15 years of AK Party rule: An evaluation in terms of health and health policies.

• Author: Yildirim, Hasan Huseyin
• Position: ARTICLE - Essay

ABSTRACT This article aims to evaluate the 15 years of leadership of the AK Party in terms of health and health policies using the Health System Framework of the WHO. It can be noted that the AK Party government has improved almost all components of Turkey's health system over the course of their 15-year tenure. Furthermore, these improvements have contributed positively to the prosperity of Turkish society, particularly its health status indicators. What should be done next? It is important that the health care field be designed and continuously improved to create sustainable policies and strategies positively associated with the Health Transformation Program and to cope with dynamic challenges such as the ageing population, changes in disease prevalence, new technologies, etc.

Introduction

Health has been at the forefront of the radical transformations undertaken by the AK Party during their 15 years in power to date. The AK Party was established in 2001, it has won all of the elections since the November 2002 general election, and has now been in power for 15 years. In 2002, the AK Party introduced its general reform framework, the Emergency Action Program (EAP), (1) and its health reform plan, the Health Transformation Program (HTP), (2) which is a health sector policy based on the EAP. Since its implementation in 2003, access to health services has improved, community health status indicators have improved, the level of satisfaction with health services has increased, and citizens have been protected from financial risks.

This article evaluates the 15 years of leadership of the AK Party in terms of health and health policies using the Health System Framework of the WHO. Many frameworks can be used to assess health systems, reforms or policies; these frameworks are similar and include the functions of a health system, that is, its building blocks. In addition to building blocks, the Health System Framework of the WHO includes the objectives and results of a health system (Figure 1). In conducting the present analysis, the WHO framework has been preferred for this reason.

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First, the historical process and background of Turkey's health policies will be presented. Second, the 15 years of leadership of the AK Party will be assessed in terms of health and health policies using the framework shown in Figure 1. Within this framework, the transformation of the building blocks (service delivery, financing, labor, management, and leadership) of the health system over the period of these 15 years will be explained and evaluated. Subsequently, the impact of these changes on the goals and outcomes (health improvements, fulfilment of expectations, protection from financial risks, and system sustainability) of the health system will be described and evaluated. Finally, the results and recommendations of the study will be presented.

Historical Process and Background of Turkish Health Policies

Notably, the roots of the contemporary Turkish health care system can be traced back to the Tanzimat Reforms (1839). However, the institutionalization and organization of the health system, with regard to the legal, physical and human resources of today, were established by the Ministry of Health (MoH) using limited resources in May 1920. (4) The MoH initially focused on the legislation for and restructuring of the health system after the Independence War. The foundations of the present public health system were established between 1923 and 1946. Over this period, laws were enacted to govern the tasks and functions of the MoH, which is responsible for the planning, organization and implementation of health programs, including preventive public health programs and programs to control communicable diseases such as tuberculosis, malaria and leprosy. Over this period, the health system was organized "vertically." Diagnosis and treatment centers were established in the districts, and fully functioning hospitals were opened in provinces such as Ankara, Diyarbakir, Erzurum, and Sivas. (5)

Over the period from 1946 to 1960, health centers were established to provide integrated health services to the Turkish community. Additionally, all hospitals were transferred from local administration to the MoH. The Social Insurance Institution (SII) was created in 1946 to provide health insurance for blue-collar workers in the private and public health sector. (6)

In 1961, Law No. 224 on the Socialization of Health Services was enacted (6) and it was the basis for the establishment of national health services. Notably, this law mandates that health services must be provided continuously and meet the needs of the people. This law provided health services to all citizens for free, or partially free, at the point of use. The aim was to develop infrastructure to expand health services, including preventive and environmental health services and health education, throughout the country, and to make access to the infrastructure easy. The concept of health centers was expanded to include health centers in rural areas as well as district hospitals. However, the large capital investments required for the expansion were absent. Most fiduciary resources were allocated to personnel costs instead of infrastructure, medical equipment and other assets required for the provision of health services. (7)

Health programs based on the Law on the Socialization of Health Services were included in the First Five-Year Development Plan, which was a result of the 1960 military coup. Discussions regarding General Health Insurance (GHI) began in the 1960s and lasted for years. (8) In 1971, the GHI Act, which supported universal health insurance, was submitted to the Turkish General National Assembly (TGNA) but was subsequently rejected. In 1974, the law was again put before the Parliament but was never addressed. In 1978, a law governing the full-time study of public health practitioners was adopted, and doctors were banned from working in the private health sector. In 1980, a new law was introduced that abolished the previous law. This act allowed physicians and other health personnel to work in the health sector part-time, primarily in the private health sector. (9)

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For 15 years following the passage of the 1961 law, although countrywide socialized health services had been planned, the plan was not implemented. However, in 1983, health coverage for the entire country was announced. Until the 1980s, Turkish health policy was based on the Law on the Socialization of Health Services. Notably, a basic health care system had been established throughout Turkey within the scope of the Law. Historically, the health system reforms of this period are considered "the first wave of health reforms." (10)

In September of 1980, there was another military coup in Turkey. This led to a new era in the Turkish economic and political system and created a health service process characterized primarily by liberalization and deregulation. The primary role of the state shifted from health service provision to the regulation or facilitation of health services. The role of the private health sector increased, especially its provision of health services. (11)

Between 1980 and 2002, Turkey granted citizens the constitutional right to access social insurance and health services. Per the 1982 Constitution, all citizens have a right to social security, and the state must provide social insurance for all citizens. Additionally, the Constitution contains provisions that strengthen the role of the state in the regulation of health services, as well as those services related to the implementation of GHI.

Between 1986 and 1989, the government enacted the Basic Health Services Act and the Bag-Kur Health Insurance Launching Act. The Basic Health Services Act governed access to and equity of health services and aimed to correct the deficiencies of the 1960 Integrated Health Care System. It aimed to increase the financing of the health sector, based on the Basic Health Services Act, because one reason for the failure of the Integrated Health Services System was financial resource constraints. However, the success of the Basic Law was limited. Neither laws that would support systemic health reforms nor a comprehensive health policy had been adopted. Efforts to stimulate the health sector had also been absent. (6)

Between 1988 and 1993, the MoH and the State Planning Organization (SPO) conducted a major health reform study to assess the needs of the health system and identify methods for its reform. Because of the findings, the National Health Policy was adopted in 1990, which governed the implementation of GHI and family medicine. This policy described health system objectives and delineated health system priorities, such as maternal health. (12) Based on this, a National Health Policy Document was introduced, which included recommendations for health system reforms and their definitions. (13)

During the First National Health Congress, held in 1992, the initiation of GHI implementation was revisited, but no progress was made. However, in the same year, the...