“Transforming” our health by privatisationBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1959 (Published 29 March 2011) Cite this as: BMJ 2011;342:d1959
All rapid responses
We read "better value for money", "performance-based payments",
"increased patient satisfaction", "improved quality and efficiency",
"increased incentives to work full time", "reduced administrative burden",
"computerized hospital management information systems", "improved
amenities", "improved responsiveness and motivation", "reduced informal
payments" in the letter of Enis Baris and Salih Mollahaliloglou for the
Indeed, it seems that they have done an excellent job in improving
healthcare in Turkey.
In neighboring Greece, we encounter the same problems in Public
Healthcare but have not managed to resolve them yet.
Various Health Ministers, over decades, have been trying to improve
conditions but failed.
For example, Public Hospitals in Greece do not have, up to this day
computerized patient archives, surgical procedure archives, performed
chemotherapy archives, cause of death archives, morbidity archives, etc
Let alone patient satisfaction...
Perhaps we could copy what Turkey has successfully done, even if it
involves extensive privatizations.
Competing interests: No competing interests
"Dogmatism and skepticism are both, in a sense, absolute
philosophies; one is certain of knowing, the other of not knowing. What
philosophy should dissipate is certainty, whether of knowledge or
In his letter1, Dr Civaner erroneously asserts that "Transformation
in Health" is a World Bank project. It is not. The Health Transformation
Program (HTP) is a White Paper issued in December 2003 by the Ministry of
Health outlining the health system reform agenda adopted by the government
based on a vision and strategy set in the "Urgent Action Plan" that was
released earlier in January 2003 at the beginning of the incoming
government's first term in office. As any white paper, its content
reflects the contribution of many, including those who did attempt to
reform the health system in the past, but its ownership lies solely with
the MOH. The World Bank did provide financial and technical assistance to
the MOH for the implementation of the reform agenda in the form of a
project aptly called "Health Transition Project in Support of the First
Phase of the Program for Transformation in Health" approved by the World
Bank in April 2004.2 In our paper we did refer to various World Bank and
MOH publications and indicated in the contributors and sources section
each author's role in the process.
We believe that it is inevitable that all mature health systems would
strive to base provider payment on performance as service delivery gets
better measured, and health systems become more transparent and
accountable to provide better value for money. The challenge of course is
to distinguish pure productivity from real performance; and to take into
consideration all aspects of the work of a team of health professionals;
not just patient care, but also their academic, managerial and other
oversight responsibilities as well as the differing nature of services,
i.e. surgical interventions vs. patient counseling. Pay for performance
in Turkey is not meant to be akin to fee-for-service. It is a payment
system that meant to incentivize both performance and cost containment in
hospitals by relying on formula-based sharing of the margin between
payment and expenditures on the basis of service and severity mix, and of
the skills mix of all personnel. Total quality management and assessment
of patient safety and satisfaction are being gradually eased in to
safeguard quality of care and affect supplementary payment. Progress is
being made to incentivize and pay providers on the basis of real
performance over the totality of the episode of care, rather than merely
on the volume of services produced, as the payment scheme is being
continuously fine-tuned to value appropriate care and team work. The
devil being in the details, performance-based payment could at best be
considered work in progress. Yet, several pieces of recent academic
research based on staff and patient surveys show that performance-based
supplementary payment has contributed to reducing the gap between expected
and real income of health professionals,3 sense of ownership,4 increased
patient satisfaction,5 improved quality and efficiency,6 increased
incentives to work full time in public facilities,7 reduced
administrative burden as a result of computerized hospital management
information systems,8 and improved amenities, responsiveness and
Another misleading assertion is the claim that our paper echoed World
Bank's 1993 publication "Investment in Health" and advocated for a number
of "treatments" attributed to it. Again a careful review, or better, a
discourse analysis would reveal that the essence of our paper is about the
efforts made to achieve universal health coverage and the response of the
health system in meeting the increased demand for a publicly-funded full
and very comprehensive package, not for a "minimum package", as Dr Civaner
seems to imply. As for the "unfinished agenda" by which Dr Civaner seems
to imply devolution of the management and privatisation of health
facilities, these are exactly the kind of challenges we claim that most
OECD countries face, including Turkey, for increased accountability and
governance for better health system performance.
In his letter, Dr Terzi10 claims that our paper was particularly timed in
view of the upcoming elections in Turkey and that it "flattered" the
government. Dr Terzi should know that the timing of a publication in a
peer-reviewed journal depends very much on the length of the review
process which cannot be accurately predicted beforehand. This paper and
another were first submitted to BMJ in early February 2010, and a revised
version merging the two on 22 April 2010 which was accepted for
publication on 10 November 2010. Our paper is about compiling data and
facts on the recent improvements in the Turkish health system, and as such
was peer reviewed and accepted for publication on that basis.
Dr Terzi goes on to claim that "a coalition of unions,... professional
associations and universities is resisting HTP in Turkey" without
detailing as to which aspects of the HTP do they resist - would that be,
for instance, providing universal coverage to the totality of Turkish
population which have now significantly increased their access to and use
of health services - or the fact that the average formal income of
physicians has increased significantly? How would this assertion explain
that only 9% of MOH doctors now work part time, compared to 89% of them
doing so in 2000? As for the claim that most of the increase in health
spending was a result of higher spending on drugs, the data shows
otherwise; pharmaceutical spending as a share of total health spending
declined from 30% in 2004 to 25% in 2008.11 It did increase in per capita
terms, quite expectedly so as a result of universal access to health
services and thus three-fold increase in per capita service use, from
US$87 in 2004 to US$157 in 2008, but it has since then come down to US$144
in 2009,12 one of the lowest amongst OECD countries.
Finally, the claim
that "Turkish people have to pay health insurance premiums and co-
payments." well the authors should know that all health systems are
financed through taxation and/or premiums, but there is no formal co-
payment for primary care in Turkey, except for 10% for the retired and
20% for others for prescription drugs.
We understand that our paper has been controversial in some academic
circles and drew criticism from the Ankara branch of the Turkish Medical
Association. This was not unexpected. Such a transformation could not be
achieved to the full satisfaction of all stakeholders. While we also
understand that some in the academia would resist to the idea of linking
payment to performance, thinking that such a change would diminish their
professional freedom and devalue their academic work, what matters first
and foremost is whether the health system improves access to high quality
health care, increases responsiveness to patients' non-medical needs and
expectations, and provides financial protection against impoverishing
health expenses. A new patient satisfaction survey13 covering 19206
discharges in 1253 hospitals shows that only 0.86% of patients were
dissatisfied with the services they have received and only 0.03% were
asked to make informal payments, in contrast to the findings of a 2002
survey which had found that 38% of out-of-pocket payments to public sector
providers were informal,14 or those of a social assessment study again
carried out in 2002 which stated ".. important issue is that users and a
large number of providers perceive the [health] system as corrupt and
unjust because of the informal payments. These are quite important and
wide spread. For some users they constitute a major factor in delaying
access to care and treatment [Authors' translation].15 The evidence we
provided here and in our paper by which we stand unequivocally show that
the Turkish health system has come a long way in reaching these
objectives. As the late Jawaharlal Nehru had said "facts are facts; they
do not change on the account of your likes".
1. Civaner M. "Transforming" our health by privatization. Letter. BMJ
2. World Bank. Project Appraisal Document "Health Transition Project in
Support of the First Phase of the Program for Transformation in Health".
Report No.: 27717-TU. April 2004.
3. Ergin G. Calisanlarin ucretlendirilmesi: Saglik kurumlarinda
calisanlarin ucret sistemini degerlendirmelerine iliskin bir arastirma.
Hacettepe Universitesi Saglik Bilimleri Enstitusu Saglik Kurumlari
Yonetimi Programi Doktora Tezi [A study on the perception of healthcare
workers on modes of payment, Ph.D thesis], p236, Ankara, 2009.
4. Simsir I. Kamu Hastanelerinde, kurumsal performans uygulamalari
baglaminda yonetici ve diger personel tutumlarinin incelenmesi, Sakarya
Universitesi Sosyal Bilimler Enstitusu, Yuksek Lisans Tezi, [Analysis of
the attitude of health personnel and managers on the application of
institutional performance based management in public hospitals, Master
thesis], p168, Sakarya, 2009.
5. Gazi A. Saglik bakanligi hastanelerinde performansa dayali ek ucret
odeme sisteminin hastalar ve saglik personeline olan etkisinin analizi,
Gazi Universitesi Sosyal Bilimler Enstitusu Isletme Anabilim Dali Hastane
Isletmeciligi Bilim Dali, Yuksek Lisans Tezi [Analysis of the impact of
performance based supplementary payment in MOH hospitals on patients and
health personnel, Master thesis], pp.140-141, Ankara-2006.
6. Taskaya S. Birinci Basamak Saglik Kuruluslarinda Calisan Personelin
Performansa Dayali Doner Sermaye Ek Odeme Uygulamasina Iliskin
Degerlendirmeleri, Hacettepe Universitesi Saglik Bilimleri Enstitusu
Saglik Kurumlari Yonetimi Programi, Yuksek Lisans Tezi, [Assessment of the
perceptions of primary care health personnel on performance based
supplementary payments from revolving funds, Master thesis] p.171, Ankara,
7. Gorgun H. Orgutlerdeki degisimin hizmet yapisi uzerindeki etkisinin
incelenmesi saglikta donusum programinin Canakkale yerelindeki etkileri.
Canakkale Onsekiz Mart Universitesi Sosyal Bilimler Enstitusu Isletme
Anabilim dali, Yuksek Lisans Tezi, [effects of organizational changes on
health services; the impact of the Health Transformation Program in
Canakkale] p186, Canakkale 2009.
8. Memis G. Performansa dayali ucret sisteminin saglik hizmetlerine etkisi
ve Nigde devlet hastanesinde gorevli saglik personeli uzerine bir
arastirma, Nigde Universitesi Sosyal Bilimler Enstitusu Isletme Anabilim
Dali, Yuksek lisans tezi [Impact of performance-based payment on health
services; a survey on the health workers of the Nigde state hospital,
Master thesis] p90, Nigde, 2010.
9. Bostan S. Saglikta donusum programinin hastane isletmeleri uzerindeki
degisim etkisi (yonetici perspektifi). Karadeniz Teknik Universitesi
Sosyal Bilimler Enstitusu Isletme Anabilim Dali, Isletme Programi, Doktora
Tezi [Impact of Health Transformation Program on Hospital Management; a
manager's perspective. Ph.D thesis] p196, Trabzon 2009.
10. Terzi C. Article was a gift to minister of health just before general
election. BMJ 2011; 342:d1957.
11. Association of Research-Based Pharmaceutical Companies.
http://www.aifd.org.tr/DataCenter/Table.aspx?p=710 [accessed May 10, 2011]
12. Association of Research-Based Pharmaceutical Companies.
http://www.aifd.org.tr/DataCenter/Table.aspx?p=264 [accessed May 10,
13. Ministry of Health. Survey of outpatient and inpatient service users
in secondary and tertiary care facilities in Turkey (unpublished data),
14. Tatar M, Ozgen H, Sahin B, Belli P, Berman P. Informal Payments in the
Health Sector : A Case Study from Turkey. Health Affairs 2007;26(4):1029-
15. Ministry of Health. Health Reform Project Social Assessment Study.
Consultant Report, October 2003.
N.B. The findings, interpretations, and conclusions expressed herein
by the authors do not necessarily reflect the views of the Executive
Directors of the World Bank or the governments they represent. The World
Bank does not guarantee the accuracy of the data included in this work.
Competing interests: No competing interests