Upload
dave-sen
View
217
Download
0
Embed Size (px)
Citation preview
8/23/2019 Dr Pallab Saha - EA & Public Health
1/24
RESEARCH
ArchitectingforBusinessInsightandStrategicForesight:ASystems
ApproachtoManagementofChronicDiseasesinSingapore
PallabSaha
NationalUniversity
of
Singapore
InstituteofSystemsScience
ExecutiveSummaryBusiness leaders operate in the realm of confounding uncertainties and
astounding complexities. These lead to incomplete and often nonactionable
informationthatmakesbusinessdecisions increasinglyspeculative.Theadvent
and diffusion of Enterprise Architecture (EA) as a metadiscipline provides
organizationsandbusinessleadersthemeanstoaddressthetwinchallengesof
businessdynamism
and
complexity.
However,
this
necessitates
the
inclusion
of
strategic(systems)thinkingwithintheEAapproach,requiringwithitacomplete
transformationofthearchitectsmentalmodelspertainingtothedevelopment
and utility of EA. As organizations become increasingly hyperconnected they
oughttobeviewedandexaminedassystems,whereintheholisticapproachand
theinterrelationshipsbetweentheorganizationalelementsplayacrucialfactor
in ensuring overall business coherency. This paper demonstrates the value of
adopting the systems approach to addressing chronic disease management in
Singapore, and provides insights to advance the impact of EA by integrating
creativethinkingtotacklecomplexproblems.
KeywordsHealthcare Systems; Public Health Transformation; Connected Health; eHealth; Coherency
Management; Chronic Disease Management; Policy Resistance; Management Agility;
OrganizationalChange;BusinessModelInnovation.
2011NUSInstituteofSystemsScience.NUSInstituteofSystemsSciencegrantspermissiontoreprintthisdocument
providedthiscoverpageisincluded.
8/23/2019 Dr Pallab Saha - EA & Public Health
2/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page2of24
IntroductionStructured enterprise architecture (EA) approach is often used to plan and implement efficient and effective
transformationefforts.However,thestrongestdriverforEAistoimproveservicedeliveryandoverallperformance
withintheorganization'sbusinesssegments.Theprincipalchallengefacedbychiefarchitectstoday istoinstitute
anEAprogramthat isabletocoordinatesustainablechangesthroughouttheorganization,whilesimultaneously
mentoringthespecifictransformationplanningthatisneededtosupportthemission.Inanutshell,EAisarobust
planningfunction
which
helps
organizations
to
understand
the
process
by
which
business
strategies
turn
into
operational reality. Hence, establishing a standard methodology for conducting architecture planning and
implementationisvital.Metaphorically,anEAistoanorganizationsoperationsandsystemsasasetofblueprints
is to a city and its buildings. However, EA comes with additional challenges given that the primary frame of
reference, the organization, is a complex adaptive system. Even as architecture teams are architecting, the
organizationsthatarebeingarchitectedcontinueto functionandasaresultremaindynamicandeverchanging.
Traditionally,byfollowinganarchitecturebasedapproach,organizationsusuallyaimtoaddress issuespertaining
to:(1)strategicalignment;(2)informationaccuracyandintegrity;(3)infrastructuremanagement;(4)security;(5)
technology compatibility; (6) business valueof IT; (7)corporategovernance; (8)businesscollaboration;and (8)
procurementamongothers.ThoughEAisoftenassumedtofollowanorganizationsstrategyandtoalignITwith
businessobjectives,increasingly,evidenceofthereverseisalsosurfacing.Inotherwords,organizationstrategies
arebeinginfluencedbyITcapabilities.
Inthe
book
Coherency
ManagementArchitecting
the
Enterprise
for
Alignment,
Agility
and
Assurance,
authors
Doucet,Gotze,SahaandBernardpresentanddiscusstheextendedandembeddedmodesofEAinadditiontothe
traditionalmode.Theyassertthatasorganizationsstartembracingthemoreadvancedextendedandembedded
modes, the need for synergy and consistency amplifies, thus facilitating the attainment of organizational
coherence,theultimategoalofEA.TheydefineEAasthe inherentdesignandmanagementapproachessential
fororganizationalcoherenceleadingtoalignment,agilityandassurance".
This paper starts with a brief discussion on the key emerging trends in the discipline of EA. This is important
becauseitdelineatesthewayinwhichthegrowthandadoptionofEAasamanagementdisciplinewilltakeplace.
The purpose of this section is to set the context for the next section, which elaborates the role of strategic
(systems)thinkinginEA,primarilyfromawholeoforganizationperspective.Thissectionalsoexplicitlyshowshow
adoptionofITleadstonationalproductivityandprosperity.Theauthorbelievesthislinkageisimportantbecause
theoperational,
product,
service
and
business
model
innovations
that
EA
brings
in
lending
themselves
to
adoption
of technology given its ubiquity. Moving forward, the subsequent sections present a case study of the use of
strategic (systems) thinking as an integral part of architectural analysis through a detailed elaboration of its
adoption in the management of long term health conditions (also called chronic disease management) in
Singapore. It is importanttonotethatthoughthecasestudypertainstoSingapore,the issueofchronicdisease
management is the foremost healthcare challenge in several countries, hence the lessons and experiences are
easilygeneralizabletoothercountriesandjurisdictions.Theauthorhasdirectlybeeninvolvedinthisjourneyasa
leadingexpertandadvisortoahealthcareclusterinSingapore.TheprimaryobjectiveofthispaperistoelevateEA
as a management and leadership metadiscipline. Given the authors own experiences in delivering several
keynotesessionsinconferencesandseminarsworldwide,withoutdoubtthishasalreadybeenachieved.
EmergingTrendsinEnterpriseArchitectureThe emerging trends in enterprise architecture stems from key misconceptions that are currently evidenced.
AuthorsGary
Doucet,
John
Gotze,
Pallab
Saha
and
Scott
Bernard
provide
the
first
glimpse
of
the
imminent
mega
trends inEA in theirbook.Thishasbeen followedby research reportsbyGartner, the twonotableonesbeing
IntroducingHybridThinkingforTransformation,InnovationandStrategyandFromHierarchytoPanarchyHybrid
ThinkingsResilientNetworkofRenewal.Additionally,GartnersHypeCycleforGovernmentTransformation2009
and Hype Cyclefor EnterpriseArchitecture 2010 provide partial insights. Presented below are the trends and
characteristics,whicharetransformingthedisciplineandpracticeofEA:
8/23/2019 Dr Pallab Saha - EA & Public Health
3/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page3of24
1. ThetransitionfromEAbeingequatedtotheEnterpriseITArchitecturetothearchitectureofenterprisedemands that it be viewed as a complete holistic metadiscipline that has the potential to link other
managementdisciplineandbring inbusinessmodel innovation.ThenextgenerationofEAwillformthe
backbone of all successful organizations, and the misconception that organizations do not have
architectureuntiltheyinitiateaformalprojectandateamtaskedwithmanagingtheprojectwillstartto
fade.Theunderlyingprinciplethateveryfunctioningorganizationhasarchitecturewilltakehold.
2. Theemphasisofarchitecturedevelopmentwillshift fromdesigningthevariousarchitecturalviewsandviewpoints to designing the interconnections between various views and viewpoints so as to achieve
organizationalcoherence.Doucetet.alhaveidentifiedthedimensionsoforganizationalcoherencewhich
are:(1)designed;(2)organized;(c)consistent;(d)connected;and(e)Institutionalized.Withinthecontext
of these dimensions, organizations will be characterized by three primary modes of EA, all operating
concurrently.
Organizations are complex adaptive systems and success in the contemporary operating environment requires
innovative ways of thinking about business problems and organizations. There will be an increased drive to
integratestrategic(systems)thinkingasacorecapabilitywithinenterprisearchitecture.Asorganizationsbecome
more hyperconnected and as the wider environment (political, economic, social and technological) becomes
uncertainandunpredictable,theabilityoforganizations tosenseand respondwillbecomeas importantasthe
abilityto
plan
and
execute.
In
such
achanging
scenario,
open
loop
(straight
line)
thinking
to
business
issues
will
be
inadequatetoaddressthem.Closedloop(systems)thinkingwillalloworganizationstheabilitytothinkaboutthe
whole,whereinsynthesistakesprecedenceoveranalysis.
TheRoleofStrategic(Systems)ThinkinginEnterpriseArchitectureEAhasgainedthecenterstageasanessentialdisciplinetoenableandevendrivebusinesstransformation.Tobe
consideredasthearchitectureoftheenterprise,itisthusanimperativetounderstandtheorganizationthatisto
bearchitected,anunderstandingthatpermeatestheentireorganization.Yet,almostallcurrentEAactivitiesfocus
primarily on the operational aspects, completely ignoring the more important strategic aspects. In order for
business leaders and policy makers to comprehend the role and intended outcomes from EA programs, it is
essential that they view such programs from a strategic viewpoint in the way these are planned, designed,
embraced,managedandgoverned.Itwouldbeanunderstatementtosaythatorganizationsarecomplex.Goinga
step
further,
governments
are
even
more
complex
and
at
times
paradoxical.
This
stems
from
the
fact
that
governmentsarebyfarthelargestorganizationsandwithsizecomescomplexity.Complexitiesinorganizationsare
ofboth typescombinatorial complexityanddynamiccomplexity. Complexity arising due to sheer numberof
componentsandelementsthatareinterconnectedreferstocombinatorialcomplexity.Dynamiccomplexity,onthe
otherhand,arisesduetothevelocityofchangeandthequantumof interactionsbetweenthecomponentsand
elements. Inaddition,unpredictabledelaysbetweendecisionsand theireffects (andcountereffects)completes
the picture of what constitutes, according to Gartner, wicked problems. In short, organizations are excellent
examplesofcomplexdynamicsystems.Asystemhereisdefinedasasetofinterrelatedthingsencompassedbya
well defined andpermeable boundary, interacting with one another and an external environment,forming a
complexbutunitarywholeandworkingtowardacommonoverallgoal.
Organizationsfaceseveralchallenges,andalotofthemareverystubborninnature(i.e.,wickedproblems),andare
thereforeunderpressuretoaddressthesechallengesinamoreopen,accountableandtransparentways.Inorder
fororganizations
to
transform,
it
is
critical
that
they
are
understood
as
complex
dynamic
systems.
Organizations
characterizedbytheabove,requiremuchmorethanconventionalthinkinginordertocomprehendtheunderlying
systemandthechallengesthatthesystemfaces.Thesuccessofbusinesstransformationprogramsthusbecomes
dependentoncomprehendingtheunderlyingsystem.Forinstance,ambiguityinunderstandingthesystemisone
oftheprimaryreasonsforpublicsectortransformationshowinglessthansatisfactoryresultsandsuccessrates.It
is amply evident that countries adopt wholeoforganization EA as t he metadiscipline to trigger, design and
realizegovernment transformation.However, in thepastdecadeorso the focusofEAprogramshavebeenon
developing frameworks,methodologies, languages,guidelines,bestpractices, referencearchitecturesandother
8/23/2019 Dr Pallab Saha - EA & Public Health
4/24
capacitybuildingactivities.Onthegovernmentside, it istobenotedthatcountriesareusingegovernmentasa
meanstoachievepublicsectorreformsandgovernmenttransformation.Thisisclearlyarticulatedintheperiodic
global egovernment surveys undertaken by the United Nations. Adoption of IT for government services and
programmesplaysan importantrole incraftingandfurtheringtheegovernment initiatives.RobertAtkinsonand
Andrew Mackay, in their report titled Digital ProsperityUnderstanding the Economic Benefits of Information
TechnologyRevolution, clearly demonstrate the role and influence of IT adoption on national productivity and
overall
economic
prosperity.
This
is
not
surprising
given
the
ability
of
IT
to
enable
nearly
every
aspect
of
a
modern
knowledge based economy thatcountries increasingly aspire tobe.The ubiquity of the IT makes it evenmore
compellingtoembraceandderivebenefitsoutof.Exhibit1depictsthesystemicviewofthisphenomenon.
Exhibit1:TheEconomicBenefitsofInformationTechnologyAdoption
Thereport,withoutanyambiguity,spellsouttheneedtoconsider ITadoption inacoherentmannerandwitha
longtermviewinmind.Understandingtheabovephenomenonisimpressiveforcountriestodesignandexecute
theirEA.Despitealltheseseemingly impressivebenefits, theadoptionofwholeofgovernment (WOG)EAhas
been less than expected. This is evidenced by Gartners Hype Cycle for Government Transformation 2009,
wherein WOG EA would require another 5 to 10 years before reaching full maturity and delivering benefits
justifying its immensepotential.Ontheupside,however,GartnersHypeCycleforEnterpriseArchitecture2010
doesstatethatWOGEAispastthebottomofthetroughofdisillusionment.Thereisnodearthofliteratureand
NationalUniversityofSingapore|InstituteofSystemsScience
Page4of24
8/23/2019 Dr Pallab Saha - EA & Public Health
5/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page5of24
other enabling resources for countries to build their enterprise architectures. Yet, after the initial enthusiasm,
thingsaredifficulttosustainwithquestionsoftenbeingraisedregardingtheefficacyofgovernmentEAefforts.
Thisisnotsurprisingatall.Withoutfullyunderstandingtheunderlyingsystem,thesuccessachievedandbenefits
derivedthroughtheadoptionofEAhasbeen limited.This leadstotwo logicallyexplainablereactions:(1)frantic
effortstoimprovetheframeworks,methodologies,guidelines,principles,bestpracticesandtoolsupport;and(2)
discontinuingtheEAaltogetherbytermingittoodifficultandtoocomplex.
Theneedofthemoment isnotbettersolutions,butbetterthinkingabouttheproblems.GaryHamelinhisbook
TheFutureofManagementstatesthatsolvingasystemicproblemrequiresunderstandingitssystemicrootsandit
isthefirstofthetenrulesofmanagementinnovation.Itisinthiscontextthatconventionalopenloopthinkingto
solvingbusinessproblemsneedstobereplacedwithsystems(closedloop)holisticthinking.Asystemicperspective
isusedtounderstandhowthenumerouscomponentsoftheorganizationact,reactandinteractwithoneanother
with the intent of improving the adoption of EA for a coherent organization. This provides a comprehensive,
holistic and a more coherent way of anticipating synergies and mitigating negative emergent behaviors, which
wouldfacilitatedevelopmentofpoliciesandotherrelevantinterventionmechanisms.Usingasystemicperspective
encouragesstrategicthinking.Exhibit2showsacomparisonofsystemsthinkingoverconventionalthinking.
ComparingConventionalandSystemsThinking
Conventional(Open
Loop)
Thinking
Systems
(Closed
Loop)
Thinking
StaticthinkingFocusingonparticularevents.
DynamicthinkingFramingaproblemintermsofpatternsofbehaviorover
time.
SystemsaseffectViewingbehaviorgeneratedbyasystemasdrivenby
externalforces.
SystemascausePlacingresponsibilityforabehavioroninternalfactorsand
actors.
FragmentedBelievingthatreallyknowingsomethingmeansfocusingon
thedetails.
HolisticBelievingthattoknowsomethingrequiresunderstanding
thecontextofrelationships.
Factorsthinking
Listingfactors
that
influence
or
correlate
with
some
results.
Operationalthinking
Concentrating
on
causality
and
understanding
how
a
behaviorisgenerated.
StraightlinethinkingViewingcausalityasrunninginonedirection,ignoringthe
interdependenceandinteractionbetweenandamongthe
causes.
LoopthinkingViewingcausalityasanongoingprocess,witheffectfeeding
backtoinfluencethecausesandthecausesaffectingone
another.
Exhibit2:ComparingConventionalandSystemsThinking
Thispaperusescausalloopdiagramstocapturenonlinearcauseandeffectrelationships inordertorealizethe
systemsthinkingdescribedearlier.Theconventionsofcausalloopdiagramsarenotdescribedhere,asexcellent
literatureisalreadyavailableinthisarea.Inordertodemonstratetheabove,thehealthcaresegmentisusedasan
illustration.This isdeliberatebecausethehealthcare issuesarecomplex,dynamic,timelyandrelevanttomany
countries.Developedcountriesaroundtheworldaresaidtofacefivecriticalhealthcarechallengesintheyearsto
come.These
are:
(1)
patient
safety;
(2)
long
term
conditions;
(3)
outcome
based
models;
(4)
cost
containment;
and
(5)servicedeliveryreforms.TheseapplytoSingaporeaswell.Thesheercomplexityofthehealthcaresystem is
mindboggling.Thissegmentishuge,multifaceted,andselfcontained.Forthese purposes,managementoflong
termconditions(alsoknownaschronicdiseasemanagement)isselectedandexamined.Aswouldbeevidentover
the course of the next few sections, the management of chronic diseases exhibits all of the complexities and
nuances described in the previous. This makes it an excellent illustration for demonstrating the potential of
embracing strategic (systems) thinking. A note of caution here for all readers the content and approach
describedinthispaperrepresentstheleadingedgeinEAdiscipline,henceitismeantfororganizationswhohave
8/23/2019 Dr Pallab Saha - EA & Public Health
6/24
thematurity toadopttheemergingbygoingbeyondwhat isalreadyestablished. Inareasonedway, thepaper
doesnotemphasizeonthetechnologicalaspectsofEA.This isdeliberatebecauseatthe levelthatthebusiness
concernhasbeendescribedandexamined,technologylooksoutofplace.
TheHealthcareConundrumHealthcare isacomplexadaptivesystemwithastrongsocialfocus.Exhibit3showsthekeystakeholders inthe
healthcare
ecosystem
as
identified
by
the
World
Health
Organization
(WHO).
Further,
the
WHO
also
highlights
the
interconnectednessthatisbothexistinganddesirabletoensurehighqualityhealthcareataffordablecosts.
Exhibit3:StakeholdersintheHealthCareEcosystem(Source:WHO)
Health care systems operate in a heterogeneous environment of public and private services, with numerous
businessoperatingmodelsthatmakeacoherentdesign,implementationandoperationofintegratedhealthcare
systemschallenging.Ingeneral,healthcaresystemsaroundtheworldareonatroublesomeanddangerouspath
with a combination of high costs, uneven quality, frequent errors, and limited access to care. The situation is
furtherexacerbatedbychangingdemographicsthatbringforth issuesthathavehithertoneverbeenanalyzed in
totality. Michael Porter and Elizabeth Teisberg in their book Redefining HealthcareCreating Value Based
CompetitiononResults listoutkeycausesofthe illsthatafflictthehealthcare industry.Broadly,theseare :(1)
prevalenceof thecommoditymindset; (2) focuson reducingshorttermcosts; (3)variation inqualityandcosts
basedongeographical location; (4) incentives to the the healthcareproviders toblend inand follow standard
procedures; (5) continued practice of academic specialties replicated in health care providers; (6) questionable
patientattitudes
and
motivations;
(7)
patient
care
cenetered
on
medical
conditions;
and
(8)
incentives
to
health
planandhealthcareproviderstoaimforshorttermgoalsandperformancemetrics.
Furthermore,theoverallhealthcaresystemsgetevenmoremuddledwiththeadventofnewandemergingissues
that get amplified due the ever changing demographics. The disease profile of the world is changing ever so
rapidly,andlongheldnotionsabouthealthcaresystemsarenolongertrueandatmosttimesevenmisleading.A
health care phenomenon that is confounding governments across the world is the ever growing issue of
management of long term conditions (or chronic disease management). Chronicdiseases have emerged as the
NationalUniversityofSingapore|InstituteofSystemsScience
Page6of24
8/23/2019 Dr Pallab Saha - EA & Public Health
7/24
largest causeof death and sourceofhealth care costs indevelopedcountries. In many countries,deaths from
chronic diseases now outstrip mortality for traditional health concerns such as injuries and communicable
diseases.Whiletheprimarypurposeofthispaperisnottopresentadetailedreviewofchronicdiseasesandtheir
management.Thenextsectiondiscussesthetrendsandinformationpertainingtochronicdiseases.Thesetrends
andinformationarepresentedastheyarecriticaltounderstandingthebusinessdomainwiththeaimofproviding
critical inputs to the systems models presented in the subsequent sections. The quantum of background
information
on
chronic
diseases
provided
is
deemed
to
set
the
context
and
fulfill
the
objective
of
this
paper
i.e.,
to demonstrate the use and value of strategic (systems) thinking as an integral element of the EA discipline,
therebymakingEAmoreforwardthinkingandbusinesseffectivenessorientedratherthanfocusingonoperational
efficiencies.ThischangeinthewayEAitselfisviewedisneccesitatedtosupportthemassiveshiftsthatarebeing
observed.
UnderstandingChronicDiseasesToset thecontext for the restof thepaper,Exhibit4 showsacomparisonofchronicandacute illnesses.As is
evident,thecharacteristicsofchronicconditionsarealltoodifferentwhencomparedtoacute illnesses. In fact,
theyareastudyincontrastandistheprimaryrootcauseofamajorityofthehealthcarechallengesthatcountries
todayface.It isclearlyevidentfromExhibit4thatpolicies,procedures,processes,systemsandothersupporting
mechanisms established for acute illnesses would be grossly inadequate and even incorrect when applied to
chronicillnesses.TheWHOlistsheartdisease,stroke,cancer,asthmaandchronicobstructivepulmonarydiseases
anddiabetes
as
the
major
ones.
This
paper
does
not
examine
any
specific
chronic
disease.
Instead,
it
views
chronic
diseasesinacollectiveaggregatedmanner.Itissufficientfortheobjectiveofthepaperasthelessonslearntand
otherfindingscanbegeneralized.
Exhibit4:ComparingAcuteandChronicIllness
Withtheabove informationascontext,the followingarethemegatrends inchronicdiseasesthatarecurrently
underway.Theyareexaminedsincetheyprovidearichsourceoffactorsandvariablestobeusedasinputsforthe
NationalUniversityofSingapore|InstituteofSystemsScience
Page7of24
8/23/2019 Dr Pallab Saha - EA & Public Health
8/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page8of24
systemsmodelselaborated insubsequentsections.It istobenotedthatthepurposeofthesemegatrends isto
understandandgainadequate insights intothephenomenonsoastoderivesufficient informationtoeffectuate
strategic(systems)thinking.The intent isnottoprovideadetaileddiscourseaboutchronicdiseasemanagement
perse.ThesefactsandfiguresarelargelytakenfromrelevantliteraturemadeavailablebytheWHO.
1. Anestimated388millionpeoplewilldiefromchronicdiseasesinthenext10years.Withincreasedinvestmentinthepreventionordelayofchronicdiseaseonset,itwillbepossibletoprevent36millionprematuredeaths
inthesametimehorizon.Withoutactiontoaddressthecauses,deathsfromchronicdiseaseswithincreaseby
17%between2005and2015.
2. Themacroeconomicimpactofchronicdiseaseswillbesubstantial.Largecountrieswilllikelyforegoinexcessof$500billioninnationalincomeoverthenext10years.Averteddeathswithbettermanagementofchronic
diseaseswouldtranslateintosubstantialgainsinthenationaleconomicgrowth.
3. Globally, a misconception that chronic diseases mainly affect high income countries is widely prevalent.Furthermore, there isalsoabelief that lowandmiddle incomecountriesmust focuson infectiousdiseases
before chronic diseases. These misconceptions are contrasted by the fact that 80% of all chronic disease
deathsoccuronlowandmiddleincomecountries.
4. Globalization, urbanization and population ageing are the key underlying socioeconomic, cultural, politicaland environmental determinants contributing to modifiable and nonmodifiable risk factors. The most
common modifiable risk factors leading to chronic diseases include unhealthy diet, physical inactivity and
tobaccouse.Thenonmodifiableriskfactorsincludeageandgenetics.
5. Chronic diseases and poverty are interconnected in a vicious cycle. On one hand, poor people are morevulnerable for several reasons, including increased exposure to risks and limited access to health services.
Whileontheotherhand,chronicdiseasescanleadtopovertyinindividualsandtheirfamilies.Together,these
two have thepotential to lead to a downward spiral of worsening disease and poverty. This phenomenon
directlybringsdowntheindividualandnationalproductivities.
6. Ingeneral,healthcareservicesandsystemsareprimarilydesigned foracutecare.Servicesandsystems forchroniccareareusuallycarvedoutbytweakingthemfromtheacutecare.This,despitethefactthatchronic
diseases constitute 70% of the disease burden, thus creating a massive mismatch between supply anddemand.
7. Thedifferentchronicdiseasesthemselveshavesomedegreeofinterconnectedness,thatis,theincidencesofcomorbidities which usually worsens with age, plays an important role in complicating treatments and
interventions.ThisisdepictedinExhibit5.
8. Thetotalnumberofpeopleaged70yearsandaboveworldwide isexpectedto increasefrom269million in2000 to 1 billion by 2050. Age is an important factor in the accumulation of modifiable risks for chronic
diseases;thatistheimpactofriskfactorsincreasesoverthelifecourse.Exhibit6showstheagepyramidsfor
Singaporein2008and2025,andthedemographictransitioncurrentlyunderwayistrulydramatic.Thatsaid,it
isimportanttonotethatmostdevelopedcountrieshavearapidlyageingpopulation,primarilyduetothedual
affectsof
increasing
life
expectancy
and
dangerously
low
birth
rates.
For
example
countries
in
East
Asia
have
atotalfertilityrateofunder1.2.Thiscomparesveryunfavorably,giventhatacountryrequiresatotalfertility
rateof2.1justreplace itspopulation.Anothernegative impactofanageingpopulation isthat it leadstoa
shrinkingpoolofpotentialcaregivers,thusaffectingtheveryqualityofchroniccare,pushingthewholehealth
systemtoafurtherdownwardspiral.
8/23/2019 Dr Pallab Saha - EA & Public Health
9/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page9of24
Exhibit5:PotentialCoMorbiditiesAssociatedwithMainChronicDiseases
Alloftheabovefactsandfiguresinsomesensecapturethesymptomsailingthemanagementofchronicdiseases.
Themostnatural reactionwouldbe toaddress thesesymptoms throughshort termquickfix typeof solutions.
Such an approach would be conventional (openloop) thinking demonstrating the characterisctics are shown in
Exhibit2earlier.
There
is
substantial
literature
elaborating
the
dangers
of
open
loop
thinking.
In
contrast,
bringing
in the closedloop thinking provides the ability to look at the big picture in a unified collective manner,
understand the interconnectedness and interdependencies between the various elements and parameters
involved.Inotherwords,inthecontextofthechronicdiseases,alloftheabovefactsandfigureswouldhavetobe
looked at collectively in a systemic perspective. There is no doubt that management of chronic diseases is a
wicked problem that requires deeper holistic thinking. It is to be noted that the megatrends above look at
chronicdiseasescollectivelyinagenericmanner,anddonotgranularize itintermsofindividualdiseasetypesor
patterns.
Exhibit6:SingaporePopulationPyramidsin2008and2025
8/23/2019 Dr Pallab Saha - EA & Public Health
10/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page10of24
EmbracingStrategic(Systems)ThinkingAccording to Edward Deming, 94% of all organizational issues are systemic in nature. Usually, leaders and
managers do not fully understand the systemic issues. This is absolutely true with regard to management of
chronic diseases. The work presented in this paper was carried out for a healthcare cluster in Singapore. The
clusterconsistsofagroupofpolyclinics, largehospitals,specialistcentersandotherproviderentities lookingat
communityandhomecareservices.Theclusterisalsosupportedbyagroupofenlistedgeneralpractitionersand
otherbusiness
partners.
In
summary,
all
the
elements
of
the
health
care
ecosystem
shown
earlier
in
Exhibit
3exist
inthiscluster.Someoftheseelementsoftheecosystemare intheirownright largeandcomplexorganizations,
havingtheirownstrategy,managementandoperations.Thebusinessareaswithinthepurviewofthehealthcare
clusteraredepcited inExhibit7.Thisrepresentstheclustersbusinessreferencemodel(BRM).TheBRMdepicts
the outsidein perspective of the health care cluster. It only shows the business areas and business functions
withoutdepictingwhichproviderentity(organization)withintheclusterprovidestheservice.Thisperspective is
importantasitorganizestheclusterbusinessinawaythatmakessensetotheservicerecipients(i.e.citizensand
patients). The service recipients do not need to be aware of the health care clusters internal administrative
structure. This makes the cluster more enduser (patient) centric without cluttering them with administrative
details.The implicationofviewing thebusiness fromapatientcentricperspective includesdisintermediationof
individualproviderentitiesandassumesseamlessintegrationbetweenthem.Inshort,tothepatientsandcitizens
the cluster appears as one, the manifestation of connected health paradigm. This is absolutely essential for
countriesaimingtoreformtheirpublichealthsector.Thoughnotcentraltothispaper,aninterestingsidenote is
thatsuch
aconnected
paradigm
in
the
health
care
sector
is
an
essential
precursor
to
the
success
of
electronic
healthrecord(eHR)programsthatmanycountrieshaveenthusiasticallyinitiated.
Purelyfromatechnologyperspective,theBRMneedstosupportedandenabledbyotherreferencemodels(e.g.
the Data Reference Model (DRM),Application Reference Model (ARM) and Technical Reference Model (TRM)).
However,thispaperdoesnotdiscusstheDRM,ARMandTRManyfurther.
Despiteeach individualproviderentitytaskedwithdifferentaspectsofthecaredeliveryvaluechain, itwasvery
clearupfront that tacklingchronicdiseasemanagement requiredaholisticand integratedapproach,because it
hadbothclusterwideandnationwideramifications.Chronicdiseasemanagementtouchedeverybusinessarea
showninExhibit6,thustheintegratedapproachisanimperative.Thecaredeliveryvaluechain(CDVC)proposed
byMichaelPorterandElizabethTeisbergintheirbookRedefiningHealthcareCreatingValueBasedCompetitionon
Results,
is
a
powerful
technique
to
capture
the
integrated
view.
The
CDVC
provides
an
excellent
technique
to
identifyandsequence thecare functionsandsubfunctions inan integratedmannerworking through thecare
journeythatapatienttraversesviathedifferentstages.TheCDVCalsodepictsthevariousparticipatingprovider
entitiesinthedeliveryofthecare.Thishighlightsthecollaborativeaspectsinthecaredeliverywhich isessential
forbetterandeffectivecare.However,inorderforustounderstandanddissectacomplexproblem,notonlyisit
importanttounderstandthe interactionsbetweenthevariousproviderentitiesandthefunctionstheyperform,
butalsotocaptureandfullyunderstandtheinteractionsbetweenthevariousfactorsandvariablesthatformthe
core and contribute to the complexity and dynamism. This is achieved through adopting strategic (systems)
thinking.Thesubsequentparagraphselaboratetheadoptionofstrategic(systems)thinkingfactoringinthemega
trends thathavealreadybeenpresentedearlier.Thiscontrastsverywellwith theusualapproach,wherein the
approachwouldbetoidentifyafewkeybusinessfunctionsfromtheBRM,sometimescalledhotspots,prioritze
them and analyze them to address the issues in consideration. This analytical approach characterized by its
divideandrule mindset is reductionist in nature and put forths all the ingredients thatusually tend to make
organizationsmicro
smart
and
macro
dumb.
The
underlying
rationale
for
adoption
of
strategic
(systems)
thinkingisthatanyassumptionthattheeffectivenessofthewholewillbeachievedautomatically,aslongasthe
partsareoptimal,cannolongerbesustainedwiththesystemicparadigm.Strategic(systems)thinkingisableto
capturethewisdomofdiversestakeholders.ThisnotionisstrengthenedbytheWHOWorldHealthReportwhich
statesthattheresponsesofmanyhealthsystemssofarhavebeengenerallyconsidered inadequateandnave.
Inadequate,insofarastheynotonlyfailtoanticipate,butalsotorespondappropriatelytoooftenwithtoolittle,
too lateortoomuch inthewrongplace.Nave insofarasasystemsfailurerequiresasystemssolutionnota
temporaryremedy.
8/23/2019 Dr Pallab Saha - EA & Public Health
11/24
That said, strategic (systems) thinking is not a silver bullet. Its adoption does not automatically mean that
addressingcomplexbusinessissuesbecomeseasierwithoutchangingthemindsetthatcausedtheproblemtostart
andaggravate.
Exhibit7:HealthCareClusterBusinessReferenceModel(Level0View)
Takingthe
chronic
disease
facts
and
figures
presented
earlier,
the
problem
framing
process
starts
with
the
common modifiable risk factors (like unhealthy diet, physical inactivity and use of tobacco) triggered by the
underlying determinants of globalization, urbanization and ageing population; this increases the overall risk of
chronicdiseases,whichleadstotheeventualonsetofchronicdiseases.Theonsetofthediseaserequiresfinancial
resources to provide for adequate care and treatments, thus increasing the overal economic burden for the
individual.Thesituationisfurtherexacerbatedbythefactthatthepopulationwithchronicdiseasesarelikelytobe
lessproductive(ascomparedtohealthypopulation),leadingtoforegoneincome.Thisleadstoadropinresources
andfinancialcapabilitytoaffordpropercare,furtherincreasingthenegativeimpactofthechronicdiseases.Thisis
depictedinExhibit8,andcollectivelytermedastheavoidableburdenloop.Thisisapositiveloopasitrepresentsa
downwardspiralandclearlydemonstratesthe longtermnegativeconsequencesofchronicdiseasesbothonthe
individualsandcountries.The loop isdeliberatelynamedsobecause it implicitlycapturesaphenomenonthat is
largelyaviodableifindividualsandcountriesfocusonreducingthecommonmodifiablerisks.Thisthinkingisinline
with
the
WHO
recommendations.
The
avoidable
burden
loop
thus
becomes
the
central
core
of
the
problem
frame,
aroundwhichotherchronicdiseasefactorsandvariablesareprogressivelyaddedintheformofmoreloops.This
processiselaboratedinthesubsequentparagraphsofthissection.
NationalUniversityofSingapore|InstituteofSystemsScience
Page11of24
8/23/2019 Dr Pallab Saha - EA & Public Health
12/24
Exhibit8:UnderlyingFactorsandtheChronicDiseaseOnset
Astheincidencesofchronicdiseasecarebecomesmoreprevalentandexpensiveduethedownwardspiralshown
inExhibit7,thereisincreasedpressurebythecitizensandthecivilsocietyonthegovernmenttosubsidizedisease
care.Beingapoliticalhotbed,mostgovernmentsprovidesubsidyenmasse,i.e.thereisagreatlikelihoodthatthe
sectionofthesocietythatnotneedthesubsidyarealsosubsidized.Toaddressthis,theconceptofmeanstesting
isrightlybeingintroducedinSingapore.Thissubsidyisrealizedthroughvariousmeans,forinstancethepatientcan
directlybesubsidized,orthehealthcareproviderscanbecompensatedfortreatingpatientswithchronicdiseases.
Usuallygovernmentsadoptamultiprongedapproachtodeliverthesubsidiesasitprovidesthemgreaterleverage.
Irrespective of the means of providing the subsidy, the impact on the national income and the economy is
inevitable.Thisistheshowninthesubsidyresponseloop.Thisleadstofurthernegativeimpactontheresources
availableforthehealthcaresectoringeneral(andchronicdiseasemanagementinspecific).Hencethesubsidyhas
thepotentialtobecomeanationalburden,ifitisnotcarefullytargetedasshowninthenationalcostloop.These
two
loops
together
work
in
tandem
and
have
the
potential
to
create
serious
shortcomings
in
the
healthcare
ecosystembyconstraining theavailabilityof resourcesandopportunitiestomanagechronicdiseases.This then
feeds intothecoredownwardspiraldepictedbythepreviouslydescribedavoidableburden loop.The foregone
national incomehasdirectnegative impacton theavailable resourcesand leads to thedeteriorationofoverall
qualityoflife,eventuallyleadingtohigherrisksofchronicdiseases.Inotherwords,individualandnationalpoverty
aggravates the problem of chronic diseases even further. On top of this, increasing life expectancy actually
worsenstheproblemevenfurther.Thisisdepictedinthelifeexpectancymattersloop.Exhibit9showsthethree
new loopsandalsoamplydemonstrateshowthesethree loopsactuallyworsenthedownwardspiral.This isan
interestingphenomenonwhereinonedownwardspiralisstrengthenedbyaseriesofotherinterconnectedloops,
viacommon factorsandvariables.Strategic (systems)thinkingmakesthisbehaviorexplicitandapparent.This is
precisely how whole systems thinking propagates and makes the approach more amenable to effective
interventionsbyanticipatingandyetformallystructuring.
Longterm
evidence
proves
that
with
timely
and
effective
interventions
and
proper
medication
management,
most
patientswithchronicdiseasescanactuallyleadnearnormalliveswithminimalinterruptions.Thisisfurthermade
possible with recent advancements made in medical sciences. This means that most patients can actually
drasticallyreducetheirvisitstospecialists.Inotherwords,inmostsituationsgeneralpractionersandpolyclincsare
sufficienttocontinuetotreatmentsandkeepthediseasesatbay.Reducing interactionswithspecialistsdirectly
leadsto lowercostsforpayersandalsoensuresthatspecialists,whoarealways inshortsupply,donotbecome
bottleneckinthewholeecosystem.
NationalUniversityofSingapore|InstituteofSystemsScience
Page12of24
8/23/2019 Dr Pallab Saha - EA & Public Health
13/24
Exhibit9:RoleofSubsidies,ForegoneNationalIncomeandLifeExpectancy
Withthepreviousnotions inmind,there isalsoempiricalevidencetoprovethatassubsidy is increased(bythe
government),itbecomesmoreattractivetoreferaspecialistandtheusualinclinationistoreferaspecialistasthe
first level intervention, irrespective of whether it is needed or not. This demonstrates normal human behavior
which is driven by incomplete and misconceived mental models on part of the patients. This behavior is the
evidence of questionable patient attitudes and motivations that Michael Porter and Elizabeth Teisberg have
identifiedandhighlightedintheirbook.Thisbehaviorleadstocrowdedhospitalsandspecialistcenters,elongating
queuesand
waiting
times.
This
has
an
impact
on
the
national
productivity
and
eventually
the
gross
national
income.Thisphenomenoniscapturedintheinvolvingspecialistsloop.
Building up from the life expectancy matters loop, and ageing population leads to a drop in working (and
productive)adults,whichhasanegative impacton thegrossnational income;aneventualdrop in investments
available for healthcare occurs as it erodes the tax base over time. Typically governments respond to this by
increasing the retirementage limits,as iscurrentlybeingseen inmanycountries.However, thedownside isan
older working population would also be more prone to chronic diseases. An erosion in the tax base results in
governmentsearninglowerrevenuesthroughtaxesandotherlevies.Inotherwords,astheproportionofworking
adultsdroptherearelesspeopletocontributeintothecountrysfinancialsystem,andanincreasingnumberwho
requirefinancialassistanceduringtheirnonproductiveyears. Inaddition,adroppingbirthratealsoensuresthat
notadequatenumberofworkingadultscomeintothesysteminthedecadestocome,furthererodingfuturetax
base. Thiseffectively has long term negative implications on the national economy and resources available for
healthcare,thereby
increasing
the
chronic
disease
morbidity
and
mortality,
further
strengthening
avoidable
burdenloopdescribedearlier.Thisbehavioriscapturedinthechronicdiseasedeathsloop.Thisaffectsthequality
of life and eventually leads to greater risks of chronic disease onset. There is evidence that as gross national
incomefalls,theproportionofthepopulationinthelower incomecategorybulgesandusuallytendstobemost
badlyaffected.Inotherwords,thepoorersectionsofthesocietybecomeevenpoorer,thusenlargingthechasm
betweentherichandthepoor,primarilybecauseof inequaldistributionofwealth.The inequality(measuredas
theGINIindex)increasestheintensityandthespreadofpoverty.This,withoutdoubt,leadstoincreasesinchronic
disease morbidity and mortality as shown in the poverty hurts loop. The WHO has clearly demonstrated the
NationalUniversityofSingapore|InstituteofSystemsScience
Page13of24
8/23/2019 Dr Pallab Saha - EA & Public Health
14/24
existenceofadownwardspiralbetweenchronicdiseasesandpoverty.Exhibit10depictstheinvolvingspecialists,
chronicdiseasedeaths,healthcareinvestmentsandpovertyhurtsloops.
Exhibit10:MacroeconomicConsequencesofChronicDiseases
Chronicdiseasesconstitute70%ofthediseaseburden.Thesupplydemandmismatchbetweenacuteandchronic
careisalreadyanobservedphenomenon.Wrongpatientattitudesandmotivationsleadingtocrowdedhospitalsis
a result of the involving specialists loop, examined earlier. This is further worsened by the fact that crowded
hospitalshaveagreatertendencytofocusonthewrongpriorities(i.e.focusonimmediatepriorities)attimeseven
hurting the long termeffectiveness.Given the immediacyofneedsandotheroperationalpressures,healthcare
providersusuallytendtospendgreaterproportionoftheirtimeandresourcesinprovidingacutecareandtreating
patients with infectious diseases. This is captured in theunclearpriorities and priority for acute care loops in
Exhibit11.
AccordingtoasurveydonebytheWHO,thecostofchronicdiseasecareisbyfarthemostsignificantchallengefor
both individualsandgovernments. Ingeneral, theescalation in thecostofhealthcare faroutstrips thebroader
inflation.Thesituation isevenmoreacutewhenviewedfromthechronicdiseaseperspective.Ascostofchronic
care treatments escalate, people attempt to cover through insurance (wherever possible). With wrong patient
attitudes and motivations, the typical behavior is for patients to prefer specialists over general practitioners
(alreadydiscussedearlier).This inflatestheoverallcosts inthewholeofthehealthcareecosystem.Ascostsrise,
insurance firmsare forced tobecomemore stringent in their checksandapprovals.Given that insurance firms
haveaprofitmakingmotive,thisworsensthesituationevenfurther.Thisincreasestheincidentsofnoncoverage
for existing customers and lengthens the list of exclusions for potential new customer, leading to insurance
becoming lessattractive.As insurancebecomes lessattractive,the insuredtendtooptoutoftheprogramsand
potentialnewcustomersnot finding insuranceattractivearenot inclinedto insurethemselvesor their families.
This creates twin headwinds for the insurance sector as existing customers optout and new customer base
expansionslowsdown.Theoverallcollectiveinsurancebasegetsseverelyrestricted.Forthepopulationwhostay
backaspartoftheinsuranceprograms,thepremiumsgoupbecausetherearenotenoughhealthypeopletopay
into the programs and plans. All of these happen, even as the whole ecosystem is plagued by increasing life
expectancies and fallingbirth rates.The paradox is in the fact that insurance firmswant to insure thehealthy,
whereasthehealthydonotwanttogetinsuredbecauseoftheoverallunattractivenessoftheprogramsandplans.
Thisdeathspiral isdepicted inExhibit12,throughthecostsoftreatment,questionable insuranceeffectiveness
andgapsinqualityofhealthcareloops.
NationalUniversityofSingapore|InstituteofSystemsScience
Page14of24
8/23/2019 Dr Pallab Saha - EA & Public Health
15/24
Exhibit11:AmplificationoftheSupplyDemandMismatchandUnclearPriorities
The loops inExhibit11alsoamplifythemismatchbetweensupplyanddemand.Thecurrent insuranceplansand
programsaredesignedforacutecare,andthentweakedtoworkforchroniccare.Inaddition,upwardstrendin
theGNIprovidethefodderforsocioeconomic,cultural,politicalandenvironmentdeterminants,magnifyingthe
globalization
and
urbanization
pre
factors
that
lead
to
increase
in
risks
of
chronic
diseases.
This
is
shown
in
Exhibit
11inthepriceofgrowthloop.
Exhibit12:TheHealthInsuranceDeathSpiral
NationalUniversityofSingapore|InstituteofSystemsScience
Page15of24
8/23/2019 Dr Pallab Saha - EA & Public Health
16/24
8/23/2019 Dr Pallab Saha - EA & Public Health
17/24
DesigningStrategicInterventionsPeter Senge in The FifthDiscipline argues that to solve difficult problems one needs to understand the inter
relationshipsratherthanthings, forseeingpatternsofchange ratherthanstaticsnapshots.Todesigneffective
interventionstrategies, it iscritical todiagnose the issuescorrectlyand frame theproblemspace. Insightand
foresightarebothcrucial.Exhibit12depictsproblemspace inasynthesizedview.Itcapturesseveralfactorsand
connectsthemviaseriesofloops,allofwhichhavebeendiscussedearlier.Itisimportanttonotethatthefactors
andthe
loops
are
specific
to
the
local
conditions
in
Singapore.
They
need
to
be
suitably
adapted
prior
to
use
in
othersituations.Needlesstomention,thespecificinterventionswoulddependonthecontextofspecificnuances.
Designingtherightinterventionsareasimportantasthelocationtheseinterventionswouldbeapplied.However,
partofthestrategicinterventiondesignshouldalsoincludeuncoveringandunderstandingthe inherentdelaysin
thesystem,forthesystemwithlongtermdelaycannotrespondtoshorttermchanges.Inacomplexsystem,there
areplaces where a small shift inonethingcanproduce largechanges in (almost) everything.The placesare
termedleveragepointsthepointsofpower.DonellaMeadowsinherarticleLeveragePointsPlacestoIntervene
inaSystem identifiesandelaboratesgeneric leveragepointswhere interventionsaremost likelytobe impactful
and resultsbearing.Moving forward, thenext logicalstep fromanarchitecturalperspective is toproposesteps
thatcouldbetakentoaddressthechronicdiseasepandemic.Thesestepsarecalledstrategic interventions,as
theytendtobe longterm innatureandoftenrequireseriesofaction itemstobeexecutedandoperationalized.
The WHO recommends ten steps to applying systems perspective in the design and evaluation of strategic
interventions. Exhibit 14 depicts the synthesized view with the strategic interventions (as arrows) and the
significantdelays
are
also
shown.
Exhibit14:SynthesizedViewoftheChronicDiseaseManagementPhenomenonwithSuggestedInterventions
Managementofchronicdiseases isanationalpriorityinSingapore,as inmanyothercountries.Thisisevidenced
by the fact that the Singapore Government has always been viewing this from a long term perspective and
designingpoliciesandprogramstosuitcurrentandemergingneeds.Healthcareservices inSingaporeareoneof
themostadvancedandarguablyoneofthebest intheworld.Withregardtochronicdiseasesthegovernment
NationalUniversityofSingapore|InstituteofSystemsScience
Page17of24
8/23/2019 Dr Pallab Saha - EA & Public Health
18/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page18of24
clearlydemonstrates longtermvision,which isachievedbyaseriesofsmallyetfocussedandprogressiveaction
items.Inthenationalbudgetannouncementfor2011,madeinMarch2011,thegovernmentannouncedaseries
ofaction itemsthatare intendedtotacklethisgiganticpublichealth issueofchronicdiseasemanagement.The
actionitemsannouncedinclude:
1. EstablishingtheGeriatricEducationandResearchInstitute.2. ExpandingtheHomeNursingFoundation.3. ScalingupoperationsoftheAgencyforIntegratedCare.4. ContributingtotheCommunitySilverTrust.5. ExpandingtheMedifundbudget.6. ExtendingtheMedicationAssistanceScheme.7. EncouragingstepdowncarewiththeexpandedPrimaryCarePartnershipScheme.These
action
items
have
not
been
elaborated
in
detail
as
that
is
not
the
intent
of
this
paper.
LeveragingthePowerofStrategic(Systems)ThinkingItisobviouslyclearfromtheabovethattheactionitemsaretargetedtomeetspecificneedsandaddresssomeof
the strategic interventions depicted in Exhibit 14 earlier. Comparing the strategic interventions and the action
itemsshowsthatthestrategicinterventionsaremorelongterminnature,whiletheactionitemstendtobemore
tactical and executable in nature. The strategic interventions are excellent inputs for governments to develop
policyenablers.Furthermore,strategic thinkingalso facilitatesdeeperunderstandingofpolicy resistance that is
oftendisplayedbystubbornproblems.
Exhibit15showstheauthorsownassessmentofthestrategic interventionscoveredwiththeannouncedaction
items.Itisclearlyseenthattheactionitemsputforthreflectthepreemptiveanticipatorythinkingonpartofthe
government.
The
problem
at
hand,
chronic
disease
management,
is
a
complex
and
stubborn
one.
Hence
the
action
itemsdemonstrate theprogressiveseriesof tasks thatarebeingplannedandperformed totackle it. It is tobe
noted that the Singapore government already has existing plans and schemes for management of long term
conditions,examplepoliciesandprogramspertainingto:(1)ageingworkforce;(2)chronicdiseasecarecosts;(3)
programsmitigatingmodifiablerisk factors; (4)preemptivescreening;and (5)GNI/GDPgrowthandeconomic
wellbeing. InExhibit15theaction itemsare limited toonesspecificallyannounced intheMarch2011national
budget. Insummary,agreatstarthasbeenmadeand it iscomfortingtoseethatprogress isbeingmade inthe
rightdirection.Thisishoweffectivestrategic(systems)thinkingisintendedtobe.Itisimperativethatthecomplex
effects, synergiesandemergentbehaviorof system interventionsare fullyunderstood inorder to takebenefit.
Additionally, any intervention with systemwide implications cannot be considered simple and allows
organizationstocapitalizeoncomplexity.
8/23/2019 Dr Pallab Saha - EA & Public Health
19/24
Exhibit15:MappingtheStrategicInterventionstotheAnnouncedActionItems
Strategic thinking establishes the vision, while action items realize the vision. This is an essential element for
enhancingthe
effectiveness
of
the
EA,
as
often
EA
is
perceived
of
being
overly
skewed
towards
housekeeping
typeofactivities,ratherthanfacilitatingtheorganizationstothinkforwardandenablethevisioningprocess.The
perceptionisnotentirelyincorrectandcurrentEAframeworksreinforcethisevenfurther.Organizationsfindthe
currentframeworks intimidatingastheytendtoquicklytakethem intoajourneyofdeepandgranularanalysis,
without spending adequate time for future thinking. Organizations overly focus on improving the operational
enablersatthecostofstrategicwisdomanddirection.Ignorance,complexityandcapabilitygapsarecitedmost
frequentlyastheprimaryreasons.Operationalenablersmean:(1)frameworks;(2)methodologies;(3)reference
architecturesandmodels;(4)toolcapabilities;(5)competencybuildingactivities;(5)guidelinesandstandards;(6)
best practices and the like. The skewness in favor of operational enablers is hard to miss. Though operational
enablers are important, they, by no means have the ability to supplant the strategic perspective. Their role is
primarly in supplementing strategic wisdom and direction. In the absence of the strategic perspective, the EA
programvirtuallynavigatespartblind leading tocynicism, lackofpersistence,erosionofconfidenceand lossof
attentionby
the
organization
leaders.
It
almost
takes
acrisis
to
make
deep
change.
And
when
it
is
time
to
address
thecrisis,thefocus isonsymptoms,notcauses.Embracingstrategic(systems)thinkingaspartoftheEAprocess
notonlyaddressestheperception,butalsoelevatestheroleofEAasamanagementandleadershipdiscipline.This
upsthe innovationstakes,movingupfromoperationalinnovationtobusinessmodelinnovation,whichgoesto
theverycoreofbusinessdesign.Thisfactors inand influencesthevaluepropositionandtheoperatingmodelof
theorganization.Becausethisinvolvesamultidimensionalandcoherentsetofactivities,innovationatthislevelis
bothchallengingtoexecuteanddifficulttoimitate.Thereisempiricalevidencethatprofitoutperformersfocuson
business model innovation by a substantial margin. The author has personally been involved in guiding such a
NationalUniversityofSingapore|InstituteofSystemsScience
Page19of24
8/23/2019 Dr Pallab Saha - EA & Public Health
20/24
mindsetchange,hencebeingabletovouchforit.Thatsaid,itwouldbeawhileforcurrentEAframeworkstomake
strategic(systems)thinkingasanintegralpartoftheirmethodologiesandapproaches.
Inthecurrentstateofpractice,EAprogramsandinitiativesareoftenconceivedanddrivenbytheITdepartment.
In this context, there already are substantial literature and other supporting evidence that the IT department,
moreoften thannot, finds itchallengingtodeeplyengage thebusinessorthedomainsideof theorganization.
AccordingtotheIBMGlobalCIOstudy,realizingbusinessinnovationhasbeenidentifiedasthefirstandforemost
activity as being increasingly expected from CIOs. Questionable credibility on part of the IT department
exacerbatesthelackofcommunication,leadingtodisengagementandeventuallossofmomentumandinterestin
EA. It gets relegated as an IT project. Embracing strategic (systems) thinking allows for: (1) a business
understandingofbusinessconcerns/problems;(2)synthesistotakeprecedenceoveranalysiswhichisessentialto
manifest the organizationwide view of the architecture; (3) triangulation of emergent strategy development
with the more traditional topdown strategic planning; (4) identification of leverage points wherein the
interventionstendtobemost impactful;(5)framingtheproblemsspace inawaythat iscomprehensiblebythe
senior executive leadership in the organization; (6) deemphasizing on the siloed mindset; (7) establishment of
collective strategic priorities; and (7) designing for coherence (consistent, collaborative, connected). Once the
aboveareachieved, identifyingthemostrelevantbusinessservices,businessfunctionsandprocessestoexecute
theactionitemsbecomesthenextlogicalstep,followedbytheotherdownstreamstepsinthedevelopmentofthe
ITarchitecture.ThispaperdoesnotattempttoelaboratethedownstreamITarchitecturestepsasthereisalready
aplethora
of
literature
available
that
covers
the
topic.
Exhibit
16
summarizes
the
phases
and
steps
that
are
typicallyrequiredtoeffectuatethebusinesstransformationthatisdrivenbyEA.Thephases,steps,sequenceand
theotherelementsdepictedinExhibit16areindicativeinnatureandthereisnofurtherelaborationinthispaper.
Exhibit16:SuggestedMethodologyforArchitectureDrivenBusinessTransformation
NationalUniversityofSingapore|InstituteofSystemsScience
Page20of24
8/23/2019 Dr Pallab Saha - EA & Public Health
21/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page21of24
MovingForwardAManifestoforManagementLeadersandArchitectsMichael Porter has asserted that strategic planning in most organizations has not contributed to strategic
thinking.InthecaseofEAthisstatementcannotbedisputedoroverstated.Strategic(systems)thinkingmakesit
possibletotranslatecomplex informationthat is interconnected intosimple,yetcompellingexplanationsofnot
onlywhatishappening,butmoreimportantlywhy.ThereisnodearthofliteraturethatidentifypitfallstoEAand
proposed solutions to avoid such pitfalls. There is also abundant guidance literature available as to how
governments(and
other
organizations)
must
adopt
EA.
On
the
other
hand,
none
of
the
currently
available
literature explain the underlyingcomplexities of EA adoptionper se.GaryHamelscontention thatoperational
efficiencydoesnot equate to strategic efficiency makes absolute sense in a scenario where governments are
graduallytransformingfromahierarchytoalattice(bothbyneccessityanddesign).Theadventofsocialmediais
hastening this transformation.And ina latticewhich ismore likely tocharacterizedbycollaboratingnodes that
form part of value networks, effective coordination and orchestration makes the difference. Moving forward,
governmentsofthefuturewillembraceprinciplesofcocreation,accountability,collaborationandconnectedness.
These will definitely be expolated to the healthcare sector. Innovation and personalization will trump
standardizationandcommoditization.Drivingchangeofanykind ischallengingby itself,butatthefundamental
levelofbusinesscoherency,suchchangerequirescommitment,insight,foresightandleadership.Allfourofthese
distinguishing characteristics are evident in the way Singapore views it chronic disease management plans and
programs.
EAis
avery
large
undertaking
for
any
organization.
EA
for
awhole
industry
sector
is
even
larger,
more
complex
and
more dynamic, making it an imperative to comprehend the underlying complexities in a holistic and coherent
manner.CurrentthinkingpositionsEAasanITmanagementdiscipline.Theresearchthispaperembodiesintends
to dispel this thinking and positions EA literally as the architecture of the enterprise, where knowledge is
supplemented with understanding and foresight is as important as insight. It is wellknown that adopting EA
requires and demands much more thanjust good frameworks, methodologies, tools and technical capabilities.
Therehavebeen someefforts to identifydistinguishing factors.However,all theseeffortshave lookedat such
distinguishing factors in a piecemeal manner and hence their proposed solutions are seldom convincing or
effective. The strategic (systems) thinking approach addresses the why of EA adoption in the context of
connectedorganizationanduncoversnonobvious interdependenciesbetweenthe factorssuchas: (1)different
organization units within the enterprise; (2) corresponding actions taken by these organization units; (3)
quantitative tangible variables (such as healthcare investments) and qualitative ones (such as operational
diversity);(4)
short
and
long
term
consequences
of
management
decisions;
(5)
uncovering
virtuous
and
vicious
cycles.EAforstrategicleadershipandadvantageisalongtermendeavor.Thetechnicalprocessofarchitectingis
difficultenough,butunderstandingtheunderlyingcomplexitiesandtheinterconnecteddynamicsthatcontribute
to particularly intractableand difficulttosolveproblems makes it intimidating formanyorganizations.Systems
thinking,used in thispaper, looksat theseproblemsandanalyzes themwith thecore intentof: (1)motivating
peopletochange;(2)generatingcollaborationbetweengroupsthatblameeachotherforthecurrentsituation;(3)
concentratelimitedresourcestopointsofgreatestleverage;and(4)ensurecontinuousongoinglearningafterkey
decisionswithregardtointerventionshavebeenmade.
Current EA frameworks and methodologies consider organizations as functional hierarchies, which employ the
commandandcontrolparadigm,astopdown,separated fromwork,targetandbudgetdrivenwithanethosof
centralcontrolandreaction.Thisbeingthestartingpoint,therestofthearchitectureactivitiesembedandeven
amplify thismindset, thuscreatingabiasedandoften incorrect viewof theorganization, leading to ineffective
architecture.Edward
Deming
has
asserted
that
organizations
need
to
be
viewed
and
managed
as
systems.
Through
the integrationofstrategic (systems)thinking,supportedwith itsapplication inthehealthcaresectorthispaper
hasattemptedtofurtherthedisciplineandpracticeofEA.
The author gratefully acknowledges Singapore Healthcare Services (SingHealth) and Integrated Health
Information Systems (IHiS) for their involvement and contribution to this work. Their inputs and enthusiastic
participationhavebeeninvaluable.
8/23/2019 Dr Pallab Saha - EA & Public Health
22/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page22of24
References
Abegunde, D. and A. Stanciole. (2006). An Estimation of the Economic Impact of Chronic Noncommunicable
Diseases in Selected Countries. Department of Chronic Diseases and Health Promotion, World Health
Organization:Geneva,Swtzerland.
Burns, P., Neutens, M., Newman, D. and T. Power. (2009). Building Value through Enterprise Architecture: A
GlobalStudy.
Booz
&
Company
Perspective.
Burton, B. and P. Allega. (2010). Hype Cycle for Enterprise Architecture 2010.Gartner Industry Research ID
Number:G00201646.
CiscoInternetBusinessSolutionsGroup(IBSG).(2004).ConnectedGovernment:EssaysfromInnovators.Premium
Publishing:London.
Cisco InternetBusinessSolutionsGroup (IBSG). (2009).RealizingthePotentialof theConnectedRepublic:Web
2.0OpportunitiesinthePublicSector.CiscoSystemsIncorporatedWhitePaper.
Dettmer,H.W.(2007).TheLogicalThinkingProcess:ASystemsApproachtoComplexProblemSolving.ASQQuality
Press:NewYork,NY.
DiMaio,A.,Claps,M.,McClure,D.,Vining, J.,Bittinger,S.,Newman,D.,Logan,D.,Kreizman,G.andR.Wagner.
(2009).
Hype
Cycle
for
Government
Transformation
2009.
Gartner
Industry
Research
ID
Number:
G00169057.
Doucet,G.,Gotze, J.Saha,P.andS.A.Bernard. (2009).CoherencyManagement:Architecting theEnterprisefor
Alignment,AgilityandAssurance.AuthorHouse:Bloomington,IN.
Dutta,S.and I.Mia.(2010).Global InformationTechnologyReport20092010: ICTforSustainability. INSEADand
WorldEconomicForum.WorldEconomicForum:Geneva.
Gall,N.(2010).FromHierarchytoPanarchyHybridThinkingsResilientNetworkofRenewal.GartnerResearch
IDNumber:G00209754.
Gall, N., Newman, D, Allega, P., Lapkin, A. and R.A. Handler. (2010). Introducing Hybrid Thinking for
Transformation,InnovationandStrategy.GartnerResearchIDNumber:G00172065.
Giesen,
E.,
Berman,
S.J.,
Bell,
R.
and
A.
Blitz.
(2007).
Paths
to
Success
Three
Ways
to
Innovate
your
Business
Model.IBMInstituteforBusinessValue,IBMCorporation:Somers,NY.
Hamel,G.(2007).TheFutureofManagement.HarvardBusinessSchoolPress:Boston,MA.
Herlands, D. and K. Brown. (2005). StrategiesforChronicDiseaseManagement. The Advisory Board Company:
Washington,D.C.
Homer, J.B. and G.B. Hirsch. (2006). System Dynamics Modeling for Public Health Background and
Opportunities.AmericanJournalofPublicHealth.March2006,96(3).
IBMCorporation.(2009).TheNewVoiceoftheCIOInsightsfromtheGlobalChiefInformationOfficerStudy.IBM
InstituteforBusinessValue,IBMCorporation:Somers,NY.
IBMCorporation.(2010).CapitalizingonComplexityInsightsfromtheGlobalChiefExecutiveOfficerStudy. IBM
Institute
for
Business
Value,
IBM
Corporation:
Somers,
NY.
Joffe, M. and J. Mindell. (2006). Complex Causal Process Diagrams for Analyzing the Health Impacts of Policy
Interventions.AmericanJournalofPublicHealth.March2006,96(3).
Johnson,M.W. (2010). Seizing theWhite SpaceBusinessModel InnovationforGrowthandRenewal. Harvard
BusinessPress:Boston,MA.
Kagerman, H., Osterle, H. and J.M. Jordan. (2011). IT Driven Business Models Global Case Studies in
Transformation.JohnWiley&Sons:Hoboken,NJ.
8/23/2019 Dr Pallab Saha - EA & Public Health
23/24
NationalUniversityofSingapore|InstituteofSystemsScience
Page23of24
La Trobe University. (2008). System Reform and Development for Chronic Disease Management. Australian
InstituteforPrimaryCare:Victoria.
Leischow,S.J.,Best,A.,Trochim,W.M.,Clark,P.I.,Gallagher,R.S.,Marcus,S.E.andE.Matthews.(2008).Systems
ThinkingtoImprovethePublicsHealth.AmericanJournalofPreventiveMedicine.2008;35(2S).
Lindgardt,Z.,Reeves,M.,Stalk,G.andM.S.Deimler. (2009).BusinessModel InnovationWhentheGameGets
Tough,ChangetheGame.BostonConsultingGroup.
Meadows,D.(1999).LeveragePoints:PlacestoInterveneinaSystem.HartlandVT:TheSustainabilityInstitute.
Mickoliet.A.,Kounatze.C.R.,SerraVallejo.C.,Vickery,G.andS.WunschVincent.(2009).TheRoleoftheCrisison
ICT and their Role in the Recovery.Organizationfor EconomicDevelopment andCooperation (OECD)
Report.August2009.
MicrosoftCorporation.(2009).ConnectedHealthFramework2nd
Edition.MicrosoftCorporation.
Moon,Y.(2010).DifferentEscapingtheCompetitiveHerd.CrownBusiness:NewYork,NY.
Reed,G.E.(2006).LeadershipandSystemsThinking.DefenseAT&L.MayJune2006.
Ross, J.W., Weill, P. and D.C. Robertson. (2006).EnterpriseArchitectureas Strategy:Creatinga Foundationfor
BusinessExecution.HarvardBusinessSchoolPress:Boston,MA.
Saha,P.(2007).HandbookofEnterpriseSystemsArchitectureinPractice.IGIGlobalInformationScienceReference:Hershey,PA.
Saha, P. (2008). Advances in Government Enterprise Architecture. IGI Global Information Science Reference:
Hershey,PA.
Saha. P. (2010).Advancing theWholeofGovernment EnterpriseArchitectureAdoptionwith Strategic (Systems)
Thinking.UnitedNationsPublicAdministrationNetwork(UNPAN):NewYork.
Saha. P. (2010).Understanding the Impact of EnterpriseArchitecture on ConnectedGovernment:AQualitative
Analysis.UnitedNationsPublicAdministrationNetwork(UNPAN):NewYork.
Savigny,D.andT.Adam.(2009).SystemsThinkingforHealthSystemsStrengthening.WorldHealthOrganization:
Geneva,Switzerland.
Senge,P.(1990).TheFifthDiscipline.DoubledayCurrency:NewYork,NY.
Sterman,J.D.(2000).BusinessDynamicsSystemsThinkingandModelingforaComplexWorld.IrwinMcGrawHill:
Boston,MA.
Stroh,P.D.(2000).LeveragingChange:ThePowerofSystemsThinkinginAction.Reflections.Volume2,Number2.
Tamara,R.andR.Damuth.(2009).EstimatingtheEffectsofBroadbandPenetrationonGDPandProductivity in
SouthEastAsia.NathanAssociatesBusinessReport.
Trochim, W. M., Cabrera, D.A., Milstein, B., Gallagher, R.S., and S.J. Leischow. (2006). Practical Challenges of
SystemsThinkingandModelinginPublicHealth.AmericanJournalofPublicHealth.March2006,96(3).
WorldBank.(2008).GlobalEconomicProspectsTechnologyDiffusionintheDevelopingWorld.TheWorldBank:
Washington.D.C.
World Econonic Forum. (2009). ICTfor EconomicGrowth ADynamic EcosystemDriving theGlobal Recovery.
WorldEconomicForum:Geneva.
World Health Organization. (2005). Preventing Chronic Diseases A Vital Investment. Department of Chronic
DiseasesandHealthPromotion,WorldHealthOrganization:Geneva,Swtzerland.
8/23/2019 Dr Pallab Saha - EA & Public Health
24/24
AbouttheAuthorDr. Pallab Saha is with the National University of Singapore, Institute of Systems Science (NUSISS). His
current research,consultingand teaching interests includeEnterpriseArchitecture (EA)andGovernance.
Dr.Sahahaspublishedthreebooks,HandbookofEnterpriseSystemsArchitecture inPractice;Advances in
Government Enterprise Architecture; and Coherency ManagementArchitecting the Enterprise for
Alignment,AgilityandAssurance.Hisbooksarewidely referredby practitionersand researchersaround
theworld,makingittotheTopSellerlistin2008and2009.Hispapershavebeentranslatedandpublished
inKorean,
Russian
and
Polish.
Dr. Saha is the primary author of the MethodologyforAGency ENTerpriseArchitecture (MAGENTA) and Government EA
GuidebookfortheGovernmentofSingaporeandhasledthemtointernationalprominence.TheyareavailableinIDSScheers
ARISToolset.He isa recipientof theMicrosoft researchgrant in theareaofGovernmentEA supportedby theUNand the
WorldBank.Heconsultsextensivelybothinthepublicandprivatesectors.HehasprovidedconsultingservicestotheMinistry
of Defence, Defence Science and Technology Agency, Infocomm Development Authority of Singapore, Integrated Health
InformationSystems,IPOfficeofSingapore,CPFBoard,SingHealth,GovernmentsofOmanandKazakhstan,andGreatEastern
LifeAssuranceamongothers.Hehasbeen invitedasakeynote/distinguishedspeaker to theWorldBank,CarnegieMellon
University,UNUniversity,TheOpenGroup,Microsoft,SAPLabs,DenmarkITSociety,KoreaInstituteforITArchitecture,IEEE,
SGGovCamp,NanyangBusinessSchool,Governments of SouthAustralia, Jordan,UAE, Macau, Korea, Kazakhstan, Colombia,
BangladeshandseveralSingaporeGovernmentAgencies(AGO,WDA,MUIS,IDA,CIOForum,MHA,SPRING).Hisworkhasbeen
featured and cited by the UN, WHO, United States DoD, Carlsberg and The Open Group and has contributed to the World
Banks EA Guidelines for Vietnam. Featured as anArchitect in the Spotlight by theJournal of EA he has been an external
examinerfor
research
degrees
to
the
University
of
New
South
Wales,
University
of
Indonesia,
aVisiting
Researcher
to
the
UN
University,andhasbeeninstrumentalinbringingAsiasfirstGovCamptoSingapore.
Earlier,asHeadofDevelopmenthehasmanagedBaxter'soffshorecentre inBangalore.Hehashadengagements inFortune
100organizationsinvariouscapacities.Dr.SahaholdsaPh.DinManagement(InformationSystems)fromtheIndianInstituteof
Science, Bangalore and has received the best research design and best thesis awards. He is an alumnus of the MIT Sloan
NationalUniversityofSingapore|InstituteofSystemsScience
f