On the Consequences of Health Policy

Making the public feel that they are being offered the best in health policies is an important part of the propaganda strategies of all governments all over the world. In Turkey, it was not difficult to foresee that health policies would be the starting point for the AKP government, which won 363 out of 550 seats in the Turkish Grand National Assembly with 34% of the votes in the November 2002 elections. Just as it was the result of an understanding that the votes of almost half of the people were left unrepresented in the Turkish Grand National Assembly, for the AKP, predicting the political orientation it would prefer in order to carry such a result was merely a function of the same results.  
Coming to power with populist rhetoric about queues in front of hospitals, AKP launched the ‘Health Transformation Programme’ (HTP) with a catchy slogan in 2004. Increasing the share of global capital in the Turkish health system was one of the agenda items of all international health conferences since the 1980s. For this purpose, it was necessary to completely abolish the system established by the ‘Law on the Socialisation of Health Services’ No. 224, which prioritised preventive health and aimed to expand and increase the effectiveness of primary care services. This reality was the starting point of the SDP's road map.
In fact, while the problem could have been solved by establishing a referral chain, reducing the burden on the 2nd and 3rd steps and improving primary care services, an alternative political choice was made that would have been much more expensive and whose consequences would have been more devastating than anticipated. Moreover, with practices such as ‘General Health Insurance’ and ‘co-payments’, the increasing costs were placed on the backs of those benefiting from public services. While one of the objectives of the SDP on paper was announced as ‘reducing the increasing per capita health expenditure costs’, health expenditures increased five times in 10 years in dollar terms with the implementation of the implementation. 
Treatment-orientated health systems not only failed to protect public health, but also led to large increases in the health expenditures of countries. In Russia, large hospitals built after the revolution as a symbol of state power led to the collapse of the health system in the 1980s. In contrast to the preference of the previous years, in 2004 Turkey started to take steps towards a treatment-oriented system that almost eliminated preventive health and primary care. In order for the public to accept the policy, the 2nd and 3rd step health services of the previous period, which were deemed inadequate, were used as propaganda. In this propaganda, not the quality but the quantity of the service was emphasised. Because the quality is quite good. In addition, the question ‘What should be the quantity of 2nd and 3rd step services?’ is a matter of serious debate.
The deficit in secondary health care services created by the implementation of the SDP was closed by agreements with private hospitals. Thus, everyone has been able to access secondary health care services easily. However, the lack of an effective supervision system has led to two important consequences. The first is that the state has incurred losses due to the inadequacy of the contracts made with these private health institutions. The second is the loss of public employee status of health workers and the proletarianisation of the qualified labour force in the field of health. The failures that emerged for the public receiving health services from these institutions remained as outputs that could not be easily detected and produced serious consequences as a result of inadequate health services. 
As the cost of health expenditures increased, the cost of services provided by private health institutions also started to increase for citizens. Contribution fees show a continuous increase periodically. Afterwards, the treatment-oriented system started to dictate its own needs with its own dynamics. As a result, ‘City Hospitals’, which are seen as a big mistake with the results they have created in the countries where they have been implemented, have started to be built. The COP (public-private partnership) method preferred in the construction of these hospitals in Turkey has put the treasury into a debt spiral that will last for years. In addition to the problems caused by the fact that these hospitals are much larger than the optimum size envisaged for health institutions, the problems created in the health system have been devastating due to the closure of hospitals that provide effective service with their institutional culture. 
In public service provision, services that must be provided by the state, such as health and education, are called administrative public services. The purpose of this is to avoid the problems caused by leaving the provision of these public services to the private sector. Although there is no harm in the private sector being authorised to provide these services, it is essential that the public sector should have full control and that the public sector should continue to provide these services no matter what. The private sector, which is authorised to provide public services, must provide these services under the effective and continuous supervision of the public sector. This is already the definition of public service. 
In fact, when the health transformation programme was initiated, policy texts emphasised the role of the public sector as a policy-maker rather than an implementer and stated that the public sector should be withdrawn from implementation as much as possible. In this respect, the SDP seems to have adopted an approach that erodes the administrative nature of public services. It should be noted that nothing happens by chance in the field of public policy. The results of public policy are to a large extent foreseeable or expected. When unforeseen consequences arise, they should be immediately put on the agenda and resolved by policy makers. 
When an administrative public service is thrown into the gears of a mechanism that operates according to market rules, it is difficult to supervise and control it. Throughout history, the greed for money has been so threatening and persistent that it can pulverise the most stringent rules. Therefore, public policy processes are only effective if they are matured with the participation of stakeholders. If they are shaped solely according to the interests of capital (and the global capital that stands behind it), it can be difficult to predict where the results will lead. Therefore, public policy processes should be carried out in the public interest. 
When the SDP was put on the agenda, a package that was not clear how, where and by whom it was prepared was implemented as public policy in a very serious area such as health. When we look at the public policy results that emerged in the long term, it can be understood why policy processes were skipped. Each of the problems I have written below can be confirmed by asking the associations and trade unions fighting for the rights of health workers. However, I still think that I have been able to write very few of them. 
First of all, individual expenditures on health have increased and insurance companies and private health institutions have profited from this. Preventive health practices were pushed to the background, resulting in an explosion in drug use and expensive examinations. In the same period, a large part of the Turkish pharmaceutical industry was taken over by foreign pharmaceutical companies. In serious chronic diseases, patients' rights have regressed, and in some diseases, treatment has become impossible for those who cannot afford it. It has become more difficult than before to be examined by specialists, and health workers have lost their rights in every field and entered a process of proletarianisation. Health workers have been thrown in front of the masses of public service providers and the increase in violence in health has been condoned due to purely political preferences. Medical education has suffered a great blow, and professors in faculties have been forced to prefer the private sector. Health workers, including retired civil servants in general, have become afraid to retire due to usurped pension rights and have been forced to continue working. Profits of international pharmaceutical and medical device monopolies from Turkey have exploded. In the past, SSK used to purchase a medicine at one tenth of the market price, but this system has collapsed and the national pharmaceutical industry and local entrepreneurs have been destroyed. Military pharmaceutical factories have been closed down and the state has suffered enormous losses.
Private health institutions have been able to recruit qualified health workers at very cheap prices much more easily than before. More serious than this, there has been a great increase in corruption in private health institutions. The latest example of this is that a gang, which is a disgrace to humanity, did not hesitate to kill innocent newborns for money. The architects of the SDP are the ones who created this picture, the details of which make us ashamed of our humanity. Now no one can evade political responsibility and say to the people ‘look at the bird’. The cap has fallen off and not only the bald head but also the malicious brain behind it has been seen. The Turkish people have to face the political consequences of a looting order that has been ignored until today. Everyone should know that this will not be done by saying ‘God damn them’. 
Trade unions, associations, professional organisations and chambers active in the field of health must come together and seek ways out of the political wreckage created by the SDP. Otherwise, the health of the Turkish people is about to be irreversibly damaged. The concept of PUBLIC INTEREST is the litmus paper to reveal the mistakes of the SDP. Which practice has served the public interest? The anti-scientific vested interests who take the title of professor and strive for the establishment of this system should answer this question. 
Today, if we are discussing the nationalisation of private hospitals (which I agree with), we should also discuss the closure of state hospitals, dispensaries, ignored preventive medicine, the quagmire that the treatment-oriented health system has put Turkey in, city hospitals and the unfair profits obtained from them, within the framework of the public interest. And with as loud a voice as possible. In other words, the issue requires a struggle much more than just trying to fix the system where we can see that it is broken. If you try to have the transformation in health policy implemented by those who do not know the meaning of public policy, there will be neither public interest nor public health...