In September of 2005, a small group of IPPNW medical students from Germany spent 10 days in Turkey, visiting the cities of Izmir, Zongulodak and Istanbul in order to get a sense of the Turkish public health system. They were led by IPPNW doctor Gisela Penteker who has been to Turkey on numerous delegations in the past.

Besides paying visits to state institutions, they also met with human right organisations, the health workers’ union and the national chamber of physicians. Before we start, however, a few words to Eastern Turkey, although the trip never actually took us there - but here was always a BUT. When comparing the statistics of infant and maternal mortality, health expenditure per capita or physician density, the West of the country was close to European standards, whereas the East of the country had numbers comparable to developing countries.

Following WWII, the Turkish health system of 1920 was reformed by the introduction of public hospitals and health centres. Since 1961, a law guarantees every person free access to the public health system. Up to this day, a  four-step program is in force: the 12.000 health stations without physicians are mainly involved in preventive measures.

Basic public health coverage is guaranteed by a network of nurses, physicians, midwives and public servants in about 6.000 health centres. At the top of the chain are the state hospitals, university clinics and, as a fourth pillar of the health system, numerous private institutions.

The health centres we visited ranged from extremely well staffed and stocked houses like the Seferihisar Urban Health Centre treating 250 patients a day all the way to the small village health centre consisting of only one doctor and one nurse and treating about 5 patients a day.

The first large hospital we visited was the university clinic of Izmir, a marble-studded house fill with the most modern array of medical technologies. The hospital of Eregli was also very decent. We were, however, only allowed to visit two floors. The other part, which, according to the head of the hospital “would not be very interesting to us”, seemed to reveal a different truth. Almost all doctors working in hospitals or health centres worked in lucrative private practices in the afternoons.

Apart from the Social Security Agency SSK there are two more state insurances: Ba-Kur, the insurance for self-employed and Emekli Sand, which is mainly responsible for public servants. And of course there are countless additional firms offering private insurance. Members of state insurances have to pay extra for most services. Not being able to pay results in long waiting lines and limited choice of physicians. The so-called Green Card (Yesil Kart) is handed out to people earning less than minimum wage. However, a wrong political opinion can also cause a deprivation of access to health services. We asked about the people without insurance and received elusive answers. As in other countries, it mainly boils down to health personal being willing to overlook the missing insurance and deliver services without receiving payment.

For years, the EU and the IMF have been, as everywhere else in the world, pressing for a greater privatization of the Turkish Public Health System. The physicians we talked to were afraid that this would cause even more people to loose access to the health system and remain without adequate health coverage. There’s also the fear that the choice of therapy in the future will be governed more by the wallet than by medical rational.

Coming to an end, we can conclude that there are structures which need to be improved, but which have the potential for improvement as well. It would not make sense to replace the existing system by a new one, the dire effects of such measures having been demonstrated in many Eastern European countries.

Özgür, our dear friend from Zonguldak aptly summarized it like this: “Health for all!”

Verena Huke
5th year medical student
Giessen, Germany