1. A system is a collection of interconnected elements that work together towards a common goal. A healthcare system can be analyzed using a systems approach that views it as having inputs, processes, outputs, and feedback. 2. Applying a systems approach to healthcare involves analyzing it across four levels - the individual patient, care teams, healthcare organizations, and the broader political/economic environment. This allows understanding how each component interacts and influences outcomes. 3. Adopting a systems approach in Bangladesh's healthcare would help move it from the current disorganized model to one with better coordination and synergies between different entities, leading to improved quality of care.

1. Colonel Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), MBBS
Armed Forces Medical Institute (AFMI

2. Concept
In a system, everything is in a dynamic
equilibrium and in a balance.
Speed of light: 1,86,000 miles/sec

3. A system is a collection of elements or components that are
organized for a common purpose.
System is an assemblage of interconnected, interdependent and
interrelating elements, forming a complex and unitary whole.
Example: Cardio-vascular System; where Heart and Blood Vessels
work together in an interconnecting manner to serve the common
purpose of making blood available to every parts of the body.

4. Human body as a system:
-Human body consists of many systems
-Each system consist of multiple organs
-Each organ consist of multiple tissues
-Each tissue consist of multiple cells
-Each cell consist of multiple molecules
They all work together for sustenance of life.

5. Components of System Theory
Systems are usually made up of four major elements
(Components):
1. Input (the energy or material that goes into the system)
2. Processes (the actions that happen within the system that
transforms the input)
3. Output (what results from the processes)
4. Feedback (the information that is produced that can be used to
evaluate and monitor the system)

7. The outcome of the system (food served to customers) is influenced
by inputs (such as ingredients, organisms, chemicals) and processes
(such as storing, preparing, cooking, and serving) that make up the
system. Internal system variables such as food workers, equipment,
and the economics also influence the outcome. It gets feedback
from the external environment to make necessary changes in the
system.

8. Ambience: A feeling or mood associated with a particular place, person, or thing ; atmosphere

9. Types of System
Systems are of two type:
1. Open System:
An open system interacts with its environment through giving and
receiving inputs/outputs/information. The elements or processes
can flow into or out of the system. For example, an automobile
engine is "open" with respect to gasoline--gasoline flows in and
exhaust (oxidized gasoline) flows out. In an open system, there are
interactions between the system and its environment. Open system
responds to change.

11. 2. Closed System:
In closed system, the elements or processes do not leave the
system.
For example, an automobile engine is largely "closed" with respect
to lubricating oil--the oil does not leave the engine. A closed system
is one, which does not interact with its environment. It is self-
sufficient entity. Automatic machinery system (Automatic watch) is
an example of closed system.

13. System also works in case of any organization. Every system is
delineated by its boundaries, surrounded and influenced by its
environment.
Karl Ludwig von Bertalanffy (1901 – 1972), an Austrian biologist known as one of the founders
of General Systems Theory (GST).
Boundaries: Barriers that define a system and distinguish it from other systems in the
environment.

14. The Systems Approach
The systems approach to management is a concept that regards an
organization as comprising three parts that are interconnected:
Input, process and output.
Inputs will include raw materials, funds or technology. The process
may refer to manufacturing and quality assurance operations in an
industrial setting, or activities related to management. Outputs will
be the products or results of the undertaking.
The systems approach principle emphasizes the use of feedback
response to aid in correcting or minimizing errors.

15. Systems Approach (SA) can thus be defined as a systematic process
of solving problems. Changing one part of the system usually affects
other parts and the whole system. For systems that are self-
adapting, the positive growth and adaptation depend upon how well
the system is adjusted with its environment. Managers thus, basing
on feedback information, manipulates the inputs and process to get
the desired outcome.

16. The systems approach to management is diagrammatically
represented as follows:

19. Suppose, a brake has gone wrong of a car. In system theory,
rather than trying to improve the braking system on a car alone
by looking in great detail at the material composition of the
brake pads (reductionist), the boundary of the braking system
may be extended to include the interactions between the:
• brake disks or drums
• brake pedal sensors
• hydraulics
• driver reaction time
• tires
• road conditions
• weather conditions
• time of day
Reductionist: A person who analyses and describes a complex phenomenon in terms of its
simple or fundamental constituents

21. System Characteristics
1. Holism/ Synergism:
Systems theory focuses on the arrangement of and relations
between the parts which connect them into a whole (Holism). The
theory that parts of a whole are in intimate interconnection, such that they
cannot exist independently of the whole.
Synergy is the concept that the value and performance of two
companies combined will be greater than the sum of the separate
individual parts. In other words, the philosophical saying – “A whole
is greater than the sum total of its parts” actually describes what a
“system” is.

22. It means that there is such a connection among the individual items
that it is better than what each one would be individually. This is
known as synergy. For instance, a team working together on a
product. If we figure out what each person can do individually, say
Kuddus can produce 3 units in 3 hours, Hannan can produce 4 units
in 3 hours, and Mokhles can produce 3 units in 3 hours. Together in
three hours, they should be able to produce 10 units; but using
teamwork, they can work together, and they can encourage each
other to have more energy, so maybe the team together can
produce those 10 units in just 2 hours. The individuals coming
together producing more than what they could on their own.
“The whole is greater than the sum of the parts.”

23. Whole as single entity carries more meaning than individual parts.

25. 2. Emergent Behavior:
Emergent behavior is behavior of a system that does not depend on its
individual parts, but on their relationships to one another. The key insight
of the concept of emergent behavior is; it's the arrangement of the parts,
and not the parts themselves, that makes the big difference. Emergent
behavior is also known as emergent property, or “the whole is greater than
the sum of the parts.”

26. System Characteristics..Cont
3. Hierarchical Order: System has smaller subsystems within
larger systems.
4. Interconnection & Interdependence: Systems rely on each
other.
5. System Boundary: All systems have boundaries that isolate
that system from its environment.
6. Permeability: System is open to its environment.
7. Equinfinality: Equifinality refers to the idea that there are a
number of paths that a system can take in order to reach the same
final state.

27. 8. Negative Entropy: Entropy means gradual decay. Negative
entropy is the ability of open systems to bring in new energy in the
form of inputs and feedback from the environment in order for the
organization to delay or to arrest entropy, the decaying process.
9. Requisite Variety (Cybernetics): If the systems that regulate
do not have enough variety to match the complexity of the
regulated, then regulation will fail. The system will be out of control.
The system with the most flexibility of behaviour will control the
system.
System Characteristics..Cont

28. Requisite Variety (Cont)
You’re running late. An unexpected detour means you’re faced with
a huge traffic jam. You have 2 options – you can accept this
challenge and sit in the traffic jam, give in to road rage & frustration
– OR you can try to find another way around the problem.
-Can you take another route?
-Can you use the time in the car productively and to your
advantage?
-Can you start focusing on what needs to get done at work?
-And is it time to make some changes?
Facebook, Google and Apple are constantly in a process of change
and consistently launching new product innovations. They move in
tandem with new technologies.

29. System Approach- Problem solving means
Meaning "to take apart" and "to put together," respectively.

31. System analysis as a problem-solving technique that breaks down a
system into its component pieces for the purpose of the studying
how well those component parts work and interact to accomplish
their purpose.
Technically speaking, system analysis consists of “Mission analysis,
functional analysis, task analysis and consideration for methods and
means” .

32. Mission analysis, It includes the various steps of identifying an
overall “mission objective”.
Functional Analysis: It consists of breaking down of functions
earlier identified under mission analysis with a view of grouping
them into various components that would make for a functional
mission profile.
Task analysis is concerned with the determination of the skills that
are required perform a task.
“Method-means analysis”. Study of the systematic procedure for
attainment of set objectives.

35. System Approach in Healthcare
A systems approach to healthcare delivery — one that understands
how elements of care operate individually and in connection with
each other — can improve the value of healthcare.
Systems approach to health is "one that applies scientific insights
to understand the elements that influence health outcomes;
models the relationships between those elements; and alters
design, processes or policies based on the resultant knowledge in
order to produce better health at lower cost.

37. WHO has specified a framework with six building blocks that can be
used as a tool for analysis of a health system. The six blocks are
leadership, human resources, information, medical products and
technology, financing, and service delivery. Health service is the
‘process’ and intermediate outputs lead to the desired health
outcomes.

38. Six Building Blocks of Health System

39. A systems approach improves health by considering the multiple
elements involved in caring for patients and the multiple factors
influencing health. By understanding how these elements operate
independently, as well as how they depend on one another, a
systems approach can help with the design and integration of
people, processes, policies, and organizations to promote better
health at lower cost.

40. Four general stages of system approach in healthcare delivery:

41. A FOUR-LEVEL MODEL OF THE HEALTH CARE SYSTEM
Health care system is divided into four “nested” levels :
1. The individual patient;
2. The care team, which includes professional care providers (e.g.,
clinicians, pharmacists, and others), the patient, and family
members;
3. The organization (e.g., hospital, clinic, nursing home, etc.) that
supports the development and work of care teams by providing
infrastructure and complementary resources; and
4. The political and economic environment (e.g., regulatory,
financial, payment regimes, and markets), the conditions under
which organizations, care teams, individual patients, and individual
care providers operate.

42. Conceptual drawing of a four-level health care system

43. The Individual Patient
Needs and preferences of individual patient should be the defining
factors in a patient-centered health care system. Overall, the role of
the patient has changed from a passive recipient of care to a more
active participant in care delivery.
The Care Team
The care team, the second level of the health care system, consists
of the individual physician and a group of care providers, including
health professionals, patients' family members, and others, whose
collective efforts result in the delivery of care to a patient or
population of patients.

44. The Organization
The third level of the health care system is the organization (e.g.,
hospital, clinic, nursing home) that provides infrastructure and other
complementary resources to support the work and development of
care teams.
The Political and Economic Environment
The fourth and final level of the health care system is the political,
economic (or market) environment, which includes regulatory,
financial, and payment regimes and entities that influence the
structure and performance of health care organizations. The
government influences care through financing the healthcare,
through regulation, and through its other establishments (e.g., DGHS,
DGDA, CMSD, DGFP, etc). Private-sector also influences directly
through provision of healthcare services, and insurance mechanism.

45. How environment influences healthcare delivery

46. System Approach in the context of Bangladesh
Health care delivery system in our context is described as a “cottage
industry.” The main characteristic of a cottage industry is that it
comprises many units operating independently, each focused on its
own performance. Each unit has considerable freedom to set
standards of performance. In addition, cottage industries do not
generally attempt to coordinate the processes or performance of
Unit A with those of Units B, C, and so on.

47. Even in many hospitals, individual departments operate more or
less autonomously, creating so-called “silos.” Many physicians
practice independently or in small groups, and ambulatory clinics,
and other organizations—often act as independent entities. We
often erroneously call this arrangement a “health care system,”
even though it was not created as a system and has never
performed as a system.
Silo (Means tall tower) describes any management system that is unable to operate with
any other system, meaning it's closed-off from other systems.

48. Moving from the current conglomeration of independent entities
toward a “system” will require that every participating unit
recognize its dependence and influence on all other units. Each unit
must not only achieve high performance but must also recognize
the imperative of joining with other units to optimize the
performance of the system as a whole. Moreover, each individual
care provider must recognize his or her dependence and influence
on other care team members (e.g., specialists in different fields,
pharmacists, nurses, social workers, psychologists, physical
therapists, etc.).

49. Benefits of System Approach
1. Synergistic effect
Synergistic is the combined effect of the components of a system
that exceeds the sum of their individual effects. 2 + 2 = 5 or more, is
the result of synergistic effect. This idea reflects when each sub-
system works in close cooperation and coordination in order to
achieve higher level results in terms of customer satisfaction.

50. 2. Marketing effectiveness
Under the system approach, all marketing activities and resources
are efficiently coordinated and utilized. They look at the total picture
and carefully design the marketing mix by giving needed importance
to all the elements which definitely enhances the effectiveness.
3. Environmental adaptation
It increases organization’s adaptability to environmental changes.
The organization is studied as a whole and not through its parts. This
enables it to adapt to the needs of the environment.

52. Disadvantages:

53. Conclusion

54. System approach is the way-out for quality healthcare. Its abysmal
lacking in the practice, is the root of quality deterioration of the
services. Changing attitudes to embrace teamwork and systems
“thinking” can be extremely difficult and may encounter resistance.
Nevertheless, a concerted, visible commitment at policy making
level and by management at implementation level, will be
necessary to achieve this new way of thinking as a giant step toward
the improvements in our disorganized healthcare system.