increased and deepened inequalities; the results of health reform activities in turkey feride...
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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