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In this background, there is a dire need to undertake and continue healthcare delivery uninterrupted to the patient by healthcare professionals, while giving low priority for professional conflicts among them. They need to continue the program of activities to tackle health inequalities through action on the social determinants of health.
While inequities in access and care exist within the health system, it accounts for a large proportion of health inequality among the socioeconomically deprived people, when compared to the powerful and influential social segment which enjoys the beneficial economic factors on health.
Those working within the health system have an important as well as an under-utilised role in reducing health inequalities through action on the social and economic factors. Tackling health inequity is a matter of social justice in order to provide the best care possible. As an example, the preventive programs that improve the conditions in people’s livelihood could help to lengthen people’s lives and years spent in good health, and save money.
Working in partnership
In order to take effective action to reduce inequalities, working in partnership within the organisation is essential. Evidence shows that effective action often depends on how services are delivered. Key elements of this are cooperative work that is delivered jointly by the health workers and in more than one sector.
In our hospitals many health professionals work extensively and successfully with other healthcare staff. This partnership has been often seen across primary, secondary and tertiary care; between nurses, psychiatrists, doctors, surgeons, etc. Every health professional has the potential to act as a powerful advocate for individuals, communities, the health workforce and the general population.
Health professionals may need to use their positions both as experts in health and as trusted respected personnel in the community. Maintaining this level of respect is of paramount importance to build the confidence of the patients and for the smooth functioning of duties. Advocacy function on policy changes and related trade union actions are essential but should not be allowed to damage the hallowed responsibility of treating patients.
In our society, health professionals are highly trusted and have established a well-recognised position in the local area. This will further increase their opportunities to understand and support patients within the social context and in some cases to increase their social and economic situation.
Many health professionals build relationships with patients that enable them to understand how their patients’ health needs are affected by the conditions and the context in which they live. Midwives, for example, visit people’s homes and build a relationship with the patients they work with. Staff in hospitals and emergency services see patients at times of crisis, when they are, potentially, most vulnerable.
Good relationship with individual patients and communities can help health professionals to improve their understanding of the multiple social and economic factors that contribute to health outcomes and tailor their work to tackle disadvantages more effectively.
Trade union influence jeopardises the working relationship
The ultimate sanction available to employees in dispute with their employer is to take industrial action in compliance with labour related legislation and protect their position. The idea of taking such action is a difficult one for medical professionals due to the responsibilities on saving the lives of recipient patients who are depending on them for service delivery. Nevertheless, experience shows that medical staff, acting together in the best tradition of trade unionism, remains a powerful and influential force through which a great deal could be achieved inflicting minimum harm to the recipients who are depending for their service delivery.
It appears that in Sri Lanka there is a policy vacuum related to the respective roles of the doctors, nurses and other healthcare workers in government hospitals. The on-going tussle between the doctors and nurses is a culmination of this situation which has led to some sections of the health workforce to keep away from the normal schedule of duties making healthcare delivery totally paralysed in government hospitals.
As an example, it has been reported that the midwives will keep away from deliveries in the maternity hospitals and also the work related to maternity clinics island-wide as a protest against the nurses been given midwifery training as part of their basic training.
They demand that the midwifery training be given only to them keeping away from the normal schedule of duties over an issue of the role of duties or training cannot be justified as the patients who are seeking or waiting for medical attention are not responsible for the issue. And this raises the question whether the workforce involved in the conflict is dedicated to the patients’ well-being?
Sri Lanka has a severe shortage of trained nurses in government hospitals and a significant percentage of nursing posts are unfilled.
The country is also experiencing an inadequate number of specialists. The demand for specialty services far exceeds the supply. Currently, the functions of government hospitals are already affected by the new technology introduced in the private hospitals. This new technology can only be used properly by specially trained physicians.
Thus, more public sector specialists are now drawn to practice in these private hospitals and they spend less time for patient care in the public hospitals. This situation further exacerbates the shortage of specialty services.
Under these circumstances doctors and nurses in government hospitals are burdened with a heavy workload which has created a confusing situation in the respective roles that they are assigned to. In addition, the smooth functioning of healthcare delivery has been further affected due to the failure of the policy makers to respond to the aspirations of the staff concerning remuneration and working conditions.
Under these circumstances, there is a need for some strategic initiative to evolve, adapt and innovate in order to continue to provide effective patient care amidst ever increasing demand, emerging technologies and limited resources. This could be achieved only through a committed cooperation among the workforce. As an innovative model, a Voluntary Bonding Scheme and demonstrations of new workforce roles could be helpful to overcome recurring conflicts among the health workforce.
To overcome the prevailing situation there is a need to review urgently the most important factors affecting the employability of medical staff, in order of importance: workload, staffing, time with patients, flexible scheduling, respect from medical administration, increasing promotion and scholarship opportunities. It is reasonable to assume that in government hospitals the dissatisfaction among the medical staff with regard to working environment has a strong impact along with the workload and pay.
The role of ethical principles in healthcare
Codes of ethics have been a long standing element in the professional control of the medical professionals and indicate a commitment to act with integrity in extreme circumstances. When patients seek medical care they are not entering an ordinary social relationship; they often feel vulnerable but need to expose and share intimate and important aspects of their lives.
Ethical codes of conduct offer some tangible protection to both patients and doctors in the circumstances. The Hippocratic Oath is perhaps the best known code of this kind, and is still administered in some countries. The implications for establishing ethical codes depend in recognising their potential value in describing the ethical environment and ethical attitudes that are shared by healthcare workers.
An overall reduction of the disease burden in a country is critical for the effective functioning of a modern healthcare system. The onus is on the shoulders of the health workforce, i.e., doctors, specialists, nurses, midwives and others. The Sri Lanka public healthcare delivery is known as pro-poor and the patients seeking free healthcare in these hospitals have great respect for the healthcare givers as the socio-economic condition of the poor deprives them of the access to private providers. But their experience with respect to availability, accessibility, affordability and quality of healthcare in government hospitals leaves much to be desired.
In this context, health planning plays an important role since it contributes to shaping the healthcare system. It appears that the current system largely runs on outdated rules and procedures and thus it lacks the capacity to think through, plan and implement major system changes to keep the health sector apace with economic development and people’s needs and demand.
Strengthening health services is recognised as a priority for the country to be able to meet the basic health needs of the people, especially for the poor and vulnerable sections of the population.
(The writer is the Manager of the Health Economic Policy Unit at IPS. For references and to share your thoughts on this article, visit the ‘Talking Economics’ blog – www.ips.lk/talkingeconomics.)
