Health Care Reforms in Turkey – 4: “The Proceedings in the Health Sector and The Emerging Risks” - Ayşe Buğra, Volkan Yılmaz (Part 2)

As part of our responsibility of providing English information on Turkey with a political perspective that is compatible with our stance, we started a series of translations of news items and articles on the transformations in the health care system in Turkey. This is the second and last part of the political analysis (“Sağlık'ta Alınan Yol ve Ortaya Çıkan Tehlikeler”), published in Bianet on August 8^th, 2011. The article, signed Ayşe Buğra and Volkan Yılmaz, discusses the long-term and middle-term consequences of the current policies, which have become more and more apparent in time.

An approach to introduce a health care reform in contravention of the medical doctors is doomed to failure especially with respect to protecting patient rights in the long run, and this long run might be a much nearer future than presumed.

[continuing from the first part]

Concerning the delivery of health care services, contemporary health care reform aims at creating a competitive market environment within which public, private and non-profit hospitals are expected to compete with one another in order to attract more patients.

In this respect, the legislated Public Hospitals Unions Law is expected to aggravate the already started commercialization of public hospitals by imposing them a market logic of governance through the introduction of hospital autonomy.

The founders of the contemporary health care reform emphasize that the reform agenda is not one of privatization. For instance, the objectives of public hospitals unions law are stated as follows: “The management of the public hospitals unions will in no way have profit orientation. It is aimed to form non-profit autonomous public institutions. The responsibility of the hospitals is to provide an extensive second step health service to the society and to attain high quality standards by securing financial sustainability.” [iii]

However this statement is hardly sufficient to eliminate the doubts about marketization and privatization. This is because; this model increases non-medical involvement in the administration of public hospitals and prioritizes income-outcome balances over health care needs of the society.

The current trend demonstrates the involvement of the private sector in the investments made in the domain of health care delivery increased. This may imply that the competition among all hospitals will produce results at the expense of public hospitals.

It can be concluded that this situation will bring about a structure where private organizations will have a more dominant role in the delivery of health care services.

Nevertheless, the mere fact that a hospital is successful in a market environment does not necessarily suggest that this hospital provides better health care services or vice versa.

It may very well be the case that the medical doctors spending more time with their patients, avoiding unnecessary diagnostic tests and examinations, applying surgical procedures only if it is essential, would not only get less salary but also would be accused of limiting the success of their hospitals.

Hospitals considered successful according to the market criteria will benefit more from public sources and be able to get larger amounts of contributory payments from the patients. These hospitals will thus be able to increase quality of their services since they will be able to invest in diagnostic and treatment technologies. Larger the amount of contributory payments they can charge, the richer segment of the society can access to these hospitals.

We would like to remind a rule of social policy studies: The more a specific social service exclusively serves the poor, the poorer the quality of this service will get.

This is because, the service providers of the poor have lesser resources and the low-income people are less capable of making their complaints heard.

Hence, it should be noted that while some of the inequalities arose from the former system are eliminated thanks to the current health care reform, the new system bears the risk of institutionalizing income related inequalities in access to health care.

In addition, we would like to remind the readers of the possible threats that a market- oriented mentality might cause in the domain of health care expenditures. Once the profit orientation in the delivery of health care services is institutionalized, it is highly likely that health care expenditures will increase.

In the aftermath of the implementation of the contemporary health care, both the share of health care expenditures in the GDP and the amount of contributory payments have increased. [v] This increase is mainly due to the transfer of resources from public health insurance fund to private hospitals.

In the new health system, if the public budget will not be able to meet and continue to subsidize the health care expenditures, this may result in the restriction of medical services covered by the public health insurance and/or drastic increases in the rates of contributory payments made by the patients at the spot.

Possible restriction of the benefit package of the public health insurance would result in an increase in the citizens’ participation in private health insurance and possibly in out-of-pocket health care expenses of the citizens. Nevertheless, we would like to remind the readers that the larger the health care expenditures does not necessarily mean better health outcomes. [vi]

In this context, it may be useful to keep the example of American health system in mind. Public health care expenditures constitute a small portion of total health care expenditures in the U.S when it is compared to other advanced capitalist countries. Generally, total health care expenditures per capita in the U.S. is much larger than its counterparts. American health care system is known by its market friendliness. Nevertheless, health outcomes of Americans is the worst among the advanced capitalist countries.

We are quite lucky to have medical doctors who had not yet become entrepreneurial in their approaches to health care in Turkey. They have the advantage of experiencing the problems of the contemporary health care reform process, thus they are the first to alarm us about the possible negative implications of the reform.

The weakest side of this health care reform process has been the total exclusion of the medical doctors in general and Turkish Medical Association (TTB) in particular from the policy making process. Turkish Medical Association is an outlier due to its political stance for the institutionalization of an egalitarian health system rather than merely pursuing medical doctors’ professional interests as its counterparts generally do. This should be seen as an opportunity for Turkey.

An approach to introduce a health care reform in contravention of the medical doctors is doomed to failure especially with respect to protecting patient rights in the long run, and this long run might be a much nearer future than presumed.

It is for the benefit of all that the criticisms of the TTB on the contemporary health care reform in Turkey are taken seriously.

* Ayşe Buğra, Professor, Boğaziçi University, Social Policy Forum.

* Volkan Yılmaz, the School of Politics & International Studies, the University of Leeds.

This translation was read and edited by Volkan Yılmaz before publication in order to terminological coherency.

[iii] Sabahattin Aydın, Kamu Hastane Birliklerine Doğru, Sağlık Haber.
[iv] The private health investments, nearly negligible in 2003, has raised to 38% in all health investments between 2004-2007. Türk Tabipleri Birliği, 2011 Seçimlerine Giderken Türkiye'de Sağlık, s. 19.
[v] OECD Sağlık Verileri 2011.
[vi] OECD Health at a Glance 2009.
[vii] Bkz. OECD Sağlık Verileri 2011.

Health Care Reforms in Turkey – 3: “The Proceedings in the Health Sector and The Emerging Risks” - Ayşe Buğra, Volkan Yılmaz (Part 1)

As part of our responsibility of providing English information on Turkey with a political perspective that is compatible with our stance, we start a series of translations of news items and articles on the transformations in the health care system in Turkey. After the first two news items that introduced the current political situation, we continue our series with a political analysis (“Sağlık'ta Alınan Yol ve Ortaya Çıkan Tehlikeler”), published in Bianet on August 8^th, 2011. The article, signed Ayşe Buğra and Volkan Yılmaz, discusses the long-term and middle-term consequences of the current policies, which have become more and more apparent in time.

An approach to introduce a health care reform in contravention of the medical doctors is doomed to failure especially with respect to protecting patient rights in the long run, and this long run might be a much nearer future than presumed.

It has long been told that the Justice and Development Party (AKP) government's health care policies constituted probably the primary reason of its success in the last election, and that especially the poor were highly contented by these policies.

Yet, we know that the Turkish Medical Association (TTB), the medical doctors' institutional representative in Turkey, objected to these health care reform policies. Thus, on March 14^th [2011], TTB organized one of the most broadly participated and most vibrant demonstrations of the Republic's history in the domain of health care policies.

There is a clear gap between the spirit of the medical doctors’ demonstration against the contemporary health care reform and the optimistic analyses about the positive social effects of the plan. This seems well worth an explanation.

And this explanation should take into account the historical background that fed into today's health care policies, contradictions within the current health care reform and the problems this reform may cause as well as its short-term positive effects in the lives of the citizens.

The former health care system of Turkey had quite important problems. In the former system, there were three public insurance schemes: one for civil servants, one for blue collar workers and one for the self-employed and the farmers. These three public insurance schemes collected different premium rates and provided their members with differential access to health care services.

In the former system, civil servants constituted the most advantaged group. In contrast to the satisfaction of civil servants with the former health system, blue collar workers and farmers could only get access to crowded public hospitals that provided low quality health care services.

In addition to the inequalities within public insurees, the former system excluded the informally employed and the unemployed (who do not have a formal worker or a pensioner family member), namely a large segment of the society most of which is poor.

In short, the former health care system failed to provide access to health care services, which is one of the fundamental social rights, on the basis of equal citizenship.

As the number of people excluded from the health care services drastically increased in the aftermath of the neoliberal restructuring of Turkey’s economy, the coalition government of center-right True Path Party (DYP) and center-left the Social Democratic Populist Party (SHP) decided to address this social problem.

DYP-SHP coalition government introduced the Green Card policy that provided the very poor with the access to inpatient health care services. Parliamentary debates on the legislative process of Green Card policy is quite interesting in that they shed light on the interpretations of citizenship and social rights in Turkey.[i]

Former Minister of Health Mr. Münif İslamoğlu from DYP put forward one of the most interesting arguments during the parliamentary debates.

Mr. İslamoğlu argued that health is a fundamental citizenship right and therefore a policy that requires citizens to prove that they are poor in order to access to health care services is unacceptable.

On the other hand, the proponents in DYP tried to convince İslamoğlu that Green Card policy would be a temporary solution. This policy would be replaced by a general health insurance policy which was to be implemented in the near future.

Despite the logic of the Green Card policy being contrary to the equal citizenship ideal, the Green Card policy can be regarded as an important development for Turkey’s welfare system since it has provided the poor with access to inpatient health care services.

The AKP government extended the benefit package of the Green Card that started to cover outpatient health care services as well as medications.

AKP eliminated the differences in benefit packages among three public insurance schemes and the Green Card scheme. All public insurees have become free to choose which public hospital they want to receive treatment from. Especially this part of the reform increased the quality of health care services so that blue collar workers, farmers and the poor could get access and it highly contributed to the social legitimacy of the AKP’s health care reform.

However, these positive developments are not enough to compensate the inherent problems of the AKP’s health care reform.

One of these inherent problems is the question of the soundness of financing the health system by premium payments rather than general taxation. Insistence upon public insurance based financing of health care is especially problematic due to the high prevalence of informal employment.

In addition to the possible difficulties in collecting the premium payments, the current health care reform keeps income means-testing intact and thereby the bifurcated citizenship status in the domain of health care.

Implementation of income means testing in the Green Card scheme has always included a certain level of discretion. Public officials have a strong suspicion about the applicant’s real and declared income levels. Current health care reform aggravates these problem-ridden aspects of the implementation of Green Card scheme. Increased suspicion of public officials against the Green Card applicants will result in the cancellation of the Green Cards, thus the denial of these citizens’ access to health care services.

Green Card scheme had always been open to the discretion of politicians as well. This became visible when a provincial administrator threatened Kurdish families to cancel their Green Cards if their children would continue to participate in demonstrations against the AKP government. Even though this provincial administrator could not realize his threat, this event once again demonstrated that the implementation of the Green Card scheme hardly corresponds to a rights-based social policy.

Secondly, the neoliberal approach of the contemporary health care reform manifests itself in its market-oriented approach to the production and delivery of health care services.

This is also observable in the introduction of performance-based premium as a significant pay mechanism for medical doctors.

One should carefully consider what kind of incentive such a mechanism would initiate, when it bases the evaluation of the “activeness” of a doctor on the number of patients he/she sees monthly, the number of demanded diagnostic tests/examinations and the number of operations he/she carries out. [ii]

In this regard, we should not forget that the doctor-patient relationship should not be treated like any other market relation between vendors and purchasers. Relationship between doctor and patient should rather be a relation of mutual trust based on the medical ethics that assumes patient's well-being. Once this is neglected, the economic and vital consequences can be quite hard.

[to be continued]

* Ayşe Buğra, Professor, Boğaziçi University, Social Policy Forum.

* Volkan Yılmaz, the School of Politics & International Studies, the University of Leeds.

This translation was read and edited by Volkan Yılmaz before publication in order to terminological coherency.

[i] Ayşe Buğra, Kapitalizm, Yoksulluk ve Türkiye'de Sosyal Politika, İletişim Yayınları, p. 213-218
[ii] For instance a recent research based on hospitals shows that the promotion system significantly increased the number of examinations, operations and visits to the polyclinics.

Çağla Ünlütürk Ulutaş, Türkiye'de Sağlık Emek Sürecinin Dönüşümü, Nota Bene Yayınları, p. 318-337.