Viswanath et al. (2019) note that current dominant models of intervention design do not account for the complexity and unpredictability of implementation challenges. In the behavioural sciences, intervention designs are affected by the enabling environment (political, regulatory, and structural factors) as well as social, cultural, and economic characteristics of the target beneficiaries. Given that many of these factors will be uncertain or unknown at the beginning of a new project, it would seem reasonable to allow time to define interventions before finalising budgets and timelines. This letter describes how we responded to feedback during the design phase of a proof of concept project to create a digital service business for Nigerian patent and proprietary medicine vendors (PPMVs).

A Nigerian PPMV is defined as ‘a person without formal training in pharmacy who sells orthodox pharmaceutical products on a retail basis for profit’ ( Brieger et al., 2004). PPMVs constitute an important component of the private sector health system, particularly for poorer and more rural communities but are not well supported to provide quality health services ( Beyeler et al., 2015). However, with so many medically trained cadres operating as PPMVs, an opportunity exists to use them to improve and expand services for primary healthcare and family planning. The need to strengthen this vital health care delivery channel has been recognised by national and state-level government. We believe that a key component of this must be to establish a mechanism to support the PPMVs that both improves their service delivery while, at the same time, meeting their business and financial needs. This is the aim for NaijaCare.

The project described here was set up to deliver a proof of concept concerning the viability of NaijaCare, a for-profit digital service for PPMVs, which would allow them to improve their service delivery while growing their businesses. As such, part of the project involved identifying potential revenue streams for a digital service business which was also capable of delivering positive economic, social and health impacts for the PPMVs and their customers.

Initial design workshops with PPMVs revealed some similarities and some differences with duka owners. A key insight was that PPMVs saw themselves as business owners rather than health providers. So, like duka owners, their primary interest was in improving their businesses. There was a strong interest in credit for stock, need for stock control and business planning. While these insights did not affect our basic ToC, it became clear that the first release of NaijaCare needed to focus on business benefits rather than health provision.

In parallel, we conducted a landscape analysis, consulting with organisations such as the Pharmacist Council of Nigeria (PCN), the National Association of Patent and Proprietary Medicine Dealers (NAPPMED), and the Society for Family Health (SFH). What became clear from these consultations was that there were a range of ongoing developments, all of which would need to consider in our design.

Key design changes resulted from reports that PPMVs are a major route for the supply of sub-standard and counterfeit medicines ( Health Communication Capacity Collaborative, 2016) and sell medicines that are not covered under their licence (e.g., Fajola et al., 2011–2012). Further, we discovered that imminent regulatory changes would create three tiers of PPMVs and require them to register with PCN. This context meant that the model built with duka owners was not enough to meet the requirements for PPMVs; a digital service that supported these businesses would need to mitigate the legal contraventions; facilitate any necessary registration; and target each PPMV with content that was appropriate to their tier. What had started as process of designing a digital platform that met users’ needs now needed to consider the needs of multiple stakeholders and gatekeepers.

Based on the landscape analysis and the business needs of the PPMVs, we felt we needed to alter our ToC (see Figure 3) to include a digital ordering facility that would enable PPMVs to order medicines from an assured provider. This required additional in-market relationships and technology development. Naturally, these additional activities led to a requirement to increase the budget envelope beyond that originally allocated.

Digital medicine ordering allows us to create a secure supply chain of assured medicines, with PPMVs only able to access those medicines covered under their licence. Further, digital ordering can provide a digital trading history that may de-risk the provision of highly-valued credit, share distribution costs through adding further products to the basket (e.g. soaps, toothpastes, skin creams) and reduce the unit cost of stock for the PPMVs by enabling group-buying.

It is our hope (to be tested) that that digital ordering will become a major reason for the PPMVs to engage with the platform and to conform with the relevant laws and regulations. It will reduce the potential friction in their lives and can be used to reassure their customers of the quality of their products. Finally, we hope that it could provide an affordable way for PPMVs to register with PCN through taking small payments as part of each transaction.

The transfer of an existing ToC provided the starting hypotheses for NaijaCare. This was tested through qualitative and ethnographic research in our user-centred design process. Further, the appropriateness in the new context was explored with a new set of stakeholders. This led us to change our ToC and add the development of digital ordering in parallel with the creation of our ‘Minimal Viable Product’ (MVP) community. The community has now launched and is being refined based on user interactions and feedback. In addition to qualitative feedback we are now introducing quantitative measures; for instance, if the completion rates on a course are low then we revise the course.

Our expectation is that, once our intervention has stabilised, we will test it more formally, providing more quantitative evidence for its effectiveness and our theory of change. Eventually, we may choose to perform a randomised controlled trial. However, we believe that it is important to spend considerable time in a more responsive mode – designing data gathering to enable decision making rather than as proofs of efficacy.

We would support the call by Viswanath et al. for a more flexible approach to behavioural interventions, whereby a theory of change is specified together with an associated level of uncertainty. If this can be accepted by all stakeholders (donors, governments, grantees), then projects can be designed in such a way to maintain flexibility in the early stages, including the use of responsive feedback mechanisms.

No data are associated with this article.