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In Turkey, new goals for health care.

In Turkey, New Goals for Health Care

The opportunity and ability to enjoy a healthy life is, indisputably, a basic human right. As a consequence, governments are responsible for delivering health care to all. Within this framework, physicians must assume the ethical responsibility for doing their utmost to achieve this goal.

Health Care Delivery in Turkey

In the early years of the Turkish republic, founded in 1923, health resources were extremely limited and epidemics repeatedly scourged the nation. The early governments of the new republic gave priority to controlling communicable diseases and improving the health care system.

Basic health care resources have been greatly expanded. Despite a nearly fourfold increase in Turkey's population between 1927 and 1987, the overall physician-patient ratio has improved dramatically, from one physician per 12,842 persons in 1927 to one per 1,360 in 1987. There has been an equally significant improvement in the ratio of nurses and midwives to patients (from 1:8,935 to 1:764), and the number of available hospital beds has risen from 3,615 to 128,146.[1]

At present, the system of health care delivery in Turkey is reasonably well-organized. The 3,142 Ministry of Health-sponsored health centers in the rural areas deliver integrated preventive and curative services. Each center serves an average population of 7,000 and is staffed by one physician and three to five nurse-midwives.[2] Primary health care in the cities and towns, on the other hand, is delivered by private practitioners in their offices, in dispensaries, and in the out-patient units of hospitals. Secondary care is administered by publicly owned hospitals. They include the hospitals of the Ministry of Health (MOH), Armed Forces, State Universities, and Social Security Agency (SSA). Only 4 percent of the hospital beds in Turkey are in private health care institutions.

Both the government and the SSA employ physicians and other health personnel on a salaried basis. Sixty-seven percent (two-thirds) of Turkey's physicians are in government employ, but retain the right to practice privately after working hours. One-third of Turkey's total number of physicians work exclusively in private offices or in private hospitals.

Sixty percent of the population is fully insured, either by the government or the SSA. Public servants, public pensioners, and their dependents enjoy free-of-charge care in hospitals affiliated with the MOH. To enjoy similar service in hospitals and dispensaries belonging to the SSA, one must be employed on a wage basis; pensioners and dependents may also avail themselves of these services. As for the urban self-employed, their social security organization, BAG-KUR, pays the MOH or SSA hospitals for service delivered to their members, pensioners, and dependents.

The rural population and transiently employed individuals in the cities and towns are not insured at present, though the government plans to incorporate them into the insurance scheme in the near future. Patients, insured or not, who are willing and able to pay for health care may freely choose their own physicians or hospital. They have access to care at no cost, but they may not choose their physicians or hospitals if they wish to enjoy free-of-charge care. Persons insured by the SSA must apply to SSA hospitals and dispensaries. Public servants are served in the health centers and hospitals of the MOH. Ambulatory care for noninsured persons is free of charge in the health centers of the MOH, except medication. They must also pay for hospital care if they cannot demonstrate indigence. The costs of hospital care are assessed on a uniform fee-for-service basis regardless of who pays for care.

Personnel shortages and lack of health facilities are not the primary limiting factors in the satisfactory provision of health care for all. Rather, inadequate finances, poor management, and limited popular use of available services are the major problems to be resolved if the health standards prevailing in Turkey are to be elevated.

The reasons underlying the inadequate financing of health services are twofold. First and foremost, Turkey is not a rich country; internationally it is classified in the middle-income group. Average per capita income is around $1,160 U.S., and income distribution is unequal. Thus the lowest 20 percentile of the Turkish population earns 3.9 percent of the total national income, while the income of the highest 20 percentile accounts for 55.9 percent.[3] The majority of the families not covered by governmental health insurance are in the lower-income groups.

Inadequate financing is also due to the fact that governments no longer give high priority to health services. The annual per capita expenditure for health care by government agencies, including the SSA, is about $12 U.S.[4] Another indicator of the low priority attached to health care is the Ministry of Health's relative share in the national budget--2.7 percent. Direct payment by patients to physicians, pharmacies, and hospitals was $51 U.S. per capita in 1985.[5]

As in most developing countries, the provision of health care is considerably impaired by poor management as exemplified by poor planning, improper allocation of available resources, and incorrect decisions on priorities. This makes itself distressingly apparent in the lack of cooperation between primary, secondary, and tertiary health care units. Given the present lack of schools of public health, the problem of training qualified public health administrators will remain unresolved, at least into the near future.

Moreover, the general population is reluctant to consult physicians for their minor problems. A vast majority of the population just do not believe it necessary, or important enough, to spend their limited time and money on such minor complaints as coughing or diarrhea. In the absence of folk practitioners, self-care with home remedies or with drugs bought from pharmacies is preferred for many common ailments. This does not reflect a lack of confidence in medical professionals, but simply neglect and nonchalance. In the rural areas, there is also the problem of having to travel long distances for health services. The number of out-patient physician consultations made by insured persons, though free of charge, was 1.5 per year in 1985, whereas the same figure was 6.1 for the OECD countries.[6] This reluctance to seek medical care is a major factor underlying Turkey's high infant mortality rate.

Level of Health

The level of health in Turkey is relatively low compared to the country's level of socioeconomic development. Life expectancy at birth, for example, was only fifty-nine years in 1975.[7] When compared with those in developed countries, age-specific death rates also show that women in their reproductive years and children are at high risk. This is demonstrated by the fact that in 1975 the maternal mortality rate was 207 per one hundred thousand live births, and the infant mortality rate 120 per thousand live births. Infant mortality declined to 90 per thousand in 1983.[8] In contrast, the health level of the general adult population is not so far removed from that in the developed countries. Life expectancy at five years of age, for example, is sixty-five, and age-specific death rates, after forty-five years of age, are close to those in the developed countries.[9] The most killing diseases for adults are cardiovascular and cerebrovascular diseases and neoplasms. For children, the "killers" are neonatal, diarrheal, and acute respiratory diseases.

All children throughout the country are routinely immunized against diptheria, tetanus, whooping cough, measles, poliomylitis, and tuberculosis. Malaria, the big scourge of the past, is almost eradicated. The most important communicable diseases at present are tuberculosis and food- and water-born diseases. The prevalance rate of tuberculosis was 3.6 per thousand in 1985, while the risk of infection was 0.8 percent. The most prevalent food- and water-born disease is infectious hepatitis, of which 26,318 cases were reported in 1988. Cases of salmonellosis and dysentery occur sporadically.

Ethical Issues and the Turkish Medical Association

Chartered by Turkish law, the Turkish Medical Association (TMA) is a nongovernmental public organization. It consists of a Central Council and forty provincial chapters, the officers of which are elected by the physician-members. Physicians in private practice must be registered, dues-paying members, and membership is also compulsory for those in part-time government employment. In contrast, membership is optional for full-time government physicians.

The TMA is responsible for supervising relations between individual physicians, between physicians and other health personnel, and between physicians and their individual patients. It is also charged to assist in raising health standards in Turkey. Among the TMA's major concerns are access to health care, primary and continuing medical education, and physicians' professional conduct.

The TMA firmly believes that access to health care, both public and private, is an inviolable human right, and that insuring such access is one of the primary responsibilities of the medical profession. It is not the sole lot of physicians themselves, however, to fulfill this responsibility. Adequate provision of health care is dependent upon a host of factors, including adequate financing, proper management, and the health education of the public. The TMA's basic policy is to press both the government and the opposition to accord health care high standing among national priorities. The TMA also insists upon active member participation in the health education of the public and cooperation in raising the standards of health care.

The TMA views medical education as the basic instrument with which physicians provide the best of medical care not just to their individual patients but to the general public as well. Prior to 1980, the quality of training received by Turkish physicians was comparable to that of their counterparts in developed countries. Following the 1980 military intervention, and the establishment of the Council of Higher Learning, the number of students accepted into Turkey's various schools of medicine was radically increased. This increase in the number of medical students, however, was not accompanied by increase in teaching resources such as funding, facilities, or staff. Although it may surprise many, Turkey will soon suffer from an inflationary excess in the number of physicians and, consequently, unemployment in the medical sector. The TMA is wary of the possibility that violations of medical ethics may become widespread in the future, not to mention the further possibility of deterioration in the quality of health care.

Another significant problem facing Turkish physicians and the TMA is the unplanned, uncontrolled, unguided character of the continuing education of physicians. While specialist societies organize congresses, conferences, and symposia to keep their members up-to-date on developments in their particular fields, general continuing education is left entirely to individual effort. The TMA, the Ministry of Health and Social Assistance, and the various schools of medicine are at present seeking ways in which to coordinate the disorganized efforts for realizing the continuing education of physicians.

The TMA has not resolved the problem of the relatively low level of physician salaries and the inferior working conditions in which they are obliged to provide health care. These problems are particularly accentuated in government and SSA-operated hospitals. Members of the medical profession do not have the right to strike or undertake other work-related actions such as slow-downs. As a consequence, direct action to improve the conditions is ineffective.

Physicians in private practice are able to provide high quality care to their patients. In the public sector, however, where care is provided by governmental and semi-governmental organizations, with their overcrowded and understaffed polyclinics, the quality of health care drops sharply. Correspondingly, complaints about physician negligence increase radically, and even the most diligent physicians come under unwarranted and unjustified criticism. The TMA continues to take the stand that responsibility for this state of affairs rests, not with the medical profession, but with the government. Accordingly, it calls for a determined effort to increase the quality of medical education and the effectiveness of providing health care.

Family planning is a further area of concern for the TMA. Prior to 1960 the sale of contraceptives and the dissemination of contraceptive knowledge was forbidden. Through the efforts of a handful of physicians, birth control is today both legal and an integral part of Turkey's population policy. Similarly, up till 1983, abortion and sterilization were legally allowed only for medical reasons. Today, however, they are permitted upon a woman's request, with her husband's consent. In vitro fertilization and embryo transfers are relative newcomers in Turkish medical practice. With the approval of the TMA, the government now allows these methods of conception, though couples must bear the costs of such treatment themselves. References [1]Nusret H. Fisek and M. R. Dirican, "Fifty Years in Public Health" (in Turkish) in Proceedings of TUBITAK IV Scientific Congress (Ankara: Turkish Scientific and Technical Research Council, 1973), 1-22; and Ministry of Health, "Statistical Informations" (Ankara: Ministry of Health, 1988), 13. [2]Nusret H. Fisek, "The Integrated Approach to Health Care: An Example of Turkish National Health Services," in Team Work for World Health, G. Wolstenholm and M. O'Connor, eds. (London: J.A. Churchill, 1971), 55-76. [3]Yilmaz Esmer, Hamit Fisek, and Ersin Kalaycioglu, "Household Income, Expenditures, and Socio-Economic Needs" (in Turkish), TUSIAD vol. II (Istanbul, 1986), 16. [4]Ugur Cilasun, Health Expenditures in Turkey (in Turkish) (Ankara: Meltem Matbaasi), 17. [5]Fisek, "The Integrated Approach to Health Care." [6]Organization for Economic and Cultural Development, Financing and Delivering Health Care (Paris: OECD, 1987), 73. [7]Frederic C. Shorter and Miroslav Macura, Trends in Fertility and Mortality in Turkey, 1935-1975 (Washington, DC: National Academy Press, 1982), 95. [8]Population Study Institute, Population, Family, and Health 1983 (in Turkish) (Ankara: Hacettepe University, 1986), 31; Samira Yener, Mortality Informations from 1974-1975 Demographic Survey (in Turkish), unpublished doctoral dissertation, School of Health Sciences, Hacettepe University, 1981, p. 45. [9]Nusret H. Fisek, Introduction to Public Health (in Turkish) (Ankara: Institute of Community Medicine/Hacettepe University, 1983), 188. Nusret H. Fisek is a physician and philosopher, and is president of the Turkish Medical Association, Ankara, Turkey.
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Author:Fisek, Nusret H.
Publication:The Hastings Center Report
Date:Jul 1, 1989
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