Intended for healthcare professionals

Rapid response to:


Healthcare in Turkey: from laggard to leader

BMJ 2011; 342 doi: (Published 21 January 2011) Cite this as: BMJ 2011;342:c7456

Rapid Response:

Privatization is the driving force of Turkish Health System !

Re: Healthcare in Turkey: from laggard to leader, Baris al. BMJ
342: 579-582.

In their article on Health Transformation Program in Turkey, Baris et
al do not mention about the historical background of the transformation
program and the private provider's details (1). One of the few agreements
on discussions of the health care system in Turkey is the characteristics
of the health service model after the year 1961. This model called
"socialization of health services" was an important crossroad for country
and tried to establish community-oriented, accessible, comprehensive,
longitudinal and multi-disciplinary team based primary care services
(2,3). Principles of the model, figured the concept of modern health care
for Turkey, seventeen years before the Alma Ata declaration. However this
model which focused on health through equity and community empowerment has
never been adopted by the governments, who were the pioneers of the Health
Transformation Program and faced with serious problems such political
interventions, lack of infrastructure and financial support, poor
management etc. Thus, Turkey entered to the eighties with various problems
about health care services. These years were also the time of the holistic
neoliberal economic policies, at the same time neoliberal policies were
started to establish in health care services and they are considered by
the Ministry of Health as the preparation phase of the health reform.

Health reform process in Turkey began in the second half of the
eighties and has accelerated in nineties. During this period, the basic
dynamics of reform was World Bank loan agreements (08/16/1990 and
09/28/1994) and health projects associated with these agreements (first
project completed in 1998, second project completed in 2004) (3). This
process has entered a new level in 2003 with the Health Transformation
Program of Ministry of Health. In this level World Bank loan agreements
remarkable too (Supporting Project for Health Transformation Program in
2004) (3). Health Transformation Program consists of eight components and
contains "governance, efficiency, satisfaction of users and health care
providers, and long-term financial sustainability"(4,5).

Health care reform process builds on the four integrative themes:
"Changing roles of the state and the market, decentralization, the
patient's authorization, rights and choice, the changing role of public
health (6). Health Transformation Program is structured on these main
themes. On the other hand, mainly controversial issue in health care
reform is privatization (7). Also privatization is the focus of Health
Transformation Program in Turkey.

Private health sector has stronger role in health services than ever.
Recently, one-third of hospitals are private in Turkey. Private hospital's
share of the total health expenditures made for hospitalized care was
around 10% in the 2002, but in 2009 was more than 30%. According to 2009
statistics, the number of inpatients in private hospitals as compared to
2005, has tripled and reached 2.5 million. One-quarter of total inpatient
hospitalized in private hospitals. Private hospital visits increased
from 4.6% (5.6 million visits) to 16.1% (47.6 million visits) and surgical
operations 13.2% (0.2 million) to 23.3% (1.6 million) (respectively 2002
and 2009) (8).

The hidden reason why "socialization of health services" has been
abolished and "the family medicine" has been introduced is to put the
primary care services on the market. The consequence of destroying all
remaining components of the socialized health care services is the health
inequalities, which are not reflected in official statistics and not
allowed to bring into the open through scientific studies. Sixty nine
measles cases reported in Istanbul in the last months is a very explicit
evidence of the fact that the improvement claimed for both communicable
diseases and other public health problems are open to questioning. One of
the claimed arguments of the introduction of family medicine was to
establish "effective end staged referral chain" (9). However, this chain
has been gradually removed since 2006 and completely removed on June 15,
before the general elections in July 2007. This has created a major
contradiction and another evidence indicating that the main target of the
government is not related to the health of the community.

Nowadays health care workers including more than 100 000 physicians
in Turkey are planning to go on strike on April 19 and 20 in order to warn
the government on their work conditions, wages, employment forms, income
inequalities and most importantly on the consequences of performance-based
payment and privatized health services on their patients.


1. Baris E., Mollahaliloglu S., Aydin S. Healthcare in Turkey: from
laggard to leader BMJ 342: 579-582.

2. Akda? R. Progress Report. Health Transformation Program in Turkey.
Ministry of Health, January 2009, Ankara, Turkey.

3. Fisek N. Introduction to Public Health, 1985.(Document in Turkish:Halk
Sa?l???na Giri?, Hacettepe ?niversitesi Toplum Hekimli?i Enst?t?s? Yay?n?,

4. Review of Turkey's health 2007, Ed: Mollahaliloglu S. et al. Ministry
of Health, 2007 Ankara(Document in Turkish: Turkiye'de sa?l??a bak??,

5. OECD Reviews of Health Sytems-Turkey, OECD and World Bank Publishing,

6. Saltman R. B. European Health Care Reform, Analysis of Current
Strategies. Regional Office for Europe of the World Health Organization,

7. Saltman R. B. Melting public?private boundaries in European health
European Journal of Public Health 2003; 13: 24-29

8. The Ministry of Health of Turkey health statistics yearbook 2009,
access date:11.04.2011

9. Health Transformation Program, Ministry of Health, Turkey, 2003.

Competing interests: No competing interests

14 April 2011
Cavit I. Yavuz
Member of Turkish Medical Association Public Health Executive Committee
Zeliha Ocek
on behalf of Turkish Medical Association Public Health Executive Committee