Reflections on Building Organization Integrity after Radical Changes
Experiences of Physicians in Turkish Healthcare Sector
Introduction
In Turkey, the Ministry of Health was established in the year of 1920 with the object of constructing and controlling legal arrangements in healthcare and supplying well-qualified health personnel in sufficient numbers. From 1938, legal arrangements and practices were developed in order to strengthen the central structure of healthcare management. The year 1961 saw the beginning of the socialization process of health services, and within this context, the Law on the Socialization of Health Services came into force.1 Under this socialization context, clinics responsible for providing the first step of healthcare services were integrated into the entire healthcare system. The healthcare system witnessed several changes in the years between 1980 and 2002. In particular, in 1987, the Law of Fundamental Health Services, the first attempt to adapt the healthcare sector to open economy, was accepted. Moreover, with the bylaw of Green Card in 1992, healthcare organizations started to provide free-of-charge healthcare services to citizens who were unable to pay.2 During the 1990s, major changes regarding gathering social security institutions under one roof and providing the same rights to all patients, establishing general health insurance, the expansion of primary healthcare within the framework of family medicine, the conversion of hospitals into autonomous businesses, and giving priority to preventive health services had been discussed, however, they couldn’t be realized until the 2000s.3
Transformation Program in Healthcare was realized in 2003, aimed at creating a radical change in the sector focusing on eight main themes:4
1. Positioning the Ministry of Health as the planner and the controller—The Ministry positioned itself as a strategic institution, which carried out the central planning and controlling for the delivery of health services.
2. Establishment of a general health insurance by gathering different social security organizations under one roof—An integrated insurance model in which social security organizations for workers (SSK), the self-employed (BAGKUR), and civil servants (Emekli Sandigi) were unified as a single organization; the Social Security Institution (Sosyal Guvenlik Kurumu) was created.
3. Creation of a widespread, easily accessible, and friendly health service system—It included strengthening primary healthcare, establishing effective integration among the healthcare organizations, and providing healthcare organizations with financial and administrative autonomy.
4. The development of a labor force equipped with knowledge, competence, and high motivation—For instance, a new education program was developed for the specialization of family physicians and nurses who would work in the primary care area.
5. The establishment of education and science institutions supporting the healthcare system—An academic structure under Health Academy or Health Specialization Institution was aimed to be established to reorganize education hospitals, to plan the current education in medicine, and to make standardizations.
6. The assurance of quality and accreditation for qualified and effective health services—National Quality and Accreditation Institution was established as an autonomous structure in order to develop systems for the measurement of health outcomes and to formulate performance indicators for health service suppliers.
7. The establishment of effective inventory management for medicine and equipment—Catching up to international standards in terms of standardization and authorization, and rational uses of medicines, equipment, and medical devices was aimed.
8. The establishment of effective health information system—it was aimed to integrate all the mechanisms of Healthcare system through effective information management.
The major driving forces behind the Transformation Program in Healthcare were achieving efficiency, productivity, and equity in the sector. The other driving forces for the program could be also considered as the “Health for All in 21st Century” policy of the World Health Organization, “Accession Partnership” document prepared by the European Union, and the need for harmonization of Turkish Health Legislation with the European Union’s, in line with the “National Program” for Turkey.5 Health Transformation Program was accepted on the principles of humancentrism, sustainability, participation, reconcilement, volunteerism, division of power, decentralization, and competition.6
Based on the components of the Health Transformation Program stated above, hospitals have witnessed the following results:
1. The unification of public hospitals under a single roof and giving patients the right to choose their hospital.
2. Giving patients the right to choose their physician.
3. The development of a performance-based wage system for the physicians—the rate of payment was related to the number of patients seen and the number of medical interventions.
4. Restrictions of physicians’ work outside the hospital—the physicians were encouraged to work at hospitals on a full-time basis.
5. Total quality management and accreditation process—quality units were generated in each hospital chaired by the deputy chief physician. These units worked in a coordinated manner with the Ministry of Health.
6. Protection of patients’ rights—patients’ rights units were established to consider patient complaints in each hospital.
7. Computer automation—in accordance with procedures to reduce paperwork, bureaucratic procedures were simplified and the use of information technology was substantially increased.7
As seen, Health Transformation Program brought radical changes. Some researchers argued that the transformation period increased the productivity, accessibility, and quality of the healthcare services.8 For instance, Diler found that the efficiency of the majority of hospitals increased after the realization of Health Transformation Program.9 Celikay and Gümüs showed that the general satisfaction of citizens with healthcare services had significantly increased.10 In contrast, other researchers stated that many important problems occurred with these changes.11 For example, Görgün indicated the negative effects of the new performance-based wage system on the working conditions and motivations of physicians.12 In the new system, performance evaluations were based on the number of patients seen and medical treatment performed. However, their results or quality were not taken into consideration. This may lead that physicians try to see more patients a day, but spare less time to each. Moreover, they may demand unnecessary treatments to increase their performance score. Also, as the scope of healthcare service was defined in terms of medical intervention numbers, it was also possible that less risky interventions carry the same score with more risky ones. Under this working condition, work peace may be broken among healthcare staff, and as a result, motivation of working collaboratively with other healthcare personnel is affected negatively. Accordingly, Görgün stated that the new performance evaluation system may create more competitive environment and stimulate unethical behaviors.13
Due to the conflicting research findings, Tatar emphasized the need for further empirical studies to evaluate the effects of Health Transformation Program on three crucial points: (a) the effect of the increasing role of the private sector on service quality, (b) the effect of a new performance-based wage system on the number of unnecessary medical interventions, and (c) state expenditures in healthcare.14
As explained, Turkish Healthcare System has been witnessing changes that radically affect the roles of physicians, units, and healthcare organizations. These changes aimed to increase efficiency and effectiveness of the system and make health services more accessible to the public. As mentioned in the main principles of Health Transformation Program, contributions of all the related parties and stakeholders are vital in the achievement of such a challenging aim.15 However, some experts argued that an indispensible part of the healthcare system, the physicians, were affected negatively and their motivation and integrity have been damaged.16
To shed light on this issue, opinions of physicians, as one of the important stakeholder groups, were taken in interviews. In that regard, five physicians with diverse backgrounds, working history, and positions expressed their opinions about all these changes and their effects on integrity. Moreover, they defined physicians, units, and healthcare organizations behaving with integrity, and offered suggestions to stimulate integrity in the entire healthcare system.
Definition of a Physician with High Integrity
Sebnem, full professor in psychiatry, described the behaviors of the physicians acting with integrity thus:
“Listening and understanding the person (patient) in front of you, helping that person and showing professional knowledge and skills in doing so, without regarding the congeniality and social background of the patient… and when you get out of your depth in terms of interest or knowledge, referring the patient to others (other physicians), asking for help, sharing your professional knowledge and lack of it… and resisting status quo and constantly improving yourself, anticipating that illnesses and symptoms may change, probably always keeping this in a dynamic process…”
Levent, a physician working in a private dialysis clinic, emphasized the importance of understanding the patients while describing a physician with high integrity:
“Someone compassionate, looking out for their (patients’) rights, able to understand their concerns, making an effort to understand and resolve them, making things easy for the patients when they face difficulties, someone realizing it when things get difficult… and of course, among our obligations for the patient is continually trying to improve the scientific aspect of the job. Improving ourselves, offering the latest treatments, asking for necessary consultations, attempting to gain a wider perspective…”
Differing from her colleagues, Hatice, associate professor in medical education, approached the issue from a more emotional viewpoint and she evoked that:
“A physician must be very compassionate, and every step he takes, he must treat the patient as he would his own parents or children. I mean I should treat you kindly, knowing that your stomach hurts, and thinking how I would treat you if we were kith and kin. What’s expected of us is empathy…”
Moreover, she defined stimulating factors for physicians to behave with integrity.
“In order to have integrity, I need to know everything positive or negative about myself, I need to know myself. What makes me unhappy, what I envy, what I can and cannot do well—I need to know all this. I need to love myself, and I need to have ideals. Having dreams and goals is particularly important for the medical practice, since you can easily fall apart if you can’t set goals…”
Supporting the views of Hatice, Cem, associate professor in pharmacology, stated that:
“To a certain extent, it’s about how you feel inside, what individuals expect from life, what they want to give to people, what they want to do in life…”
Definitions of a Healthcare Unit with High Integrity
While talking about a healthcare unit behaving with high integrity, Levent stated that:
“If you have a manager who strives to work out problems, intervening when necessary and supporting you continually in your unit, then your work atmosphere seems to be more pleasant and productive. In such a clinic, interpersonal relations will work better. If the manager sometimes puts in the effort in that unit, he or she may cover a lot of ground toward creating a more agreeable atmosphere. I experienced that when I was working [at the] university hospital; I saw how good a manager can be. It was really different. It wasn’t just about his attitude toward situations; also important, of course, was the fact that he guided people, kept them open for improvement, moving them to be productive…”
Sebnem added that:
“The attitude of the supervisor is important. Knowing that you’re liked by your supervisor… actually feeling a stronger commitment to your organization… It’s then possible to tolerate feelings such as anger. It’s also important how the supervisor handles a problem. What’s the level of fairness the employee feels when the problem is being addressed? Some people feel commitment and integrity if they feel they can express themselves.”
Definition of a Healthcare Organization Behaving with High Integrity
After discussing the characteristics of a healthcare unit behaving with integrity, Hatice defined the requirements for integrity in healthcare organizations where different units are needed to work in harmony. She evoked that:
“There needs to be symmetry of information. Ever since I was appointed to the position of the coordinator, I write journals, because whatever I do, others need to know about it, thus we can have integrity and continuity. But I know this is not the typical structure… You do something, and that stays with you; I do something, and it stays with me. Then we get together, and we don’t tell each other about what we’ve done…”
While Hatice, as a coordinator, referred to her observations in terms of required mechanisms for organizational integrity, Sebnem stated her views on this issue as a subordinate:
“The sense of equity is important. If the sense of fairness prevails in the institution, and if people know they’ll receive equitable compensation for their efforts, then no one sidetracks…”
In addition, Hatice and Cem emphasized the role of belonging in a healthcare organization with high integrity. Hatice quoted that:
“When individuals can’t properly define themselves on their own, they’re unable to do this with regards to the organization. And when they can’t do that, a sense of belonging can’t form. Inability to form belongingness is one of the obstacles in the way of organizational integrity…”
Cem added that:
“For one thing, the sense of belonging is very important. I love this hospital of mine. And because I feel I belong here, I even want to give of myself without paying much regard to financial matters…”
Physicians’ Suggestions to Stimulate Integrity in the Entire Healthcare System
Cem started with the importance of stability in healthcare system. However, he believed that Health Transformation Program brought many uncertainties to physicians’ careers. As expected, those uncertainties negatively affected physicians’ identifications with the occupation and healthcare organizations:
“In this country, when I started in medical school, there was no medical compulsory service. I graduated and it was there. I passed the exam to specialize in medicine, and compulsory service was abandoned. I finished my specialty training, compulsory service returned… I mean there’s a situation in which you can’t see the future…”
In line with Cem, Levent also criticized the continuously changing healthcare system. He clearly stated that physicians’ feelings of hopelessness prevent them from behaving with integrity.
“When you enter the profession, you’d like to think about how much money you make now and by the time you retire, about what your retirement pension would be, right? But uncertainties affect your future expectations… people don’t see a light on the horizon; therefore, they lose hope… a friend of mine is thinking about getting into the restaurant business...”
Besides the importance of the factors such as “the system certainty” and “identification,” “education” was also evaluated as another crucial factor affecting the level of integrity. Omer, assistant professor in pharmacology, strongly believed that behaving with integrity can be learnt.
“(Integrity) It can be taught. I mean, after all, we didn’t even know how to speak when we were born; anything could be taught! … Our professor used to say “when a patient with a fever arrives, don’t try to reduce the fever right away. First, follow up for a couple of days, and then intervene only when necessary.” This bit of information appears in none of the books on medicine. I never read about this in any book. That’s the professor’s comment. I could make a remark like this, too. When can I do it? When I see 45, 50, hundreds of patients, then I can do it. That’s the mentoring system.”
Although Hatice supports Omer’s opinion, she indicated the potential negative effects of mentoring system on integrity, when the mentoring system was not well designed.
“Medical training is a hierarchical one; we actually learn from those before us in a mentoring kind of relationship. While teaching, the mentor tyrannizes over the learner on occasion. (The underdog) learns to tyrannize as well. Having learnt to tyrannize, the downtrodden oppresses the next one... This damaging relationship is reflected on the patient, patient’s relatives, sometimes a colleague… When I was in medical school, we’d take the advice of our consultant professors, and we were together until six in the evening, watching how they treat the patients… until we graduated… There are some professors whom we still keep in touch with… we still haven’t drifted away… we learned so much from them… Much as we idealize and say that the student and the professor should work very closely, learn something from each other, we can’t create an environment to allow this to happen. Other than that, what kind of solution could we come up with? How could we transfer these values? I don’t know. The contact hours in education program are so few… we try to increase contact as much as possible but those contact hours to teach… teach the attitude… very few. They’re very few in internships, too…”
When it comes to the evaluation of healthcare system from the perspective of stimulating integrity for physicians, healthcare units, and organizations, the physicians were pessimistic. They started with the negative attitude of the Ministry of Health toward physicians. Cem expressed that:
“The ministry of health is, in my opinion, inadequate in protecting its staff (against violence by patients or patients’ relatives).”
In line with Cem, Levent provided a long and detailed explanation regarding the negative attitude of the state based on his experiences. He referred that:
“Politicians, prime ministers, ministers of health have always made the physicians scapegoat for anything in the eyes of the public. I mean they obviously made people believe that the main factor for the failure of the healthcare system is the physicians. … (About a problem experienced with a patient) I tried for about five months. First, I wrote a petition. I wrote to the person in charge at the dialysis center and to the managing director. It was referred to the Ministry of Health and the social security institution. We reported the incident, and a response came about five months later. When a patient files a complaint as soon as he’s out of the door, before he even makes it to the stairs, they called. Believe me; they called us from the Ministry within two or three minutes. … The money allotted by pharmaceutical companies for congresses has decreased, so did the number of people they send to these events. Therefore, you have less of a chance to attend congresses and improve yourself. In the past, let’s say a hundred physicians would attend any given scientific conference, but now, perforce, only five or ten physicians do so. They eliminated the funds (referring to the ministry of health). Well, you eliminated these funds, but you need to compensate somehow for this. I mean you need to make congresses accessible. No efforts have been made in that aspect. The ministry does not endeavor to disseminate the proceedings of congresses…”
Besides the negative attitude of the state, working conditions of physicians, the new performance-based wage system, high workload, and lack of proper control mechanisms were heavily criticized by all five physicians.
Cem:
“Working hours… very important… I mean you can’t expect performance by keeping a person in the hospital for 36 hours…”
Hatice:
“Now with the changes in the healthcare system, physicians see an average of one patient every three minutes… In any case, that doesn’t even mean seeing a patient…”
Levent:
“Time allotted for the patient is surely an important factor… the number of patients that you see in one day…”
Omer:
“There are some clear figures. While 50 angioplasties were performed annually in a city before, the number has gone up to 150 after performance evaluation system. Did the number of patients go up?”
Hatice:
“A small example… if a patient stays in the intensive care unit for three days on average, the performance score peaks… both my siblings are surgeons… they perform the surgery and discharge the patient on the same day, because they think the patient would be better off at home. Some other physicians tell them they’re crazy because they’re not making any money from the performance system then. Who ends up losing here? The physicians who do their job well…”
Sebnem:
“What does a physician do during a cesarean delivery? She cuts open the woman’s abdomen, then cuts the uterus, then intervenes with a second living being and gets 160 points for that. The point value for giving an injection is 90. When you equate the labor of the physician to a few points, you cannot separate money from healthcare… on the contrary; healthcare is money now… what else happened… all the labor of the physician goes down the drain. It’s now comparable to a few points… Money should not be an issue in terms of healthcare. Healthcare should be accessible. But while we intended to remove money from healthcare, now healthcare equals money… because each intervention has a performance score… I mean, a physician performs cesarean delivery and that has a performance score. Now how’s that point determined…”
Omer:
“The performance evaluation system needs to be substantially overhauled. Let’s say you charge 100 TL for a simple intervention, and 150 TL for a much more risky intervention, one that could be fatal. Which one would you do? Many physicians opt for the simple one. They don’t want to deal with risky patients. … Look, before here, I was a physician at Buca closed prison. I was a prison physician for six or seven years… I’d say to the inspectors who came there: ‘you always examine things like, whether I have my tie on, whether my shoes are polished, whether my protocol log is in order, whether I clocked in and out on time, whether there are complaints about the infirmary in general. Yet you don’t look into how many patients I referred to the hospital, how many of those patients had to go to the hospital, how many of them could be treated within the facilities of the prison, did I take any bribe from some patients to refer them there…’”
As seen, physicians clearly described the characteristics of a physician, a healthcare clinic, and an organization behaving with integrity. However, when they evaluate the Health Transformation Program, with its effects on health care system, they draw a pessimistic picture, and they indicated many major issues that can be reconsidered by the Ministry of Health.
Key Terms
Integrity—Calhoun indicated that integrity has three main dimensions:17 first the integrated self-dimension, integration of the parts within the person such as desires, evaluations and commitments, into a whole; second, the identity dimension, loyalty to the personal principles as a matter of character; and finally the identity and clean hands dimension, maintaining personal commitment and purity in corrupting situations.
Health Transformation Program in Turkey—a program issued in 2003 with the aim of creating a radical change in healthcare sector.18
Performance-based system—one of the seven components of the Health Transformation Program in which the rate payment for physicians became related to the number of patients seen and the number of medical interventions conducted.19
Study Questions
1. What is integrity? What is the importance of integrity in healthcare sector?
2. Is there a harmony between the principles of Health Transformation Program with the notion of integrity?
3. What are the radical changes observed in Health Transformation Program?
4. Why might physicians’ motivation and integrity be affected negatively due to the changes brought by Health Transformation Program?
5. If physicians behave with integrity, will it be sufficient to create healthcare clinics and organizations with high integrity?
6. If you were the Minister of Health, how would you evaluate the success of Health Transformation Program? what additional changes would you make?
Further Reading
Palanski, M. E., & Yammarino, F. J. (2007). Integrity and leadership: Clearing the conceptual framework. The Leadership Quarterly 25(3), 171–184.
Palanski, M. E., & Yammarino, F. J. (2009). Integrity and leadership: A multi-level conceptual framework. The Leadership Quarterly 20, 405–420.
Verhezen, P. (2008). The irrelevance of integrity in organizations. Public Integrity 10(2), 133–149.
Tatar, M., & Kavanos, P. (2012). Healthcare reform in Turkey. Eurohealth 12(1), 20–22.