LEARNING OUTCOMES
After participating in this session, students should be able
to:
1.Describe the key components of the Australian and Malaysian health systems
2.Explain the sources of health funding of the Australian and Malaysian health systems
3.Discuss the importance of ‘systems thinking’ in health systems
4.Give examples to illustrate the role of adverse patient outcomes in the improvement of healthcare delivery
5.Analyze complex relationships within the national health systems
RESOURCES
Hello Students,
Today, our tutorial will focus on systems thinking in health systems. We will explore the case of Mrs. A which will expand our understanding of systems thinking in the healthcare system and its importance.
So, let us start by examining the concept of systems thinking in health systems.
SYSTEMS
THINKING IN HEALTH SYSTEMS
A 'system' refers to an interconnected
system of parts working together to serve a common, specific purpose or goal.
Systems thinking postulates that the
sub-systems in a system are interconnected and interdependent. Every action in
one part of the system causes a reaction somewhere else in that system. These
reactions can also lead to unintended consequences, some of them adverse.
Applying this to health systems, in the
lecture on the national health system, we saw that it was important for the health
system's building blocks to work together to provide equitable care and improve
people's health outcomes. This is systems thinking applied to the health system
wherein the six building blocks are sub-systems of the health system which need
to work together in a coordinated manner to achieve the goals of the health
system. See Fig-1. For example, we saw that the departure of specialists from
the public to the private sector (Health Workforce) in Malaysia has
consequences for workload distribution (Service Delivery). Undoubtedly, this
would have implications for the care that patients obtain in the health care system.
Thus, as a problem-solving approach, systems-thinking reminds us to be mindful of:
1. the interdependence of the sub-systems in the health system
2. the linkages between the health system and the external environment
3. the need for the sub-systems to work
together in a coordinated manner
4. the importance of comprehensively examining the impact of
decisions made in one sub-system on other sub-systems and how
these interactions impact patient care. Such a comprehensive approach
is fundamentally different from a siloed approach to decision-making
when the system is complex. Two more examples of systems thinking in
health systems can be found in the Handout: Systems Thinking in Health
Systems as Suggested Reading.
CASE STUDY: MRS. A
We will now examine the case
study of a patient, Mrs. A, who was admitted to Hospital Suria Jaya for dengue.
Using the principles of systems thinking:
1. Use the health systems building blocks as
sub-systems and briefly summarize the main problems in the different
sub-systems in the case of Mrs. A.
2. Refer to Fig-2 below depicting Mrs. A' s pathway through the health care system. Identify the points in this pathway at which changes can be made to
the
system so that care for Mrs. A can be more responsive and effective.
3. Name one health systems issue that stood
out as most important for you in the delivery of effective health care. Why?
- This question (No. 3) has to be answered by each individual member in the group separately. Refer to- Instructions: Health systems tutorial submission
on Moodle and Athyna.
Dengue Situation in
Malaysia
The year 2019 saw the record highest number of 130, 101 dengue cases recorded in Malaysia, (1) surpassing the 120,836 cases recorded in 2015 (2). Selangor continued to record the highest number of cases in the country.
At the national level, there is a Dengue Task Force (3). There are dengue monitoring mechanisms in place at the district, state and national levels (3). The Ministry of Health (MOH) utilizes Geographical Information System (GIS) to map disease patterns (3). MOH also monitors epidemiological studies of diseases according to age, gender and ethnic groups (3).
The Star reported Dr Noor Hisham, the Director General of Health saying that the changing rainy and hot seasons resulting in stagnant water collected, movement of people, and increase in population density in urban areas as reasons for the spread of dengue (4).
Other government reports from previous years attributed the rise in dengue cases to rapid urbanization, expanding urban population, poverty, ineffective public health infrastructure, faster modes of transportation, globalization of trade and increased international travel (5). They also noted that contractors with weak credentials failed to collect rubbish regularly, drains were left clogged (3), the amount of solid waste at landfill sites exceeded the limit, rubbish bins were too small for household waste, and there were needless delays in dealing with complaints (3). Others cite little consideration of environmental health in urban policy and even less formal interaction between public health officials and the planners and policy makers undertaking urban development (6).
The problem is exacerbated by the local authorities' inability to communicate their messages effectively through awareness campaigns (3). Health information programs are hampered by a high turnover of volunteer staff and lack of innovative ways to engage the public (3).
Dengue epidemics pose a burden to the national health care system as critical resources such as time, hospital beds, finances, and staff have to be diverted from other serious disease areas during this time (7).
During an outbreak in 2019, the Director of a Government Hospital in the Klang Valley stated that the hospital was unable to admit patients because the beds were all full. The case of Mrs. A unfolds during this time.
Mrs. A: Profile
Mrs. A is a 70 year-old retired clerk. Until her retirement at age 55, she was
covered by a group health insurance company purchased by her company. Upon
retirement, she used her personal medical insurance which did not give her the
same extent of coverage as the previous insurance coverage provided by her
employer. She had trouble upgrading her personal medical insurance because of
existing diabetes.
SEEKING TREATMENT FOR DENGUE
In March 2019, she developed fever with
chills and rigors which continued for three days despite self-medication with
paracetamol. She suspected that she
might be having dengue because several of her neighbors had been admitted to
hospital for dengue. Mrs. A went to the
public hospital where she was being treated for her diabetes. Investigations were carried out on her. She was diagnosed to have dengue fever. She was advised admission but all the beds in
the female wards were full. Thus, her
family got her admitted to a private hospital.
Entry into the Health Care
System
In the private hospital, a full examination
was done by the Medical Officer (MO) on call in the Accident and Emergency (A
& E) Unit who ordered a full blood count (FBC), blood urea and serum
electrolytes (BUSE), and blood sugars (RBS). All systems (CVS, RS etc) were
normal. The only finding on general examination was clinical features of
dehydration (dry tongue, dry mucous membranes, sunken-appearing eyes, and
decreased skin turgor). Her vital signs (pulse rate, respiratory rate, BP) were
normal. The full blood count results came back with a platelet count of less
than 70 x 109/dl. The values of the other laboratory investigations were within
the normal range. A diagnosis of dengue was made.
Inpatient Admission
The MO advised admission. However, she
could not be admitted immediately because they had to wait for five hours for
the insurance company to approve the admission. An intravenous fluid (1/5
dextrose saline) drip was set up and vital signs were monitored every one hour.
She was also given paracetamol for her fever.
After five hours, at close to 7 p.m., she was taken to the ward and
admitted to a room for four patients according to her insurance coverage.
In the ward, the nurses contacted the
physician on call who ordered treatment over the phone. The finger stick blood
test revealed a value of 12 mmol/L. The physician on call was contacted again
and he ordered a change of the IV drip to normal saline. The physician arrived
in the hospital one hour after the patient was admitted to the female ward. He
spent 15 minutes with the patient taking a brief history and doing a brief
examination. He then ordered the continuation of the treatment, i.e., of fluids
and paracetamol and three hourly checks of blood sugar and vital signs. An FBC and RBS was again ordered. The doctor
left the hospital.
The nurses changed shift at 9 p.m.
Replacing the four nurses in the day shift were only two nurses on duty for the
night shift as per practice. However, one nurse who was supposed to be on duty
called in sick. It took one hour to get a replacement for the nurse. In the
meantime, there was another admission of a patient with acute appendicitis in
the female ward. Being under-staffed and attending to the newly admitted patient,
the nurses forgot to monitor Mrs. A.
When they received the FBC results, they remembered
that they had forgotten to monitor the patient. The platelet count had fallen
to 45 x 109/dl, and her latest BP reading was 90/60 mmHg. The physician who was
immediately informed about the situation by phone, ordered two packs of
platelets to be transfused. He also ordered an FBC to be done after
transfusion. During transfusion, the patient was noted to have petechiae and
gum bleeding. Her blood pressure dropped to 70/50 mmHg, she became unconscious
and went into shock. The nurses frantically informed the physician over the
phone and also called the MO from the A&E to attend to Mrs. A. When the MO
arrived, CPR was initiated, and the patient was intubated and transferred to
the Intensive Care Unit (ICU). The physician arrived after the patient was transferred
to the ICU.
Mrs. A was stabilized. During the treatment
in the ICU, her platelet count increased to 120 x 109/dl. She could breathe
without assisted ventilation and was transferred to the ward after four days.
DischargE
Mrs. A was in the hospital for about six days, and the bill came to RM 20,000.00. This amount exceeded her insurance coverage. Her family had to borrow money to pay the balance of the bill that was not covered by her medical insurance. She was discharged with paracetamol and vitamins, which cost her 50 percent more than the cost she would have paid at a private pharmacy. These medications would have been provided free of charge had she been treated in a government hospital.
REFERENCEs
1. Fong LF, Ahmad R. Number of dengue cases
set to hit all-time high [online]. The Star; 2019 [Available from:
https://www.thestar.com.my/news/nation/2019/12/01/number-of-dengue-cases-set-to-hit-all-time-high.
2. Kementerian Kesihatan Malaysia. Dengue
incidence rate & case fatality rate 2000-2016: Malaysian Remote Sensing
Agency (ARSM), Kementerian Sains, Teknologi & Inovasi (MOSTI) dan Bahagian
Kawalan Penyakit (BKP), Kementarian Kesihatan Malaysia (KKM) 2017 [Available
from: http://idengue.remotesensing.gov.my/idengue/content/statistik.pdf.
3. Anthony MC, Cook ADB, Amul GGH, Sharma A.
Health governance and dengue in southeast Asia.
NTS Report No. 2. May 2015 Singapore: S. Rajaratnam School of
International Studies, Nanyang Technological University; 2015 [Available from:
https://www.rsis.edu.sg/wp-content/uploads/2015/06/NTS-Report-No-2-10June2015.pdf.
4. Fong LF. Dengue cases at an all-time high
[online]: The Star; 2019 [Available from:
https://www.thestar.com.my/news/nation/2019/08/10/dengue-cases-at-an-all-time-high.
5. Malaysia. Dengue incidence rate & case
fatality rate 2000-2016: Malaysian Remote Sensing Agency (ARSM), Kementerian
Sains, Teknologi & Inovasi (MOSTI) dan Bahagian Kawalan Penyakit (BKP),
Kementarian Kesihatan Malaysia (KKM);
[Available from: http://idengue.remotesensing.gov.my/idengue/content/statistik.pdf.
6. Mulligan K, Elliott SJ, Schuster-Wallace C.
The place of health and the health of place: Dengue fever and urban governance
in Putrajaya, Malaysia. Health & Place. 2012;18(3):613-20.
7. Liew SM, Khoo EM, Ho BK, Lee YK, Omar M,
Ayadurai V, et al. Dengue in Malaysia: Factors associated with dengue mortality
from a national registry. PloS one. 2016;11(6):e0157631.
We
also hope you grasped the effectiveness of a systems thinking approach to
problem-solving in complex health care situations. Such an approach is able to
consider the interdependence of the different sub-systems and how a change in
one part might dynamically effect changes in other parts of the system .
As we saw in the case of Mrs. A, when systems thinking is absent, there can be adverse impacts on patient care.
See you at the lecture on Health Determinants! 