Turkish Health System: From Socialisation to Privatisation
A few weeks ago, BMJ published an article about Turkish health system
written by officers of Turkish Ministry of Health (MoH). Their writing
style and the title of article was extremely haughty (Healthcare in
Turkey: from laggard to leader)1. History has witnessed many governments
who suggest history starts with their own election. However history of the
Turkish health system is longer than the last eight years.
Although health services are under responsibility of the state since
1923 (the foundation of Turkish Republic), the service is not equally
distributed throughout the country and there are differences between
urban/rural areas and Eastern/Western populations. Physicians, having the
right to work both in state and private sector, caused inequalities in
health services until 1960. Therefore health services have been
reorganised with a socialization law in 1961 and starting with, the most
disadvanteged groups in the Eastern region, it aimed to provide free and
equal services to all as Goodman's article in 1964 Lancet stated(2). The
most important institutions in the re-organisation process were health
centres planned for the primary health care services. Health centres
became widespread throughout the country between 1961-1983 and reached to
nearly 5000. In 1960s, physicians had permission to work for the state or
private sector and as a result of decrease in wages of physicians working
for the state, with a legal regulation, simultaeous work in the private
sector was allowed again after 1980s and this caused a deterioration in
public health services and high level of investment into private sector.
Justice and Development Party (government party), in power since
2003, initiated health reforms under the title of Health Transformation
Program (HTP). Government is planning to increase privatization in health
services in the next 10 years as we have seen but not approved in the USA
model. The main components of this program are privatisation of health
services (to encourage the private sector to play a larger role in the
health care system, and increasing access to health care by making use of
private facilities), introducing private family physicians at first level,
compulsory health insurance with the possibility of supplementary
voluntary health insurance operated by private insurers, and giving public
hospitals more financial autonomy without governmental support.
Additionally, insurance premiums will be increased for Social Security
Institution (SSI) and some new arrangements will have to be made such as
the basic benefits package and cost sharing. This will likely result in
very high, out of pocket, health expenditures.
In 2006, the family doctor (FD) project was implemented in 10 large
cities with 10 more cities in 2007 and spread throughout the country by
the end of 2010. In this program, FDs are defined as private doctors who
contract with the MoH. They will be renting their practices (offices) from
the MoH in health centres. The team (nurse, midwife, sanitary technician,
labarotory technician, health officer, secretary etc) will not be
available at the primary level and FDs will practice with the help of one
nurse or a midwife. Job insecurity and work overload will be other
possible consequences for all health employes. But the worst, preventive
services such as vaccination and family planning will be seriously damaged
under this plan. Prime Minister Erdogan stated several times that their
goal is "to have at least 3 children for every family", not less(3). FD
services are also not sufficient for vaccination of children especially in
the schools and for giving DOT for tuberculosis patients. We are expecting
new tuberculosis, diphtheria and measles outbreaks in the next 5 years in
Turkey.
Patients are seemingly pleased with the FD system because the
referral chain is no longer in place. Therefore people can apply to every
physician (from general practitioner to specialist in a university) but a
professional relationship can not be maintained between the levels. On the
other hand the crowding in 2nd and 3rd levels causes serious problems, as
long waiting times and difficulties in getting appointments are main
issues for patients, today.
Finally, health expenditures are increasing every year because of new
investments while more is needed for establishing the family physician
offices which in turn will increase the cost of curative health services
further. Total health expenditure went up four times from $10 billion in
2001 to approximately $40 billion in the year 2009(4). On the other hand,
according to the MoH data one third of health expenditures is used for
acquiring medicine and it is estimated that this portion will exceed half
of all health expenditures in 2007.
Another crucial innovation in 2011 concerns the financing of public
hospitals (State and University Hospitals). SSI declared that all payments
for hospital expenditures will be determined by Global Budgeting System
until 2012. This means that hospital budgets would have been determined by
SSI a year in advance, and no hospital can run over budget whatever the
demand they face. Government passed a new legislation "performance based
payment" (PBP) system for MoH hospitals in 2006. Since February 2011 this
legislation applies to all hospitals including academics. Academics are
protesting this new regulation for applying a compulsatory system in the
universities. PBP system is based on number of patient examinations,
diagnostic tests and operations while it is not appropriate for
educational and research activities in medical schools.
Turkish Medical Association (TMA), trades unions, other political
parties and public health academics have been protesting against these
regulations imposed by the government. Three weeks ago, approximately
30,000 health workers protested these regulations in Ankara in front of
the MoH building. The biggest strike to date in Turkey is now in the
planning stage to start in June by TMA and unions with the participation
of all health workers.
In short, if I wrote an article about Turkish health system, it would
be entitled "Healthcare in Turkey: from socialization to privatisation".
This would be more appropriate.
1Baris E et all. "Healthcare in Turkey:from laggard to leader" BMJ,
March 12, 2011(342):579-582.
2Goodman NM "Turkey's experiment in the socialisation of the medicine" The
Lancet, January 4, 1964:36-38.
Rapid Response:
Turkish Health System: From Socialisation to Privatisation
A few weeks ago, BMJ published an article about Turkish health system
written by officers of Turkish Ministry of Health (MoH). Their writing
style and the title of article was extremely haughty (Healthcare in
Turkey: from laggard to leader)1. History has witnessed many governments
who suggest history starts with their own election. However history of the
Turkish health system is longer than the last eight years.
Although health services are under responsibility of the state since
1923 (the foundation of Turkish Republic), the service is not equally
distributed throughout the country and there are differences between
urban/rural areas and Eastern/Western populations. Physicians, having the
right to work both in state and private sector, caused inequalities in
health services until 1960. Therefore health services have been
reorganised with a socialization law in 1961 and starting with, the most
disadvanteged groups in the Eastern region, it aimed to provide free and
equal services to all as Goodman's article in 1964 Lancet stated(2). The
most important institutions in the re-organisation process were health
centres planned for the primary health care services. Health centres
became widespread throughout the country between 1961-1983 and reached to
nearly 5000. In 1960s, physicians had permission to work for the state or
private sector and as a result of decrease in wages of physicians working
for the state, with a legal regulation, simultaeous work in the private
sector was allowed again after 1980s and this caused a deterioration in
public health services and high level of investment into private sector.
Justice and Development Party (government party), in power since
2003, initiated health reforms under the title of Health Transformation
Program (HTP). Government is planning to increase privatization in health
services in the next 10 years as we have seen but not approved in the USA
model. The main components of this program are privatisation of health
services (to encourage the private sector to play a larger role in the
health care system, and increasing access to health care by making use of
private facilities), introducing private family physicians at first level,
compulsory health insurance with the possibility of supplementary
voluntary health insurance operated by private insurers, and giving public
hospitals more financial autonomy without governmental support.
Additionally, insurance premiums will be increased for Social Security
Institution (SSI) and some new arrangements will have to be made such as
the basic benefits package and cost sharing. This will likely result in
very high, out of pocket, health expenditures.
In 2006, the family doctor (FD) project was implemented in 10 large
cities with 10 more cities in 2007 and spread throughout the country by
the end of 2010. In this program, FDs are defined as private doctors who
contract with the MoH. They will be renting their practices (offices) from
the MoH in health centres. The team (nurse, midwife, sanitary technician,
labarotory technician, health officer, secretary etc) will not be
available at the primary level and FDs will practice with the help of one
nurse or a midwife. Job insecurity and work overload will be other
possible consequences for all health employes. But the worst, preventive
services such as vaccination and family planning will be seriously damaged
under this plan. Prime Minister Erdogan stated several times that their
goal is "to have at least 3 children for every family", not less(3). FD
services are also not sufficient for vaccination of children especially in
the schools and for giving DOT for tuberculosis patients. We are expecting
new tuberculosis, diphtheria and measles outbreaks in the next 5 years in
Turkey.
Patients are seemingly pleased with the FD system because the
referral chain is no longer in place. Therefore people can apply to every
physician (from general practitioner to specialist in a university) but a
professional relationship can not be maintained between the levels. On the
other hand the crowding in 2nd and 3rd levels causes serious problems, as
long waiting times and difficulties in getting appointments are main
issues for patients, today.
Finally, health expenditures are increasing every year because of new
investments while more is needed for establishing the family physician
offices which in turn will increase the cost of curative health services
further. Total health expenditure went up four times from $10 billion in
2001 to approximately $40 billion in the year 2009(4). On the other hand,
according to the MoH data one third of health expenditures is used for
acquiring medicine and it is estimated that this portion will exceed half
of all health expenditures in 2007.
Another crucial innovation in 2011 concerns the financing of public
hospitals (State and University Hospitals). SSI declared that all payments
for hospital expenditures will be determined by Global Budgeting System
until 2012. This means that hospital budgets would have been determined by
SSI a year in advance, and no hospital can run over budget whatever the
demand they face. Government passed a new legislation "performance based
payment" (PBP) system for MoH hospitals in 2006. Since February 2011 this
legislation applies to all hospitals including academics. Academics are
protesting this new regulation for applying a compulsatory system in the
universities. PBP system is based on number of patient examinations,
diagnostic tests and operations while it is not appropriate for
educational and research activities in medical schools.
Turkish Medical Association (TMA), trades unions, other political
parties and public health academics have been protesting against these
regulations imposed by the government. Three weeks ago, approximately
30,000 health workers protested these regulations in Ankara in front of
the MoH building. The biggest strike to date in Turkey is now in the
planning stage to start in June by TMA and unions with the participation
of all health workers.
In short, if I wrote an article about Turkish health system, it would
be entitled "Healthcare in Turkey: from socialization to privatisation".
This would be more appropriate.
1Baris E et all. "Healthcare in Turkey:from laggard to leader" BMJ,
March 12, 2011(342):579-582.
2Goodman NM "Turkey's experiment in the socialisation of the medicine" The
Lancet, January 4, 1964:36-38.
3http://islamizationwatch.blogspot.com/2008/04/pm-erdogans-call-for-
minimum-three.html
4Akdag R. Health Transformation Programme in Turkey. MoH publications
No:807, 2010, Ankara.
Competing interests: No competing interests