Bernard Kennedy in Ankara -
The rapid growth of Turkey's private health sector has attracted a lot of interest from foreign investors. But the recent introduction of a new health insurance scheme has done nothing to ease worries that the government is turning its back on the reform.
The Justice and Development Party (AKP) government, in power since 2002, has encouraged private hospitals, clinics and health centres by making it possible for patient members of state-run social security schemes to receive examinations and treatment at accredited private hospitals, clinics and health centres, whereas previously they had to to travel to specified, overcrowded public hospitals.
According to a recent Deloitte Touche Tohmatsu paper on health economics in Turkey, Turkey spends about 7.6% of GDP on health - below the average for OECD countries, but above average for countries with similar income levels. Ä°n 2006, total health spending was TRY43.2bn (€24bn), of which close to 30% came from private sources. Between 2004 and 2008 the number of private hospitals in Turkey rose from 98 to 377 - to say nothing of the other private health facilities - with some of the investment coming from foreign sources. In September, the Greek health company Hygiea announced it will pay $48m for a 50% stake in Safak Hospitals, which operates four hospitals in Ä°stanbul. This follows the acquisition by Dubai-based private equity fund Abraaj Capital of a 22% stake in Turkey's only listed hospital group, Acibadem, in 2007.
As well as opening up the private sector, the government gave millions of poorer families lacking regular employment or insurance cover "green cards" entitling them to free healthcare at the taxpayers' expense.
The AKP's landslide victory in last July's general election has been attributed in part to these benefits. But since the election, the government has been making life harder for the private sector. First, the licensing of new private clinics and health centres was abruptly halted pending a needs assessment, and tough new criteria were introduced for building standards. Then a limit of only 30% was set on the differentials chargeable by private establishments to patients applying to them under the general health insurance (GSS) system, which as of October replaced the health arms of the existing state-run social security schemes. Finally, a TRY10 user fee (about €5) was introduced for patients diagnosed in private facilities, compared with TRY3 in state hospitals or TRY6 in university hospitals. "It's not working out the way we expected," affirms Yasar Yildirim, general secretary of the Istanbul-based private hospitals association OHSAD. "It looks as if the private health sector is in for quite a rough ride."
In Ankara, Serdar Sargin, general secretary of the 900-member health enterprises association TUSIDER, puts it more bluntly: "The private sector has been used for populism and now that's over it is being thrown on the garbage heap."
Economists are quick to draw attention to the large total deficit of the public pensions and health system, which reached 5.2% of GDP in 2007. "This requires intolerably high transfers from the budget," underlines Can Buharali of the consultancy Istanbul Economics, the author of the recent Deloitte paper on health economics in Turkey. The GSS is, in fact, a product of the IMF-sponsored social security reform legislation which was finally approved by parliament in April after a series of presidential vetos, Constitutional Court challenges and amendments.
Analysts say opening up the healthcare system to the private sector made health expenditures more difficult to control due to increased demand and the danger of abuse. "The government is only trying to keep things under control," argues Ibrahim Ersoy, editor of Medi-Magazin, a newspaper for health professionals, who believes it was right for the government to check the "uncalculated" expansion of private health service providers.
TUSIDER's Sargin sees a policy of bias against small enterprises owned and run by doctors and in favour of large commercial hospital chains and groups politically close to the government. And while Ersoy agrees it doesn't look as though the Health Ministry will allow private establishments to have a big patient portfolio like the state hospitals, he says there is no need to be alarmed. "It's obvious that we also need the private sector. And the private health sector has developed more under the present government than at any other time."
All concur that Turkey's health service model has not yet crystallised, and that more zig-zags are possible. Plans for public/private partnerships on UK lines only add to uncertainty about the future. In the meantime, the best prospects could rest with the few prestigious institutions - mostly in Istanbul - which can afford to reject the government's terms and concentrate on patients with deep pockets and/or private health insurance, as well as attracting patients from abroad.
Indeed, poor quality elsewhere could increase demand for such institutions. "We are having trouble meeting demand at the moment," says Metin Atak, director of Ankara's JCI-accredited Mesa Hospital, one of only two in the capital that are going it alone. The hospital treats 10,000 outpatients a month and has suspended marketing activities pending expansion plans.
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