Rethinking Health Policy

Health policies are the priority of every country in order for the economic and social life of countries to function uninterruptedly and effectively. One of the important factors in the change of political power is the failures in health policies. Accessibility, quality and cost of health care for every population is very important. For this reason, political authorities have to give special importance to the satisfaction of the people with regard to health services. Because health policies are the policies with the most visibility and the widest area of ​​influence among public policies. Health expenditures, which have a significant share in the Gross Domestic Product (GDP) of countries, also emerge as one of the most important expenditure items in budgets. From another point of view, it is an important public service that structures the legitimacy of political powers. The reason for the existence of hospitals, which can be shown as an example of the misuse of public resources (with unnecessary luxury and a size above the optimal size), although there is no real benefit in addition to an understanding of quality only on the basis of the service provided, is to create the legitimacy ground they need for political powers. An example of this is the Russians' demonstration of the power of the state by building large hospitals after the October Revolution. However, this irrational system became impossible to sustain by the 1980s.

While constructing health systems, models suitable for the needs and socio-economic structure of each society can be preferred. However, as one moves from the primary to the tertiary level, the cost and scope of services increase, and the opportunities for access to services decrease/should decrease. The strong establishment of primary care reduces health expenditures. In addition, the effective establishment of the referral chain instead of making unnecessary hospital investments is part of what should be a cost-effective system. Effective communication and data transfer between levels is also an element that increases the efficiency of the system. Health as a public service is a public service of an administrative nature. In order for a public service to be of an administrative nature, it is expected not to fulfill at least one of the following characteristics; (Eyes, 2007: 205)

The subject of the service should be similar to the activity of private enterprises.
The service must be financed by the money paid by the users of the service.
The service should be operated according to private sector procedures.

In other words, an administrative public service is a public service that the state can never abandon. The answer to how the state will provide a public service is in public policy. The question of how the state organization relates to all public services is answered by public policy. Health policy is also part of public policy. The answer to the question of how is also the answer to where and how the resources will be transferred. In other words, a country's health policy is also a decision of the political power, which is in the decision-making position in the public policy process, about where and how much resources will be transferred.

If the created health policy largely privatizes the health service delivery and establishes a hospital-based health system, it means that the resources will be transferred to the world's pharmaceutical and medical device companies rather than the public's health. Although it is a matter of much debate whether health care is paid or free here, in a marketized system, free health care system serves to transfer money from the state to drug and medical device companies. If the implemented policy strengthens primary care and preventive health, operates the referral chain effectively, and removes private hospitals from the social security system to a large extent, then it will be possible to raise funds for the health service to be free to a large extent.

Being aware of the results of the implemented policies may not be in the perception of the public most of the time. In this sense, it may be a good method to compare the country's health data with international data. However, what is being compared here, what the comparison means must be interpreted scientifically. OECD statistics provide a good database enabling international comparisons of health policies. While examining the data in this area, it would not be scientifically correct to consider a few data and conclude that the health system is effective or ineffective, but a better understanding of the differences between political discourses and scientific facts can be achieved.

According to OECD statistics for 2019, when the ratio of health expenditures to GDP is analyzed, it is seen that the USA is the country that allocates the highest share to health with 16.8 percent, while Turkey is in the last place with 4.3 percent. Considering the 2020 data (in the table with temporary data of some countries), significant increases are observed in the expenditures of all countries during the pandemic process. For example, the rate increased from 10.2 percent to 12.8 percent in England. Looking at the expected life expectancy, Turkey has an average life expectancy of 78.6 

and the Slovak Republic, Poland, Mexico, Latvia, Lithuania and Hungary. While the USA ranks first in health expenditures per capita with 11071 USD, Turkey ranks above Colombia and Mexico with a health expenditure of 1337 USD per capita in 2019, where the OECD average is 4222 USD. Of course, money is not the only factor that determines the success and effectiveness of the health system. For example, when we look at the maternal-infant mortality rates, Turkey differs significantly from other countries, with the rate of 9 per thousand, with the exception of Mexico and Colombia. Although there has been a continuous improvement in the data of the Ministry of Health since 2002, OECD statistics on infant mortality rates have a data of 17 per thousand for Turkey between 2005 and 2011 only in 2008. As a country that provides regular data to the OECD, it should be questioned why Turkey does not transmit the data on the Ministry of Health page to the OECD or whether there is a problem in the methodology of the transmitted figures.

The "Health Transformation Program", which started to be implemented in Turkey in 2003, is a complete policy change in terms of political power. It is useful to take a brief look at how we got here. In 1961, Dr. Law No. 224 on the Socialization of Health, prepared by Nusret Fişek, was designed on the dissemination of 1st level health services and preventive medicine practices forming the backbone of the health system. In the period that started with Muş in 1963 and actually ended with the Health Transformation Program in 2003, health centers and primary care services were extended throughout the country. However, this Law, which can be an example even for today, was abolished before it could fully reach the expected targets due to the insufficient allocation of funds by the governments, inadequacies in training qualified personnel and deficiencies in infrastructure.

The newly emerging approach in public administration since the early 1980s announced the beginning of the neo-liberal era in which the state was reduced to the position of policy maker and supervisor in the delivery of public services. Meanwhile, clues regarding the health service delivery of the next period were also evident in international conferences. The 1978 Alma Ata Declaration emphasized the multisectoral nature of health care. Although emphasis was placed on public health in these conferences, IMF "Stand by" agreements and World Bank loan agreements continued to shape the health policies of the new era.

In the document prepared by the Ministry of Health for the Health Transformation Program, what is written under the title of "Diagnosis" really gives the impression of seeing what will happen in the future (Ministry of Health, 2012: 21). In the "previous" system, it is mentioned that the limited access to health services and the inadequacy of the payments of health workers are mentioned. However, the health system needs to be evaluated correctly from two aspects. The quality and quantity of health care are two different things. The solution to the quantitative inadequacy of a correct system should not be to abolish that system. At best, this approach can be policy discourse to justify the decision to allocate resources. Let's end the issue here in order to discuss the Health Transformation Program as a whole in another article, together with the problems experienced by healthcare professionals today. Let's continue our evaluation based on OECD data.

Interesting results emerge when we look at the proportions of doctors and nurses studying abroad in OECD data. Countries employing the highest number of foreign-trained doctors; Australia 32%, Canada 24%, Chile 23%, Israel 57%, Norway 41%, Sweden 28%, Switzerland 37%, England 30%, USA 25%. Of course, a small part of the doctors trained abroad consists of the citizens of the country who studied abroad. When we look at the data on the displacement of nurses, it is seen that the same countries employ nurses who have received education abroad at a higher rate than the others; Australia 18%, Israel 10%, Switzerland 26%, England 16%. However, it is also seen that the rate of international displacement among nurses is less than that of doctors. On the other hand, in Turkey, it is seen that there are 0,19% of doctors and 0,3% of nurses, employment of health workers with education abroad, which is far below the OECD averages.

Training of health personnel requires cost and time for countries. For this reason, their replacement is not easy and their professional satisfaction is very important for the healthy functioning of the system. However, the phenomenon of marketization in health transforms the labor of this specially educated mass into easily tradeable labor. Here, it is possible to say that private health enterprises have an impact on the health labor market. However, in the final stage, it is the public that determines the price of the labor required for an administrative public service. The effect of private health enterprises on public administration 

The size of the person is a pressure factor on the public administration. What matters is the effectiveness of this pressure. That is, on whose side the public takes a stand. Regardless, it is necessary to be more careful in determining the price of educated labor suitable for international circulation so that the health service in the country is not disrupted. When we look at the figures especially among doctors, it is seen that Turkey is not in a position to use the labor coming from outside, but to lose the labor she has trained herself. In OECD data, it is also seen that the international mobility of doctors is from low-income countries to high-income countries. This situation makes the international mobility of personnel trained at high costs a public problem for countries like Turkey. However, in order to create a public policy, the existence of this public problem must first be accepted. Here, I tried to draw a general framework for health policies. Of course, we are talking about a multidimensional field and such a superficial evaluation is not enough. However, from the perspective of public policy, I think the details that cannot be seen in the technical field seem more obvious.

With my love and respect...

References:

Kemal Gözler, (2007), Introduction to Administrative Law, Ekin Bookstore, (7th Edition), Bursa.

Ministry of Health, (2012), Health Transformation Program Evaluation Report (2003-2011), Ankara.

https://stats.oecd.org/ , 24.02.2022