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. 

Health Care Reforms in Turkey – 2: “İstanbul Right-to-Health Assembly founded against AKP's attacks on health services”

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. The first item in this series discussed the overlooked effects of the reforms. This second news item (“AKP'nin sağlığa saldırılarına karşı İstanbul Sağlık Hakkı Meclisi kuruldu”), published in the soL news portal on February 28^th, gives a flavor of the steps taken by the opposition movement against these policies.

Medical employees and the people came together gathered to fight against AKP's health reforms. Several organizations gathered today [February 28^th] to declare the foundation of The Right-to Health Assembly of Istanbul. The Grand Right-to-Health Assembly of Turkey will be founded on March 11^th.¹

The medical employees and the people are gathering to fight against AKP's reforms on and the privatization of the health care system. Today [February 28^th], The Right-to-Health Assembly of Istanbul organized a public meeting to declare its foundation.

“Each step of the health care services have been commercialized.”

In the opening speech, Prof. Dr. Taner Gören (Turkish Medical Association – Istanbul branch) stated that the health services are given to the hands of the capital by the AKP government. He pointed out that the first step of health care is completely commercialized by the introduction of Family Health Centers and Family Practice Centers. Highlighting that these practices resulted in a decrease of quality, he added “Only two physicians are employed in these Family Practice Centers, they are considered to be supermen and made to do all kinds of work.”

“We came together to stop the new General Health Insurance policy.”

After Gören's opening, Ersoy Adıgüzel (Confederation of Public Laborers' Unions, Istanbul Branches Platform) read out the declaration of foundation on behalf of the supporter organizations and told that with the participation of trade unions, public laborers' unions, professional chambers, political parties, consumer associations, village societies, the unemployed, the women and the youth will come together to stop the new General Health Insurance Policy.

Everyone is included in the GHI except the MPs.

“In addition to the struggle lead by medical professional chambers and health laborers' unions, we, the representatives of the millions of patients, are determined to claim our rights to health.” said Adıgüzel, and emphasised that by January 1^st, 2012 everyone was imperatively included in the new GHI mechanism but the MPs and the members of the Supreme Court were excluded.

Remarking that the medical examination contribution fees and the medicament contribution margins are constantly increasing, Adıgüzel added that now everybody will have to pay an extra 35 TL contribution for the health services. He emphasized that with this regulation every citizen will be debted to the state, and reminded that the lower limit for it is determined to be an monthly income of 295 TL which cannot be considered as the starvation line, not to mention poverty line.

He finished the declaration by announcing that with the foundation of “The Grand Right-to-Health Assembly of Turkey” in Ankara on March 11^th, the people who defend their health and labor will confront those who want to sell out the rights for health.

Many organizations support the cause.

Some of the organizations who take part in The Right-to-Health Assembly of Istanbul are as follows: Istanbul Medical Chamber, Istanbul Pharmacists Chamber, Istanbul Dental Chamber, The Chamber of Veterinary Surgeons – Istanbul, Confedaration of Progressive Trade Unions of Turkey (DISK), Confedaration of Public Laborers' Unions (KESK) – Istanbul Branches Platform, Confedaration of Turkish Trade Unions (Türk-İş) 1. Region Branch, Union of Chamber of Turkish Engineers and Architects (TMMOB) Istanbul Provincial Coordination Council, Health and Social Service Employees Union (SES), Freedom and Solidarity Party (ÖDP), The Community Centers (Halkevleri), Communist Party of Turkey (TKP), Labour Party (EMEP), Socialist Party of the Oppressed (ESP), and Pir Sultan Abdal Cultural Association.

1  We will translate their declaration as part of our article series.

An Introduction to Why Atheists Should Take Communists Seriously

0. Introduction

With this essay, we intend to extend the discussion initiated in a previous essay titled “An Introduction to Why Communists Should Take Atheists Seriously”. In that piece, we pointed out the convergent characteristics of atheists and communists (historical approach, revolutionary approach, militancy) and emphasized that freedom from religion aimed at by atheists can contribute to communist political programs. Hence, in the conclusion, we stated that

It is part of the duty of the atheists to listen to what communists can offer them in their march against religions. ... Atheists should take it seriously to form comradeships with the organizations that are closest to their views, namely communists.

We now would like to elaborate on this phrase.

For the sake of continuity, we will use the definitions adopted in the previous article: By the words communist and socialist, we will mean a person who employs the materialist conception of history and who aims at the Aufhebung¹ of private property of (at least) the means of production. (These two items we take as definition will lead to the answer presented in the title.) Moreover, we will maintain our distinction between non-believers and atheist; we will characterize a non-believer by her/his choice not to believe in the existence of some sort of a god, whereas by atheist we will mean someone who deliberately rejects either the concept of god, the possibility of god, the probability of god, the existence of god, or at least the institutionalization of god – depending on how much thought she/he has given to the issue.

1. Is it correct to stigmatize communists as atheists/irreligious?

In short, the answer is yes. Historical materialism requires one to use scientific method when analyzing social phenomena.² Communist theories explain phenomena such as nations, patriarchy, industrialization etc. in terms of the historical development of the productive forces. Religion is not exempt from this analysis. For a communist, to create such an exception for religions (or anything else) is a methodological mistake and is clearly anti-Marxist. In Turkey and all around the world, communist organizations mostly managed to avoid making this mistake. They have nothing to do with the god delusion – no matter how much they would like to respect the values of the society. The communists are bound to irreligiousness.

Furthermore, historical materialism explains how religions survived till now. This explanation is not only better than the speculations of liberal atheist thinkers (that are based on non-religious dogmas), both also stronger in the sense that it provides an outline of how religions are to be abolished.

Monitorizing the historical development of productive forces unfolds the rise of religions and how they became reactionary. For instance, the Abrahamic religions have built partiarchy and heterosexism in Europe and Middle East. In a period when a state's power was determined by its population, it was the correct political tactic when Moses prohibited homosexuality altogether, or when the Catholic Church declared every sperm sacred. One can enlarge the list of these examples; and the historical correctness of such tactics is proven by the fact that the Catholic Church, almost two millenia after its foundation, is still the richest mafia and the strongest illegal political organization in the world. (The task of integrating the Arab society to this division of labor, which has become widespread in Europe and Anatolia, was taken by Mohammed.)

Yet, the historical correctness of these moves has become a historical fault with the rise of industrialization. In a world where a single software can be distributed to the use of billions, in a world of nuclear weapons capable of destroying humankind several times, population is far from expressing power. Capitalism did revolutionize the economic structure, and actually, that revolution was against the past objective bases of religions. It is not a coincidence that religions have lost their power with the rise of capitalism.

However, when capitalist production itself became reactionary, that is, when it became an obstacle for the productive forces, capitalism cooperated with all the other reactionary ideologies in hand; which comes very handy for understanding the recent resurrection of religions (and nationalism and racism). (This is also the explanation of the facts that witchcraft – which was considered to be a mere superstition in the Middle Ages – was suddenly recognized by the Church in the Early Modern Era in order to play the people off against itself and to create a social hysteria, by inventing various scapegoats (especially women). )³ And this brings us to the second part of the essay.

2. Who are more atheistic, communists or atheists?

Most atheists aim no further than secularism carried to its end, that is, the complete separation of the state and religions. This is a liberal demand within the scope of capitalism. However, as argued above, this “solution” is superannuated together with the capitalist system. For communists, both the state and religions are political problems as superstructural institutions of the class society.

Moreover, there are more gods now. Manifesting itself in forms of money, free trade, wage-labour, commodification, profit maximization, economic development etc. (which we can summarize as offsprings of private property), a bunch of taboos and non-criticizables surround our lives today. Atheism should be the rejection of not only creator gods but also all kinds of “omnipotents”. In this sense, communists are more atheistic than atheists. If you are an atheist who would be satisfied by a genuine secularism, then communists (rejecting the sovereignty of money) are one god ahead of you.

3. Who, if not communists?

As communists are more atheistic than atheists, they always took side of the secularists and atheists in religious issues. This would suffice to argue that atheists should take communists' words seriously; but there is more to it.

Religion is not a discrete, ahistorical problem. For careful eyes, there is only a formal difference between the ecology movements who fight against nuclear plants or hydro plants planned in the name of “national growth” and who choose the ecosystems over the economy, and the atheists who are indignified by a government who plans to raise a religious generation to “protect moral values” and who don't postpone happiness to other worlds.

In our previous essay, we noted that

a typical atheist is well aware of the difference between the pope and a Christian layman, and how they create each other in the course of history.

Religion is not only a sociological phenomenon but also part of the power relations. One can well think religions to be independent of the power relations, but this is not the way to win the struggle against religions. While it is part of the duty of the communists to mobilize atheists in favor of the emancipation of humanity, it is one of the most important duties of the atheists to take communists seriously in the march to save the world from all gods.

1  Depending on the context, translated as Abolishment or Transcendence

2  This is the starting point of Marx's criticism of Hegel. In Hegel, philosophy is upside down, since Hegel described the world as the manifestation of the Idea. However, scientific method requires to first look at observable reality to make abstractions out of it. Hegel puts everything into historicity, but dogmatizes history itself. Marx repeats his emphasis on scientific method on the discussion of how the value of commodities are determined. He explains exploitation by analyzing surplus-value and labor force, and observes that, due to these notions, exploitation cannot be done away with without the Aufhebung of the private property of the means of production. This is why the socialism described by Marx and Engels is scientific socialism.

3  We are aware that this paragraph needs more argumentation, but to keep the essay within its scope, we will be satisfied by leaving it as it is.

1993-2012 Türkiye: Yangın yeri*

2 Temmuz 1993’te, Sivas’ta, Pir Sultan Abdal Şenlikleri’ne katılmak için şehirde bulunan 35 aydın ve sanatçı yakılarak katledildi.

Madımak Oteli durup dururken çıkan bir yangınla kül olmadı. Madımak Oteli’ndekiler, saatlerce süren “Müslüman Türkiye”, “Sivas allahsızlara mezar olacak” haykırışlarıyla beraber yakıldı. Ölenler farklı inanç, mezhep ve etnik kökenden olsalar da; o gün orada Pir Sultan Abdal Şenlikleri’ne katılarak özgür düşüncenin sesini yükselttikleri için öldürüldüler. Göstericilere “Allahım bu senin ateşin” nidalarıyla benzin bidonu uzatılmasını televizyonlar canlı yayınladı.

Sivas’ta katliam da, hukuksuzluk da, zaman aşımı da göz göre göre ve devlet eliyle geldi. Sekiz saat boyunca süren olaylar sırasında jandarma ve polis oradaydı, müdahalede bulunmadı. Dönemin gazete ve köşe yazarlarının, öncesinde hedef gösterip sonrasında katliamın sorumluluğunu yakılanlara yıktığı manşetleri/başlıkları da, Başbakan Tansu Çiller’in “Halktan kimseye zarar gelmedi” sözü de, Refah Partili Adalet Bakanı’nın katliam sanıklarını hapishanede ziyaret edişi de unutulmadı. Dava başından sonuna uzun bir skandaldan ibaretti. Polis kayıtlarında linç güruhunun 15 bin kişiyi bulduğu tespit edilmişken, onca kamera kaydına rağmen 124 kişi yargılandı, yalnızca 47 kişi ceza aldı. 19 yıl boyunca yakalanamayan davanın baş sanığı Sivas’ta öldü; diğerleri sigortalı memur olarak çalıştı, askerlik yaptı, evlendi, çocuğunu nüfus müdürlüğüne kaydettirdi, sınır dışına çıktı ancak bir türlü “yakalanamadılar”.

Sivas Katliamı’nın yaşanması da, yirmi yıla yakın zamandır örtbas edilip davanın zamanaşımına uğratılması da bir kaza ya da tesadüf değildir. Sivas’ı ortaya çıkartan zihniyet, bugün sadece temsilen değil, bizzat iktidardadır. Öyle ki, dava sırasında sanıkların avukatlığını yapanlar bugün iktidar partisi milletvekilleri olmuş, Sivas Katliamı davasında zamanaşımını engelleyecek düzenleme ise Meclis’te iktidar partisinin oyları sayesinde reddedilmiştir. Sivas Katliamı, radikal bir grubun bir anlık öfke histerisinin değil; her türlü muhalif ve özgür düşüncenin karşısına sistematik biçimde Türk-İslam sentezci söylemiyle dikilen ayrımcı ve dışlayıcı devlet politikalarının sonucudur. Yanık bedeni Sivas 93’ün simgelerinden olmuş Metin Altıok’tan lanetli bir kehanet gibi bize kalan “tekinsizim size göre / ibret için yakılması gereken” dizeleri, bu düşmanlıkla yüzleşmek zorunda kalmış hemen herkesin haykırışıdır.

Sivas Katliamı, doğrudan özgür düşünceyi hedef alan bir saldırıdır. Hiç gizlemediği inançsızlığı yaşananların sonrasında dahi katliama gerekçeymiş gibi gösterilen Aziz Nesin’in ve orada hayatını kaybeden tüm aydınların fikri miraslarını Sivas cehenneminden ayrı anamayacağımız gibi, Sivas Katliamını da bu aydınlardan ayrı anamayız.

Nice Sivas'ların yaşandığı bir ülkede Başbakan halen “Ateist nesiller mi yetiştirelim?” sözleriyle ateistleri, siyaseten işine geldiği her fırsatta da sünni müslümanlık dışındaki inançları hedef gösterebiliyorsa; Sivas Katliamı davasının zamanaşımına uğratılması, yeni Sivas'lara davetiyedir. Bu hedef gösterme karşısında yapılacak en anlamlı şey, dincilerin yaktığını dindar nesillerin unutturmasını engellemektir.

Sivas Katliamı Davasının zamanaşımına uğratılması, devlet eliyle gelen katliamın yine devlet eliyle ört bas edilmesi demektir. Sivas Katliamı sorumlularının cezalandırılmaması; siyasi görüşleri, inançları ya da inançsızlıklarını sebep göstererek insanları yakan bir zihniyetin devlet tarafından korunması ve böylelikle cesaretlendirilmesi demektir. Ateist/ agnostik/özgür düşünceliler olarak bizler; yeni Sivas’ların bir daha yaşanmaması için, özgürce söz söyleme güvencemizin olması gerektiğini savunuyoruz. Bu güvencenin sağlanması adına; açık bir nefret suçu olan Sivas Katliamı’nın “insanlığa karşı işlenen suçlar” kapsamında tutularak, sorumlularının cezalandırılmasını istiyoruz.

*Bu metin; 2 Temmuz 1993’te Sivas’ta yakarak, bugünse davayı zamanaşımına uğratarak bizi susturmaya çalışanlara karşı; “Özgür düşünce engellenemez” demek ve Sivas Katliamı Davası’nın takipçisi olan herkesle dayanışmak için aşağıda ismi geçen blog, web sitesi ve sayfaları tarafından kaleme alınmıştır.

Ateist Filmler

Ateist/Agnostik Video Sayfası
Bir Kara Kedi İçin Blues

Dinlerden Özgürlük

Düşünsel Evrim

Felis Agnosticus

Garajımdaki Ejder

Greener Nautilus

Hümanist Homosapiens

Mustafa Türksavaş

Out for Beyond

Turan Dursun sitesi

Veda Kubbesi

Health Care Reforms in Turkey – 1: “Before AKP, After AKP: The Health Services”

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. In this first news item (“Sağlıkta AKP'den öncesi ve sonrası”), published in the soL news portal on February 29^th, the ignored and/or overlooked sides of the effects of the health care reforms are summarized.

The AKP¹ government has been claiming at having made a revolution in the health services. Yet, if we look closely to that “revolution”, we note prescription fees, patient shares, bed fees, equivalent medicine costs and the paid health centers, none of which existed prior to AKP. We present: before and after AKP in health services...

The recently published brochure “Before AKP, After AKP: The Health Services” by the Grand Right-to-Health Assembly of Turkey demonstrates how health services became payment-based during AKP's rule. The brochure provides many striking examples of this transformation.

Outpatient clinic patient shares arrived with AKP

When the AKP government introduced the patient share mechanisms, it was declared that for patients with social insurance the share would be just 2 TL². But in time it reached 40 TL.

Before AKP, the patients with social insurance, state employees and pensionists were utilizing public hospitals and university hospitals for free, and also they were paying no fees to utilize the private, agreement hospitals. But the AKP rule set off a new tariff system in which the prices for family physicians (that replaced health centers) became at least 4 TL, for public and university hospitals at least 12 TL, and for private universities 18 TL plus the additional costs. Similarly, for the same services, the middle-income families used to pay 3.10 TL and the pensionists thereof 1.55 TL.

Patient shares are increasing

Before the General Health Insurance Policy was launched, it was announced that patients with social insurance would pay the same amount of money and that there will be no extra fees. However, 11 new items of payments appeared already. Some of them are as follows:

• Prescription fee is introduced: 3 TL up to 3 medicines, and 1 TL for each additional.
• Family physicians used to provide free services, now it's at least 4 TL.
• The emergency services were free; now it is at least 12 TL for public hospitals, and 18 TL plus extra costs in private hospitals.
• There is an extra fee of 5 TL in case a patient wants a second examination in 10 days. For the moment, there is no limit for the equivalent medicine costs.
• There was no extra fee for inpatient treatment, but now a single room costs 90 TL/day and a double room 45 TL/day.

You can avoid sanguineous operations if and only if you are rich enough.

Another item the AKP government introduced is the “exceptional health services”. If a patient wants to take a service classified as such, s/he has to pay in advance three times the cost of that operation, in cash.

For instance, a patient who wants an operation for the displacement of gallstones has to pay 2160 TL in cash to the hospital. Otherwise s/he should be assent to have a surgery that involves the cutting of the abdominal region from top to bottom.

A new loot: Public-Private partnerships

One of the last steps for the commercialization of the health sector will be the public-private partnership. Within this framework, city hospitals will be built, the state will provide the land and pay the rent, but the private company who makes the construction will benefit.

The private company will get a rent from the state for 25 years, and will also have the privilege to run the parking lot, the cafeterias and the ambulance services.

1  AKP (Adalet ve Kalkınma Partisi): The Justice and Development Party. The governing political party since 2002.

2  TL stands for the Turkish currency, Turkish Lira. When this news item was translated, the approximate exchange rates were $1=1.8 TL and €1=2.3 TL.