What is common between these two very different settings: sitting in a moving aeroplane and having a surgery done in an operation theatre? Well, both are highly complex, man-made environments that their end-users (passengers and patients) are hardly aware of. These environments are operated by highly skilled technical teams that carefully monitor several parameters on real-time basis and do the needful to give a good experience to its users. These environments are designed in such a manner so as to minimise human error, for an error could prove to be fatal for its users.
These complex environments don’t exist in isolation. There is a full ecosystem around these controlled settings that prepare patients or passengers for it. For instance, if you are catching a flight, you need to follow a well-laid down procedure of collecting/printing your boarding pass, handling check-in baggage, undergoing security checks, boarding an aircraft and so forth. Similarly, for a patient who is to undergo a surgery, his body vitals such as blood pressure and sugar levels are brought under control, all the necessary documents — be it diagnostic reports or consent forms — are put in order before rolling a patient in an operation theatre.
How is this all created? Well, systems thinking is applied to design these complex environments as well as to create an ecosystem around it. A design team is typically a multidisciplinary team consisting of engineers, architects, behavioural scientists, management experts and so forth, who co-create the environment while evaluating it from different perspectives. The entire ecosystem is designed from users’ perspective.
Systems design thinking is needed not only for the aviation and healthcare sectors. It’s needed for solving almost every development challenge — be it in infrastructure, education, transportation, energy, water supply and sanitation and so forth — in any country. Systems thinking is quite common in the developed countries, but not so in the developing countries. When systems thinking isn’t applied, we end up either solving only a part of the problem or solving it superficially, or creating new problems elsewhere.
To illustrate, Delhi’s public transport system is a good example of lack of systems design thinking. While Delhi Metro Rail Corporation as a sub-system has done a fabulous work in providing mass rapid transit solution, the same cannot be said of the other modes of public transport. Because of the “tunnel vision” of the policy/decision-makers that didn’t plan for the last mile connectivity and didn’t think of the larger design of the public transport system, the city roads remain congested. For an efficient and effective public transport system, each mode of public transport needs to be developed as a sub-system, with each sub-system feeding into the other. This can happen only by designing city’s public transport system holistically, which is what the systems design thinking is all about.
Another example to consider is the education system in India. Not only is the education system highly fragmented, the quality of teaching at each level is highly suspect. Perhaps with the exception of missionary schools, most private schools have turned into money-making institutions with little focus on quality education using latest tools and techniques. Resultantly, majority of school students end up seeking private tuitions. Similarly, Indian universities hardly ever prepare students for job markets. What is needed is not just tweaking the existing system but applying systems thinking to reform the entire education system.
A similar thing could be said for the Indian healthcare system too. That India’s healthcare system is broken and needs fixing is a known fact. That the NDA government has prioritised health is also recognised. A large part of NDA government’s response to India’s broken healthcare system is a programme called Ayushman Bharat (AB) that consists of two pillars: the primary care pillar is about converting 150,000 health sub-centres that provide selective care into health and wellness centres that would provide comprehensive primary healthcare; the hospital care pillar consists of hospital insurance programme, Pradhan Mantri Jan Arogya Yojana, aimed at providing financial protection of `500,000 per household to almost 100 million poor households against hospitalisation costs. Undoubtedly, AB is a big and bold initiative. But it will not be able to fix India’s broken healthcare system as that requires a holistic approach that also addresses the challenges of trained human resource, public financing, management, governance, accountability and so forth.
In this context, Niti Aayog’s initiation of a development dialogue — a series of multi-sectoral conversations on India’s development issues — is very welcome. The first of this conversation, which was focused on health system for a new India, seeks to bring systems design thinking into healthcare.
Healthcare is one of the most complex development challenges. Solving this challenge with a systems design thinking needs a longer-term horizon than what is covered in the National Health Policy 2017. Systems thinking doesn’t come naturally to public administrators. So, getting a group of experts in a room to deliberate and develop a blueprint is a progressive step. But the real test of it will depend on achieving a necessary coordination between the Centre and states.
The writer is a development economist, formerly with the Bill & Melinda Gates Foundation and the World Bank