Health care and development

I have recently been discussing Turkey’s placement on the United Nations’ Human Development Index (HDI) and presented my opinions on the economic and educational dimensions of HDI in my previous columns.

This time I will present some facts and provide my comments on health care in Turkey.

According to the HDI, Turkish citizens’ level of health is around the same as other nations with similar development scales. Notably, the HDI has recently been increasingly used to measure a government’s success. Individuals’ level of health depends on many factors, including genetics, lifestyle, diet, environment and access to health care. Most of these elements are beyond the reach of government influence but an effective health care system can still have a tremendous impact on the welfare of patients and their relatives.

In 2000, the World Health Organization (WHO) assessed the health care systems of all member states based on statistics pertaining to citizens’ levels of health, responsiveness to citizens’ needs and the fair financial contribution of the state to the health care system. The Turkish health care system ranked 70th and the results of satisfaction surveys regarding the health care system were in line with the WHO ranking. Getting sick in Turkey is a terrible experience.

The long lines, disorganization and very short consultation time with doctors in hospitals made it almost impossible to get decent health care at public institutions. So people did not go to the hospital unless they absolutely had to or instead went to private hospitals and clinics that were not covered by the main health insurance programs. Turkey had the lowest per capita doctor consultation rate among Organization for Economic Cooperation and Development (OECD) countries after Mexico. Partly as a result of this situation, it had the lowest life expectancy at birth among OECD countries. Similarly, the infant mortality rate was five times higher than the OECD average.

The early Justice and Development Party (AKP) governments made it a priority to improve the health care system and made some major organizational changes that improved the ease of access to health care services. The arcane regulations that artificially reduced citizens’ options in terms of public health care institutions were removed and private health care institutions were included in public insurance systems. Overall, significantly more public money was allotted to health care and the public funds’ share of total health spending increased significantly.

Soon positive results were seen. Health care began receiving the highest scores on satisfaction surveys. The objective measure of health improved as well: The gap between the life expectancy of Turks and citizens of other OECD countries narrowed. In regards to infant mortality, Turkey managed enormous success with the infant mortality rate (deaths per 1,000 live births) decreasing from 31.6 in 2000 to 7.4 in 2012. In fact, the WHO organized a committee to investigate the dynamics of this tremendous success.

However, in recent years there have been some worrying signs. The public’s share of total health expenditures has been decreasing since its peak value in 2009. Copayment levels in private health institutions increased significantly. This trend was sped up after Dr. Mehmet Muezzinoilu, who used to own a private hospital, became health minister. A mentality focused on profits coupled with budgetary concerns made it more expensive to receive health care services at private institutions.

Moreover, human resources are seriously inadequate. The number of doctors and nurses per 1,000 citizens is the lowest among OECD countries. There are 1.8 nurses per 1,000 individuals in Turkey, while in countries like Norway and Denmark it is 15 and within the OECD 8.2 on average. The number of medical school students also offers no glimmer of hope that the relative position of Turkey will improve in the near future. In fact, despite the acute deficiency of human resources, the Ministry of Health has refused to license an oncology hospital funded by the Foundation of Children with Leukemia (LOSEV) that would provide free cancer treatment. Officials claim that if the LOSEV hospital was opened, it would attract medical doctors from public hospitals.

As a result of these deficiencies, it has also become much more difficult to access decent health care in public health institutions, particularly in big cities like Istanbul, Ankara and izmir. I know from personal experience that it takes longer than four months to get a doctor’s appointment and longer than one year to get an MRI in university hospitals. As a response to this crisis, the government has started a type of public-private partnership with huge city hospitals — private companies would construct the hospitals and rent them to the government. As a health care economist, I have strong reservations about the size of the city hospitals and their property ownership structures.

Moreover, because of the AKP government’s policy of low drug prices, multinational companies have been increasingly limiting drug supplies to Turkey. This is especially relevant for new and novel drugs. Pharmaceutical companies fear that the low prices in Turkey negatively affect their positions in other countries and are therefore very reluctant to bring their new drugs into the Turkish market.

Obviously, all of these factors have a negative effect on Turkish citizens’ health. In fact, Turkey experienced an increase in infant mortality rate in 2014, which is a first in the last 40 years. The government’s response to these negative trends is to introduce new programs to subsidize medical tourism in Turkey! Like in most areas, the AKP government’s health care policies in recent years have started to lose some of the gains made by earlier policies.