I had experienced the improvement of the health system while I did my internship at certain hospital. There was a implementation of the novel chemotherapy ordering system because the former system had many unnecessary processes. The new system was the web-based application so training the personnel to use this system could be a hindrance to the system improvement, because some of personnel was computer-illiterate. And when it came to the change of the routine, it took some time for everyone to adept to the new system.

HIS (Hospital information system) implementation or upgrading might be an example of health system improvement. Decent HIS can improve many aspects of health system, including increasing cost-effective of taking care of patient, improve quality of delivering health services, providing information for further improvement.

There are many factors that could affect the process of implementation. I try to consider the factors in aspect of framework of health system.

– Leadership/Governance : Leadership is vital to make the process of implementing HIS success. Organization’s leader will be the one deciding how the process should be done. Leader who doesn’t realize the importance of IT might be the biggest barrier in the process.

– Human resources : It takes many officers to implement the HIS. Another possible barrier is some healthcare provider might resist to change their way of work.

– Financing : Implementation of HIS is usually expensive. Although there are a few way to decrease cost of implementation, such as develop our own local made HIS and buying a bundle of license for many hospitals, it still tooks much financial resources.

– Information : To maximize the benefits of using and implementing HIS, the information should be structured and standardized.

I would like to give an example from the current situation. Currently, Thailand’s health care system is transforming the Universal Coverage Scheme to make the patient easier to access care. Before the transformation (“30 Baht Treat All”), in order to use the Universal Coverage Scheme, the patient must visit the hospital or the health care provider that they registered with as a primary care service before visiting other hospitals. The plan of transformation is that the patient can visit any hospital without having to visit their nearest registered health care provider (“30 Baht Treat Anywhere”).

While the transformation is considered to be the big leap of health system improvement to widening the health care coverage, there are several barriers that could occur in that system improvement process.

– Health workforce: the workforce must distribute appropriately in order to serve the patient that can access the healthcare anywhere (eg. some hospitals might have more visitors than others due to various reasons)
– Information: if the patients can visit any health care provider, accessing the medical record must be available from every hospital. Referring patients from one hospital to another must be easy and seamless.
– Medical products and Financing: like the health workforce, they must be distributed appropriately to serve the patients.

An example of health system improvement in Indonesia is the establishment of Universal Health Coverage in 2014. Although it is still a work in progress because improvement of the system is needed, but I appreciate that the government take action to provide health protection and service to the citizen.

One of the issues I can think of is the limited number of healthcare professionals. The ratio of doctors and the population is 4:10.000 which is the second-lowest in Southeast Asia. Moreover, there are also casualties from Covid-19 pandemic. If there are fewer healthcare professionals that can provide service to the public, the wait time for medication will also be longer and thus can result in decreasing public health and well-being.

An example of a health system improvement based on my experience where I work now is the development of a malaria information system called SISMAL. Previously, using paper-based. After SISMAL implementation data is available, it becomes easier to evaluate the program. SISMAL’s challenge is reporting in remote areas because it requires an internet network.

Please let me share the challenge we observed when my former hospital tried to introduce the laboratory management system as part of the hospital’s electronic medical record system in Japan over 20 years ago.
The newly introduced system with a very simple LAN and client/ server system, although the latest technology back then, was expected to change the whole laboratory management drastically including the process of sampling, pre-treatment, analysis, that would realize timely reporting and better quality control, as well as efficient/ effective HR management, thereby achieving patient-centered laboratory management.
One of the biggest challenges observed during the transformation process was actually a people’s mindset to resist the unavoidable change due to the fear and annoyance of changing routine works, and needs of learning new technologies. I learned about the importance of leadership, as the hospital governance and management played a crucial role in the introduction and implementation process.

One of the health system improvements I could think of is COVID-19 vaccination appointment in the Philippines. It was early 2021 when vaccines were rolled out in the Philippines. At that time, there is no real system for enrollment. The person will just walk-in to the vaccination site and wait for hours to be vaccinated. In other areas like ours, the village captain will collect the names of those who would like to get vaccinated. Not only the time was wasted, but also prolonged exposure may result to community transmission of the disease. Further, not all may be reached by the village captain.

Good thing some cities were innovative – they rolled out online registration site where you could already key in your details and be able to declare your health condition prior. Once registered, the authorities will just provide your schedule of vaccination. This has improved the service delivery of vaccines to the people and saved tons of time lining up on vaccination sites.

However, there were barriers on this approach. One is that, the registration websites were being overloaded with requests; hence, were usually slow across users. Users are met with registration errors. Second, information security was also a concern. Sensitive information were being disclosed on these registration sites and may be susceptible to unwanted use. Third, senior citizens had a hard time using the website and needed assistance in filling up the form. This resulted to inequity among these population since the cities implemented “no schedule, no vaccination” policy.

In my previous workplace, the government had implemented different strategies for the better outcome of health for the underprivileged population. Different stakeholders from the community also participated to aid the government in delivering the information in health promotion, vaccination. But due to the barriers in technologies and infrastructure, the project was not successful. With the advancement of technologies, service delivery in the healthcare field is improving.

An example of a health system improvement based on my experience is the Online Adverse event reporting system implemented by the Thai FDA. Previously, all hospitals and pharmaceutical companies needed to report adverse events to the FDA using the paper-based form and send it to the FDA. Then, FDA officers would document it manually. It took time and workforce. It could also delay the response and management plan when serious AEs have occurred after the Online AE reporting system is implemented. All sites can report spontaneous AE individually and save time intaking data in the AE system. Additionally, the FDA can analyze the data on a real-time basis and respond to any critical events on time.

Several factors could affect the process of implementation. First, healthcare professionals might not be familiar with the system when it first launched. Due to the high workload of healthcare professionals, reporting AEs to the AE system would create an extra workload and take time for them to learn how to use the system. In addition, all data filled in the AE system should be standardized. Therefore, the users need to understand the structured data in order to complete the reporting process. Moreover, creating a new online system would require financing for initiation and maintenance costs. Also, the hospital leaders need to agree and advocate for their employees to use the AE system.

Health Information Exchange (HIE) implementation is an example of health system improvement. In Thailand, there is a platform called ‘Health Link’ to connect and improve health data access in national level. Challenges and possible barriers that can affect the process may not only about financial, data interoperability and data security issues, but also the accessibility to the system. Health Link platform require smartphone or computer to access the system so this is an issue that this platform may not be able to access by some group of population and it can cause inequality.

Since HIE implementation has many advantages to the health system improvement in national level and may be extended to international level, establishing the stable and accessible system is the big challenge to develop the reliable and standardize health system.

An example of health system improvement was the development of a surgical safety checklist which was the service part of the health system. The surgical safety checklist has three steps: sign in, time out, and sign out. These steps are designed to improve communication and teamwork for surgeons, anesthesia, and nurses involved to ensure that critical safety measures are performed before, during, and after an operation. The possible barriers could be the attention and cohesion of team members to apply the surgical safety checklist to all patients.

1. The medical and public health resorce management is the good example of Thailand’s health system improvement. In the past, we use the paper-based management system which spend a lot of time, money and personal for proper administration. In the present, Ministry of Public Health use information technology and public health informatics as the tool for organize the resource management system. There are many benefits on administration purpose such as easy to access, import/export the information, and interpretation demand and supply of biomedical institute , which can predict and make the proper public health policy in the future.
2. For the possible barriers of the system improvement process are
-initial investment in technology setup but for the long term benefit, it’s good cost-effectiveness one.
-personal in the improvement process which required experienced condition in the biomedical and related technological field.
-executive vision on the technology which drive the development process to the goals.

Taksin U.