Increased and Deepened Inequalities; the Results of Health Reform Activities

in TurkeyFeride Sacaklioglu, Onur Hamzaoglu

Crisis of Capitalism

1970’s

How capitalism gets rid of the Crisis?

Wars Restructuralization of

the state

Since 1980’s...

World Bank imposes structural adaptation programs

Washington Consensus between IMF and WB

The Aim of the World Bank

Liberalization of trade Deregulation of banking system Privatization of public enterprises Tax reform Privatization of agriculture

What Happened ?

of national income 19 % of the population gain < 1 $ per day Richest 1% gain 13.000 $ Poorest 1% gain 54 $

of unemployment 2,5 million – 12 % of the working age group

The Division of Health Budget

30,9

21,6

14,4

5,1 5,1

24,5

51

41,9

1,2

6,3

11,4

18,9

0

10

20

30

40

50

60

1990 2001 2003

personnell

investment

interestsocial security

Ministry of Health; 2004

70% of the budget is from indirect taxes

Reorganization of Services according to Market Economy

Municipalities Energy Transport Telecommunication

Education Health Engineering

services

Neo-liberal Change of Concepts...

Health is...

need versus right Access to health care is...

personal responsibility versus public responsibility

And Health Reform...

Limitation of public funds for health Increase of foreign capital support Privatization of health services Decentralization Contracts in public services Private health insurances Public finance techniques

What Health Reform Means?

the share of general budget in health finance the share of insurance, out of pocket payment General Budget replaced by the revolving funds Patients become customers Customers buy the health service if they have money

What Health Reform Means?

Division of service providers and the financers Creating a competition between this two bodies in

order to get cheaper health service

What Health Reform Means?

Health staff are forced to work Contract based Part-time Performance based Abuse of job descriptions

Loosing social rights!

Health Services till late 70’s Health services given by public sector till the

late 70’s in central and peripheral capitalist countries

Socialization of Health Care Law ; 1961 Well defined, population based primary health

care system Health was…

Social right Public responsibility Free of charge in health centers

Organization of Health Care according to Socialization Full time Team work Continious professional development Population based Integration Referral system Intersectoral collaboration Priority given to prevention Home visits Community participation

80-83National Security Council

83-87 87-91 91-95 95-99 99-03

First Health Project

Arbitration Act

Second Health Project

Health MasterPlan

Economic CrisisIncentives

Supporting Private Sector

Revolving Fund Hosp.

Health Care Law

Health ReformNew

Constitution

Privatization of Hospitals

03-05

Foot Steps of Health Reform in Turkey

9396

9798

99 Transition ofHealth

87

04

Economic Crisis

Revolving Fund PC

Right Wing Right Wing-Left Wing

Right Wing-Left Wing-Faschists

Fundamen-talists

99Social Security Law

Reform...Active and passive privatization of

health care Hospital care privatized

gradually (1990’s) Cleaning Catering Health staff...

Primary care privatized recently Outpatient care (since 2001) Family planning ....

Inequalities in Health

Deliveries Occured Outside of Health Facilities and PAR according to

Residence

36,2

29,4

31,9

28

36,6

0

10

20

30

40

50

60

70

80

1983 1988 1993 1998 2003

0

5

10

15

20

25

30

35

40

Urban

Rural

Population AttributableRisk

Turkish Population and Health Surveys; 1983-2003

Deliveries Occured Outside of Health Facilities and PAR according to Demographic Regions

36,2

51 51,3

62,6 62,6

0

10

20

30

40

50

60

70

80

90

1983 1988 1993 1998 2003

West

South

Central

North

East

Population Attributable Risk

Turkish Population and Health Surveys; 1983-2003

Deliveries Occured Outside of Health Facilities and PAR according to Mother’s Education

70,3

86,2 85,9

0

10

20

30

40

50

60

70

1993 1998 2003

60

65

70

75

80

85

90

No educ./Prim.incomp.

Prim.comp.

Prim. +

Population Attributable Risk

Turkish Population and Health Surveys; 1993-2003

Deliveries Occured Outside of Health Facilities and PAR comparisons according to Residence, Demographic Region and Mother’s Education

36,2

31,928

36,636,2 37,3

51 51,3

62,6

70,3

86,2 85,9

29,4

0

10

20

30

40

50

60

70

80

90

1983 1988 1993 1998 2003

PAR(residence)

PAR(region)

PAR(mother's education)

PAR (%)

Turkish Population and Health Surveys; 1978-2003

Infant Mortality Rate and PAR according to Residence

11,2

33,735,5

16,417,6

20,7

0

20

40

60

80

100

120

140

160

1978 1983 1988 1993 1998 2003

0

5

10

15

20

25

30

35

40

Urban

Rural

Population AttributableRisk

Turkish Population and Health Surveys; 1978-2003

Infant Mortality Rate and PAR according to Demographic Regions

19,4 18,8

42,7

18,823,4

27,6

0

20

40

60

80

100

120

140

160

1978 1983 1988 1993 1998 2003

West

South

Central

North

East

Population Attributable Risk

Turkish Population and Health Surveys; 1978-2003

Infant Mortality Rate and PAR according to Mother’s Education

17,115,5

37,9

0

10

20

30

40

50

60

70

80

1993 1998 2003

0

5

10

15

20

25

30

35

40

No educ./Prim.incomp.

Prim.comp./+

Population AttributableRisk

Turkish Population and Health Surveys; 1993-2003

Infant Mortality Rate and PAR comparisons according to Residence, Demographic Region and Mother’s Education

11,2

35,5

16,417,6

20,719,4 18,8

42,7

18,8

23,4

27,6

17,115,5

37,9

33,7

0

5

10

15

20

25

30

35

40

45

1978 1983 1988 1993 1998 2003

PAR(residence)

PAR(region)

PAR(mother's education)

PAR (%)

Turkish Population and Health Surveys; 1978-2003

Undernourished Children (Weight for Age) and PAR comparisons according to Residence, Demographic Region and Mother’s Education

21,7 21,3

26,2

46

38,1

54,9

76,775 76,2

0

10

20

30

40

50

60

70

80

1993 198 2003

PAR(residence)

PAR(region)

PAR(mother's education)

PAR (%)

Turkish Population and Health Surveys; 1993-2003

Unimmunized 12-23 months old children and PAR comparisons according to Residence, Demographic Region and Mother’s Education

27,2

19

46,5

24,3

41

53,5

33,731,2

11,2

0

10

20

30

40

50

60

1993 1998 2003

PAR(residence)

PAR(region)

PAR(mother's education)

PAR (%)

Turkish Population and Health Surveys; 1993-2003

Population per Health Center according to Geographic Regions 1996-2003

0

5000

10000

15000

20000

25000

Marmara

Aegean

Mediterranean

Central Anatolia

Black Sea

East Anatolia

South-east Anatolia

Ministry of Health, Primary HealthCare Yearbooks ; 2001, 2003

Two way variance analysis tukey test p<0.05

Health Units without Midwife according to Geographic Regions 2000-2003

6668

75

79

30

40

50

60

70

80

90

100

2000 2001 2002 2003

Marmara

Aegean

Mediterranean

Central Anatolia

Black Sea

East Anatolia

South-eastAnatoliaTurkey

Ministry of Health, Primary HealthCare Yearbooks ; 2001, 2003

Two way variance analysis tukey test p<0.05

Population per Midwife according to Geographic Regions 2000-2003

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2000 2001 2002 2003

Marmara

Aegean

Mediterranean

Central Anatolia

Black Sea

East Anatolia

South-east Anatolia

Ministry of Health, Primary HealthCare Yearbooks ; 2001, 2003

Two way variance analysis tukey test p<0.05

Population per Physician according to Geographic Regions 2000-2003

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2000 2001 2002 2003

Marmara

Aegean

Mediterranean

Central Anatolia

Black Sea

East Anatolia

South-east Anatolia

Ministry of Health, Primary HealthCare Yearbooks ; 2001, 2003

Two way variance analysis tukey test p<0.05

Conclusion

Not only in Turkey Not only in health sector The attack to public sector must be discussed

with a holistic approach Unless the economic policies, economic

inequalities and privatization of health care changed, the inequalities in health will increase