Turkey’s healthcare: a bad prognosis By Mehmet Adıyok
Turkey’s healthcare system has never been far from the country’s agenda in recent years, whether thanks to the sector’s role as a draw for private investment or headlinegrabbing remarks by the prime minister. Less prominent, however, has been the voice o
An assessment of the current status of Turkey’s healthcare system from a practitioner’s perspective.
When it comes to healthcare, the Turkish media’s focus of late has been on Prime Minister Recep Tayyip Erdoğan’s views on the issues of abortion and caesarian section, as well as on recent face transplant procedures. Regarding the former, the premier stated: “I am a prime minister who is against births performed by cesarean section. I know that these are systematic efforts and constitute steps to retard the growth of this country’s population. I also know that these moves have the aim of procuring financial resources. These efforts are leaving the population stagnant. I believe that abortion is murder.” Meanwhile, earlier in the year the Ministry of Health was quick to comment on the transplant procedures, saying that they had made the necessary legislative amendments and that Turkish doctors had performed the surgery.
It is shame no one bothered to put a microphone in front of Turkey’s medical practitioners and ask them what they had to say. Our health system has undergone many dramatic changes over recent years. By and large, the public has been happy with these changes. Doctors, on the other hand, have been less welcoming. Those among them who have attempted to voice their concerns have found themselves the victims of disinformation and accusations. But doctors have no problem with the public receiving quality healthcare.
Doctors are highlighting a problem with Turkey’s healthcare system itself. The concerns of the healthcare sector are now more closely related to costs and profit margins than to a healthy society and its future wellbeing. While this currently seems only to bother the practitioners, it won’t be long before it also raises objections among patients.
The ministry views Turkish Medical Association (TTB) criticism in matters relating to the profession as “defiant political opposition” and is unwilling to take seriously its views on healthcare and professional rights. Consequently, the concerns of doctors, as echoed by the TTB, are drowned out by government and corporate power. As with the partisan media, unyieldingly disparaging of the
government’s every move and refusing to acknowledge the positives, the hostile attitude displayed here to even the slightest criticism is of no benefit to anyone.
This article aims to present a summary of the current problems with the Turkish healthcare sector.
(1) Increase in healthcare spending lags Turkey’s economic growth
Superfluous prescriptions and unnecessary procedures are cited as the culprits for increased per capita healthcare spending. According to Organization for Economic Cooperation and Development (OECD) health statistics1, average health spending in the organization’s countries is 9.5 percent.
The US leads the way in healthcare spending among OECD countries, contributing 17.4 percent of its annual GDP, followed by Holland in second place with 12 percent, France with 11.8 percent, Germany with 11.6 percent and Turkey in last place with 6.1 percent.
Turkey’s health spending as a percentage of its GDP was 4.95 percent in 2000, 5.16 percent in 2001, 5.37 percent in 2004 and 6.04 percent in 2007. Between 1999 and 2003, the average increase in health expenditure as a percentage of the GDP was 3.91 percent. The rate of increase was reported as 2.45 percent between 2003 and 2007. The drop in this rate is the most important indicator of savings that had already been made on healthcare by the government.
Health statistics compiled by the World Health Organization (WHO) put global spending on health at $5.3 trillion; 60 percent of this comes from public institutions. In Turkey a comparison between the increasing number of patients receiving health benefits and the increase in health spending clearly undercuts the claim that health costs are on the rise. Achieving an ideal level of healthcare will not be possible in Turkey unless the budgetary expenditure on healthcare is in step with the increase in national income.
(2) Doctors are required only to provide treatment and are in effect prevented from furthering their skills and attending conferences that might equip them with the skills to use the most recent treatment methods available
Healing is among the oldest professions in the world. A doctor’s resources consist of their knowledge and experience. While most of the changes being made to the healthcare sector relate directly to treatment services, there appears to be no effort being made toward developing doctors’ skills or facilitating their engagement with new scientific developments. Currently wages in the medical profession make it difficult for doctors to attend scientific conventions using their own means. Although there has recently been some support for enabling doctors’ participation in such conventions, docking their working capital share and deducting vacation time for attendance has made this untenable. Touting Turkey’s modernization and development, its rising GDP and its status as the world’s 17th ranked economy while showing reluctance in allowing practitioners to attend these scientific conventions is indefensible at best. Most state hospitals currently lack a library and do not subscribe to scientific journals. Where these are available, they are grossly insufficient2.
(3) The performance system engenders low job satisfaction and does little to help the patient
The performance system incorporates bell-curve grading on a regional basis. The doctor with the most points is ranked highest in terms of performance, while those with lower scores are ranked in descending order. This system is open to exploitation and doctors are now being made to compete for points. Nor are there clear standards for doctors on the basis of their field. Official statements have even (falsely) claimed that all doctors have been performing at the highest level.
Patients initially welcomed performance grading, which aimed to reduce waiting lists by having doctors work longer hours. They are now complaining about inadequate treatment and poor medical attention. As a result, the number of dissatisfied patients and second opinions are increasing daily.
Although the requirement, as part of this assessment, for medical lecturers and doctors work full time may turn out to be a positive development, it will be necessary to put in place the additional infrastructure required for this and to allow doctors who wish to work in the private sector to do so. Given the choice, a patient applying at a university clinic will naturally elect to be seen by a professor. However, the working hours of medical lecturers must be freed up so that the needs of patients requiring such specialized treatment can be met.
Furthermore, limiting various medical procedures to training hospitals has prevented them from being carried out at special centers, which are equipped to handle such cases. Hence, the field in which these trained individuals can work has been marginalized.
(4) The Social Security Institution (SGK) has monopolized the healthcare system
A monopoly has been established with the transformation of the SGK into a department that invoices and oversees 90 percent of the procedures carried out at all private and state health facilities. Seemingly no authority exists to field complaints against occasional deductions that are made unfairly. Any complainants who apply in person are told to refer the matter to the courts and advised that “any quarrel with the institution will be to their detriment,” thereby forcing them to forego their rights. In fact, the SGK has the right to delay payment by three months to any health facility with which it has a standing agreement. Is it any wonder people are so reluctant to go to the courts?
An institution that pays you and then proceeds to offer premiums to auditors responsible for overseeing your facility, based on deductions they have made from your fee, will inevitably exploit this state of affairs. There exists no supervisory authority to address such grievances nor the slightest indication that there will be in the future. The SGK refuses to acknowledge certain medical procedures. A procedure well-known to you and frequently carried out will not be billable if it is absent from the SGK’s schedule of fees. As a result, the patient will be liable to pay for the procedure despite their insurance coverage.
The SGK currently keeps a record of all practitioners issuing prescriptions, together with the drugs that they have prescribed. Also kept on record are the number of patients examined and the names of the practitioners who carried out the examinations, in addition to the number of tests requested and the names of those filing the request. Any doctor attempting to abuse the process can easily be singled out. It is true that the SGK’s efforts to reduce drug expenditure have been instrumental in reducing a serious burden on the state. However, this has had hidden consequences. Some drugs, for instance, have been suddenly dropped and taken out of payment coverage due to the manufacturer’s refusal to offer further discounts during that particular year, despite having formerly cut the price on several occasions.
The SGK also involves itself in matters concerning doctors’ professions on economic grounds. The majority of these decisions are rejected by the courts. For instance, limitations imposed by the SGK on the number of drugs and dosages contained in a prescription have been overturned by the courts and left to the discretion of the practitioner. Announcements relating to these court rulings are made by the TTB and other professional organizations, such as specialist associations, rather than the SGK itself.
HEALING IS AMONG THE OLDEST PROFESSIONS IN THE WORLD. A DOCTOR’S RESOURCES CONSIST OF THEIR KNOWLEDGE AND EXPERIENCE
(5) Differences in standards between private health institutions and state institutions
The exemption of state health facilities from the stringent standards imposed on private institutions is a cause of worry for both patients and their doctors.
Whereas private health institutions are subject to checks for the amount of time they devote to patients, this practice is unheard of at state hospitals. While the 10 minutes per patient policy is seemingly favorable, no one appears able to question its absence in state or university hospitals.
The government bears almost none of the cost for examinations carried out at private hospitals. Despite this, both the ministry of health and the SGK are doing all they can to discourage patients from applying to private hospitals (restrictions on staff and patients, changes to physical conditions, bizarre fines and penalties imposed by the SGK).
(6) Doctors are unable to live where they want: staff norms and compulsory service
Curbing the freedom of doctors to live and work where they please is among the grossest violations of their personal rights. First, staff norms were implemented in the private sector, restricting the number of doctors able to work in a specific field. This put doctors in the private sector under the close supervision of the state, which assumed authority over all their affairs without actually paying them or providing any of the advantages enjoyed by an employee of the state. (As a health practitioner -- private sector or not -you are only allowed to work where the state deems appropriate. Moreover, you are not allowed to request a transfer based on spousal privilege.) A set of legislative amendments was enacted to prevent state doctors from switching to the private sector. Fees for examinations, tests and surgical procedures were cut dramatically in private hospitals, lowering the income of doctors. Later, the introduction of staff norms made the switch between private hospitals just as difficult as the crossover from state to public hospitals. While all other sectors were becoming liberalized, private enterprise came increasingly under state supervision. Previous spousal privileges were lifted for compulsory service, with no one seeming to care for the families that were being torn apart. Hundreds of married practitioners were, for a certain period, forced to live and work away from their children.
Transfers and appointments were restricted even after compulsory service had been completed with requests being made for additional work. Such requests were found to be in violation of the Constitution.
(7) Defensive medicine: The result of exaggerated patients’ rights and complaints
There’s nothing odd about evaluating patients’ complaints in order to ensure their satisfaction. However, in practice, discrimination against doctors has recently led to serious losses in working hours and fostered a tense working environment, all in the name of keeping up appearances.
The number of malpractice suits has risen dramatically in recent years. The Forensic Science Institute received 12,000 malpractice cases in 2010, up from only 600 in 2005 (these figures were obtained from the institute). The 184 hotline has made it easier to file a complaint against a doctor, contributing to the rising number of cases. However, this may also be due to developments in healthcare that took place between 2005 and 2010, bringing with it easier access, but also a system that impacted patient satisfaction. An increase of 70 percent in patient satisfaction coupled with a 20-fold rise in the number of complaints received by the Forensic Science Institute against medical procedures also points to the need to further investigate this matter.
(8) A symptom of the system: violence against doctors
Some 56 percent of healthcare workers have reported witnessing violence in the workplace in the last year. General practitioners rank highest with 66 percent. The number of healthcare workers claiming to have witnessed at least one act of violence during their career is 96 percent.
In the past year, 45 percent of healthcare professionals were subjected to physical violence (women 58 percent, men 26 percent). Violence also impacted 36 percent of specialist doctors in that timeframe. This figure is 45 percent for specialist doctors active in state hospitals but drops to 5 percent for specialist doctors working in the private health sector. The number of general practitioners subjected to violence at least once in the last year comes in at 63 percent (women 69 percent, men 61 percent). The figure is 55 percent among family practitioners. A total of 33 percent of resident doctors have had to
contend with violent behavior in the last year, with women residents having to bear the brunt of attacks.
When we look at the nature of the violence healthcare workers have been subjected to we find that profanity, insults, spitting and threats are the most common, with 84 percent, followed by physical attacks such as slapping, punching, armed assault and sexual harassment.
Violent behavior is most commonly encountered in emergency wards, the medical worker’s own working environment, clinics and inpatients wards. Among these, emergency wards are the most common for incidences of violence with 23 percent. Meanwhile 45 percent of healthcare workers reported encountering violence during the dayshift.
The leading causes of violent behavior against doctors are the current health system and statements made by political leaders. That is, insufficient time allocated to patients; overcrowding in hospitals due to a lack of support staff and the absence of a referral system; non-emergencies in emergency wards; and poor physical conditions. The political grandstanding and insults against doctors by officials are not only casting aspersions on doctors, but also encouraging violence against them.
Dwindling confidence in doctors is causing patients to shop around for second opinions and stopping them from taking their prescribed medication. These factors all play a role in rising health costs, unnecessary drug purchases, growing patient numbers and increasing violence against doctors.
(9) The system of ‘chain referral,’ widely used in many countries to prevent hospital overcrowding, is not being implemented due to populist concerns, despite complaints about doctor shortages
The chain referral system prevents patients from applying to any hospital at any given time and as often as they like, while simultaneously enabling many patients to receive treatment from their family practitioners without having to apply to specialist clinics.
Medical university lecturers, private practices should be reopened, and fees for patients referred to them by specialists should be borne by the state. In the event other patients pay their own way, specialist doctors will be able to devote more time to patients requiring specialist attention.
(10) Health tourism and medical labor
Doctors have little enthusiasm for the notion of health tourism, a subject that occasionally crops up in the news media. There are two reasons overseas patients flock to Turkey: the service is better and it is more affordable. The pricing of most supplies conforms to an international standard, so what makes this option affordable is quite simply the reduction in the cost of medical labor.
Seeing as how the final fee (inclusive of all charges) charged for certain surgical procedures in Turkey is barely enough to cover the doctor’s fee in certain countries, health tourism is nothing more than an admission that doctors are grossly underpaid in this country.
The average annual income for a first stage doctor in the US is $161,000, whereas a second stage specialist earns an average annual income of $222,000. First stage doctors in Germany earn an average annual income of 80,000 euros, while their second stage specialist counterparts make 85,000-125,000 euros3.
There is no average for the figures often mentioned in Turkey and official disclosures usually tend to refer to the highest possible salary, misrepresenting it as a standard that applies to all. The net monthly salary of a specialist currently stands at TL 1,800. With improved performance, this may increase by an additional TL 3,500, although this is uncommon. The average monthly salary of a family practitioner is around TL 4,000. ( These averages were calculated informally from figures disclosed by several other doctors and are not official.)
The health minister has remarked that this is unacceptable and that his ministry is making efforts to remedy this inconsistency. The statement “ensuring the implementation and development of the medical profession for the betterment of the public and the individual” was struck from the existing legislation with the enactment of Statutory Decree 11- 663.
The sole purpose of removing this statement is to prevent the judiciary from blocking any law that does not subscribe to the good of the public and the individual and to lay the legal groundwork for transforming healthcare into a for- profit industry.
(11) Allowing foreign doctors to practice is likely to do more harm than good at this juncture and will have repercussions for the personal rights of doctors
Doctors are usually allowed to travel and work overseas, provided that they are qualified and have the necessary language skills. In Turkey, however, the tendency is quite different, instead forcing doctors into compulsory service to work under difficult conditions while leaving foreign doctors free of any such obligation, undermining the claim that this proposed solution will alleviate doctor shortages. Overseas doctors need only speak a passable level of Turkish in order to secure employment. No inquiries are made to professional organizations in their country of origin to obtain information on their professional record. Documents obtained from the Ministry of Health and the relevant embassy, indicating that they are authorized to work, have been viewed as sufficient evidence of their employment credentials. There are currently no laws to help direct overseas doctors to work in healthcare black spots. Overseas doctors will not be subjected to compulsory service. Only Turkish citizens will continue to be liable for three tours of duty at 300 to 600 days each in order to complete medical school, specialist and sub-branch training.
Professional organizations are responsible for keeping doctors’ professional records in democratic countries. However, these records are not required for authorization by the TTB. Instead, a document obtained from an embassy or a consulate, proving the absence of any restrictions to medical practice, is adequate. Legal safeguards that would enable professional organizations to vet doctors and impose penalties and receive damages in the event of professional misconduct have not been introduced to ensure the right to healthcare.
DISCRIMINATION AGAINST DOCTORS HAS RECENTLY LED TO SERIOUS LOSSES IN WORKING HOURS AND FOSTERED A TENSE WORKING ENVIRONMENT
(12) Criticism of the transformations in the health system is not ideologist in nature
The minister of health gave a speech on 14 May in honor of Health Day. The minister’s admission that the retirement benefits of doctors were insufficient was quite accurate. However, the comparison he drew between doctors’ incomes and the minimum wage, saying that “you should be thankful you’re not receiving the minimum wage of TL 750,” was something of a blunder. His reaction to criticism, describing it as ideological and not conducive to solving the problem, wasn’t received well, but may indicate that he understands that doctors have concerns and that there may be viable solutions for addressing them. If only he had chosen to address the problem instead of vilifying those who were in disagreement.
There’s currently an effort to lend credence to the idea that health costs are constantly rising, despite the fact that Turkey ranks last among OECD countries in its budgetary contribution to health. Turkey’s budget health expenditure lags behind the growth rate of its national income. If we are in a phase of prosperity, then our nation’s health should reap the benefits. It is a damning indictment that the most significant factors attributable to the 20-fold rise in the number of complaints received by the Forensic Science Institute against medical procedures, despite a 70 percent rise in patient satisfaction, and the escalating violence against doctors, include the current health system and the Ministry of Health’s doctors.
We are currently facing a Ministry of Health that views each and every criticism made by the TTB as an ideological ruse. Doctors now find themselves helpless due to the ease with which the TTB, the voice of the medical community, can so easily be dismissed as an “ideological” organization. Why aren’t the TTB, specialist doctors associations, patients’ rights organizations and the Association of Pharmacists consulted in making a joint decision? Doctors are seldom surveyed for their opinion, let alone asked to consult on these issues.
Criticism of recent developments in health is not tolerated and is usually branded an invasion of the political arena. If to be critical is to be political, then this should present no problem in a democratic society.
Around 3,000 healthcare sector workers and unionists protest in Beyazıt, İstanbul. Dec. 21, 2011