by Abdullah Alibrahim
In May of 2014, President Barack Obama received a report titled ‘Better Health Care and Lower Costs: Accelerating Improvement through Systems Engineering (SE)’ by the President’s Council of Advisors on Science and Technology. The report marked the culmination of healthcare’s longstanding relationship with Systems Engineering to unravel and optimise the complex patchwork of operations in the US healthcare system. Bolstered by measurable improvements attributable to SE in US healthcare, developing healthcare systems in the Gulf Cooperation Council (GCC) stand to gain the most from specially suited SE tools for comprehensive healthcare reforms.
SE is concerned with systems – collections of interconnected elements that serve a shared purpose. Complex systems’ behaviours are intrinsically difficult to predict due to the underlying elements being tightly knit and highly embedded, creating interactions that are challenging to unravel. Typically, the whole behaves differently than the sum of parts, which makes inferring outcomes challenging by examining individual elements of a system. Consider the human brain, social networks, and financial markets, where many emergent system behaviours are non-derivable from reducing the system to its fundamental parts. For example, the sophistication of the human mind cannot be extrapolated from the simple functions of neurons, and healthcare is similar.
Healthcare systems are not merely collections of hospitals, clinics and people. They are inherently more complex and have idiosyncrasies that cannot be captured by separating the elements mentioned above. Simply constructing more healthcare facilities, training more personnel or inviting private sector participation rarely results in long-term improvement of population health outcomes. Instead, healthcare systems should be viewed as complex systems with deep-seated economic, regulatory and cultural roots that require multidimensional dynamic solutions. Interventions and policies that fail to account for the multitude of existent forces cannot capitalise on potential synergies. Consequently, numerous seemingly positive healthcare reform initiatives yielded unintended adverse outcomes.
SE offers a host of tools to analyse, design, manage, and measure improvements in efficiency, productivity, safety, quality, and costs. Tools include computational simulation modelling, mathematical optimisation, decision analysis and data analytics, to name a few. Amid ongoing health reforms in the GCC, these tools are suitable to provide valuable systems-level insights to inform effective policy design.
Healthcare tops GCC priorities with regards to development plans and strategic visions (see, for example, Saudi Arabia’s Vision 2030 or Kuwait’s Vision 2035). Reforms include capacity expansions, financial overhauls, and structural rebuilding to improve operations, align incentives and enhance outcomes. In Kuwait alone, the cost of health facilities in Vision 2035 is nearly $4.57 billion. These costly and consequential undertakings warrant thorough evaluations to ensure coherence with overarching system goals and needs.
Healthcare Policy & National Strategies
Simulation modelling is a powerful tool to study the impact of policy changes on healthcare capacity and costs. It became a standard part of health reform development and a required element in enacting health legislation in some countries. This point is highlighted in the instrumental role of the Congressional Budget Office (CBO) in passing the 2010 US Healthcare Reform (known as ‘ObamaCare’) and failed repeal efforts. The CBO develops dependable national-level models to estimate the impact of health policy by harnessing the power of simulation modelling, economic theory and vast amounts of data. Models guide decision-makers towards leverage points – areas where minimal intervention produces a significant impact – and allow them to hone their efforts on the most effective policy levers to produce optimal outcomes.
In the wake of the economic downturn in the region, simulations afford an in-depth look into what if questions without overlooking essential behavioural and adaptive elements. For instance, illustrative results from our simulation model showed that informed patient choice of provider reduced total costs and improved outcomes, all while incentivising providers to participate in Accountable Care Organizations. In the GCC, models can empirically justify shifting the focus from the alluring prospects of pristine mega healthcare facilities to politically mundane but critical efforts on prevention, care continuity and patient empowerment as integral parts of reform strategies.
Healthcare Delivery and Continuity
The impetus for SE is prompted by the complexity of medical treatments, diversity of specialties and intertwined facets of quality of life. It is challenging to overlay the medical specialties, levels of care and non-medical elements in the care continuum. Nevertheless, notable opportunities exist to reinforce systems for better health outcomes. Opportunities are catalysed by the proliferation of technology, computing power and analytics. As disciplines converge to tackle mounting health challenges, SE provides essential links to integrate insights into practice and allow for more data-driven and informed decision making.
Substantial capacity gains are viable by leveraging technology, computer intelligence and domain experts. For instance, machine learning algorithms can identify at-risk groups for targeted prevention, remote visits alleviate the point-of-care pressures, and wearable/implantable technologies capture essential measures for informed medical decision-making. The opportunities above require seamless workflow integration, as many previous efforts failed due to disruptive integration in hectic clinical workflows. When meaningfully integrated, opportunities amount to sizeable improvements in patient experiences, increases in patients served and reductions in utilisation. Capitalising on the process-focused toolsets within SE facilitates the integration of advancements for non-marginal and scalable capacity gains using existing resources in the GCC.
Numerous distinctive forces drive healthcare systems, and that further obscures the forecasting of outcomes. Demand from aging populations and non-communicable diseases outpaces capacity growth in GCC. Concurrently, market-like dynamics emerge as effects of incentive schemes cascade down to provider and patient experiences and behaviours. Constantly shifting forces within the healthcare systems necessitate continuous evaluations of proposed reforms and delivery models.
As GCC countries embark on far-reaching healthcare reforms, SE tools enrich essential cross-disciplinary approaches and facilitate the successful adoption of novel technology to combat pressing healthcare challenges. Economic and sustainability pressures in the GCC force narrower margins of errors deeming the cross-disciplinary approach vital for optimal resource allocation in healthcare. Infusing SE tools in existing GCC healthcare policy planning and evaluation processes will guide pragmatic and evidence-driven reforms that collectively enhance healthcare operations, costs and outcomes.
Abdullah Alibrahim is an Assistant Professor of Industrial and Management Systems Engineering, Kuwait University who was a Short-term Fellow with the Kuwait Programme, Middle East Centre in 2019. He holds a PhD in Industrial and Systems Engineering from the University of Southern California (USC). He is involved in diabetes-related research at the Dasman Diabetes Institute and health reform discussions at the Ministry of Health, Kuwait.