s a quiet confidence in the way people speak about their ability to treat it all using traditional methods. He gave one of us a quick massage, which showcased his years of experience, expertise, and knowledge.

When we met him, he showed us a stack of certificates, some even issued by the state government, almost like a bridge between belief and formal validation. When asked about formal medicine, he said that he believes every medicine system has its value, not just his own. When he falls sick himself, he goes to a hospital without hesitation.

And yet, he holds on to one idea very firmly: medicine has to remain personal. No screens, no remote prescriptions. A doctor should see the patient in front of them; that’s non-negotiable for him.

The next day, we set out for Jongksha PHC in the East Khasi Hill region. We spoke to a staff nurse who works closely with the e-Sanjeevani system on the doctor’s side. With the medical officer often not physically present, the staff nurse takes calls on his behalf, understands the case, and relays it to the doctor over the phone, then inputs the prescription into the system. 

For him, e-Sanjeevani works best as a record-keeping tool rather than a communication platform, especially since specialists are usually contacted directly to save time. He has also built small workarounds, like recording calls to avoid miscommunication during teleconsultations. 

While he supports increasing the teleconsultation target slightly, he’s careful about where to draw the line. Pushing it too high, he feels, would end up burdening the nurses at subcentres who are already stretched. For him, the idea behind increasing the target isn’t just numbers; it’s about slowly building awareness, letting patients ease into the system, especially those who don’t have easy access to doctors or specialists.

It’s less about scale, more about making the system feel usable in everyday life.

With the opportunity areas clearly defined, the process shifted from broad exploration to constructing more concrete concepts. Instead of generating more ideas, the focus now was on refining, combining, and selecting the most promising ideas or opportunities to move forward with from what had already emerged.

At this stage, three key questions guided the development of each concept:

What specific problem is this concept solving?

How does it work as a system, not just a feature?

What would make people adopt and trust this?

Structuring the Concepts

Rather than jumping to polished solutions, each concept was formulated by thinking through elements that would make it whole:

Core Idea – the central intervention.

Value Proposition – what are we offering to make the system better.

User Journey – how a vendor will navigate in the new system.

This helped develop a well thought out and structured concept rather than coming up with ideas and features.

Outcome of This Stage

The result of this phase is a set of early-stage concepts that are more cohesive than individual ideas but still open enough to evolve.

After interviewing a few patients and MLHPs in sub-centres, we set out for Myriaw PHC, which works differently from other PHCs. Myriaw PHC, in collaboration with NGO Karuna Trust, has developed a distinctive healthcare model that stands out among PHCs in Meghalaya. The facility runs its own in-house laboratory for diagnostic tests that would otherwise require a visit to district hospitals, and has implemented a digital system for efficient patient record management.

Upon talking with the Medical Officer, we came across some of the most interesting insights about teleconsultation in Meghalaya.

No network, no teleconsultation - you can't digitize healthcare where the internet doesn't reach

25 consultations a month mean nothing if the system behind them is broken

Top-down doesn't work here - policies designed in boardrooms fail in the hills of Meghalaya; doctors on the ground need a seat at the table

PHC doctors are overworked and under-incentivized, juggling OPDs, emergencies, and deliveries. Without monetary recognition, teleconsultation stays last on the priority list

Linking sub-centres to PHCs first, and let PHC doctors escalate to specialists — not a randomised free-for-all

A simple appointment slot system could save hours for both patients and doctors, making teleconsultation feel less like a burden

Next, we visited Sokhrat sub-centre under Myriaw PHC and interviewed the MLHP, who painted a picture of a system failing at every touchpoint. Doctors don't show up for their shifts on the platform, medicines run out before prescriptions can even be filled, and each teleconsultation can take up to an hour just to fight network issues.

"Patients mostly come here for free medicines. Sometimes, we run out of even paracetamol." — MLHP, Sub-centre

For her, hitting 25 teleconsultations a month on eSanjeevani feels more like a burden than a goal, since the platform rarely works reliably over failing networks. She would rather switch to a simpler platform to conduct teleconsultations. Trust in screen-based consultations, too, remains low compared to in-person care.

On the third day of fieldwork, we moved beyond urban centres into remote villages of West Khasi Hills to understand how e-Sanjeevani functions where distance is not theoretical, but lived. Our focus was on patients, the intended beneficiaries and on how teleconsultation is embedded (or not) within everyday health-seeking behaviour.

Sub-centre Realities: When Metrics Drive Practice

At the Mawdoh Sub-Centre, the Mid-Level Health Provider (MLHP) surfaced structural tensions within teleconsultation delivery:

Target-driven utilisation: Teleconsultations are sometimes logged to meet numerical expectations rather than clinical necessity, suggesting performance metrics may be shaping behaviour more than patient need.

Temporal misalignment: Limited active hubs and restricted doctor availability (often early mornings or late evenings) rarely align with sub-centre OPD hours. As a result, teleconsultations occur opportunistically ‘when time permits’ rather than as a reliable service channel.

Stock-based prescribing: In practice, the MLHP often prescribes from available sub-centre stock instead of initiating a teleconsultation, indicating that drug availability may outweigh digital connectivity in decision-making.

Service concentration: Patient footfall is largely driven by immunisation services, raising questions about whether curative teleconsultation has meaningfully penetrated routine care-seeking patterns.

Parallel informal systems: For bone injuries and dental concerns, local healers remain primary points of contact, reinforcing the continued relevance of informal providers.

Patient Perspectives: Trust Is Interpersonal, Not Digital

Village interviews (a mother seeking immunisation services, an elderly couple, and a father of six) revealed a consistent pattern: trust in teleconsultation is mediated through trust in the MLHP, not in the technology itself.

One respondent explicitly questioned the idea of “free” care, expressing a preference for private providers who offer consultation, prescription, and medicines in one consolidated experience. This suggests that perceived value is linked to completeness and tangibility, rather than cost alone.

In effect, telemedicine does not substitute relational trust; it borrows from it.

Rambrai PHC: Infrastructure Without Institutionalisation

At Rambrai PHC, the parent facility of Mawdoh Sub-Centre, we encountered an unexpected gap: the PHC does not currently practice teleconsultation and initially assumed we were visiting to conduct training.

Interviews with a dentist and a nurse highlighted several institutional constraints:

Absence of formal telemedicine training, resulting in low adoption despite infrastructural availability.

Nurses as trust intermediaries, translating medical terminology, reassuring patients, and mitigating communication barriers.

Preference for physically available providers, including informal practitioners, due to immediacy and familiarity.

Need for outreach-based care, particularly for pregnant women, elderly patients, and palliative cases contexts where teleconsultation alone is insufficient.

Emerging Themes

Across sites, three structural insights emerge:

Incentive–practice mismatch: Quantitative targets may incentivise usage reporting rather than meaningful integration.

Temporal and operational misalignment: Doctor availability, OPD timings, and workflow realities are poorly synchronised.

Trust as infrastructure: Human intermediaries, not digital platforms, remain the core enablers of adoption.

Telemedicine, in this context, appears less as a replacement for physical care and more as an overlay, its effectiveness contingent on local actors, stock availability, and relational credibility.

If you’ve worked within public health systems, telemedicine, or government healthcare programs or if you see blind spots in our interpretation—we would value your perspective. Write to us at [email protected].

With a set of How Might We questions in place, we moved into concept generation. We began with a broad brainstorming session, intentionally keeping the space open to avoid locking into solutions too early.

This exercise helped us surface the overarching categories where most ideas naturally clustered. Across the board, ideas fell into a few recurring directions: awareness and assistance, instant or easier access to loans, repayment systems, and incentives to encourage continued engagement and repayment.

At this stage, we consciously stepped back to examine whether what we had generated were full ideas, individual features, or assumptions carried over from existing systems. This distinction became important—it helped us identify which directions had the potential to evolve into standalone concepts and which were better suited as supporting elements.

From there, we began refining and combining ideas, framing them into early concept directions rather than finished solutions. The focus remained on exploration: testing how different ideas might work together, what problems they addressed, and where they fell short.

Following fieldwork in both cities, we moved into a phase of synthesis and analysis. We revisited interviews with street vendors, bank officials, and urban local body (ULB) representatives, pulling out key quotes, recurring themes, and moments of friction.

This process helped surface not just what was said, but also what remained unsaid - patterns of dependency, trust, confusion, and workarounds that shaped how the scheme functioned on the ground.

This process helped us move into deriving insights by connecting patterns across interviews and contexts. These insights became the foundation for reframing the problem and guiding our next design decisions. From these insights, we moved into framing How Might We questions that helped us reframe the problem space and open up opportunities for exploration.