Home ยป Soft Systems Extension to a Hard Systems Case Study: Design and Implementation of a Health Management Information System in Malawi: Issues, Innovations and Results.

Soft Systems Extension to a Hard Systems Case Study: Design and Implementation of a Health Management Information System in Malawi: Issues, Innovations and Results.

B. Sc (Hons) Business Information Systems Module: BSNIS3001 Business Analysis Soft Systems Extension to a Hard Systems Case Study: Design and Implementation of a Health Management Information System in Malawi: Issues, Innovations and Results. Contents 1. 0Question 13 1. 1Introduction3 1. 1Summary of case study3 1. 2History of health issues in Malawi3 2. 0Our problem4 2. 1Definition of a problem5 2. 2Soft and Hard problems5 3. 0Examples of a hard systems approach5 3. 1Student Example5 3. 2Health example5 3. 3Relating the problem approach to the case study6 . 0Defining the problem as a hard problem6 4. 1Means Ends Analysis6 4. 2Identifying the ends6 4. 3The Ends6 4. 3. 1United Nations7 4. 3. 2Malawi Government7 4. 3. 3Development partners7 4. 3. 4Ministry of health and population7 4. 3. 5Directors of Hospital institutions8 4. 3. 6 District Health Management Team (DHMT)8 4. 3. 7Patients8 4. 4Effectiveness9 4. 5The constraints11 5. 0The Solution11 6. 0Conclusion of hard systems approach12 7. 0Question 213 7. 1Soft Systems Methodology13 7. 2Stage 1 and 2: The Problem Situation Unstructured and Structured14 7. Stage 3: Root Definition of Relevant Systems17 7. 4Stage 4: Building a Conceptual Model19 7. 5Stage 5: Comparison of Conceptual Models with Real World21 7. 6Stage 6: Define Desirable and Feasible Changes22 7. 6. 1Procedural Changes22 7. 6. 2Structural Changes22 7. 6. 3Attitude Changes23 7. 7Stage 7: Action to Improve the Problem Situation23 7. 8Conclusion23 8. 0 Question 323 8. 1 Law of Conceptualisation23 8. 2 Sub-optimisation25 8. 3 Synthesis27 8. 4Emergent Property28 8. 0References30 9. 0Bibliography31 10. 0Glossary of Terms32 1. 0 Question 1 1. 1Introduction

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As a group we decided to choose the case study called, Design and implementation of a health management information system in Malawi: issues, innovations and results. The reason that we chose this case study was due to the fact that we could give a very efficient report on the case study. The main aim of this report is to identify the problem within the case study and then put the problems into two different methods which are both Hard & Soft problems. Once these are identified we will then go into more detail on the methods. Then to some up our report well will draw up ecommendations and conclusions which will give the reader a better understanding of the report. 2. 1 Summary of case study As many struggling countries like Malawi, it is very hard to collect efficient data on the current health issues and also how the health services are being managed; these two issues are the two main weaknesses within Malawi’s current health information system. The case study gives allot of data and graphical data on the HMIS design and implementation, this is very useful as it will help us with the facts of what is actually happening in Malawi.

Within the case study there is quite allot of information on the current and previous health issues in Malawi and also facts alongside them to give the health issues in more detail. The best way in which the case study can be summed up is it shows Malawi’s problems in detail. It gives a sub title of the problem and then information on the problem, this helps us as a group as we are taking these problems and splitting them up into both Hard & Soft problems to come up with a heath system in order to make Malawi’s current system more efficient. 2. 2 History of health issues in Malawi

Malawi’s life expectancy is the worst in the world as the average male lives to just 37 and the average female to just 36 and it is unlikely that children survive past the age of 4 due to disease and illnesses. HIV continues to be fought in Malawi. Hardly any country in sub-Saharan Africa has not been affected by this epidemic, and Malawi, too, feels the scourge. Most estimates claim that 16 – 18% of Malawians are infected with the virus. The effects are far reaching. The greatest numbers of those infected are the people in the main workforce between the ages of 18 and 49.

These are the people who are running the day-to-day operations of Malawi, and they are dying at a significantly high rate. They leave behind young orphans, who, following cultural norms, go to live with relatives. Malawi’s first AIDS case was reported in 1985. In response, the government implemented a short-term AIDS strategy (including blood screening and HIV education programmes), and in 1988, created the National AIDS Control Programme (NACP) to co-ordinate the country’s AIDS education and HIV prevention efforts.

Some have argued that these measures did little towards controlling AIDS in Malawi, and that it was not until 1989, when a five-year AIDS plan was announced, that the government began to show any real commitment towards tackling the problem. By this point AIDS had already damaged Malawi’s social and economic infrastructure. Farmers could not provide food, children could not attend school and workers could not support their families, either because they were infected with HIV or because they were caring for someone who was.

In 2002, Malawi suffered its worst food crisis for over fifty years, with HIV recognised as one of the factors that contributed most significantly to the famine. A report suggested that 70% of hospital deaths at the time were AIDS related. 2. 0 Our problem As we mentioned before in the introduction the case study that we selected is called, Design and implementation of a health management information system in Malawi: issues, innovations and results. The case study is about a problem with the current health information system in Malawi. The problem being that the system is not giving accurate results on the health issues.

However within our case study there are lots of problems with their current information system which you can see below: * Accountability – This is when the people responsible for holding public servants accountable do not have the training or skills to access the information system or collect data. The manager themselves don’t take their financial accountability seriously, this has nothing to do with the lack of the system that takes disciplinary actions against poor performance or corruption, but also due to lack of management knowledge and skills. Resource constraints – The health facilities cannot get its daily resources needed to address the problems. In most health facilities, less than 50% of positions of nurses, doctors, clinicians and technicians are filled. * Leadership – Leadership is needed to put a problem on the agenda and to influence and lobby for decisions. HMIS people must feel responsible for the use of information. * Lack of holistic vision/approach – The health system lacks discipline on system thinking, vision and team approach. Organizational and behaviour change strategies – The newly designed information system is part of the reform process. The creation of new information systems is an essential component in the creation of accountability. * Punitive environment – This has all to do with motivation which cannot be imposed. The environment in the Malawi government system is a punitive, not an encouraging one. * Lack of management training, skills and personality – It is very shocking that most of the medical staff are young, this isn’t good as they have no experience therefore more prone to mistakes. Incentives and disincentives – When the incentive to perform and to monitor quality is low, the use of information can be expected to be equally low. A system of paying an annual premium for reaching specific targets could promote the use of information. * Inadequate dissemination – The social and political dimensions of any decision-making process are critical. Decision-making steps are influenced by socio-political pressure groups such as political parties, media and religious groups. Information can influence decisions only if it is made available to them.

Next the case study will be further analysed to figure out the hard system used, if there was a soft system used, and how these where implemented 3. 3 Definition of a problem ‘A problem is a question raised for enquiry, consideration, or solution’. (Merriam-Webster 2011) Furthermore a problem can be split into one of two categories; either a soft problem or hard problem. 3. 4 Soft and Hard problems With every problem a solution has to be found, however when approaching a problem we are required to know which type of problem in order to tackle the problem most efficiently in order for it to be solved.

A hard problem is said to be well defined ends or objectives therefore the ends provide means in order for the problem to be solved. On the contrary to this, soft problems are ill defined ends or objectives and do not give efficient means and therefore hard to solve the problem. As any possible ‘end’ could ultimately become problematic in itself. 3. 0 Examples of a hard systems approach 4. 5 Student Example An example of hard system thinking is a student having a piece of coursework to complete, a hard system would allocate the issues as to why it isn’t done and aim to complete it within the given time.

It won’t take into account the human element of the student having to attend lectures, probably having work to go to and other coursework to focus on as well. A hard system would say it was down to poor organisation and not consider the other options available. The problem with hard systems is because they usually have a well defined problem the approach doesn’t tend to look outside of that problem and so only identifies one solution. This causes more problems as a hard system doesn’t take into account outside interference and so the solution that is suggested might not work if the human element is taken in as a factor. 4. 6 Health example

An example of hard system thinking is if a patient dies unexpectedly in a hospital, again the hard system would allocate the issues as to why this happened and how. It will not take in to account of the human element of the doctor/nurse giving a wrong drug, not taking care of the patient properly. A hard system would say it was down to a fault in the machinery and not consider any other options. Again the problem with hard systems is because they usually have a well defined problem the approach doesn’t tend to look outside of that problem and so only identifies one solution. 4. 7 Relating the problem approach to the case study

When looking at the specification requirement’s for this report, we searched for a suitable case study that would show the use of a hard problem’s methodology. We believe the case study that was chosen to be the most suited example of using a hard system’s approach and therefore we will use the analytical techniques we have at our disposal to show our reasons for this theory. 4. 0 Defining the problem as a hard problem The case study of the design and implementation of a health management information system in Malawi can be considered and ideal case study in which demonstrates a hard systems approach to its problem.

In order to determine the nature of the hard systems approach, a means ends analysis will be conducted which will identify the organisations goals/ends and the means in which the can be achieved. “A ‘hard’, or structured, problem is one which is exclusively concerned with a ‘how’ type of question” (Wilson, 1984) 5. 8 Means Ends Analysis Means end analysis is used when a system does not run as how it is supposed to run. The system has to be changed in order for the system to change its behaviour and establish ways in which to overcome the problem. This in turn will bring solutions and help decide which alternative should be applied.

In order to do this we must explore the ends, identify the problems with them, explore the means and identify the best means to suit the ends. 5. 9 Identifying the ends In order to identify the ends, the first thing to consider is the stakeholders and who have a direct influence on the business. Stakeholders can be defined as a specific person or group that will be affected in any way by the systems behaviour. Within the Malawi case study, the group identified the following stakeholders * United Nations * Malawi Government * Development partners (WHO, UNICEF) * Ministry of health and population Directors of Hospital institutions * DHMT District Health Management Team * District Health Management Team (DHMT) * Patients 5. 10 The Ends What somebody wants can be suggested as an end, it gives purpose to the situation. In order to find the ends of each stakeholder then you must have to figure out the means as to what is required to achieve the ends. The most important point that is required is exploration and research into how to reduce the gap between the end state in what the stakeholders require and the existing state. 4. 3. 1United Nations The United nations have a huge influence of what happens throughout the world.

The United Nations commits world leaders in the combat against poverty, hunger, disease, illiteracy, environmental degradation and discrimination. With regards to the case study concerning Malawi, the UN will what to ensure that the HMIS system is a success as they will not be able to eradicate to stated goals without the necessary information. Malawi is currently one of the poorest countries in the world, with disease and poverty rife in parts. In order for Malawi to regain some sort of control of the issues that are affecting the country, it is pivotal that every stakeholder is on board with the HMIS externally and internally. . 3. 2Malawi Government The Malawi government are one of the key stakeholders. The ends of the government will be similar to the UN, to eradicate poverty and disease. Without an influx of investment and leadership the new HMIS will fail. The main role and responsibility of the government will be to ensure proper management of health information and sufficient use of information in planning and management of health services. 4. 3. 3Development partners Partners such as the WHO (World health organisation) and UNICEF are part of the general assembly created by the United Nations.

The WHO’s constitution states that its objective “is the attainment by all people of the highest possible level of health. ” Its major task is to combat disease, especially key infectious diseases, and to promote the general health of the people of the world. UNICEF on the other hand provides long term humanitarian and developmental assistance to children and mothers in developing countries. Both will want to combat the issues with regards to the health system in Malawi as Maternal mortality rates are pushed up by poor access to essential healthcare and the quality of services. 4. 3. Ministry of health and population The Ministry of Health and Population (MOHP) has implemented a comprehensive and integrated routine Health Management Information System (HMIS) for Malawi. The organisation has a direct influence on how the system operates and how it is monitored. The primary objective of the information system is to provide reliable, relevant, up-to-date, adequate, timely and reasonably complete information for health managers at community, facility, district and national levels. This is of substantial importance when combating health issues as inaccurate date could lead to wrong diagnoses.

The MOHP will want to be portrayed as making a difference to the world with the implementation of the system. 4. 3. 5Directors of Hospital institutions The Directors of the hospitals will want to see a change in the way the hospitals operate. Through the use of the HMIS, data can be captured and put to greater use when making more informed decisions. The directors will also perceive the system as a means to invest more in technology and equipment if applicable. The directors will want to see an improvement in the health indicators which are crippling the country which are among the worst in the world. 4. 3. District Health Management Team (DHMT) The district health management team are responsible for managing all the data that is recorded by the health care assistants. There ends are relatively east to define. The DHMT will want to ensure that all data recorded will be of the highest standard in order to ease the burden of sifting through reams and reams of useless data thus maximising the use of accurate data at local levels. With regards to training, members of the DHMT will also want to ensure that the quality of training which has been given is of high standards as this approach will have a cascade effect right through the organisation.

If the quality is poor, more and more resources will be wasted, resources the government of Malawi do not have. 4. 3. 7Patients With disease and poverty among the top issues of concern within Malawi, health care is a key indicator of which to target. The people of Malawi will want to see an improvement in life expectancy and individual health care. The current life expectancy stands at 37. 3 for males and 38. 4 for females. This is an issue of great concern and it is easy to understand why the system has to be implemented.

The old system suggests that patient’s records are impossible to trace through a lack of organisation and leadership. The HMIS main goal is to bring structure to Malawi’s health care system, in doing this, patients records can be recorded and stored enabling the health care assistants to review the history of a particular patient. With the ends clearly defined for each stakeholder the next sector will cover how the ends can be achieved through the use of measures of effectiveness. 5. 11 Effectiveness In order to measure effectiveness then we need to take into consideration five rules Measures of effectiveness need to be specific to the end so that they can be measured * Measures of effectiveness need to be measurable to see how effective they are at achieving what has been agreed * Measures of effectiveness need to be agreed with the client as to what is expected of them in order for the to be measurable * Measures of effectiveness need to be realistic in achieving goals * Measures of effectiveness need to be time bound in order to measure the progress over a certain period of time A simple table has been drawn up to help with the diagnosis of the measures of effectiveness for each defined end.

SMART| Yes/No| Specific| Y| Measurable| N| Agreed| Y| Realistic. | Y| Timebound| N| The first end that will be measured is the UN’s fight to combat against poverty, hunger, disease, illiteracy, environmental degradation and discrimination The only way the UN’s ends can be measured as a success as if it is specific to the ideals of the world leaders and that they are all on board. It cannot be measured because of the nature of the ends but work can be carried out towards the ends based on statistics and whether certain criterion has decreased.

Each Leader within the UN has agreed to commit resources and allocate funding to countries in a worst state than their own; this can come from donations to development partners such as UNICEF and Action Aid. The UN’s Combat against world issues are realistic, they have been in correlation with helping the third world since the united nations charter was signed in 1945. The timescale however cannot be measured accurately. This is because it has been an ongoing problem in Malawi for years, there have been improvements but the combat against the issues still remain ongoing and cannot be measured. SMART| Yes/No|

Specific| Y| Measurable| Y| Agreed| Y| Realistic. | N| Timebound| N| The next end to be measured is the Malawi Government investing into healthcare and new technologies. It would be easy to say that Malawi should invest in healthcare and new technologies but the actual suggest that it’s and end which, put into perspective, is unachievable. The target is specific as the government know that the issue is of great importance. The statistics of Malawi show that they are among the worst health care indicators in the world. With the HMIS the indicators can be measured along with the data collected from patients.

The ends have been agreed with everyone involved, they know the system needs to be developed but without an influx investment, it’s impossible for the ends to realistically be met. There cannot be a specific time set for the redevelopment of the healthcare system it is continuous project. SMART| Yes/No| Specific| Y| Measurable| Y| Agreed| Y| Realistic. | Y| Timebound| Y| The next end to be measured is the MOHP monitoring of the HMIS and increase of accurate data. The ends for the Ministry of health and populations can all be measured effectively. The end is specific as the HMIS is specific to what the Malawi healthcare system requires.

The data collected by healthcare assistants can be measured as diagnoses can be recorded along with information of the patient. The targets have been set and agree with everyone involved with the project, the system will not be a success if everyone is not on board, this runs right through government right through to the patients. The ends are achievable if healthcare assistants assist with the data collection, morale has a big part to play when it comes to the data collection and revision. If the morale is low the quality of useful data collected will be low so it’s important that incentives are used in order to keep morale at a high.

There has been a time scale set from the implementation phase of the system right through to the monitoring, this has been set at four years and already things are starting to look up although the optimization of the data collected has not yet been fully achieved. SMART| Yes/No| Specific| Y| Measurable| Y| Agreed| Y| Realistic. | N| Timebound| N| The next end is the DHMT and the ends of training to train. The ends for the District Health Management Team can be measured effectively as the trained staff train other members of the team in a cascade method.

This method is specific to the Malawi healthcare system as it does not allocate a substantial amount of resources as the training given by more experienced staff can help train others within the system. It can be measured by the amount of staff that currently operates in the system. The ends are agreed because all of the DHMT know what is expected of them when giving training events, however due to the nature of the case study, there are not that many experienced staff so the training can be time consuming which means the ends are unrealistic.

There is no timescale in place because the system is continuous. SMART| Yes/No| Specific| Y| Measurable| Y| Agreed| Y| Realistic. | Y| Timebound| N| The final end is the improved health conditions of the patients of Malawi The ends for the people of Malawi can be measured effectively as they would want to see a significant improvement in health conditions and a decrease in the life expectancy age. They are specific to the patients because if the health conditions are improved across Malawi, then it give them confidence in the health system knowing that it could lead to a happier, healthier life.

This can be measured by the health care booklets which are used as a means to improve the quality of personal health care. By using these booklets throughout their lifetime, patients have agreed to play a part in help improve the system as well as their own personal health. Through the use of the booklets, Malawi’s healthcare system will realistically start to see significant improvement over time although the timescale has not been set it is ongoing. 5. 12 The constraints An important factor when initialising a means ends analysis is to consider the constraints placed upon the means.

By analysing the situation, for example by communicating with the stakeholders we can determine any constraints that may occur so that a truly viable solution can be found. Constraints could come from a wide range of sources; this could include social, environmental or political aspects. For example, while a possible solution may seem viable, there may be political constraints in place. The need for investment within the Malawi healthcare system is imperative; however without capital and investment, the Malawi government are unable to allocate resources to ensure the development of the healthcare system.

The repercussions of this will lead to a loss of many lives. 5. 0 The Solution The proposed solution for the case study was to take full advantage of the lessons learnt from pioneers around the world. The implementation of the HMIS has brought welcomed changes to Malawi and how the health care system operates. In the process of implementing the government’s policies and plans, the ministry of health and population took an inventory of the existing system in 1999 and endorsed a strategy for the establishment of an integrated HMIS from early 2000.

Throughout the process the HMIS has been developed in a well structured systematic way. The focus of each and every step of development has been geared towards the establishment of an information culture within Malawi. As soon as the minimum set of indicators were agreed, the DHMT was oriented to start improving the quality of existing data and using them in bettering management. Once the tools and procedures were approved for nationwide implementation, all health and support personnel in the country were oriented on HMIS tools and procedures.

The HMIS team in headquarters have received appropriate training abroad to provide required support to the periphery. Data processing at district and central level has been computerised which a huge step forward considering the existing system contained many areas of weakness. The Software that was implemented has evolved over almost a decade in South Africa which has been adapted for Malawi to process the data. Maps have been digitised showing the catchments area of each public health facility in the entire country for use in planning and monitoring of health services by districts and facilities.

Numerous innovations have been applied to improve the quality and use of information. It has been noted that remarkable achievements have been made in the establishment of HMIS in the country. 6. 0 Conclusion of hard systems approach In conclusion the case study identified the underlying problems which affected Malawi; the initial problems were mainly due to the crippling health indicators which are damaging the population of Malawi. The problems were identified and analysis was completed in order to use a hard systems approach to tackle the underlying problem, the health care system.

The problem was that the data used was inaccurate an useless but with the introduction of the HMIS over a four year period brought a remarkable change in how the system operated. By using a hard system approach, it identified all stakeholders who had an integral part to play in order for the HMIS to become a success. Although the issues in Malawi are not yet completely resolved, the hard systems approach has made it more realistic to see that the changes are being made. 7. 0 Question 2 8. 13 Soft Systems Methodology

Developed by Peter Checkland in 1970, the soft systems methodology was created to enable the analysis of complex situations in which the problems where difficult to identify. Checkland et al (1990) state that ‘the soft systems methodology was developed expressly to cope with the more normal situation in which the people in a problem situation perceive and interpret the world in their own ways and make judgements about it using standards and values which may not be shared by others. ’ As discussed above, the problems are not so easily recognised.

When trying to identify the problems it is very important to take all stakeholders into account, and understand how each problem (if there is more than one) will affect each of the stakeholders. It is also important to research all of the different stakeholders views to enable the development for the appropriate system to suit everybody’s needs, if this isn’t done then problems may occur that have previously occurred and the business will want to get this right first time, otherwise it will cost them a lot more money in the long run.

The soft systems methodology consists of seven stages. The seven-stage methodology is now seen as one option in a more general approach to trying to tackle coherently the problematical situations in which we find ourselves in professional or private life. (Checkland et al 1990) Source: Christian Fuchs (2004) Figure 1 shows the seven stages of the SSM. Stage 1, ‘the problem situation unstructured’ is when and where problem is encountered. Stage 2, ‘the problem situation structured’ is the stage where the problem in place has been determined.

Stage 3, ‘root definition of relevant systems’’ at this stage the problem will be spread widely so the root of problem could be identify and faced. Stage 4, ‘conceptual models’ is made of the activities in which must exist in the system; 4a, ‘formal system concept’ and 4b, ‘other system thinking’. Stage 5, ‘comparison of stage 4 with stage 2’ this Stage is where series of comparisons between the text based definitions created in ‘Stage2’ and the diagrammatic models used in ‘Stage 4’ will take place. Stage 6, ‘feasible and desirable changes’ this stage allows solutions to be identified this could be probable and feasible.

Stage 7, ‘action to improve the problem situation’’ this is an implementation stage for the solution to the problems. This will later be discussed in more depth, with a thorough case study analysis for each stage. The stages above the dotted line show the ‘real world’ activities which are the activities involving the people in the situation. The stages below the dotted line ‘system thinking’ are the activities concerned with thinking about the problem. The stages that can be determined to take place in the ‘real world’ context are; 1, 2, 5, 6 and 7.

These stages consist of activities that involve a form of human interaction within the problem situation. The stages that are determined to take place in a ‘systems thinking’ context are 3 and 4. These stages usually do not involve human interaction within the problem situation, but involve the use of system languages to develop root definitions and their systems required. Now each of the different stages will be explained in a bit more depth, and each stage will be taken into consideration for the Malawi case study. 8. 4 Stage 1 and 2: The Problem Situation Unstructured and Structured Stage 1 and 2 are an attempt to build up a rich picture of the situation in which there is perceived to be a problem, further on a rich picture has been created for the Malawi case study. The rich picture is completed by viewing the problem from a number of different peoples perspectives, and by doing this it provides a balanced view of the situation from all angles as well as enabling the selection to be made of certain view(s), and to problems in the later stages of the SSM.

Medrand et al (2010) explain that a rich picture integrates the different interpretations of the social actors that participate in the work and processes. As described in the case study there are a number of problems facing both the Malawi government and the health service before the introduction of the health management information system (HMIS) which are stated below. The health service is currently of poor standard within Malawi, then life expectancy is low. According to Index Mundi (2011) average life expectancy at birth for anyone born in Malawi is 51. years. Life expectancy for males is 50. 93 years, whilst female life expectancy is a bit longer than males with it being 52. 48 years. There is no accurate record keeping for patient’s information currently in place. Most of the information is scattered all over the country which makes it hard for the health service to collate information regarding patients, which can result into errors. This information which was gathered was never being used to manage the health services for the country either.

There was no effective system of information on the health services as it was not priority for most of the Malawi districts. There was also no central storage system for information, resulting into doctors and patients not being able to access the information required. There is difficulty in proactive analysis or planning purposes as the Information related to diseases, vital statistics, maternal, child and reproductive health indicators, and tracking of financial resource allocations was never inputted into a system which was easily accessible.

The lack of up-to-date technologies to save the patients details on resulted into a lot of information being duplicated, which caused a waste of a lot of time and resources. These problems stated will be explained in further detail by the use of a rich picture, Figure 2. This rich picture shows the relevant systems requirements from the management perspective. It requires; a system that delivers data on time, a system that delivers accurate data and a system in place to improve hospital management as well as to help train staff to use the system efficiently.

Will the information be accurate? Records must be stored for easier access and more efficient work Figure 2: Rich Picture Health Information System is required to improve our health issues Will the use of the new Health Information System improve our health? Will we be trained properly in order to use the system efficiently? Will the information be delivered on time? Will the new Health Information System improve the health service? Hospital Staff System must be easily accessible and easy to use for all staff Health Service Patients Information System . 15 Stage 3: Root Definition of Relevant Systems Above a rich picture has been used to express the problematic situation graphically. This was had to be done before we could start stage three, where the root definitions will be identified. A root definition is a structured description of a system which is relevant to the problem. The chosen outlook will be written into a statement which describes the nature of the situation, for example what the system is. Orsoc (2011) state that, ‘it is structured in such a way as to enable modelling the system. A well defined root definition can be found using CATWOE which will also be considered in this part of the report. There are a number of things in which a root definition should identify; who will benefit or suffer from the system, who is involved in the system, who has commissioned the system, the perspective from which the root definition is formulated (Weltanschauung – worldview), environmental constraints and the purpose of the system. When conducting a root definition in a certain situation it is best to take into account several different possibilities.

They are best to be prepared based on the perspectives of the main roles in the situation. The root definition for Malawi Health Management Information System will be Primary Task Root Definition as the health system processes had been studied. The root definition of the relevant system will comprises 3 elements [what, how, why] What : The Health Management Information System (HMIS) for Malawi is a evidently target to be able to store patient information, allow easy access to the information’s by the relevant department so they can use the information to improve the well been of the people’s lives.

How: This will be by investigating the current system, writing and developing a new system, adequate training for the staffs. Why: The Health Management Information System (HMIS) for Malawi is done to bring about effectiveness and efficiency into the countries health system and improve the well been of the citizen. CATWOE is an abbreviation for Clients, Actors, Transformation, Weltanschauund (worldview), Owner and Environmental Constraints.

It identifies the different areas of improvement and world views that need to be used to help solve the problem(s). CATWOE will be analysed for the Malawi case study. Clients: In the case of Malawi health service, the Patients i. e. the people of Malawi will be at the receiving end whatever the system does negatively or positively. If the aim of the HMIS is achieved by having a good system in place to access the health information about the people correctly it will bring about huge improvement in the life of the people.

For example the life expectancy might be improved and people of Malawi will live longer than the current standard of 37. 3 years for males and 38. 4 years for females. Actors: The actors in this case are the District Health Management Team (DHMT), Directors of Hospital institutions and the Ministry of health and population these departments will actually carry out the activities envisaged in the notional system being defined, monitor and manage the result.

Transformational Process: The transformation process of the system is all about the inputs to convert them into the outputs, which will start from the collating and inputting the data of the people, access it by the relevant department to carry out health procedure. Weltanshauund: The newly implemented system will be view by the whole world and its performance will highlight the consequences of the overall Malawi health system For example the World health organization, which is part of United Nations can use the success of HMIS system to rate the health status of Malawi and the failure of the HMIS system may have huge consequences.

Owners: The owners of HMIS system are Malawi government as the key stakeholder and big beneficiary, Partners and other beneficiaries such as the WHO (World health organisation) and UNICEF through United Nations also have sufficient formal power over the system to stop it existing if they so wished (though they won’t usually want to do this). Environmental Constraints: The environmental constraint on the system could include things such as ethical limit (Professional Ethics, Technical Ethics, Business Ethics and Personal Ethics), regulations, financial constraints, resource limitations, limits set by terms of reference, and so on. . 16 Stage 4: Building a Conceptual Model Checkland (1999) describes a conceptual model as, ‘a systematic account of a human activity system, build on the basis of that system’s root definition, usually in the form of a structured set of verbs in the imperative mood. ’ In this stage a conceptual model is built upon the activities that must exist in the system, which is defined in the root definition. When building this conceptual model whoever is building it will have to ask themselves, what activities in sequence need to occur in order to transfer from the old to he new system? Unless there are constraints in the root definition then how the activity should be done should be asked at a later stage. At this stage sometimes sub-systems for different activities undertaken are also illustrated as shown earlier in figure 1 (4a, ‘formal system concept’ and 4b, ‘other system thinking’). When building the conceptual model it is really important to address the information flows that are needed if the linked activities where to be carried out efficiently, which include the content, the source and the frequency of the system.

This may entail modelling an information or planning system to serve the main activity system modelled. It is also important that first a model is developed and agreed on for the activity system before modelling begins. This will apply whenever one system serves the purpose of another which includes all information, planning and (quality) control systems. It is also a very important factor to recognise that a conceptual model isn’t a description of human activity; it is used in stage 5 as a tool to generate a debate. Figure 3 below shows the way in which the conceptual model works. Transformation input (TI) Transformation output (TO)

Source: Lutwyche (2011) After analysing the case study we have built a conceptual model for the Malawi case study. Transformation Input: To find and edit/update patients records on the system. 1. Login to the system 2. Search for customer 3. Easily access the customers details 4. Be able to easily update/edit customer details 5. Save customer details 6. Details will be updated for next time they need accessing Transformation Output: The new system saves a lot of time for the health service workers as patients details are easily accessible, and easy to update. Figure 4 shows this below. Figure 4: Conceptual Model for Malawi HMIS

Transformation Input: To find and edit/update patients records on the system. Login to the system Be able to easily update/edit customer details Search for customer Save customer details Easily access the customer’s details Details updated for next time they need accessing Transformation Output: The new system saves a lot of time for the health service workers as patients details are easily accessible, and easy to update. 8. 17 Stage 5: Comparison of Conceptual Models with Real World At this stage in the SSM, the models from stage 4 are brought into ‘real world’ and then set against the different perceptions that exist there.

The aim of this is to create a debate with concerned people within the problem. The first part of this will find out if the activities present are in the ‘real world’ and how well are these activities completed? Alternatives which are suggested by the models are discussed, and the outcome of the situation may be either to change how things are done or to introduce new activities. Here we have linked this to our case study with the findings stated below. Activity| Exist in Real Situation? | How is it done? | How is it judged or measured? | What are the problems? | Proposed Changes? | General Comments? Login into the System| yes| There will be a login Id for every users| There will be a measure in place to check the functionality of the logins | Staffs might sometimes forget the Login details as this is a new system| Have computer department that can change/override and issue another login details| There will be time saving if all users can login easily| Search for customer| yes| Users will login and do the search by using names, place and date or birth| Record data will be collecting at interval | There might be multiple names and same dob as there was no appropriate records before| Updating the system to differentiate between any same identity| There will be time saving if all users can login easilyand will help the patients| Easily access the customers details| yes| Users will login using their login ID| When the information come up as expected| If it not saves well| none| This will bring improvement to the health services| Easily update /edit customer details| yes| After Users login the new details will be enter to override the old one| The record will show the changes made| When the patients did not inform the staff about the changes| Informing the patients on the benefit of the changes| Create fast work and accuracy| Save customers details| yes| After Users login and the new details enter| I will be stored after entry | There might be an error from the staff by not save the detail after changes| None| Make easy access next time | Details updated for next time they need accessing| yes| Users will always safe any changes done to the system| There will be a complain if the information’s cannot be access when needed| Staff might not save the patient detail because of omission | None| There will be a chance to measure the performance of the system| 8. 18 Stage 6: Define Desirable and Feasible Changes

This stages purpose is to define any possible changes regarding to the situation that are either desirable and/or feasible. This should be done by each of the people concerned debating and concluding an outcome which benefits all. The changes can be done in three different ways, starting with the least difficult to change; procedural changes, structural changes and attitude changes. 8. 19. 1 Procedural Changes This is how activities are done within the structure. Checkland (1999) explains, ‘Procedural changes are changes to the dynamic elements: the processes of reporting and informing, verbally or on paper, all activities which go on within the static structures. ’ 8. 19. 2 Structural Changes

This is the organisational groupings and responsibility. Checkland (1999) explains these as, ‘Structural changes are changes made to those parts of reality which in the short term, in the on-going run of things, do not change. ’ 8. 19. 3 Attitude Changes This is the changes of influence, learning, values and norms within the organisation. Checkland (1999) describes attitudinal changes as, ‘Influences and expectations of people’s behaviour that they have in various roles. 8. 19 Stage 7: Action to Improve the Problem Situation At this stage action is taken to improve the problems found at stage 6. The end product of this stage is a new problem situation that can be confronted sing the methodology in a recurring fashion. The best way in which the system can take action would be to go through the system and identify if there are any ways in which problems can be solved or improved. The SSM will have to be looked at as a whole and then the correct people will have to be identified to manage each task. We did not identify any desirable or feasible changes regarding the situation in the case study, this is was earlier illustrated in stage 5 and stage 6. 8. 20 Conclusion The soft system approach took this into account and realised that to solve a problem the whole picture has to be thought about and not just the issues that directly affect the problem.

The Soft System Model outlined issues, stakeholders and tasks that could be undertook to find the solution to the problem. It was then suggested to find a best solution using a system that all users had access to the system and be able to update the system and work together as a team to better the HMIS. Using CATWOE this was the preferred solution to enable the accessibility of the new system to be cost effective and also the one that saved time, money and live for all the stakeholders involved including staffs and patients. Overall the Soft System Model was a better solution than a hard system approach, although the long term benefit will be better as the short term one will cost too much money.

The long term one will also allow the country and the health department to be more effective and bring about efficiency this will save lives and also improve the reputation of the country outside the world In conclusion we believe that the soft systems solution that was found would be the best for the case study to use as it address different issues and considers how to overcome them. 8. 0 Question 3 8. 1 Law of Conceptualisation The organisational perspective becomes relevant due to Checkland’s law of conceptualisation which states that, ‘a system which serves another cannot be defined and modelled until a definition and a model of the system served are available’ (Checkland 1999).

In summary this means that the perspective of the organisation is more applicable in relation to the case study. It is easier to define a system when you know what that system does for any other system it’s in contact with. The reason behind this is the way the system served will be conceptualised to clearly show the concept of service and in turn would be fundamental to serve or support it. In a case where two systems are in direct interaction with each other, for example where system A serves the other system B. It’s not possible to design or redo the design of the first system, which is system A without having a full understanding of system B. Understands System A System B Serves Model Figure 5. Law of Conceptualisation Model

When discussing the case of the Malawian Health Management Information System (HMIS) there are numerous subsystems that feed into the HMIS. In turn then the HMIS is used to serve the entire system of Malawi patient care. (Figure 2). Abbreviations: HMIS = Health management information system HSMIS = Health services management information system HRMIS = Human resource management information system FMIS = Financial management information system LMIS = Logistics management information system PAMIS = Physical assets management information system IDS = Integrated disease surveillance HSIS = Health services information system Figure 6: Integration model of the national health management IS Source: Chaulagai et al (2005)

It is understood when talking about the case study that the HMIS requirements are as follows: * An information system that can handle the co-ordination of all the data collections functions * The collection and compilation of all data from all sources used * The storage of the data in the appropriate or corresponding format * Storing the data in the appropriate formats and the distribution of the data in various different formats for quick use so that the requirements of different users can be met just as effectively and efficiently to try to give the best quality of care for every individual * Keep a consistent standard coverage of health services (HS) in community areas * It must improve the patient’s health status in any areas of catchment When applying Checkland’s Law of Conceptualisation it’s clear that there was a good understanding of the Malawi patient care system and the system’s needs that were already in place before the actual design or modelling of the HMIS was done. This made it possible to create a straightforward but complete and manageable HMIS that in turn could firstly be conceptualized then developed and finally introduced. 8. 2 Sub-optimisation Machol states that ‘Optimizing each subsystem independently will not in general lead to a system optimum, or more strongly, improvement of a particular subsystem may actually worsen the overall system.

The principle of sub-optimisation provides the basis for a link between organizational structure and the policies adopted. ’ (Machol, 1965) In theory this means that when optimising the outcome of a subsystem this does not mean that the outcome for the overall system will be optimised. With this come three different things to think about in relation to the attempted design and optimisation of subsystems: * Subsystems should not be optimised individually * Subsystems should not be designed in isolation * The total system should be considered during any plans of optimisation When looking at the Malawi case study there are numerous examples of sub-optimisation which can be discussed and looked at in detail.

In the beginning the HMIS method used for any reports were all paper-based this meant that for each employee would have to firstly record each report and then make their analysis of the report and then finally they would be able to compile these reports so that they could be of any use during the day-to-day running of the system. All health related staff members’ functions are to manage the information provided to them that is directly related to what they do within the business and then to use this information in a productive manner. Any program coordinators within any of the district health offices (DHO) were in charge of the compilation of any data specific to their corresponding department and also had monitor all functions on a day-to-day basis. The disadvantages and advantages are as follows respectively: * The recording of reports is quite time consuming. Difficult to pin point were any human error might have occurred. * Difficult to trace were reports originally began. Despite the disadvantages mentioned above, the system has the ability to inform people as to the performance of any particular department or facility as soon as the report arrives. The current paper based system was obsolete as soon as a computer program for the processing of data was created and implemented. This software can: * Calculate reported population coverage * Show reports from raw data * Present Geographical Information System data on maps This increased productivity in both the reporting and processing of data but program coordinators lost their input in this process.

After the data processing system was eventually changed to a computerized system it affected certain employees mainly the program coordinators which became inactive patrons to any information coming through the data processing system. The next program that was introduced was a specific program for routine data processing which was an exchange between: * Contribution of data processing program coordinators * More efficient and effective data availability 8. 3 Synthesis Synthesis is a term meaning a process that uses a combination of two or more elements that are already in place and turns these into a hybrid. Furthermore Systems Synthesis is a term that means to take not just a perspective approach to system building but it needs to entail more than one perspective when doing so.

When looking through the Malawi Health Service it’s clear that developers have made use of many different diagrams to try and develop a map of the HMIS. This means the related groups have recognised and made clear the actions of the different properties within the given situation. There is a clear need to an innovative IS as there is a major shortage of dependable, consistent data and the insufficient understanding and utilisation of accessible information in preparation and organisation of Malawi HS systems. When discussing the quality of health services IS are more important than ever in relation to calculating the quality of HS and also when trying to improve the coverage of the health services.

The reason for its steady increase is due to the fact that the HS is trying a different approach which from simply curing patients after they come in with symptoms to actually trying preventive care which is trying to protect people from actually catching something in the first place. This is not the only reason for the importance of IS in the health service and the rest of the reasons are as follows: * Changes from hospital to public health care * Changes from centralised to decentralised health care * Changes from a precise approach on individuals to a complete sectional approach All the reasons that have been mentioned above are not just local changes in Malawi but are more like global changes. This brought about the re-organization of the incoherent health IS into a more solitary health management IS.

The theory of the improved system is to generate a health sector that encourages the optimisation of information in balancing the choices made towards the planning and to the actual management of HS but unfortunately is has not went entire to plan as of yet. Within Figure 3 below, is any behaviour that took place within the task. This diagram can used to follow decisions as they are being made to see which direction things will go after that decision has been made. Figure 7: The process through which the health management information system evolved in Malawi. Source: Chaulagai et al. (2005). To be clear this is only one tool which was used but there are multiple different similar tools that can be used to support any analysis of the specific problem. The other tool could really be useful is that of Influence Diagrams and to a lesser extent decision timelines and risk timelines.

These tools recount and describe any important areas in which there is a sense of uncertainty which basically means any unpredictable behaviour which is outside of our grasp to change. In relation to helping evaluate the group’s most viable option, the different relevant strategies that are legitimate possibilities should be considered. 8. 4Emergent Property Emergent property is a term which is linked to a system in its entirety, and arises when a new attribute or task crops up due to relations among various sections of a system. When discussing emergent properties in relation to the Malawian case study the main one has to be that of the training issues for the HMIS.

Originally the training was designed so that it can be divided into different districts so that the head trainers could oversee all the training in these separate groups. Although resulted in the national vertical program being replaced by a different method of approach which was to make sure that all of the trainers are fully trained this change was due to the lack of collaboration from the NVP. The training took around the half year mark before the national training was finished. It has to be mentioned that some of the performance of new members in the workforce was more accurate and precise that than certain members of the team that already possessed training in the HMIS.

Employees can perform better with half the amount of the original training which was 5 days, this was clearly shown by the new members of the workforce as they only had half the length of time for their training of the HMIS but the quality analysis of any collected data and the arrangement put to use during the distribution was of a higher rate than those of their peers who received the 5 day training session. 8. 0 References Figure 6: CHAULAGAI et al (2005) Design and Implementation of a Health Management Information System in Malawi; Issues, Innovations and Results. CHECKLAND, P. and SCHOLES, J. (1990) Soft Systems Methodology in Action. John Wiley ; Sons, Chichester.

CHECKLAND, P. (1999) Systems thinking, Systems Practice. John Wiley ; Sons Ltd, Chichester. Figure 1: Fuchs, C. 2004. Journal of Knowledge Management Practice. Knowledge Management in Self-Organizing Social Systems, [on-line] (Accessed 16th February 2011) Available from http://www. tlainc. com/articl61. htm Figure 3: LUTWYCHE, L. (2011). Soft Systems Methodology Lecture Notes. Index Mundi (2011) Malawi life expectancy at birth [on-line] (Accessed 8th March201) Available from http://www. indexmundi. com/malawi/life_expectancy_at_birth. html Lancs (2011) Comparing Hard and Soft Problems [on-line] (Accessed 4th March201) Available from http://www. lancs. c. uk/users/incism/back2. html MENDRAND, A. E, et al (2010) The Soft Systems Methodology, pp 1-9. Merriam-Webster (2011) Problem Definition [on-line] (Accessed 8th March201) Available from http://www. merriam-webster. com/dictionary/problem Orsoc (2011) Root Definition [on-line] (Accessed 8th March201) Available from http://www. orsoc. org. uk/about/teaching/strategicproblems/m_s_10. htm Lancs (2011) Comparing Hard and Soft Problems [on-line] (Accessed 4th March201) Available from http://www. lancs. ac. uk/users/incism/back2. html Wilson, B. (1984) Systems: Concepts, Methodologies and Applications. Wiley, London Machol. (1965). PRINCI_SUBOP.

Retrieved march 23, 2011, from PRINCIPIA CYBERNETICA WEB: http://pespmc1. vub. ac. be/ASC/PRINCI_SUBOP. html 9. 0 Bibliography http://www. friendsofmalawi. org/learn_about_malawi/institutions/healthcare. html http://books. google. co. uk/ http://www. unohealthcare. com/eng/index. php http://www. medicmalawi. org/ http://digital. lib. msu. edu http://www. malawiproject. org/about-malawi/the-nation/hospitals-healthcare/ http://www. biomedcentral. com/1471-2458/7/78 http://www. trocaire. org/news/2006/09/18/malawi%E2%80%99s-overwhelmed-healthcare-system http://www. who. int/countryfocus/cooperation_strategy/ccsbrief_mwi_en. pdf http://cimms. ou. du/~doswell/TSIII/TSIII_concept. html http://www. ispub. com/ostia/index. php? xmlFilePath=journals/ijanp/vol6n1/research. xml http://serc. carleton. edu/introgeo/conceptmodels/ http://en. wikipedia. org/wiki/Conceptual_model_(computer_science) http://www. who. int/countries/mwi/en/ http://www. who. int/en/ http://news. bbc. co. uk/1/hi/world/africa/country_profiles/1068913. stm http://www. indexmundi. com/malawi/life_expectancy_at_birth. html http://www. unicef. org/infobycountry/malawi_statistics. html 10. 0Glossary of Terms HMIS -Health Management Information System HS -Health Services DHO -District Health Offices IS-Information Systems NVP-National Vertical Program

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