Health reform quackery
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1711 (Published 17 March 2011) Cite this as: BMJ 2011;342:d1711
All rapid responses
Dear Editor,
Thanks for contributing to revealing the truth behind the Turkish Health
Transformation Program and its opponents secret agenda. Allegedly, 30
thousand health professionals were on the streets in this meeting.
Security forces had made controls for illegal materials before the meeting
but not ID controls. I mean that, noone knows the number -and percentage-
of 'real' health professionals in this meeting. Therefore, it is not wise
and fare to say that "perhaps doctors are always against reform", at least
in Turkish case, since it was a just simple 'socialist attraction'
organized and conducted by leftist NGOs, and participated by 'co-ideologists', some of whom have nothing to do with 'health'.
I have to say that I categorically disagree with the previous two
Turkish respondents. It seems that, sometimes 3000 km distance is not a
disadventage to be able to see the 'real picture' and living in it does
not make you to realize it.
One of the respondents was disturbed by the timing of the article
written by the authors from Turkish Health Ministry and published in BMJ,
and wrote "I hope, it must be a coincidence to publish such an article
just before general election in the world's most influential and widely
read medical journal." Similarly, thousands of doctors and millions of
Turkish citizen were also disturbed with the 'timing' of this
meeting/demonstration. They believe -in fact know- that, like many other
meetings and demonstrations in the Country in those days, "13 March
Protest Meeting" of 'a group of -so called- health professional' was
organized to influence the general elections. However, I am afraid these
organizations will not serve their aim but strengthen the position of the
Ruling Party.
All in all, as a medical doctor, Bioethics Professor and the
President of a Medical Chamber, I am concerned about the picture given by
health professionals' NGOs to the public, as much as I am concerned about
the future and outcomes of the Health Transformation Program in Turkey.
Competing interests: No competing interests
Dear Editor,
You've recently published an article about analysis on health care in
Turkey (1) and then you wrote an editorial about health reforms in all
around the world (2).
Although Turkish health reform is a very controversial issue, Baris et
al., flattered the government party and the minister of health even
putting one of his photograph in the article.
I want to draw attention that there will be a general election in three
months time in Turkey and Health Transformation Programme (HTP) of the
government is one of the main topic of political debate.
I was disturbed by the timing of this article. I hope, it must be a
coincidence to publish such an article just before general election in the
world's most influential and widely read medical journal.
I believe medical journals can actively contribute and influence to a
political debate. But editors must balance the voices of different groups.
Two authors are working in Health of Ministry as high level bureaucrats.
The timing of this article reminded me story of the most dramatic firing
of a journal editor of recent years. American Medical Association (AMA)
fired George Lunberg, the editor of JAMA, in 1999. He was fired not to
publishing but for speeding up the publication of a paper that suggested
many American students did not think of oral sex as sex. The publishing
timing of the article was so important because of the impeachment of
President Clinton which featured a discussion of whether or not he had had
sex with Monica Lewinsky and lied about it. AMA which owns JAMA felt that
the editor has sensationalized the issue and tried to influence the
decision of the Senate. Although, Lunberg was a successful editor and an
important opinion leader describing and deploring the industrialization of
medicine, encouraging health reform, this egocentric behavior was an
editorial misconduct.
I like to point out that a coalition comprised of unions, professional
associations, universities Turkish Medical Association (TMA) (majority
doctors belong) is resisting to HTP in Turkey. It is defined exporting
'managed care' from to Turkey as a market reform. The most of Turkish
doctors think "Medicine is a public service, not a supermarket" just like
you quoted in your article (2). A week ago, a mass demonstration was
organized by this coalition in order to protest our authoritarian
government who is privatizing public health service.
Health reforms are not happening only in Turkey. During the late 1980s and
early 1990s, Europe looked like a good bet for managed care organizations.
Reforms in several European national health programs also introduced
principles of managed care, market competition, and privatizing of public
services. These reforms received the strong support of the Thatcher
government in Britain, as well as varying degrees of enthusiasm from
conservative parties in other countries. However the popularity and
successes of public sector programs in Europe proved to powerful
disincentives to privatization. Since United Kingdom has reversed many
policies that attempted to privatize their national health programs.
The exportation of managed care is receiving enthusiastic support from
World Bank, other multilateral lending agencies such as IMF, and
multinational corporations. Turkey is experiencing strong pressure to
accept managed care as the organizational framework for privatization of
its health system. As public systems are dismantled and privatized under
the auspices of managed care, multinational corporations will enter the
field, reap vast profits and exit within several years. It happened in
Latin America in 1990s, especially in Chilie.
I agree with Baris et al., that health expenditure was dramatically raised
in Turkey between 2002-2009 but it was mainly for pharmaceuticals rather
than primary care. In the same period, Turkey has become the leading
country in OECD, in terms of drug expenditure. Turkey has become the sixth
country in drug market in Europe, after Germany, France, England, Italy,
and Spain. The share of private hospitals was increased from 8% in 2002 to
nearly 40% in 2009 and their share of the reimbursement of public money
was reached to 1/3 of total. Under the HTP, Turkish people have to pay
health insurance premiums as well as co-payment for nearly all health care
services even in primary care.
Although, Baris et al., made controversial ideological claims saying that
the government put the state at the service of its citizens (1), I believe
HTP is not the only option, nor the best from the perspective of a
population health.
1. Baris E, Mollahaliloglu S, Aydin S. Healthcare in Turkey: from
laggard to leader. BMJ. 2011 Jan 21;342:c7456. doi: 10.1136/bmj.c7456.
2. Godlee F. Health reform quackery. BMJ 2011; 342:d1711
Competing interests: No competing interests
A week ago, more than 30,000 healthcare workers were on the streets
of Ankara, protesting the privatisation policies of Ministry of Health.
Organized by Turkish Medical Association, the demonstration was the
biggest in Rebuplic's history. It may be true that doctors are the members
of a conservative profession in general as historical instances show, it
would be a hasty judgement to categorize these protests as a reaction for
conserving their societal position and advantages. As the re-forming
policies are being implemented gradually and changed their regular working
environment by commercialisation, doctors and healthcare workers slowly
but certainly understand that cost-effectiveness driven business approach
to healthcare conflicts with right to healthcare as much as their job
security, income levels, and pension funds. Although personal concerns
were one of the motivator for up in arms, defending right to healthcare
was the other leading theme, as they now know better that those two are
unseparable; you cannot have one without the other.
Transforming doctors into commissioners (or to petit-entrepreneurs as
in Turkey), patients into customers and healthcare services into commodity
are just a few reflections of privatisation policies which inevitably
conflict and erode professional values. These are not reforms to fix the
flawed parts of the system, but the steps of a huge transformation
procedure. What we need to do in order to resist metamorphosis of
caregivers is to object privatisation policies as a whole. Defending right
to healthcare and professional values together provides us solid grounds
both for developing justifiable objections and convincing our patients and
society in general that our interests are common.
Competing interests: No competing interests
Quackery is one of Corruption's Voices
Corruption has several faces; it is a big chimera with several
incongruous and monstrous forms. It changes good to bad in morals,
manners, or actions and degenerates all social spheres, and health
sector is no exception. Here we can meet an indefinite number of
corruption's forms, from lying, robbery to making criminal procedures and
killing patients. In its bribe activity, corruption very well orchestrates
its styles, methods and manners of performing its macabre work. It is an
elegant process. Pretending to cure disease, professionals and ordinary
people sell or prescribe well presented but not tried or probed
experimentally unsafe drugs; they make or promote bad procedures or
practices for their patients, out of the ethical standards for medical
profession, which at last, often produces terrible effects. Colombia is a
huge nutritive soup where corruption does its dirty work in order to
exploit the people's ignorance in health as very lucrative work
for the promoters.
The question is terrific, with very low daily wages people must be
permanently affected by any disease. You must be sick in countries where
it's essential to work hard in order to earn some money to eat. Disease
makes life very difficult for people and they do anything possible in order
to ameliorate their state. So they are an easy target for unscrupulous
people with excessive avarice, incompetence, indifference, who use these
patients in order to sell dangerous, destructive not approved substances,
products or services. In the land of lies, quackery has its basic function,
to instruct patients using people, radio, TV, internet, newspaper and
other written communication means, by telling or writing or acting to them
multifaceted nonfactual stories, in order to persuade the patients in ways
to earn from them the maximum money. Procedures, protocols and inadequate not approved
practices are promoted. Some of these are allowed by
official organisations that control the dynamics of health in several
countries.
Competing interests: No competing interests