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 8th, 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 for 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.

Ege M. Diren

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