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How targets have introduced a form of corruption to healthcare

21 Oct 2022

  • ‘Jaffna Medical Journal’ editor claims setting targets has had a corrosive effect on sector
BY Ruwan Laknath Jayakody The concept of setting targets has, according to the Jaffna Medical Journal, exerted a profoundly corrosive effect on the healthcare of Sri Lanka by introducing a form of corruption described as being much worse than the financial kind. This observation was made by the editor of the said journal, consultant paediatrician, Jaffna University Senior Lecturer in Paediatrics, Colombo University Postgraduate Institute of Medicine Member of the Board of Study in Paediatrics, and Sri Lanka Forum of Medical Editors Member Dr. M.G. Sathiadas in an editorial titled “Health management and patient care” which was published in the said journal’s 34th volume’s first issue in August 2022. Productivity, in general, means an average output per period, by the costs incurred or the resources consumed and personnel utilised during the said period. When health is considered, this measure may not correctly reflect productivity. The traditional approach to measuring healthcare productivity typically defines the output as spending on health goods and services, e.g. drugs, hospital services, and physicians’ services. It can be argued that most productivity growth in healthcare has come in the form of improved quality rather than a lower cost. There has been a heavy push towards redefining the health sector’s output as disease treatments, rather than as medical goods and services. This approach was advocated by the National Academics’ Committee on National Statistics in 2002. Hospital productivity is measured as the ratio of outputs to inputs. Outputs capture the quantity and quality of care for hospital patients while inputs include staff, equipment, and capital resources applied to patient care. Output measures are based on the number of patients treated, the average cost for the patients who are treated, the quality of the treatment, the quality-adjusted life years associated with the treatment, the waiting time for the treatment, the 30 days post-discharge survival rates, the ratio of elective patients to non-elective patients, and the age and gender profiles of the patients treated.  Utilising a variety of different inputs including labour, capital such as land and buildings, and intermediate inputs comprising drugs, dressings, disposable supplies and equipment, are also considered. Teaching hospitals might incur higher costs and appear less productive than non-teaching hospitals because they tend to treat more patients with complex or more severe conditions. Moreover, teaching might introduce delays to the treatment process, as consultants tend to spend more time when assessing a patient in order to train medical students. Many innovations in the medical field in recent years have reduced the cost of treatment and thereby, productivity in healthcare has increased by several factors. According to “Measuring productivity in healthcare: An analysis of the literature” by L. Sheiner and A. Malinovskaya of the Hutchins Centre on Fiscal and Monetary Policy at the Brookings Institution in the US, moving from inpatient care to outpatient care was a key step forward. Converting the double-checking of medications by humans to electronic checking and minimising human documentation is one such innovation. In contrast, healthcare productivity has also declined due to complex new equipment which are used with limitations, the increased capabilities of the healthcare workforce with sub-specialities, and reduced provision with a lack of a system integration plan. The health leadership insists on productivity more than when compared to the values of healthcare. There is broad agreement that the value of healthcare needs to be improved. Preventable harm continues to cause significant morbidity and mortality. While medical practice is continuously improving, it has however not kept up with patients’ rising expectations. In the mid-20th Century, when medicine could do a great deal less than it can now, much more attention was given to kindness, caring, good communication, honesty, reliability, and trust, which are the interpersonal aspects of the doctor-patient relationship. The rise of scientific medicine has led to a preoccupation in our minds which has led to the erosion of personal values, Sathiadas opines. A. Halligan’s “The importance of values in healthcare” pointed out that the systems that are in place for better productivity have hindered professional touch and care towards patients. Per a Japanese study (K. Mori, T. Nagata, M. Nagata, S. Okahara, K. Odagami, H. Takahashi, and T. Mori’s “Development, success factors, and challenges of Government-led health and productivity management initiatives in Japan”), the wholistic care of a patient is affected not because of the actions of individuals and the impressive care and professionalism of so many of the staff who care for the patients, but because of a lack of values reflected in uncaring systems and processes that leave patients powerless, frustrated, and frightened. The time spent with a patient, a hand held, an act of small kindness, a caring act, and honesty, any of these seemingly inconsequential actions have a critical impact well beyond their stand-alone worth. Sheiner et al. noted that these critical but un-measurable behaviours cannot be bought or commanded, as they arrive with a set of values and thrive or wither as a function of the organisational culture. An organisation must strive to serve patients rather than deliver targets. Doctors believe that targets have compromised patient care and undermined clinical decision-making. The concept of setting targets has exerted a profoundly corrosive effect on the healthcare of our country, thus introducing a form of corruption much worse than the financial kind and the unintended consequences are the deep intellectual, moral and spiritual decline that renders all official statements doubtful. J. Larsson and S. Vinberg’s “Leadership behaviour in successful organisations: Universal or situation dependent?” observes that the profession has failed to make its voice heard and thereby challenge the leadership to make things right for the patient and to rediscover lost values. Dr. Sathiadas concluded by citing a quote attributed to the American civil rights leader Martin Luther King Jr. who purportedly stated that “our lives begin to end the day we become silent about things that matter”.  


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