A slowing economy and rising healthcare costs, coupled with a possible crackdown on physicians’ moonlighting, could reverse gains made by Turkey’s decade-long overhaul of its healthcare system.
Broadening access to high-standard healthcare has been lauded as a key achievement of the Justice-and-Development-Party (AKP) government since it came to power in 2002. In 2003, only 24 percent of Turks from the poorest 10 percent of society had health insurance, according to a survey of 25,290 households by the Turkish Statistical Institute. In 2011, that figure had risen to 85 percent of 3,551 households surveyed. Correspondingly, overall satisfaction levels with healthcare among queried households increased from 39.5 percent to 75.9 percent.
But now, economic trends are pointing to a rockier future. “There’s been a significant increase in healthcare expenditure at a rate well above the rate of GDP growth, and that can’t continue forever,” said Martin Raiser, World Bank country director for Turkey.
Healthcare expenditure increased by 11 percent per year between 2002 and 2011, according to Raiser. Over the same period, Turkey’s average Gross Domestic Product (GDP) growth was around 5 percent. The World Bank recently reduced its growth-predictions for 2014 from 3.5 percent to a mere 2.4 percent. Economists widely predict lower growth rates over the coming years as well.
That slowdown likely could increase unease within the medical profession; some doctors claim a government effort to prevent state employees from moonlighting in privately owned medical facilities risks driving the best-qualified physicians out of the state sector.
In 2014, base monthly salaries for doctors and specialists working in state hospitals were 3,456 liras ($1,612) and 4,187 liras ($1,953), respectively, according to an announcement by the Ministry of Finance. (Performance related-bonuses can increase these amounts substantially).
Later this year, Turkey’s Supreme Court is expected to rule on an appeal by the government in a 2010 case, in which a lower court struck down an amendment to prevent doctors at university hospitals from working privately.
Macit Arvas, a gynecological oncologist at Cerrahpaşa, a prestigious university-affiliated medical facility in Istanbul, says he will quit the hospital where he has worked and taught for 34 years if the Supreme Court reverses the earlier annulment and upholds the law. “It would not be possible to go on working at the university hospital if they go through with this. The problem is making enough money,” Arvas, 61, told Eurasianet.org at the private doctor’s office where he works evenings, and as a specialist in a university hospital earns an above-average salary.
A similar moonlighting ban at non-university state hospitals has already driven many of the most experienced physicians to work full-time in the private sector, where salaries can be up to 10 times higher than those paid by the state, he added.
Ali Çerkezoğlu, head of the Istanbul Medical Association, agrees. “When the government brought in the restriction on working privately, they did not increase public sector pay,” Çerkezoğlu said.
“Many doctors escaped to private hospitals, especially successful and experienced doctors, and the result has been that the quality of care in the state hospitals has been decreasing.”
Currently, oncologist Arvas performs an average of one or two operations a day, mainly on cervical and uterine tumors.
“If people like me leave the university hospital, people without a lot of money will not be able to get proper healthcare—that’s the effect you’ll see,” he said. Government reforms have opened up university hospitals to citizens who could never have afforded them in the past.
Arvas also fears that an exodus of talent could drive down the quality of teaching, leading to a longer-term decline in professional standards.
In response to questions from EurasiaNet.org, a statement from the Ministry of Health asserted that the opposite was the case. It claimed that doctors’ part-time private work cut into their public and university commitments and, as a result, led to lower standards.
“This practice has negatively affected the education of assistants and the patient care services, and has opened the way to discontent in the service field,” the emailed statement read. “It becomes more difficult for doctors in their practices to focus on their job with the divided attention [caused by working privately].”
For now, both the government and Arvas are holding their breath for the Supreme Court ruling on moonlighting. The Health Ministry affirmed that the government will abide by the court’s decision.
Raiser, the World Bank director, who described Turkey’s healthcare advances of the past decade as “remarkable,” predicted the days of satisfied patients may be drawing to a close. Turkey will have to work harder to improve care in the future, he added. “Turkey will need to prepare for a situation in which the next generation will be assuming that healthcare access will be there and will increase their demands,” he said.