“Health Transformation Program” and the 2012 Turkey Health Panorama


Do you think that incomplete, wrongful, disagreeable former practices make the present incomplete, wrongful and disagreeable practices forgivable?

In other words, is this an issue of quantity? When you compare the former with the present in the most basic terms, the tendency of the change, thus, the scale of devastation would be clearly understood.

In the good old days, the health of a citizen was under the responsibility and guarantee of the state. The facilities were few, the resources were inadequate; but, although success could not always be reached in every aspect, the health of citizens, and society in general, was a priority rather than merely the diagnosis and treatment of illnesses.

In the new model “health and well-being is a subject to be solved on one’s own.” Meanwhile, the responsibility of the state is just to create a system for the “diagnosis and treatment” of the emerging illnesses and to monitor and control the institutions under that system. Only the ones who are able to pay for the provision of services can benefit from this system. In this way, the state has already discharged its duties to public health by assigning itself the function of “regulating and controlling the healthcare field” as defined under the 1982 Constitution.

After the 12 September 1980 coup, even starting from the beginning of 80’s, the concepts of “general health insurance”, “family physician model”, “privatization of public health services” and their overall “liberalization” and “opening to foreign capital” in parallel with global tendencies constituted the key elements of the “Health Transformation Program”.

This means the continuity of general economic policies of the “right-wing” governments shaping the economic order facilitated by the 12 September coup. Yet, the best practitioner in this program has been the AKP government, which is not only “in the right-wing”, but also adopts a “religious” discourse. Within the 10 years since 2002, this model has been transformed with public support, in other words, “democratically”. Though not entirely successful, the foundations of this transformation are partially installed. Rather than adopting a “trial-error-change” style and bringing all elements of the model together through “early implementations”, with the advantages of the “lobster” method, significant progress has been made towards pre-determined targets. Two elements of the program are still in progress and the pre-conditions of the third have already been fulfilled.

The practices implemented within that period have resulted in a higher support than the voting rate of the AKP, in spite of the 10 per cent threshold. This support comes mainly from middle and lower middle classes and is based on the “voluntary” practice of doctors. Because this process is determined by the above factors:

1. The main elements of this model, “the obligation for everyone to pay an insurance premium”, “the referral requirement”, the payment of “additional charges” have not been implemented and have constantly been postponed.

2. Many healthcare services have been provided “without usage fee (presently 3-25 TL), contribution (20 per cent in average) and additional fees (presently, the upper limit is 90 per cent of the portion paid by the Social Security Institution, SGK)”, which represent the key elements of the model, people benefited from these services almost without paying any money.

3. Retirees have been able to, under the scope of health insurance, access “private health institutions” without restrictions and the invoices of these services have been paid by combined SGK resources.

4. Thus, during this process, too many resources are being used increasingly (today it is 5 times more than 2002) and all services provided are subsidized by the State. Private healthcare institutions showed eagerness in participating in this process and did not charge any additional fees from patients, considering the regular flow coming in from the SGK.

5. As a result of the high fees given to healthcare personnel and doctors under the name of “extra or working capital share”, “customer satisfaction” based practices were realized.

Thus, for a long time, the model has not been implemented in its entirety.

Nevertheless, in June 2011, after the general elections, express regulations in accordance with the requirements of the model have gradually begun to be realized in these matters.

Starting in 2012, new regulations have been made, particularly in the General Health Insurance field:

By reviewing the status of “Green Card” holders, everyone is included in the scope of obligatory health insurance other than the poor, whose income is less than one-third of the minimum wage. According to their income, a premium between 35 to 213 TL must be paid to the SGK. In case of non-payment, they would become indebted to the SGK and during this period, they cannot benefit from diagnosis and treatment services.

In all levels of service, including “family physicians”, a regressive “usage fee”, a minimum 20 per cent “contribution” for all services and an “additional fee” payment obligation for services provided by private/privatized health institutions are introduced. If you cannot pay these, you cannot benefit from healthcare services.

The family physician practice has supposedly begun to be implemented in the whole of the country; however, it cannot go beyond a “diagnosis and treatment service unit” for the “lowest income holders”. 

The disadvantaged groups such as the totally “poor” segment of society, people with “permanent care needs”, “elders”, “disabled”, “unemployed”, “immigrants”, “clandestine” using these kinds of services frequently do (and can) not consult family physicians, since they are not placed under the scope of the SGK and do not have economic opportunities.

These groups go to “emergency” departments of the upper level institutions when their illnesses become “fatal”. Therefore, today, these segments of society become unhealthier, their illnesses are more serious and the service they need is more “expensive”. Consequently, today, the poor and disadvantaged segments cannot reach any “diagnosis and treatment” facilities. On the other hand, the distribution of the existing service institutions is also not equal. The healthcare institutions are established in places with “the ability to pay”.

Accordingly, people living in the poorest urban zones and the distant and deprived rural areas have now less opportunity to benefit from healthcare services.

The government decided to provide emergency health services free, but as a result of additional costs caused by this practice, the Ministry of Health introduced a re-regulation upon the request of the SGK. As of today, many consultations are rejected on the grounds of “non-emergency”. The services for the protection and improvement of public health are provided based on regions under units called “public health centres”. The opportunity to benefit from this service is decreasing in line with the distance between the service unit and the beneficiaries. These services are not included into the scope of the SGK. Since the medical staff working at these centres is paid lower wages, the services are usually provided with fewer personnel than needed. Hence, the existing staffs are working half-heartedly. They tend to transfer to other institution with higher salaries whenever possible.

The communities most in need of health protection and improvement are the lowest segments in socio-economic terms. Thus, their health is poorer and, in particular, they face community-based diseases.

The citizens and healthcare providers are placed on opposite sides of health care service. In particular, politicians and executives project negative opinions and behavior towards medical doctors and healthcare personnel. When they become the victim of financial difficulties and false norms, people see healthcare providers as the cause of their problems and often resort to violence against them. Today, we see aggression and violence towards, including murders of, medical staff.

In conclusion, it can be said that the real object of the Health Transformation Program is not the health and well-being of society. This program does not aim to provide a healthcare service for the entire society, but to “manage the various illnesses” of the insured sector. This is because, as a result of the many features it carries, the healthcare field also becomes a means and platform to accumulate capital for a “capitalist system”. And, in this regard, Turkey is a suitable “market and implementation area” with its population and resources.