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Thursday, March 24, 2011

AKP's Achilles Heel

On March 13th 30,000 doctors, nurses, pharmacists, lab technicians and other healthcare workers from across Turkey travelled to Ankara to hold what may have been the largest anti-government protest to date. Turkish healthcare is in very poor shape. Yet, the AKP only wants to have its own share by selling state institutions to the highest bidder. Yesim Erez examines the AKP's slow murder of the Turkish healthcare system.

Turkey, under the Justice and Development Party (AKP) is increasingly run as an autarchy. With the June general elections looming, it is busy manufacturing consent. A victory in June will be much more than just a political win, it will allow AKP to continue the implementation of neo-liberal policies, limiting welfare and increasing costs in an environment already lacking social balance. Among these industries is healthcare, traditionally a state welfare system which provides a safety net to the poorest classes. Number of physicians per capita is less than half of the OECD average and according to ’06 UN population data, infant mortality at 27.5 deaths per 1000 born, a figure several times higher than any country in the EU. Turkish healthcare spending actually needs to be better managed and increased as a whole but AKP wants to have its cake and eat it too. How this is carried out is examined below:

To quiet dissent, AKP has obtained control of media by buying national outlets. More than 50 journalists are in prison on charges of a so-called “Ergenekon plot” to overthrow the government, a measure meant to serve as a scare tactic for the remaining independent media outlets which are already wire tapped by the government. The September 2009 referendum called for a Yes/No vote on a package deal of 26 constitutional amendments and the results limited the military’s, Constitutional Court’s and the High Council of Judges and Prosecutors powers to show opposition or to remain independent. 

Healthcare, an Achilles heel for the AKP, had been a large driver in the 2002 and the 2007 elections, as votes are typically driven by individuals’ needs rather than political issues. Healthcare generally ranks at the top of issues that drive the vote and AKP predictably aims to use healthcare to garner votes in the upcoming general election in June.

On the other hand, AKP juggles wider access to healthcare with keeping healthcare expenditures low as deficit has a direct impact on Turkey’s credit rating. The two objectives being at odds, there is no way to optimize a real solution in the short term so marginal payments for healthcare services were introduced and also a set of regulations depriving citizens who owe on insurance premiums was passed. The new law cuts cost further by pushing out of the social welfare system, not only unemployed and seasonal workers but also women, who are increasingly under-employed under the AKP regime, by excluding them from health insurance coverage as dependents of their families. (Cosar/Yegenoglu 4/09). Government cash reimbursements for state health benefits to hospitals is also being reduced, controlled and delayed.

The Turkish State Statistics Agency conducted a 2009 report on public satisfaction reporting a 15 percentage point increase in overall satisfaction with healthcare services since 2003 to 65%.   While AKP,s move to allow citizens use their state benefits at private hospitals gained public praise, the highest driver of dissatisfaction was healthcare worker availability, followed by the response to a leading question “How satisfied are you that doctors serving at public hospitals are allowed to have their private practices?”. The construct of this state survey foreshadows the AKP agenda to force doctors to leave private practice positions to only work in public hospitals.

70% of all Turkish inpatient healthcare facilities are publicly owned. According to a brand new set of healthcare regulations, doctors working part-time in state hospitals must now close down any private offices, giving up their only meaningful income. In state hospitals, compensation has been switched to become proportional to the number of patients examined and the number of surgeries performed. Appointments are dictated at 5 minutes per patient and no more or the doctors pay is cut, a move that seriously increases the likelihood of malpractice. 

In response to the new regulations, doctors in the public sector began resigning to practice privately. AKP then confronted them with a new by-law which enumerated unreasonable requirements for private offices including dictating the office size, the dimensions of the doors and the number of toilets, effectively precluding opening of a new office. This new by-law compelled most of the doctors who only worked in their private practice to quit working.

Pay for performance system dictates that training of residents at teaching hospitals is now neglected due to an abnormal schedule and patient overload. Furthermore, to cosmetically increase the number of general practitioners referred to as “family doctors”, a grossly inadequate 10 day training was implemented for medical school graduates who lack specialization, following which, they are allowed to serve as general practitioners. The AKP regulations are thrown together in haste, without either consultation with medical professionals, or consent from professional associations. More importantly, they endanger public health and health education for the price of making short term cosmetic changes.

On one hand, AKP is coercing physicians to work only for state run hospitals, on the other hand, it is squeezing out private hospitals not affiliated with its sympathizers: It holds the purse strings of state benefits reimbursements to private hospitals, and has control over the cash position of each hospital. Medical Park chain, 40% of which was recently sold the US firm Carlyle, or example, is rumored to be owned by those close to the prime minister. Remainder of the private hospitals have to deal with a severe cash constraint imposed by the government and were told they can increase co-pays from 30% to 70% in order to make up the shortage, making them very expensive.

In March 2010, AKP adopted a State Hospitals Union Bill which requires a gradual privatization of all state hospitals.  While the move is concealed as an attempt to bring market economies, it actually aims to sell off state hospitals to the highest bidder with no concern for public health. Privatizing the public system will decrease the quality of the healthcare and eradicate an important safety net for the working class.

Doctors, nurses, pharmacists, lab technicians- the entire community of healthcare workers are dismayed about AKP’s policies held what may have been the largest public protest in the capital city of Ankara on March 13th. Over 30,000 professionals from all over the country traveled to Ankara, the capital to hold a protest together in harsh winter conditions. Photos from the event can be seen on www.tabip.tv but there was no significant media coverage of the event. While this is partially explained by the fact that media outlets have been quieted, neither of the main opposition parties CHP and MHP made meaningful endorsements of the healthcare professionals cause. Both have refrained from aligning against the AKP on the healthcare issue since the consent AKP has “manufactured” around its success of its health policies. 

Not standing up against AKP’s slow murder of the Turkish healthcare system is a mistake CHP and MHP must avoid making.  Healthcare is AKPs Achilles heel and laying out an alternative plan that saves public health and addresses the valid concerns of the Turkish healthcare professionals could help the opposition win the next election.

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