Turkiyedeki saglik sisteminin bir analizi

vHealthcare in Turkey. Another analysis with some more data

* H. Ozden Sener, Member, on behalf of Ankara Chamber of Medicine Executive Committee

Professor of Neurology Ankara University School of Medicine Dept. Neurology

Dear Editor,

We read Baris and colleagues' "Analysis" on health system transition in Turkey.1 They make optimistic comments and present statistics beyond what the figures actually are which makes it more a piece of self-flattery rather than a scientific article. We call it self-flattery because we find the authors are officials of the people who own this system.

Who owns Health System Transition in Turkey?

The World Health Organisation (WHO) report on Health System Transition in Turkey had been released in 1996, long before AKP (the current ruling administration of nine years) was established. The report was removed from the WHO website a few months ago; we can provide a PDF copy on request. Every step of the so-called transition was written in that report. Although it is not an AKP project, they have performed each step enthusiastically as had been planned long before. World Bank and its components proudly declare they provide financial and technical support to the project.2

Why is World Bank interested in the health systems of various countries?

On one hand, they increase demand (although unnecessary) to health services. Health expenses fold on and on. On the other hand, they devaluate the labour of both the physician and the health team. The goal is to provide an appetizing market for "global investors". The local population's state of health is not a core issue of concern for this organization.

Improved health statistics in Turkey?

It is not surprising that United Nations Human Development Index, Health Index (UNHI) or Income Index (UNII) all steadily improve in every single country with only a few exceptions from 1970 to 2010.3 If every country is improving the author's attribution of these improvements to Turkey's health system transition is unacceptable. Figure 1 in Baris and colleagues' paper also shows a steady decrease in infant mortality rates between 1990 and 2009 in all countries ranked.

According to UNHI 2010, Turkey is at 90th place out of 180 countries. The same source, however, classifies Turkey as 63rd highest Income Index (UNII) country. This simple data clearly uncovers a fact that Turkey is not a leader but a laggard. Turkey's health system outcome is even worse than poorer countries' such as Armenia (66th at UNHI, 106th at UNII), Paraguay (89th at UNHI, 115th at UNII) or Sri Lanka (62nd at UNHI, 111th at UNII).

Our babies?

Here is another set of data about infant mortality rates by country.4 According to this data, Turkey's estimated infant mortality rate in 2011 is 24 per 1000. Only 83 out of 223 countries or regions showed higher infant mortality rate figures and it seems that governments of 139 countries or regions take care of their babies better than Turkish health authorities. Countries with less gross national income per capita such as Romania, Bulgaria, Armenia, Georgia, El Salvador and even Gaza Strip, which is surrounded and under Israel's embargo, protect their babies' lives more successfully than Turkey.

Transition's success!

In fact, some numbers grew in Turkey during this period. For example, the mean physician's visit per capita-year increased from 2.6 to 7.0 from 2002 to 2010 (Oral declaration of the Minister of Health). Drug consumption raised five times at the same period.5 While hospital visits grew 2.2 times, the number of surgeries tripled.6 The number of MR scanners in state hospitals expanded from 18 to 247.6 Whether or not these increases improved the quality of health service is debatable.

Are the doctors and patients happy?

Physicians in state hospitals work in a pay-per-visit system. A specialised physician's regular wage is 1200 USD. A pay-for-service fee added to this is 1500 USD on average. It is strictly forbidden to give an appointment to any patient in these hospitals. Every patient is seen on the same day she/he applies. A neurosurgeon examined his 118th patient at 4 p.m. on the first day of March 2011 and a cardiologist examined his 134th patient then at Diskapi Yildirim Beyazit Training and Research Hospital in one single day (registered by Ankara Chamber of Medicine official team). These are not an extraordinary examples, this is the everyday norm at state hospitals in Turkey. To be seen by a doctor means waiting in the queue with others for a couple of hours and staying in the examining room for about five minutes. A recent Ankara Chamber of Medicine survey showed that 83% of physicians are not satisfied with their salaries and 88% had no hope for the future.7 Eighty-three percent of the physicians believe that people do not receive satisfactory health service.

Does pay per visit provide quality?

Private hospitals are very enthusiastic to find patients because they need to survive. Doctors are complaining that many hospital directors force them to perform diagnostic and therapeutic procedures even when these are unnecessary. Two examples (close to the date of Baris and colleagues' paper) were published online: Date: 2 Dec 2010. Daily journals stated that seven consecutive patients who had undergone cataract surgery were threatened by losing their eyes because of infection.8 They had been collected by a bus from their villages and brought to a private eye clinic. They were operated on the same day and got eye infection. Date: 17 Jan 2011. Daily journals reported another eight consecutive patients who underwent cataract surgery suffered endopthalmia, this time in a state hospital.9

Compensation fee from minimum waged citizens!

Before the transition, all state hospitals were at the service of the people without compensation. Health expenses were based on income taxes and health and retirement premiums. Now, after the health system transition, an extra compensation fee has been added to the payments. Unfortunately, 43% of employees work without registration and at lower wages than minimum wage in Turkey.10 Forty-one percent of all registered employees work for minimum wage. An enormous gap exists between rich and poor. The poorest 20% of the people take 5.6% of national income while the wealthiest 20% get 47.6%.11 Minimum wage is 393 USD and the compensation fee in state hospitals is 5 USD. Patients should pay another 20% of the bill for prescriptions, as well. This means that if one of your children is seen by a doctor only once it costs a sum of one month's milk that the child needs. Date: 18 Jan 2011. News of a death of a 2.5 month old baby was in daily journals.12 The death report was prepared by the physician who last examined Kubra and the reported cause of the death was starvation. Although the Minister defends himself saying 5 USD is a fair sum when compared to the gross national product per capita, the population's changed attitude denies this. Approximately every third patient who applies to a hospital has now started to prefer emergency rooms because there is no compensation fee there.13

How reliable are health statistics of Turkey?

Following is a striking example of the unreliability of the health statistics published by Turkish Ministry of Health and cited by WHO. Bursa, an industrial city, is one of the largest and most developed cities of Turkey with most of the population living in an urban area. Even the rural parts are well connected to the city. Nearly all childbirths occur in hospitals. Demographic records should also be expected to be reliable compared to many other less developed cities. According to Bursa Provincial Health Authority and Provincial Population and Citizenship Authority, the annual infant mortality rate for 2008 was 6.0 (206 out of 34,362 infants) and 5.6 (235 out of 42,052 infants) per thousand, respectively. Pala and colleagues from Uludag University used a practical method to cross-check those rates.14 The authors collected data from all municipalities and also checked all cemetery records in order to reveal infant mortality rate in Bursa. They found that the number of buried babies under one year old was 795 and annual infant mortality rate for 2008 was 20.8 per 1000 in Bursa. This example tells much. First of all, Turkey's health system "reform" can not keep our babies alive even in the wealthiest parts of the country. Secondly and very sadly, we cannot correctly find the number of deceased babies. Provincial Health Authority is not even aware of the 589 deceased babies in Bursa.

How many new medical schools do you think were established in last five years?

The number of medical schools was 45 in 2006. Now we have a total of 78. A recent report from Turkish Medical Association and Ankara Chamber of Medicine points out that many new medical schools are facing vital deficits.15 While ten schools do not have cadavers for dissection, thirty lack a pathology lab. The country's aim is to make the number of physicians double by the year 2020. Competition for a job will be an invaluable instrument for devaluating doctors' labour no matter what the quality of training is!

One last note for the editor: Baris and colleagues were very bold accusing all of the doctors in Turkey saying "Most physicians remained on the public payroll for job security and benefits, but supplemented their low salaries by taking under the table payments in public facilities or working part time in private. Rampant absenteeism and low productivity and technical quality, especially in primary care, was common, with unnecessary referrals to outpatient specialist services." These kinds of accusations against "most" Turkish doctors are certainly going to be responded to legally and ethically. We wonder how you, as an editor of a scientific journal, permit such generalisations without referred evidence to be published in a "scientific" paper?

"Getting Health Reform Right. A Guide to Improving Performance and Equity" is a book written by Mark J. Roberts and colleagues and published in 2004. The Chief Editor of the Turkish translation of the book is the Turkish Minister of Health and the book is in the virtual library of the Ministry of Health's website.16 The book is really a guide for the reformer. Section 4 "Political Analyses and Strategies" is a masterpiece! From that section: "Provide allies media time and notice. Give them money, personnel or facilities. Physicians' associations are enemies. Discredit them. Avoid them to be seen on media. Introduce them as unexpert, unloyal, selfish, dishonest, self-seeker. Do not supply data to opposition. Divide them. Neglect them." And finally "These strategies may be unethical"!

You state in your comment that "Turkey provides a shining example".17 Please let the readers decide.

1. Baris E, Mollahaliloglu S, Aydin S. Healthcare in Turkey: from laggard to leader. BMJ 2011; 342:c7456.

2. World Bank Awards Turkey Health Transformation Program 'Improving the Lives of People in Europe and Central Asia' 2010 Competition. World Bank, 2010. www.worldbank.org.tr/WBSITE/EXTERNAL/COU...itePK:361712,00.html

3. United Nations Development Program. Worldwide Trends in the Human Development Index. UN, 2011. 1970-2010 hdr.undp.org/en/data/trends/

4. The World Factbook. Infant Mortality Rate Country Comparison. CIA, 2011. www.cia.gov/library/publications/the-world- factbook/rankorder/2091rank.html?countryName=Tuvalu&countryCode=tv&regionCode=au&rank=70

5. The Minister of Health Presantation on Health Budget in Turkish Parliament, 2011. (Turkish) www.saglik.gov.tr/TR/dosya/1- 70836/h/saglik-bakanligi-2011-butce-genel-kurul-sunusu.pdf

6. Health Statistics Yearbook. Turkey Ministry of Health, 2008. www.saglik.gov.tr/EN/belge/2-323/health-statistics-yearbook- 2008.html

7. Physicians' Opinion Survey. Ankara Chamber of Medicine, 2011. (Turkish) ato.org.tr/#/ato/anketler

8. Turkish Health Ministry shuts clinic after botched eye surgeries. Hurriyet Daily News, 2010. www.hurriyetdailynews.com/n.php?n=privat...spital-investigated- health-minister-says-2010-12-02

9. Investigation into botched cataract surgeries launched. Hurriyet Daily News, 2011. www.hurriyetdailynews.com/n.php?n=an- investigation-on-the-alleged-cataract-surgeries-turning-people-blind-2011- 01-17

10. Labour force statistics. Turkish Statistical Institute, 2010. www.tuik.gov.tr/isgucuapp/isgucu.zul?dil=2

11. Income distribution. Turkish Statistical Institute, 2009. www.turkstat.gov.tr/PreTablo.do?tb_id=24&ust_id=7

12. Baby dies of hunger in Samsun. Hurriyet Daily News, 2011. www.hurriyetdailynews.com/n.php?n=turkis...ss-scan-for-jan.-19- 2011-01-19

13. Arslanhan S. Muayene sayisindaki artis, anlamli bir erisim artisini mi ifade ediyor? (Does increase of number of examinations mean a significant access increase?) TEPAV (Economic Policy Research Foundation of Turkey), 2010. (Turkish) www.tepav.org.tr/upload/files/1284627104- 1.Muayene_sayisindaki_artis_anlamli_bir_erisim_artisini_mi_ifade_ediyor.pdf

14. Pala K, Turkkan A, Gercek H. How correct are the infant mortality rate calculations in the provinces of Turkey? A study from Bursa. Turk Arch Ped 2010; 45: 264-7. www.turkpediatriarsivi.com/sayilar/92/264- 267.pdf (Turkish. English Abstract)

15. Canlar Tip Fakulteleri icin caliyor. (The Bells Ring for Medical Schools) Turkish Medical Association, 2010. www.ttb.org.tr/index.php/Haberler/mote-2312.html (Turkish)

16. Saglik Reformunun Dogru Yapilmasi. Performans ve Hakkaniyetin Gelistirilmesi icin bir Kilavuz. (Getting Health Reform Right. A Guide to Improving Performance and Equity), Turkey Ministry of Health, 2010. sbu.saglik.gov.tr/Ekutuphane/kitaplar/sarefdoyap.pdf

17. Godlee F. Iatrogenic radiation, and unethical health reforms. BMJ 2011; 342:d1551

Competing interests: None declared
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Published 3 April 2011