The politics of healthcare in Turkey
‘The Politics of Healthcare Reform in Turkey’ by Volkan Yılmaz (Palgrave Macmillan, 267 pages, €95)
A “revolution” in Turkey’s healthcare system is among the most trumpeted achievements of the ruling Justice and Development Party (AKP) in its 15 years in office. It may not get much attention abroad, but the revamping of healthcare since 2002 is always near the top of the party’s election material. According to the official line, the system in “Old Turkey” was chaotic, limited and ineffective, while healthcare in “New Turkey” is fairer, more comprehensive, and more efficient.
In “The Politics of Healthcare Reform in Turkey” Boğaziçi University assistant professor Volkan Yılmaz digs into the weeds of this reform process. What underpinned it? What were the results? What changed from the old system? What got better? What got worse? Who gained? Who lost? Unsurprisingly, the picture that emerges is more nuanced than election campaign material.
Yılmaz describes the old system as a fragmented, sometimes ad-hoc structure that was far from comprehensive and left many citizens outside of the system. State expenditure on healthcare was low and public healthcare coverage was overwhelmingly dependent on whether one held a position in the state apparatus, leaving many outside of the formal social security system. An acronym soup of agencies had different areas of authority in social insurance, while private healthcare was available for those with sufficient means.
The AKP came to power in 2002 amid a severe financial crisis that swept the old mainstream political order away. Among its early pledges was a vow to rearrange the healthcare system amid a broader range of painful economic reforms. On one level, the reforms appear in line with typical liberalizing and free market-fostering policies often described as “neoliberal.” But the reality is more complicated. In Yılmaz’s words, the changes “included both pro-market and redistributive measures.”
The reforms established a compulsory general health insurance model covering all citizens (eventually put into practice in 2008). As a result, all citizens are now obliged to contribute to the public health insurance fund regardless of their employment status. The only exceptions are those whose income (or lack of it) makes them eligible for an exemption or a state subsidy. The reform also made specific healthcare services such as emergency services and cancer treatment free of charge for all citizens in both public and private hospitals. Public healthcare expenditures increased, though Turkey still spends less on healthcare services than all other members of the OECD in proportion to its GDP.
At the same time, the government actively supported an increased role for the private sector in healthcare provision, introducing user fees and supplementary private health insurance to top-up public health insurance. This expanded choice for healthcare recipients while “creating a strong commodification and marketization dynamic,” Yılmaz writes. Patients no longer have to make contributory payments when they visit primary healthcare services, but they are obliged to make flat rate payments when receiving medications and outpatient services in public hospitals. Such flat-rate out-of-pocket payments are regressive and are among the continued obstacles for poor people in accessing healthcare, Yılmaz notes. The changes have also led to increased workload for physicians, who say they are unable to provide adequate services for patients (which is one factor behind rising cases of violence against healthcare professionals in Turkey).
Despite drawbacks, the public has responded positively to the changes. According to the Turkish Statistics Agency (TÜİK), the rate of citizens “highly satisfied” and “very highly satisfied” with the country’s healthcare system increased from 40 percent in 2003 to around 75 percent in 2013. Yılmaz also quotes figures reporting that per capita hospital visits rose from 2 in 2002 to 5.1 in 2012, while doctor consultations per capita increased from 2.8 in 2000 to 8.3 in 2014. “Among other factors, the introduction of the healthcare reform was a sine qua non for the AK Party to become politically legitimate,” writes Yılmaz.
Too often left-wingers unsubtly dismiss the AKP’s political project as a textbook case of aggressive “neoliberalism.” This lacks sophistication. As Yılmaz writes, the AKP has “simultaneously pursued both neoliberal economic policies and populist social policies,” combining pro-marketism with welfare expansionism. Healthcare may not be the sexiest or most polemical area, but it does neatly showcase this “two-tiered policy agenda.” Yılmaz’s carefully researched book shows that this agenda is impossible to summarize in snappy all-encompassing terms.