By Cansu Canca
In July, the Lancet covered Turkey’s development and implementation of universal health coverage extensively in an article and in supplementary comments. The main article, written by those who are directly involved in the development of the health systems reform (including the former Health Minister), presents a success story. Within Turkey, however, the success of the reform has been disputed. Two points in particular are being repeated by the Turkish Medical Association (TTB), doctors, and journalists: the negative effects of the reform on (1) the quality of health care personnel and (2) privacy.
1. Quality of health care personnel
One of the most disputed elements of the reform is the “full-day rule.” This rule requires doctors who are employed in public institutions to work full-time and not to engage in parallel private practice. The Lancet article acknowledges that this rule resulted in resignations of some clinicians. But it then quickly goes on to cite an overall increase in the number physicians and other health care personnel working in public service.
This passing point in the article has been extensively discussed in Turkey. What the article fails to mention is that according to several reports in Turkey, the resignations of high numbers of experienced physicians caused a chaos within the public system. Newspapers reported that Istanbul’s largest public hospitals became unable to perform surgery because of these resignations. It has been claimed that the education in teaching hospitals is also suffering.
In addition, doctors have voiced concern about how the number of family physicians and medical students has increased with the new regulations. A specialist in family medicine explained it to me as follows: Before the regulations, one had to specialize in family medicine in order to serve as family physician. With the new regulations, medical doctors are allowed to practice as family physicians after a seven day workshop regardless of their original area of specialization. Moreover, the number of admitted medical and nursing school students increased even though the educational infrastructure was not developed in parallel.
The Lancet article dedicates a section to the new system to monitor pregnant women. It refers to the positive effects of this system for antenatal care and subsequent birth. In this respect, this system is certainly very useful, especially in lower socio-economic strata. But the article does not mention the rule’s effect on privacy and what this may mean in the Turkish setting.
The system to monitor pregnant women has been a topic of ongoing debate within Turkey. The system requires physicians and nurses to contact every pregnant woman within their area to have them come for their examinations.
With about 3500 patients registered to every family physician, such a requirement can demand significant time and effort. Cases have surfaced where the overwhelmed health care personnel contacted a woman’s father, called up a woman’s husband, or simply showed up at the door explaining the pregnant woman needs to come for her antenatal care not knowing that she secretly had an abortion. Such a violation of privacy is problematic in any circumstances. In Turkey, however, it is possibly life threatening. There is a strong tradition against sex before/outside marriage, a long history of honor killings, and a high level of violence against women.
It is not clear whether these problems are just the expected side effects of an otherwise successful system, or alerts of its failure. While the Lancet article and the government’s progress report paint a beautiful picture, the question remains a hot topic of debate within Turkey.