TRANSITION TO GENERAL HEALTH INSURANCE

SYSTEM AND DISADVANTAGEOUS POSITION OF PEOPLE IN

SOUTHEASTERN TURKEY: Finding an alternative

Prepared by
ÖZLEM GONCA YALÇINKAYA 1325604 Soc. 4

For
Soc. 307 Issues in State and Social Policy
Prof. Dr. YILDIZ ECEVİT

METU, 2007
Ankara

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 OUTLINE

• Introduction.

• Globalization, Neo- liberalism and Supranational Institutions.

1. Changing aspects of Welfare State related to social provision and security and the
understanding of citizenship.

• Structural Adjustment Programs for 3rd World Countries.

1. Its implication on internal affairs in Turkey and social security.
2. Privatization of the Health Services, Health Transformation Program.

• Transition to General Health System.

1. Family Doctor Program.

• People in the Southeastern Anatolia and Health Reform.

1. Probable effects of Health Transformation Program on people in the region.
2. Changing aspects of citizenship and loyalty of people in the region to Turkish state.

• Solutions to the assumed problems in General Health System by Ç. Keyder and A.

Buğra.

• Conclusion.

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 Turkey is one of the developing countries which are highly familiar with ‘neo- liberal’ and
‘neo- conservative’ discourses considering welfare state and social policy. In this regard, it is argued
that the grand solutions for the micro- level state problems have been outdated. These are the
argumentations supported in Millennium Development Goals as well as in the structural adjustment
programs by the supranational organizations such as World Bank and United Nations etc. in order to
minimize the state and reduce it mere a ‘night watcher’. Then, it is insistently emphasized that the
needs and the preferences of the individuals should be taken into account and should be left a room for
individual initiatives regarding the human rights and social justice. According to the neo- liberal
theories, as long as the individuality is stressed, by privatizing the social or welfare provisions, people
are able to use their own initiatives and be more rational and responsible. In this way, the market will
function properly and the social justice is able to be provided through the market mechanisms- luck,
hard work and ability- and developing countries are to be saved from the vicious circle of
underdevelopment and the over- determination of the state. In accordance to that, it is suggested that
general welfare services should be limited to the ones who are not able to receive the services through
market. In other words, the privatization of the services provided by the state should be transferred to
the market by abolishing the universal service provisions and adopting targeted and selective social
provisions. Hence, health care services are among those services which are planned to be privatized
and which will be no more provided by state itself.

According to me, health services are among the social rights provided by the state for its
citizens in the Turkish constitution. However, it has been argued that Turkey, as a candidate country
for EU, should rehabilitate the welfare services and adjust to the economic structure of the union.
Hence, General Health Insurance Reform is one of the issues Turkey tries to deal with. Considering
the health reform, it is supposed that all citizens will be united under a singular health program in
which people are supposed to contribute by paying health premium. In this paper, I will try to describe
the ‘General Health Insurance Reform’ and its probable effects on the people in the Southeastern
Anatolia Region.

To begin with, I plan to mention on the various aspects of globalization and global
governance. In this regard, I want to summarize the rise of neo- liberalism and rise of different
supranational organizations such as WB, EU, and IMF etc. In addition, I want to touch upon their
effects on welfare state and the changing trends on social provision, social security and citizenship.
Afterwards, I plan to refer to Structural Adjustment Programs and Millennium Development Goals
recommended for 3rd World Countries. Then, I will pass to the issue of General Health System. I want
to mention on three respective contents of General Health System (GHS) which are ‘privatization of
state hospitals, Family Doctor Program and individuals’ payment of premium to health services.’

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Regarding the issue, I want to intensify mainly on the people in Southeastern Anatolia Region. Here, I
will discuss the probable effects of GHS and the people’s probable reaction to this issue. As a
conclusion, I want to refer to the solutions carried out by Ç. Keyder and A. Buğra.

I. Globalization, Neo- Liberalism and the rise of Supranational Institutions:

Without understanding the engines that lead to the provision on welfare services, it is hard to
understand the GHS and the transition period. That’s why, in this section, I want to mention on
globalization, neo- liberalism and the rise of supranational institutions as the forces of globalization.

In the late 19th and early 20th centuries, there raised a notion of welfare state to hinder the
intensification of worker movements and the expansion of communism (Kazgan, 2005, p. 236). As a
result, the scale of facilities of state expanded and socialization of the market was experienced while
the market economy gained pace (Ibid.). As Hayek argued after the 1973 OPEC OIL Crises,
distribution of the resources should be left to market institutions (Sönmez, 2005). In this way, rational
decisions are on the way and the prodigality is to be prevented (Ibid.). Also, the governance should
gain pace all around the world (Ibid.). Coming to 1990s, as the threat of communism disappeared;
efforts towards the social states in Periphery became the target of democratization enforcements by
Center (Kazgan, 2005, p. 237). Kazgan (Ibid, p. 15) indicates that a new world system, originated
from USA, has emerged and diffused all around the world. It paved the way for economic liberalism,
export- oriented industrialization and the decay of nation states (Ibid.). The initiators of this new
system were Washington Consensus, multi- national corporations (MNC) and Wall Street - the finance
capital (Ibid.). Afterwards, WB, IMF, OECD and WTO joined this cooperation (Ibid. p.16). This is
how supranational institutions, which supersede the power of nation states, in terms of decision-
making, application of policies and control, emerged (Ibid.).

Keyman argues that globalization is a hegemonic discourse which is a turning point for
discussions both on analyses of international political, economic and cultural interactions after Cold
War and on the critics of modernization for a different version of democracy (n.d.). Related to that,
according to Koray (n.d.), globalization is about economics, technology and politics. As well, it affects
our life on regional, national and individual level (Ibid.). Further, it is about the production and the rise
of the financial capital against the investment capital (Ibid.). Hence, the new forces of global politics
seem to be the global firms (Ibid.).

This fact leads to the loss of power of nation states and the enforcements of transnational
institutions on them to behave as an agent of adjustment (Ibid.). They are convinced that they will
remain, otherwise, as old-fashioned (Kazgan, 2005, p.xvii). To make it clear, they are forced to
provide flexibility for the global capital as a condition to make investment in those countries (Koray,

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n.d.). They are advised to withdrawn themselves from any interference to free market mechanisms; in
this way, resources of production will be distributed justly for the welfare of the society (Kazgan,
2005, p. xviii). Then, state will be minimized and the sovereignty of the global firms will be
established (Ibid. p. 4). As well, they are forced to provide stability and trust for global firms (Koray,
n.d.). In addition, they are advised to unify their national economies with the global economy and
introduce rules of full competition and reduce the power of trade unions (Kazgan, 2005, p. xviii).
Moreover, it will be wise to privatize the market operations such as the duties of social state (Ibid.).

These enforcements result in loss of income and high rates of inflation and debt, which
inhibits nation state to invest for the welfare purposes (Koray, n.d.). So, development and economic
growth is not guaranteed in undeveloped countries, which are forced to adapt to the rules of
globalization and to liberate their national economies (Ibid.). In other words, the inequalities between
the regions become more and more intensified and the social rights of the labor side are regarded as
unjust demand now and then (Ibid.). That’s why, people become demanding more on individual
liberty, democracy and recognition for their identities etc. (Ibid.). From a different perspective, we
encounter with the rise of individualism and decline of social state- which is a balancing system
between different classes (Kazgan, 2005, p. 18). As such, deification of entrepreneurship and full free
market economy results in the rejection of public benefit and the resolution of the social state (Ibid.).
Hence, social benefit and cost calculations begin to be ignored as the profitability become
determinative of the distribution of wealth and income (Ibid.p.19). In this way, there established
individualism, rule of rationality, priority of free market and individual market (Özdemir& Özdemir,
2005).

As I have tried to indicate above, social state is related to the sphere of social rights and the
welfare of the society. Then, while talking about the shrinking of the welfare state, we should consider
its effect on the social rights and the welfare of the people who mainly need the welfare provisions in
order to live a humane kind of life. The retrenchment of social expanses, privatization of social
security and the state economic enterprises (KİT) are among the politic advises of supranational
institutions such as WB and IMF (Kazgan, 2005, p.237). Kazgan points out that revision of social
services is the most concern of most vulnerable groups in society since they are the ones who become
unemployed because of the prescriptions supervised by IMF and WB etc. and who can not meet their
health and education needs without the state intervention (Ibid.). Nevertheless, welfare states replace
with private institutions, which are substitutes of state subsidized social services (Ibid. p.238). In this
way, as Polanyi pointed out, economy will gain its autonomy from the politics and the public sphere
will turn into a market of exchanges (Bayramoğlu Özuğurlu, 2005).

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 This is the logic of globalization. It is globally assumed that privatization and full market
competition is inescapable and that is what is rational and profitable.

II. Structural Adjustment Programs for 3rd World Countries:

As I have tried to summarize in the first part, globalization necessitates a globally unified
liberal economy and political system. Hence, developed countries introduce prescriptions for
developing countries in order to make them suitable for their capitalist and imperialist hollowness.
Hence, in this part, I want to mention on the Structural Adjustment Programs of various supranational
institutions and on how their policies are shaped.

As Chossudovsky points out Bretton Woods institutions are the key agents of the restructuring
of global economy (1999, p. 16). IMF (International Money Fund), WB (World Bank) and WTO
(World Trade Organization) can be assumed as the regulators in terms of economic and financial
benefits of capitalist system (Ibid.). They are for the Structural Adjustment Programs, which are macro
economic reforms carried out in order to create neo- liberal economies whole around the world (Ibid.).
These programs remove the obstacles that can inhibit the movements of money and commodity across
the borders, irregulation of credit system and transfer of the property of state and land to international
capital (Ibid. p. 18). In addition, they advise developing countries to a sort of discipline budget,
devaluation, trade liberalization and privatization (Ibid, p. 40). To control their budgets and sustain
economic growth, individual states are given credits if they are to apply the policies recommended
(Ibid., p. 59). ‘Alleviation of Poverty’, ‘Social Emergency Fund’ and ‘The Social Security Network’
are the projects related to social engineering in order to decrease the cost of social anxiety for the sake
of creditors (Ibid. p. 79). They advocate for shrinking of the state and not interference of state to
public sectors (Ibis.). Then, they are carried out not to lighten the burden on people, but lighten the
burden on developed countries.

Related to the regulations in health sector, it is argued that the facts above are determinative:

1. The aging population.

2. The maturity of retirement programs.
3. The increasing costs of health care services.
4. High rates of unemployment.
5. Inefficient resources.
6. Inflation.
7. Limited social security.
8. The changing structure of employment and labor power, such as flexible labor etc.
9. The international migration and labor power.

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 10. International competition.
11. Neo- liberal tendencies.
12. The fall of East Block.
13. Demographic transition.
(Talas, 1992, p. 121, 125)
As a result of neo- liberal policies and working conditions, it is aimed at integrating people into social
security systems as individuals (Ibid.).

Considering EU, we should indicate the importance of the Maastricht Agreement. In European
Countries, Social security is arranged according to the imperatives of this agreement (Talas, 1992, p.
19). According to this agreement, universalized and institutionalized social services should be turned
into residual and selective services (Ibid. p. 20). In other words, only the people who are the neediest
ones deserve assistance and supervision of the state (Ibid.). As well, the assistance and the supervision
should be according to the individual differences and needs; that’s to say that, the social services
should be presented to the needy people according to the means targeted and needs assessment criteria
(Ibid.). In addition, the social policies should be arranged in accordance with active labor market
policies (Ibid.). Then, health care services should be regulated as it is able to keep people active in the
market and less dependent on the state. So, a state should not do these in order to sustain equality in
society and growth in economy (Özveri, 2005, p. 149):
a. Sphere of Social Security should not remain under the monopoly of the state; rather private
enterprises have to be able to compete in this sphere.
b. State should escape to redistribute the wealth and resources of the production and GNP.
c. There improved individual responsibility rather than social responsibility.
d. Only the poor people should be targeted in terms of social services.
e. The Social Security Network should be extended.

Stiglitz advocates that the cost of globalization is much more than the benefits of it (2004, p.
30). Talking about the benefits of globalization and neo- liberalism, abolishing the public enterprises
can lead to anxiety and chaos even private institutions can substitute of them (Ibid. p. 77). Inevitably,
IMF perceives the reality from the perspective of finance capital; for that reason, the interests of both
IMF and financial capital become similar (Ibid. 234). It is advocated that privatizing the health care
services will pull the costs of the services for individuals by the help of competition; but it is not as
good as in reality as it is in theory (Kocaeli Tabip Odası, 2003). Then, people are expected to
perceive social services, which are originated form their social rights as humans and citizens, as
labor which is a commodity to sell and buy in the market according to individual preferences
and choice as well as its price (Özdemir& Özdemir, 2005). Hence, sphere of social services will
turn into of individual consumption and taxation (Ibid.). As a result of the policies there closed down

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many schools and hospitals all around the world and old diseases were raised again (Chossudovsky,
1999, p. 37). In addition, national economies are turned into cheap supplies of labor and natural
resources (Ibid., p. 42).
Chossudovsky argues since there spared a limited budget for the social services as a sphere of
social rights, such as health care, health sector in developing countries began to decay and there
emerged a shortage of medical equipment (Ibid. p. 83). Further, work conditions and wages of staff
worsened; treatment of diseases replaced with preventive health care services (Ibid.). Moreover,
partial privatization of the health sector resulted in the exclusion of vulnerable groups who can not pay
the premiums (Ibid.). Then, reforms related to health care can be assumed as for the sake of the rich
people in free market (Ibid. p.84). It is argued that the contributions of rural people by paying
premiums are necessary for both efficiency and equality (Ibid.). However, this will lead in a social
polarization in terms of the system of health care services as well as limitation in these services and
intensification of exclusion of vulnerable groups who are already excluded in the existing systems
(Ibid. pp. 84- 85).

Considering the peculiar situation of Turkey, Somel argues that we are not ready for such
a reform (2005). We do not encounter with a demographic transition as it is in European
Countries (Ibid.). As well, corruptions rather than the rationale of Turkish welfare state inhibit the
economic growth (2005). To sum up, this prescriptions of supranational institutions, such as
WTO, IMF, WB and EU, are far from being ethical and just. In addition, they are not appropriate
for Turkish Context. As far as I understand, the main aim is to let laissez faire rule for the sake of
the global firms, to eradicate the public or state support and turn each individual to a client.

III. Transition to General Health System:

Basic Features:
In this section, I will try to give a brief information about the Social Security System in
Turkey. Afterwards, I will mention on social security reform in Turkey and its implication on health
sector. In this way, we are able to define significance of supranational institutions and global firms on
health care system and the decay of social policies.

To begin with, we have to consider about the social security system in Turkey. Talas (1992, p.
183) Turkey has adopted a welfare state similar to Bismarckian model, which is based upon the
occupational organizations. However, this model, he says, creates opportunity for the redistribution of
wealth by taking from the rich and giving to the poor (Ibid. p. 183). Talking about the structure of the
social security system in Turkey, it is widely dispersed, there is no harmony between different
institutions and the benefits, provided by each of them, are highly different and unequal (Ibid.). In

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Turkey, we have three different social security institutions each of which meets the health care needs
of individuals who work at different occupational statuses (Ibid.):
1. Pension fund (Emekli Sandığı- ES). This fund serves for the health, maternity, disablement
and old age needs of people who employ in public sector.
2. Social Security Institution (Sosyal Sigortalar Kurumu- SSK). This institution meet the health,
maternity, old age and accidents related to work etc. of workers and some civil servants.
3. Social Security Organization for Artisans and the Self-Employed (Esnaf ve Sanatkarlar ve
Diğer Bağımsız Çalışanlar Sosyal Sigortalar Kurumu- Bağ- Kur). This institution caters the
old age, illness and death risks of individuals who are self- employed.

Talas (1992, p. 196) argues that this type of a social security system can be perceived as a
social solidarity of nation wide. It provides solidarity between different segments of society and
maintains equality as well as the distribution of risk among people (Ibid. p. 195). It is based
upon the contributions of employers, employees and the state (Ibid. p 197). It has been
experienced that this structure will lead to unification under a singular social security system
(Ibid.).

Regulations on Health Care Services:

In this part, I want to show how the social security understanding has changed throughout the
time and come to the transition period.

Bakar& Akgün (2005, p. 340-342) indicate that we can analysis the transition in health care
sector by categorizing into 4 periods:
1. Republican period: Some of the heath centers (sağlık ocağı) were transformed into Numune
Hospitals. As well, the protective/ preventive health care (koruyucu sağlık hizmetleri) services
were introduced as the primary health care services.
2. Period up until 1960: Seven regional hospitals were established for maintaining both the
protective and treatment- oriented health care services.
3. Period between 1960- 1980: This period is marked as the most populist period. It was
provided that, without the cooperation between different sectors and the contribution of the
society, there can be no health care. This is a discourse emerged by the ‘Law on the
Socialization of the Health Care Services’
4. After 1980: 1980 is the turning point for transition to market economy. In 1982 Constitution
of Turkish Republic, we encounter with the signals of transition to General Health System and
privatization of the health care services. In the Fifth Five Year Development Plan (period
between 1985- 1989), it was pointed out that The Ministry of Health will be responsible for

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 the standardization, development and planning health care services. Further, there was no
budget separated for the improvement of preventive health care services. It was defended that
there emerged a financial deficit because of the health care provisions. It was advocated that
1/3 of the cost of health care services should be met by the individual getting these services. In
addition, the qualities of the services as well as the segmented structure of the social security
institutions were questioned. There 1 million individuals were committed to Green Card
(Yeşil Kart) as a precaution in the absence of General Health System.

Moreover, Akbulak (2004, p. 131) define that, in the 1982 Turkish Constitution, it is indicated that
everyone has a right to protect his/her health. As well, state is responsible to maintain the continuity of
people’s physical and psychological well- being (Ibid. p. 21). In this way, labor is to be provided for
the cooperation and solidarity by planning the health care institutions and maintaining the health care
services (Ibid.). According to me, this is an indication of how the importance of the health care
services can be manipulated for the sake of industrialist efforts. Then, when there is no shortage of
labor and the full competition economy rules, there is no need to take on the responsibility of paying
for the well- being of the workers.

Considering the 1990 Master Plan Study in Health Sector carried out by State Planning
Institute, there decided upon 4 objectives to be fulfilled.
1. The rehabilitation of the health care services and the existing status of the social security
system
2. The establishment of free market strategy.
3. The establishment of a new strategy on health services.
4. A strategy towards consensus between different sectors.
(Bakar& Akgün, 2005, p. 345).

Before talking about the impact of changes on health sector, I want to mention on the
influence of supranational organizations on Turkey’s national master plans.

World Health Organization (WHO) specifies 3 main periods related to their approach to health
care services (Bakar and Akgün, 2005, p. 339-340):
1. In this first period, in 1940s, we encounter with welfare states and national health services
based given by social security institutions.
2. In the second period, Selective Primary Health Care services were generalized. In 1978
Almaty Conference, WHO and UNICEF reported the health indicators, which illustrated that,
health care services in developing countries are very inefficient. Then, a main objective of
‘Health for all’ in 2000 was adopted.

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 3. In the last period, attainable goals and the importance of Cost- effective planning were
highlighted. Finally, in 1987, report on Financing Health Services in the Developing World:
an Agenda for Reform was issued.

WB and World Health Organization (WHO) advice that basic health care services should be revised to
improve the well being of citizens and the financial, political and legal arrangements should be carried
out (Bakar& Akgün, 2005, p. 345). It was argued that since there is a shortage of budget for the health
care services, the quality of given services are decreasing sharply and the needs of the society can not
be met (Ibid.). Then, the level of quality of health care services should be raised, the capacity of
administration, both in the rural and the urban areas, should be advanced, and preventive health care
services should be generalized by providing allocate efficiency and technical efficiency (Ibid.).

Before talking about the reform in health care services, we have to indicate ‘what the reform
in health care services mean’. According to Cassel (in Bakar& Akgün, 2005, p. 342), it refers to
facilities regarding efforts to change the structure of social policies and institutions. In addition, it is a
structural change process which is planned and supervised by the state in order to increase
functionality and performance of health sector (Ibid.). In this way, the satisfaction of the recipients of
services and the eradication of inequalities for the sake of disadvantaged groups are to be sustained
(Ibid.). According to me, the conceptualization of this term is very neutral and humanistic. However,
before coming to a conclusion, we have to analyze how the authorities utilize this concept while
applying their plans and projects.

In this point, there comes the 2003 Transition in Health Sector in Turkey. According to
Bakar& Akgün (2005, p. 346), the notion of General Health System was prepared in 1967; in the
Second Five Year Development Plan, it was discussed on and finally it was pointed out in the 1982
Turkish Constitution (Ibid.). In 2003 Transition in Health Sector Project, in Urgent Action Plan, it
was indicated that (Ibid.):
1. The organization and the presentation of health care services should be revised. It is highly
complex and the primary health care services are not adequate and efficient.
2. The Financier side of the services should be reconsidered. In addition, a mixed structure
should be adopted, based upon general taxation, social security and out of pocket expenses as
clients.
3. Considering the human resources, there is an inefficient and imbalanced distribution.
4. A new information system should be introduced in order to sustain cooperation and
coordination and to increase the level of efficiency.
5. Finally, while the level of medicine usage in Turkey is very low, the costs of drugs are very
high.

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 In this manner, we experience the transition in Health Sector in three fields:
1. The efforts towards making each state hospital an autonomous enterprise.
2. The transition to General Health System
3. The establishment of the Family Doctor.

1. Hospitals as Autonomous Enterprises:

As I have tried to represent above, the rules of game, the neo- liberal logic, necessitates full
market competition, shrinking of the state and the contribution of individuals to the services, that were
once a time provided by the state, to increase the quality and the efficiency of these services. The
efforts towards making each state hospital an autonomous enterprise is, hence, a move towards the
neo- liberal economy.

Regarding the welfare state and the principle of general administration, state is the provider of
the health care services (Ataay, 2005, p. 66). Rather than being a night watcher or a gendarme, state is
the provider of the social services, such as education, health care etc. for the sake of the public good
and not for profit making purposes (Ibid.). Such information about the state is a counter discourse as
against the neo- liberal understanding of state. In this way, solutions for health problems are to be
more holistic and community oriented, (Ibid.). However, according to the neo- liberal thesis, state
should remain passive in the market exchanges (Ataay, 2005, p. 67). Rather than depending on
principle of general administration, social services should be distributed among the nation according to
the principles of management (Ibid.). Hence, the main aim is to make profit and to let private firms
compete in the market to provide services. It is to mean that it is not the state that defines the prices of
the services, but the laissez faire politics and the market (Ibid.). In a such a system, health care
services are bought in the market, where is now an opportunity for the private firms to maximize their
profits (Ibid.).

In this regard, the resources of each SSK hospital will be privatized and they will not provide
services any more (Kocaeli Tabip Odası, 2005, p.246). All the resources and debts will be transformed
to each hospital (Ibid.). The hospitals belong to SSK will be transformed to Ministry of Health and the
institution itself will be no more provide health care services, but finance the costs of the services
(Ibid.). In other words, the financier and the provider of the services will be separated (Ibid.). Also,
everyone, who is registered in GHS, will be able to benefit from these hospitals (Ibid.). However, with
the approval of the Restructuring of the Public Administration Project, public properties will be
privatized at the expense of welfare of citizens and nation (Ibid.). This means that each hospital
becomes an autonomous enterprises which seek nothing but maximizing its benefit and profit. In this
way, state hospitals will be transformed into structure as Built Own- Operate- Transfer (Akkaya,

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2005). This process has been developing since Özal and Çiller (Ibid.). We must not forget that Özal is
the one who approved the separation of the Ministry of Social Assistance and Ministry of Health
(Ibid.). Moreover, eradication of the services given by state hospitals became a fashion and people
became conditioned to go private hospitals for meeting their heath care services (Özveri, 2005). As
we can see easily, it is a move towards the commodification of social services (Ataay,2005). At this
point, as we can see, the inequality between different groups in the Turkish society became
institutionalized.

The notion of Hospitals as Autonomous Enterprises is not the individual concern of health
sector; rather it is an inter- sectoral problem. It comprehends and affects the society as a whole. Then,
we should be aware that solution can not be privatizing health care services, which will result in more
costs for both Turkish society and state. According to Somel (2005, p. 323) we should be careful while
searching for the deficits in SSK budget and decay of health services. He argues that the reason why
system corrupted is not the inefficiency or the overload of SSK, but the transfer of SSK’s resources for
industrialization efforts, based on import- substituted economy politic, which resulted in
disappointment (Ibid.). Then, it is not related with only cost reduction.

1. General Health System:

As I have tried to indicate above, we have a segmented type of Social Security System in
Turkey. It is true that this structure leads to inequality while benefiting from health care services.
Hence, there provided a solution, the transition to GHS, which will unify different social security
institutions and generate equality in terms of benefiting from social security institutions.

To understand the issue, we should approach the subject from different points of views.
TÜSİAD (Turkish Industrialists’ and Businessmen’s Association) argues that Turkish governments
should let rules of international full competition, individual initiatives and responsibility in order to
develop and compete with other nations (Tuncay, 1997, p. 13). In addition to the inappropriate health
care services, high levels of premiums employers are obliged to pay are among the inefficiencies of
existing social security system, which inhibits the development of Turkish society as a whole (Ibid.).
Moreover, such a segmented structure leads to inequality before receiving health care services (Ibid. p.
40). Hence, we need an urgent need of transition to GHS (Ibid.).

GHS is assumed to comprehend the society as a whole. But, in order to benefit from this
system, people are assumed to contribute by both paying a level of premium and by working at least
120 days officially (Kaan, 2005, p.124). Here, we should question the scope of GHS: whether it is
more efficient than the previous system or not. If it is to be efficient, such phenomena should be
evaluated (Kaan, 2005, p. 125) (Özveri, 2005, p. 148):

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 1. The scope of population integrated into the GHS.
2. The scope of social risks integrated into the GHS.
3. The conditions to benefit from services provided by GHS.
4. The level of protection.
5. The determination of who will have the right to finance.
6. The determination of who will have the say on GHS

First of all, employees are expected to pay 5% of total 12.5% health care premium whereas
employers are expected to pay 7.5% of the total payments (Öztürk, 2005, p. 144). Moreover, people
who gain more than 1/3 of minimal wage are expected to contribute to the expenses (Ibid.). Further,
people, who get Green Card, will also contribute to the expenses to a certain level (Ibid.).

According to Kaan, people employed in informal sector and people who can not meet the criteria
to get Green Card, but living in the margins of the society, are to be excluded from the GHS like as the
people who have loan to Bağ- Kur (2005, p. 125). In this way, it is believed to be preventing
unnecessary health problems and misuse by increasing the level of self- control and contribution
(Öztürk, 2005, p. 145). To sum up, such objectives are to be met to integrate an individual to GHS
(Özveri, 2005, p. 149):
a) Having education and qualifications.
b) Having a high level of employability.
c) Having guaranteed contribution to society.
d) Having a certain level of income.

Then, it is right to say that ‘social protection’ will replace with ‘social security’ like as ‘grace’
or ‘benevolence’ will replace with ‘right’ (Öztürk, 2005, p. 145). But it should not be forgotten that
social security is not a favour or assistance; rather it is a right (Özveri, 2005, p. 148). Also, it is
about organization of the society, which provides opportunity to state to protect each individual
from the social risks and individual to maintain his/her, livelihood (Ibid.). Hence, if a reform,
considering the health, care is needed, then, first of all, rehabilitation, considering the organization
of the society and social relationships, should be reconsidered.

3. The Family Doctor.

One of the other reforms planned to be carried out in health sector is the Family Doctor
Program. To understand, its implications, we should analyses this program as a model.

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 First of all, we should mention on the restructuring of the health care services. By the
establishment of the Health Sector Reform, the health care services are to be divided into 3 steps in
order to provide better services (Kocaeli Tabip Odası, 2003, p. 246):
1. Primary health care institutions, the Family Doctors.
2. Secondary health care institutions specialized in a branch.
3. Third step health care institutions, health foundations or private hospitals.

In order to benefit from the services provided by GHS and Basic Assurance Package (Temel Teminat
Paketi) without payment or with discount, people are expected to adapt to the chain of sending (Ibid.).
Then, they should be in accordance with their own Family Doctor.

The Family Doctor Program is assumed that people are free to choose their own doctors, who
will take care of his/her patients, whatever he/she needs. However, Aksakoğlu et. al. (2003, p. 255)
argues that this program is not appropriate for Turkish contexts. Family Doctors are educated not to
specialize in a branch (Ibid.) As well, they are not interested in preventive health care services; rather
they are educated for the diagnosis and treatment of the diseases and it is not their concern to pay
attention to social anxiety (Ibid., p. 256). Moreover, they are not appropriate to work in village clinics
[which have very important roles in Turkish society, especially the rural parts] (Ibid.). Their main
concern is to attract patients in order to make much more profits [by giving more pills, making more
surgical operation etc. (S. Kalaycıoğlu, SOC. 400 Lecture, April 13, 2007)] (Ibid.).

This is how health care recipients have become clients. As we can see primary health care
services are to be destroyed and they are privatized beginning from Family Doctor Program
(Özdemir& Özdemir, 2005, p. 140).

IV. People in the Southeastern Anatolia and Health Reform:

Health Reform will affect the life of each and every individual in Turkish society. According
to my point of view, people, especially living in the margins of the society, will be affected most, by
the Health Reform and the changing roles of Turkish welfare state. I have tried to summarize the
various aspects of globalization, neo- liberalism and the decay of welfare states. As well, I mentioned
on the Health Reform in Turkey and its various contents. In this part, I want to mention on the people
living in the Southeastern Anatolia Region (SEAR) and the reform’s effects on the lives of these
people. I think, to depict the situation of these people can be an ‘appropriate’ example to illustrate that
how needy and poor or excluded people can be affected by the winds of change.

Keyder& Üstündağ (2006, p.6) points out that according to the findings of UNDP, SEAR has
the worst life conditions among the regions in EU. First of all, people try to survive in a battle area

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(Ibid.). As well, they are forced to migrate and leave their motherlands (Ibid.). Also, they have
problems with state, military and police forces (Keyder et. al., 2004). As a result of migrations,
poverty and unemployment is increasing day by day (Ibid.). The rate of poverty is nearly 60% (Ibid.).
Moreover, poverty nutrition in SEAR is three times bigger then average of Turkey (Özkan, 2004, p.
29). Further, the rate of people employ in informal sector is nearly 45.9 % (Keyder et. al., 2004). The
rate of people employ in informal sector is nearly 45.9% whereas the rate of people who have a social
security is 30% (Ibid.). As well, as Küçükkaraca (2005) points out child labor is very widespread
because of unemployment and poverty. Related to that the level of vulnerability in urban SEAR, it is
estimated as 93% (Özkan, 2004, p.32). Also, it is known that as the size of household increase, the
level of vulnerability increase, too (Ibid.). In this regard, it should be noted that majority of poor
people in Turkey reside in SEAR, who have low level of education, low level of income and many
children (Yılmaz, 2004, p. 49).

Considering the health care problems of people living in SEAR, they face with difficulties
while applying for getting Green Card since they have problems with civil servants and local
governments (Keyder& Üstündağ, 2005). That’s why; it is very difficult for these people to get Green
Card and integrate into GHS (Ibid.). In addition, since most of the people meet their health needs
through informal networks, transition to Family Doctor Program will be very harsh for them (Ibid.).
For an instance, some doctors or nurses working there feel sympathy towards the people and help
them informally as opposed to central government (Ibid.). Talking about a system, in which doctors
are awarded according to their performance, rather than the quality of services they give, it will be
difficult to cater the needs of people who needs guidance (Ibid.). From a different perspective, since
some staffs believe that these people are ignorant, it is difficult to pursue people to get services they
need (Ibid.). In a system, where doctors are conditioned to alienate themselves from the society and
social problems, more people will be willing to cater their needs by using primitive methods. Also, the
number of staff and village clinic are very low (Ibid.). That’s why, child mortality is very high and the
contagious diseases are very common (Ibid.). It is advocated that, by introducing privatization in
health sector and making subcontracts with doctors to employ, the scarcity of staff will be eliminated
(Kocaeli Tabip Odası, 2005). However, it does not sound very realistic while assuming that most of
the people will not prefer to go to SEAR since there is a high level of contagious diseases and
mortality (Ibid.), (Keyder& Üstündağ, 2005). Moreover, these people are mostly employed in informal
sector and they do not have a regular income (Keyder& Üstündağ, 2005). Furthermore, since most of
people work as family labor as informal workers, it will be difficult to integrate these people into GHS
(Çelik, 2005). For that reason, GHS, which is based upon premium payments, will exclude most of
the people from the health care services (Keyder& Üstündağ, 2005). For an instance, it is indicated
that 70% of people living in this region have no health security (Buğra & Keyder, 2006, p. 5). That’s
why; these people do not go to hospitals or doctor to get any health care service (Keyder et. al., 2005).

1
 In addition, most of the people, registered in Bağ- Kur, fail to pay their loans to the institution
(Keyder et. al. 2005). Then, in a system, in which people who have loans to Bağ- Kur will not be able
to benefit from GHS, people will be inhibited to cater their needs (Ibid.). According to me, there is one
more thing which is very important for achieving health care services: the existence of health care
staffs who know Kurdish (Keyder& Üstündağ, 2006, p.8). Keyder and Üstündağ argue that (2006) this
will be an obstacle to get secondary health care services like as it will be hard to get primary health
care services which are given by Family Doctors. Moreover, the situation of the people in rural areas
should be reconsidered. It is known that most of the people living in rural areas could not pay for Bağ-
Kur (Keyder, 2004). As well, they can not benefit from Green Card since they have property such as
land or a house in the village (Ibid.). There are a number of 10 million people who live in such a
situation (Ibid.).

We should not forget that health is an inter- sectoral phenomenon. Then, as WHO indicated
that unhealthiness and poverty should not be assumed as two separate things; rather, poverty is not just
an absence of a certain level of income, but it is a syndrome which comprehends the subjects such as
unhealthiness, illiteracy and vulnerability etc. (Dedeoğlu, 2004, p. 51). Related to that, poverty is the
main reason of many health problems (Ibid. p.52). In addition, it is a concern of both human rights and
morality (Ibid.). Further, individuals themselves should not be blamed as being dirty, lazy and
irresponsible (Ibid. p. 53). Rather, most of the times, poverty is caused by the unethical Structural
Adjustment Programs of supranational institutions and this notion is utilized in order to justify the
interference to internal politics (Ibid.).

V. Solutions:
It is well- known that people, who are healthy, can make future plans. That’s why; regarding
the sustainable development plans in SEAR, state should meet basic needs, such as health care, of its
citizens (Keyder& Üstündağ, 2006, p. 7). In addition to that, in order to maintain the motivation of the
citizens, state should provide services such as health and education etc. (Ibid.).Then, state should
invest more in this region in order to sustain social justice as well as to integrate these people into
Turkish society (Ibid.). Considering the financier side of the GHS, it would be wise to finance the
health care expenses by general taxation rather than depending on the premiums (Keyder et. a., 2004).
In this way, more people can be integrated into the system whereas the social justice between the
regions can be maintained. Also, the redistribution of wealth from rich to poor people will solve the
social problems while solving the tension of inequality (Kaan, 2005). However, it should also be
considered that, with the establishment of The Restructuring of Public Administration Project,
decentralization should not threaten the well- being of the citizens by carrying out unjust distribution
of wealth and power. The scope of Green Card recipients should be extended and the level of income,

1
rather than the property ownership, should be the criteria to get Green Card (Keyder& Üstündağ,
2005). Moreover, poverty line should be reconsidered and the criteria should be well- defined (Türk
Tabip Odaları, 2003). As well, basic health services should be provided for every individual through
village clinic, which aims at preventing the diseases, in this part of Turkey (Ibid.). Then,
decentralization of the health care services should be provided (Ibid.).

We assume that social rights are integral to the politic and civil rights. Since these people are
politically excluded, they can not benefit from the social rights, such as getting health care services, as
oppose to Marshall (Keyder& Üstündağ, 2006). Then, community oriented projects for the
development of SEAR will both improve the political, social and civil status of people (Ibid.). In
addition, [in order to increase the level of participation to civil society] Keyder and Üstündağ argue
that people should be paid cash assistance of 150 YTL (2006). As well, to prevent unemployment, the
level of employability, of especially the children, should be increased (Keyder et. al., 2004).

Finally, we should be aware that globalization does not only cost for individuals in 3 rd World
Countries, but also we, as individuals living in a global community, can benefit from globalization.
First of all, we should be aware that we are not a unique state who deals with poverty, unhealthiness
and reforms. Then, in order to be successful and to benefit from the grace of globalization, we should
cerate link between other nations. Stiglitz argues that we can not escape from globalization; it will be
remain as a part of our lives (2004, p. 249). So, we should take part in the movements which aim at
regulate the rationale and the rules of globalization (Ibid.). It is to mean that we should initiate Global
or International Global Policy Institution in order to benefit from globalization and protect our social
rights during this process.

Conclusion:
In my point of view, each and every individual deserve a life which is humane and which has
dignity. That’s why; in this paper, I wanted to show different aspects of Transition in Health Sector
and the related reform and their effects on people. I think, even if a small number of people are
damaged by a planned reform or policies, the policy makers or bureaucrats should withdraw their
policies and should not insist on establishing a new sort of system, whish is not appropriate for an
individual context. Then, recommendations should be listened and analyzed carefully if they sound
rational and logical. What I suggest is the fact that more sociological researches must be done before
establishing new systems and people from academic area or professional block must be taken into
consideration if it is to be for the sake of an individual nation state. According to me we must not
forget that our national interests and dignity is much more important than the investment of global
firms in order our economy to grow.

1
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