Browsing by Subject "Health Care Systems"

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    The implementation of an integrated prevention of mother-to-child transmission of HIV (PMTCT) programme at McCord Hospital, South Africa, 2003-2013
    (2015) Giddy, Janet; Olivier, Jill
    Integration is an important emerging health systems issue, which has relevance to different health programmes. Improving prevention of mother-to-child transmission of HIV (PMTCT) programs in South Africa would reduce preventable maternal and infant morbidity and mortality, assist with achieving Millennium Development Goals 4 and 5, and help in the response to the WHO call for the elimination of MTCT, the new international PMTCT goal. Integrating PMTCT care into routine maternal and child health programmes has been recommended as a way to optimize PMTCT care. The Part B literature review in this dissertation examines the reasons why PMTCT programmes need to engage with integration as an issue, challenges to implementing integrated programmes, followed by a discussion of the benefits and lessons to consider in planning integrated PMTCT programmes. Theoretical concepts and frameworks such as Atun's framework, complexity, Theory of Change and innovation in health systems are discussed, as they have key relevance to the research findings. Lessons about implementing health system changes can be learned from programmes which have done so successfully. Using Case Study methodology, the process of developing the fully integrated longitudinal clinic at McCord Hospital is described in Part C, and reflections on the experience of providing integrated care are captured through qualitative interviews with the staff. Recommendations regarding innovation and change within complex systems are made, emphasizing the need to understand contexts which are receptive to change and the importance of leadership in managing change.
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    Medicine and medical process as a learning system
    (1996) Van Wyk, Gerrit Christian Burggraf; Strümpfer, J P
    Health care systems all over the world are in crisis. The presenting symptom is a cost spiral that is out of control. Money supply is finite, and if this problem continues the system will eventually collapse. There are a number of causes associated with the problem that are usually analysed by reduction, an approach based upon an assumption of simple linear causal relations. This study shows the problem to be the dialectic opposite, in other words these problems are all interrelated through complex causal interactions. Therefore, the health care system is a complex social system and solutions to its problems may be found in terms of the interactions in such a system. An investigation into the history of the health care system shows that the system started with a simple one on one interaction between patients and physicians. At the time of its initiation, very little empirical knowledge was available about illness. After the renaissance, this changed dramatically with a subsequent increase in the ability to diagnose, but also in the complexity to treat illness. However, modern beliefs about illness and illness processes do not reflect the complexity of this knowledge. Beliefs about both illness and knowledge contribute to the process of diagnosis (medical decision making, or problem solving). Furthermore, the expectations, wants, and needs of patients and physicians, as well as the decision environment, increases the complexity and difficulty of this decision making process. These decisions initiate treatment processes that are ultimately represented in the health care system as cost. Therefore, the patient-physician system as the simplest initial interaction is an event that ultimately affects cost. This system is not functioning efficiently at present and a system of inquiry that can improve it may make a contribution to an improved system, and therefore a saving in cost. Altering the diagnostic system from a linear into a circular process, in other words into a learning system, improves both decision making and the use of knowledge. However, an inquiring system is needed in addition that can enhance the rigour of this process. Charles West Churchman devoted a large part of his work to knowledge and the way we acquire knowledge, in other words inquiring systems. His belief is that problem solving ought to be approached in a comprehensive way in order to minimise the risk for making incorrect decisions. Furthermore, because decisions are made upon incomplete information, the solutions will be the cause of new problems. Therefore, problem solving is a never ending cycle of learning. In order to have as complete information as possible about the problem, we have to: know the history of the problem, take a broad view that includes the environment of the problem (use a systems approach), and consider all the alternative solutions to the problem. Virtually all of our knowledge is based upon underlying assumptions. In order to test the validity of the knowledge we use for inquiry and decision making, it is important to test the assumptions upon which the knowledge is based. This is valid in regard to empirical knowledge as well. Finally, according to Churchman, decision making has to be ethical. Therefore, we have to do all we can to ensure that the implementation of the decision will improve the situation, not only now, but also in the future. The application of Churchman's approach to the patient-physician interaction, assists in the synthesis of a more comprehensive world view of health care and illness. This study shows that this leads to important changes in the negative interactions identified as contributing to the health care crisis. In terms of Churchman's approach, the role of physicians can be seen as managers of illness. Their purpose is therefore to plan for the improvement of illness (the problem) in an ethical way. Such planning should include the values of patients in deciding upon appropriate treatment. It is the submission of this study that only a methodology that is able to address complex human systems, such as a systems approach, and a comprehensive philosophy of inquiry, such as that of C West Churchman is appropriate to address the current problems of the health care system.