Ahmet Arif Eren / Altug Murat Koktas (eds.)
Dynamics of Globalization
at the Crossroads of Economics
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Altug M. Koktas and Ali Gokhan Golcek
Globalization and Health: An Evaluation on
Globalization had first started as the convergence and deepening of the inter-
national relations. Later, changing circumstances and political and economic
conditions caused globalization to be evolved from a fact to perception by changing
its dimension and transforming itself. The actors that had roles in theatrum mundi
changed, and the stage became more modern but more ruthless as well in this
process. Especially with the liberalization policies after the 1980s, globalization
transformed into a new form by achieving a new level.
Despite the nature of social sciences and although globalization is a difficult
term to describe and a consensus cannot be achieved for its description, it became
an excessively used term in time which is remarkable. Although the term
generally began to be used commonly in the 1960s,it had been emphasized
even before. For instance, there were messages about the globalization of world in
Westphalia Peace of 1648.In the same vein, in 1795,Immanuel Kant used the term
(world citizenship) in his
by mentioning a project
that embodies all the humanity which aims to envisage to limit the global aggres-
sion and to gain a universal prestige to human dignity. There were statements
towards globalization in the 19th century as well. Some determinations that Karl
Marx and Friedrich Engels made in their work
written by them in 1848and has been accepted as the creed of communism empha-
sized the significance of globalization as well. However, it can be claimed that these
examples are far from the notion of globalization nowadays.
Globalization is a fact and even perception that involves several concepts and
enormously has been referred in the usages other than its real meaning. Because
historical accumulation and perception is indispensable to even mention globaliza-
tion; therefore, although an absolute political or economic term has not been men-
tioned; it is possible to define globalization as a process that involves and embraces
all of the political, economic and historical connections, relations of production
and capital movements. In other words, it will be appropriate to consider the glob-
alization as an alteration movement rather than a transformation.
The aforementioned alteration has given birth to some consequences in
the health sector as well as every field. The different countries that have been
implementing various economic policies have prepared similar health programs
with each other with globalization, and health has become a problem in global scale.
Reform in Public Sector
Capitalism, that is called as "Neoliberalism" these days, was radically transformed
in the center and nearby countries during the transition process that took place in
the 1970s and 1980s.Neoliberalism is the ideology of the benefits of both market
and private sector unlike the state intervention into the economy.
is a new social
order where the power and incomes of upper classes of ruling class were rebuilt
entirely after a period of regression (Horton, 2007: 1).In this regard, the targets of
neoliberal policies can be summarized as reviving free market and perfect title and
in the cases where there are no markets and property rights have been limited,
implementing this mechanism or the counterparts of it into every field (to soil, to
water, to every other natural resources, labor force, delivery of public services and
international economic relations) and if it is necessary, even implementing these
policies with state intervention (Boratav, 2013:34).
In microeconomic level, neoclassic theory acknowledges the activity of market
rather than state. The state intervention and ownership have disrupted the resource
allocation and produced wastage. On the other hand, the enormous state activity
has originated injustice on apportionment by distributing rents to the cream of
is advocated that the market should take care of economic develop-
ment issues such as industrial growth, international competition and employment.
According to this thought, the state should be pushed aside and the construc-
tion of required legal and economic infrastructure for national defense and func-
tioning market should be the issues that state should be interested (Saad-Filho,
2008: 193).In this regard, it can clearly be seen that neoliberal policies are domi-
nant today. These are the deregulation of financial markets, the debilitation of the
protections on labor unions and labor market with social protection institutions,
the minimization of state activities, the reduction of the top tax brackets, the devel-
opment of international goods and capital markets and the renouncement of full
employment under the disguise of natural rate. "Washington Consensus" domi-
nated the international economic policy, and it advocated the liberalization, free
market, export-oriented growth, financial capital mobility, deregulation of labor
market and macroeconomic austerity policies. In the center of "Washington Con-
sensus", ten primary proposals were suggested for the reform in policies, and the
five of them were closely related with health policies. These are as follows:
- Financial discipline,
- Redirecting the priorities of public expenditures into the fields, that have both
high economic return and the potential to provide justice in income distribu-
tion, such as the primary care health service, primary education and infrastruc-
- The liberalization of cash flows and foreign direct investments,
- Liberalization (the abolition of barriers for the entry and exit to the markets)
Globalization and Health: An Evaluation on Turkey
Since the destruction of Berlin Wall in 1989and the dissolution of the USSR,capi-
talism has comprised of hegemon economic framework almost in every countries.
All of the reforms that have been applied since the end of 1980shave been shaped
in a large spectrum without differentiating the countries whether they are poor or
rich (Lister, 2005).As a matter of fact, a wide section of literature assumed that the
capitalist market has presented an appropriate model for developing health care
and health reform.
In essence, the reform works that represent a new phase in the policies of health
care have been originated from
global faith to the market mechanisms
Wilding, 2002: 64). "Structural Adjustment Programs" were put into practice in
the 1980s with the expansion of neoliberalism, and they were implemented as
the condition to take credit from International Finance Corporation. The coun-
tries that have encountered with the balance of payment problems due to debts
or foreign currency crisis may borrow from these institutions such as IMF and
World Bank under one condition, accepting stability and structural adjustment
programs that have been recommended by IMFand World Bank. Since the number
of poor countries that was forced to accept at least one of these kind of programs
became approximately a hundred during the past twenty years, it can be argued
that the neoliberal policies were imposed across the globe by increasing the
programs (Saad-Filho, 2008: 191-194). In conclusion, it may be held forth that the
reform discourse in the health sector has appeared as a result of these impositions
3 Reform in Health Care
The reform works in the health sector have gained wide currency in several coun-
tries, and a wide coverage has been given to them in the literature of health eco-
nomics. The problems, that the countries have encountered, such as aging, new
methods of treatment and advanced technology have paved the way for the reform
works by creating pressure towards the increase of health expenditures (Saltman
and Figueras, 1998:3).Some of the reasons for health reform are the inefficient use
of the sources, lack of access to the health care that are required for individuals and
health care that cannot meet the requirements of individuals (Cassels, 1995:330).
On the other hand, it is noteworthy that governments with different political views
apply similar reform packages in the poorest and developing countries, as in high-
and middle-income countries (Lister, 2005).In this regard, the reform policies in
the health industry that took place in Western, developed economies since the
second half of the 1980s are among the most significant initiatives of the coun-
tries (Flood, 2003: 1). Eastern European countries expand their social insurance
programs, South American countries expand the scope of their health insurance to
include the poor people who live in rural and urban areas, the financial decentral-
ization has been using for generating additional resources to the hospital in Africa
and for increasing the efficiency, and several countries have been using draw-
back systems and the organization of the delivery of health care. Furthermore,
globalization supports the demand of the health care. Along with the elements,
that enlighten the individuals more about the health care field, such as internet
and media, the desire for continuous consumption affects health care both quanti-
tatively and qualitatively. Individualistic expectations require the best care along
with the latest technology and these conditions suppress the governments (Ro-
berts et al., 2009: 3-17).
In this regard, there are two main reform trends within the frame of neoliberal
policies. First is the reforms towards reducing the costs and it has been applying
since the 1970s. Second is the policies that aim to reconstitute health care system
with the aid of market style mechanisms and it has been applying from the 1990s
till date (Lister, 2005). The structural and administrative reforms in the health care
can be labelled as the initiatives that seek to find a cure against the constant failures
of profit-oriented capitalist system about introducing health care which is afford-
able and fit for the global market. Within this context, the "new public administra-
tion" policies in the health care can be considered as marketization reforms (Preker
and Harding; 2003: 2).
4The Reform Implementations on Health Sector in
The reform works towards the health care have been initiated with the declaration
of Republic in Turkey. Along with the delivery of health care with good quality,
the fair distribution of health care and the improvements on health indicators were
aimed with the aforementioned reform works. Until the beginning of the 2000s,
the desired result cannot be achieved with the intended reform works and the
realized economic crises affected this process negatively as well. Health indicators
fell behind the developed countries, the problem of financing on health care and
the budget deficits of social security institutions grew, the irregularity of regional
distribution of the delivery of health care could not be fixed, and the hydra-headed
structure in health sector could not be altered.
The hint of policy changes towards health was given in the "Immediate Action
Plan" with the government reshuffle of November 3,2002 and an extensive notion
of reform brought to light. The articles of indicated policy in the mentioned plan
can be organized as follows: "Within the scope of targets such as the creation of an
effective healthcare system with good quality, the execution of primary healthcare
of everyone by cooperating with private sector, equalizing the distribution of health-
care at the national level in Turkey; In a year;
The works towards abolishing the
distinction of public hospital, insurance hospital and institutional hospital will be
The works for providing the administrative and financial autonomy of
hospitals will be started, iii) The System of General Health Insurance will be estab-
lished, iv) The execution of family practice will be constituted and a durable con-
veyor chain will beformed,
Thepreventive medicine will bepopularized, vi) Private
sector will be encouraged to make investments to the healthcare field. Within the
Globalization and Health: An Evaluation on Turkey 231
Tab. 1: Number of Hospitals by Yearsand Sectors
Ministry of Health
Source: Health Statistics Yearbook 2017, Ministry of Health
frame of the principle that the people live under the securest economic and social
conditions without discrimination, again in a year;
The norm and standard unity
in the social security institutions will be provided, a unified social security network
will be installed,
In order to enable the creation of an integrated social service and
assistance network, the disorganized social service activities will be gathered under
the same roof, iii) The resources of Fund for the Encouragement of Social Cooperation
and Solidarity will be increased, the procedures and principles of expenditures will be
redetermined and governing structure will be strengthened."
In this sense, the polit-
ical suggestions in the "Immediate Action Plan" have laid the foundations for an
extensive reform thought in the health and social security systems (DPT,
When the objectives in the above have been evaluated, the reform works of
Turkey have also included the finance of health in the same time for the most
part. Especially gathering several social security institutions under the same roof
is quite significant in terms of justice for financing and usage. On the other hand,
it was desired to actualize a strong health system with the executions such as gen-
eral health insurance and family practice. This objective was supported with the
unification of all providers of health care. In the meantime, the encouragement of
private sector to make investments into the health sector can be considered as a
reflection of "liberalization" thought that has been accelerated with globalization
and has been mentioned in Washington Consensus before.
With the Health Transformation Program, it was aimed that private sector will
make investments into the health sector more than before. Thus, the deficiency
of providers of health care will be overcome, and the service uses of individuals
will be supported. Tab.
demonstrates the number of hospitals with regard to the
sectors for the years
As it is seen in Tab.
hospitals in Turkey by year
of them is public,
of them is university,
of them is private and
is other hospitals. In this regard, the delivery of health care was substantially actu-
alized through public sector. The private sector was encouraged with the reform
and the number of private hospitals rapidly increased. By the
the number of private hospitals reached
Therefore, the existence of
Tab. 2: Total Number ofVisits to a Physician byYears
2008 2010 2012 2016 2017
208.966.049 527.566.394 539.085.967 621.786.297 685.709.179 718.924.809
Health Statistics Yearbook
Ministry of Health
private sector in the health sector can be seen intensively, and it is stated that the
health sector gained a place in the market.
On the other hand, the significant obstructions in the access to the providers
of health care were removed with HTP and the access of individuals to the
providers was eased at the same time.
is seen that the service providers of
public, private and university hospitals were more intensely used specifically
as a result of the unification of public hospitals and the abolition of conveyor
demonstrates total number of visits to the providers of health care
The total number of application to the providers of health care was approx-
in Turkey. The chance to access the providers of
health care was eased in
with a new application, and the share of popula-
tion within the scope of social security increased by years. As a result of these
factors, the number of application to the providers of health care showed an
increase as well. Within this context, while there were
this number increased to
The increase of this issue
can be evaluated as extraordinary; it can also be held forth that this condition
is actually originated from the improvement in access to the providers of health
care for the population with green card. As a matter of fact, the scope of social
security was expanded with the realization of General Health Insurance dated
and as a result, the number of applications to the providers of
health care increased. Moreover, the number of applications reached approxi-
When it is considered that the rate of application to
the physician per capita is
in average in OECDcountries, Turkey is located in
quite high levels with the rate of
This condition, however, gave
rise to a thought that redundant applications have been made to the providers
of health care and as a consequence, the expenditures have unnecessarily been
The increases in the number of applications to the providers of health care by
the individuals within the demand for health care and the abolition ofobstructions
in front of these applications are undoubtedly positive in terms of the welfare
of society. However, the rapid increase in demand here is affecting the health
expenditures, and as a result this condition affects the sustainability and finance
of health negatively. Hence, the encumbrance on the state budget with the huge
deficits that social security system has through the health expenditures can be
Globalization and Health: An Evaluation on Turkey 233
characterized as an enormous threat on the health care for the following years.
Therefore, the co-payment has been put into practice with the intent of financing
the expenditures in the health care system. Decreasing the number of redundant
applications and the contribution of health care of users into the finance of health
care have been targeted. The definition of current co-payments is as follows:
order to benefit from the healthcare, amount to be paid for the people with general
health insurance or dependents" (SUT, 2019). Besides, their amounts are mentioned
- 6 TL in the providers of secondary health care,
- 7 TL in the training and research hospitals of ministry of health which have
been used with universities collectively,
TL in the tertiary health care providers which are affiliated to university
- 15 TL in the private providers of health care.
On the other hand, the co-payments have also been taken for the drugs that have
been provided as a result of ambulatory treatment: i) For the medicines paid by
of co-payments from the income and monthly recipients of SSI and their
dependents, and 20
of the other persons are charged. ii) Besides, for each and
TL for drugs supplied in up to
boxes (including three boxes)
TL for every box that has been provided in addition to
boxes has been
taken as a co-payment. Nevertheless, the practice of co-payment is affecting the
welfare of household negatively, and households are becoming poor due to the
health expenditures (Yereli et al, 2014).
Another reform application that neoliberal health policies have caused specific
to Turkey is "City Hospitals" within the scope of public-private partnership.
held forth that a market centric and profit-oriented financing system has been
implemented with the aforementioned application. (Pala et al, 2018: 44). In this
regard, ministry of health has 31 city hospital projects with 44.409 beds in total.
One of these projects is Ankara-Bilkent Hospital, and it is indicated that this hos-
pital will be the world's biggest hospital with 3.704 beds (Ministry of Health, 2018).
PPP has been defined basically as ''contractual partnerships between public and
private sector agencies, specially targeted towardsfinancing, designing, implementing,
and operating infrastructure facilities services that were traditionally provided by the
public sector" (Chakravarty et al., 2015: 129), and it has been aimed at the risk and
reward sharing between public and private sectors with PPP. However, it has been
considered that both the encumbrance on the budget will be increased and addi-
tional payments can be demanded from the patients as a result of that application
(SASAM, 2018: 90).
11 1 US $
6 TL, 22.05.2019
A transformation has occurred in both supply and consumption of semi-public
goods and services, such as health and education with the influence of globaliza-
tion. Both structural adjustment programs and internal dynamics of countries has-
tened this change, and it evolved into a general structure. Reform and alteration in
health care field accelerated especially with the application of neo-liberal policies
after the 1980s. At the helm of the most common problems of the countries, older
population, chronic and contagious diseases and therefore, the unemployed pop-
ulation who are out of economic production mechanism due to these aforemen-
tioned medical problems take the lead. Thus, the mentality and pursuit of reform
that had begun in health sector with the 1980s continue today as well.
Although the health reforms had started in Turkey with the first years of
country, these activities advanced enormously in 2003. Health reform gained a
modern structure with the Health Transformation Program. Improvements have
been observed especially in the number of hospitals and delivery of health care and
access to the providers of services eased.
While the total number of application to the providers of health care was
approximately 209 million in 2002 in Turkey, this number reached 719 million
in 2017. Therefore, the co-payment has been put into practice with the intent of
financing the expenditures in the health care system. In fact, the costs that have
been used by the householders for the usage of health care increased due to the
measures such as the co-payment and additional payment and by this way, they
have been impoverished. In conclusion, it can be held forth that catastrophic health
expenditures will increase and the welfare of household will be affected negatively
with them as well.
(2013). "Neoliberal Transformasyonun Arka Plaru". Avrasya Sosyal
Bilimler Forumu, Diinya Ekonomisinin Gelisim Paradigmasi: Piyasa ve Otesi,
34-40. Baku: Azerbaycan iktisat Universitesi.
Cassels, A. (1995). "Health Sector Reform: Some Key Issues in Less Developed
Countries". Journal of International Development, 7 (3), 329-347.
Chakravarty, N., Sadhu, G., Bhattacharjee, S.
Nallala, S. (2015). "Mapping
private-public-partnership in health organizations: India experience".
International Journal of Medicine and Public Health, 5 (2), 128-132.
DPT. (2002). Acil Eylem Plani. Ankara: DPT.
Flood, C. (2003). International Health Care Reform: A Legal, Economic and Political
Analysis. London: Routledge.
Wilding, P. (2002). Globalization and Human Welfare.
New York: Macmillan.
Globalization and Health: An Evaluation on Turkey
Horton, E. (2007). "Neoliberalism and the Australian Healthcare System
(Factory)". Proceedings 2007 Conference of the Philosophy of Education Society of
Australasia. New Zealand: Wellington.
Lister,]. (2005). Health Policy Reform-Driving the Wrong Way? A Critical Guide
to the Global 'Health Reform' Industry. Canada: Middlesex University Press.
Ministry of Health. (2018). 2019 Yilt Biitce Sunumu TBMM Plan ve Biitce
OECD. (2018). Health Data 2018.
Bilaloglu, E., Ilhan, B., Tukel,
Adiyaman, S. (2018). "Public-
Private Partnership in Health Care: Case of Turkey". World Medical Journal, 4
Harding, A. (Eds.). (2003). Innovations in Health Service
Delivery: The Corppporatization of Public Hospitals. Washington: The
Roberts, M., Hsiao, W., Berman, P.,
Reich, M. (2009). Getting Health Reform
Right: A Guide to Improving Performance and Equity. Oxford: Oxford
Saad-Filho, A. (2008). Washington Uzlasmasmdan Washington
Uzlasmasma: iktisadi Kalkmmaya Dair Neoliberal Gundemler, In A. Saad-
D. Johnston (Eds.), Neoliberalizm MuhalifBir Secki (pp. 191-201).
Figueras,]. (1998). Avrupa Saghk Reformu Mevcut Stratejilerin
Analizi. Ankara: T.C. Saghk Bakanhgi, Saghk Projesi Genel Koordinatorlugu.
SASAM. (2018). Sehir Hastaneleri Arasttrmasi. Ankara: Saglik-Sen Sendikasi.
SUT. (2019). Saghk Uygulama Tebligi. Sosyal Giivenlik Kurumu.
Williamson, ]. (2000). "What Should the World Bank Think about the Washington
Consensus?". World Bank Research Observer, 15 (2), 251-264.
Yereli, A.B., A. M. Koktas, I.S. Selcuk. (2014). "Factors Affecting Catastrophic
Health Expenditure in Turkey". Sosyoekonomi, 22 (22), 273-295.