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Public-Private Partnership in Health Care: Case of Turkey.

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Abstract

The nature of neoliberal health reforms that brings market orientation to health and making it a new area of profit maximization for capital has, within the last three decades, deeply affected public hospitals in Turkey in terms of organization, financing and employment. The financing structure of public hospitals has radically changed in this process.
44
Health Care
e nature of neoliberal health reforms that
brings market orientation to health and
making it a new area of prot maximization
for capital has, within the last three decades,
deeply aected public hospitals in Turkey
in terms of organization, nancing and em-
ployment. e nancing structure of pub-
lic hospitals has radically changed in this
process. While citizens have already taken
up the burden through direct and indirect
taxation, hospitals are forced to seek funds
from extra budgetary resources and conse-
quently it became necessary to have citizens
to contribute to the nancing of health ser-
vices through social/private security contri-
butions, cost-sharing/user fees and out-of-
pocket costs.
Changing the nancial and organizational
structure of public hospitals is the princi-
pal approach in widening the operational
sphere of capital in the eld of health. In
this context, the building of and service
delivery by public hospitals on the basis of
the model called public-private partnership
(PPP) is brought to the fore in Turkey.
Historical Background
e rst arrangement in Turkey relating to
the building of health facilities under the
public sector through “leasing” was made in
2005 by adding an article (Additional Ar-
ticle 7) to the Fundamental Law on Health
Services No. 3359 dated 1987. en, a new
regulation (2006) and legislation (2013)
established in detail the scope and content
of leasing. ese arrangements were rst
referred to as “Integrated Health Campus”,
followed by other terms including “Health
Campus”, “Public-Private Partnership” and
“Public-Private Cooperation.” Finally, hos-
pitals built through public-private partner-
ship were introduced to the public as “City
Hospitals”. Presently there are 6 active city
hospitals in Turkey (Yozgat, Mersin, Adana,
Isparta, Kayseri and Elazig).
Opinions of neither the Turkish Medical
Association (TMA) nor trade unions were
solicited during arrangements related to the
drafting of the law in 2015, regulation on
the enforcement of the law and in estab-
lishment of the Ministry of Health Depart-
ment of Public-Private Partnership.
On land allocated free by the public for city
hospitals, the Ministry of Health goes out
to tender for buildings whose projects were
developed by the Ministry and these tenders
are generally won by group of companies
active in the elds of medical equipment/
technology, construction and nancing. Ac-
cording to tender specications, winning
companies have to nish hospital buildings
within three years (in many contracts this
condition is not met; for instance, the con-
struction of Kayseri City Hospital tendered
out in 2009 was completed only recently),
and to undertake care/maintenance works
throughout the leasing period (25 years).
Information available about tenders is kept
limited since it is considered as “business
secret.”
Contracts acted by the Ministry of Health
and companies are subject to private law
provisions and related disputes are to be
settled by arbitration. At this point it must
be recalled that Prof Alfred de Zayas, Unit-
ed Nations Special Rapporteur for Human
Rights warned that the privatization of
public services through public-private part-
nerships would lead to human rights viola-
tions and it would harm citizens in longer
term since arbitration is but a mechanism
making the powerful also rightful [1].
Decisions related to the building of city
hospitals used to be taken by the High
Planning Board under the Ministry of
Development comprising relevant Min-
isters under the chair of Prime Minister.
e Ministry of Development was closed
with the new government system in Turkey.
e decision making authority of the High
Planning Board was withdrawn and at pres-
ent the building of city hospitals is to be de-
cided by the President as the sole authority.
Until recently, the Board used to decide on
building city hospitals on the condition that
the number of beds in existing hospitals is
reduced by the same amount as needed by
prospective hospital or the closure of exist-
ing hospitals. Following the completion of
a city hospital, state hospitals move to their
new buildings, old buildings remaining
Kayihan Pala Ozgur Erbas Eris Bilaloglu Bayazit Ilhan Rasit Tukel Sinan Adiyaman
Public-Private Partnership in Health Care: Case of Turkey
TURKEY
BACK TO CONTENTS
45
Health Care
within the city are closed, and consequently
no inpatient beds are added to Ministry of
Health hospitals in provinces where city
hospitals are built. For example, while public
hospitals in Adana used to deliver services
with bed capacity of 3,011, this number rose
to only 3,025 after the opening of the city
hospital with bed capacity of 1,550. In An-
kara, the capital city of the country, the plan
for the closure of 13 deep-seated hospitals
of the Ministry of Health located at central
town and delivery of health services by two
city hospitals will radically transform health
services and urban structure.
It was revealed upon lawsuits brought by
the Turkish Medical Association that ten-
der specications prepared by the Ministry
of Health also included the free transfer of
land once occupied by closed public hospi-
tals to tender winning companies for their
business enterprises such as hotels, luxury
housing or shopping malls though not en-
visaged either in Board decisions or legisla-
tive arrangements. Upon this, the Council
of State decided to suspend tenders relat-
ed to Ankara-Etlik, Ankara-Bilkent and
Elazig city hospitals. en a legislative ar-
rangement was introduced to the eect
“tender specications envisaging the trans-
fer of hospital land to companies are not to
be complied with.” In order to stand against
any possible decision of annulment by the
Council of State, the clause “decisions of
annulment by the administrative jurisdic-
tion are not enforced; but relevant revisions
are made according to justications given
for annulment” was introduced.
“Commercial revenues” in city hospitals
are left to tender winning companies and
both “Clinical Support Services” and “Sup-
port Services” are also delivered by these
companies. roughout the period of con-
tract (25 years) companies are to be paid
Availability payment as rental and repair/
maintenance, and volume based “Service
payments” for clinical support services
(Laboratory, imaging, sterilization and dis-
infection, rehabilitation, etc.) and other
support services (Linen and laundry, cater-
ing, waste management, etc.). Companies
that undertake city hospital tenders in Tur-
key are guaranteed that hospitals will be op-
erated by rate of occupancy of 70% in terms
of volume-based care. is rate is 80% for
high security forensic psychiatry hospitals.
e denition of “clinical support services”
included in tender specications is not suf-
ciently clear. Due to this lack of clarity
branches such as physical treatment and
rehabilitation and radiation oncology to-
gether with medical imaging and labora-
tory services are included in “clinical sup-
port services” and left to private companies.
Upon an amendment made later, ambigu-
ity went further and it was accepted that
“services requiring advanced technology
and high funding” may be handed over to
companies. is means that all services with
high rates of return may be transferred to
companies upon their request.
It is agreed that availability and service pay-
ments for city hospitals is to be paid by the
Ministry of Health or from revolving fund
budgets of its aliate facilities and/or by
central government budget. But it is un-
certain whether revolving funds can cover
very high service costs. Due to neoliberal
health policies, base salaries of doctors and
other health workers are low in Turkey and
the system of performance-based additional
payment is adopted on the condition that
that it is covered by revolving fund. Since
priority in the use of revolving fund is given
to payments due to companies, there are
cuts in additional payments of doctors and
other health workers.
As can be understood clearly from what has
been said above, public-private partnership
is a model of investment and service deliv-
ery that is based on State’s long-term con-
tractual relationship with a group of private
companies. In this model, hospitals are built
by private companies and leased to the State
for long-term (i.e. 25 years) while the State,
on its part, both pays rent and transfers all
services other than “core services” to these
companies.
Public-private partnership is a privatiza-
tion method and cases from many countries
clearly show that public-private partnership
initiatives serve not to the interest of pa-
tients but nanciers. ere are many studies
conrming that investments in infrastruc-
ture made through public-private partner-
ships are costlier than others made through
routine tendering procedures. In public-pri-
vate partnership model, risks and costs rest
with public whereas private companies en-
joy means of nancing through rental and
income guaranteed on the basis of service
transfer.
Problems Coming to
the Fore in Turkey
e major problem related to city hospitals
in Turkey is the high cost of hospital build-
ings and equipment to the public. Exam-
ining the amount of xed investment and
annual rentals in tenders arranged by the
Ministry of Health we come across signi-
cantly high costs. According to a report by
the Ministry of Development, for 18 city
hospitals whose contract price amounts to
10.6 billion USD, an amount of 30.3 billion
USD is to be paid in 25 years to compa-
nies building and operating these hospitals
[2]. Given that the number of city hospitals
planned is 31 (for the time being) we can
foresee that Turkey will undertake a debt
burden of over 50 billion USD for a period
running until 2050 only as availability pay-
ments. Considering that the total invest-
ment budget of the Ministry of Health is
1.5 billion USD for the year 2018, it is un-
derstood better how high the cost of public-
private partnership is in the eld of health.
In case the State has its investments within
the framework of a plan there will be no
need to resort to methods like PPP by going
into long-term debt or paying rental. Such
methods are too costly and paid through
TURKEY
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46
taxes collected from people. For instance, it
is gured out that with 2.6 billion TL allo-
cated from the 2018 budget of the Ministry
of Health to presently operating hospitals
it is possible to build 64 full-edged hos-
pitals each with 150 bed capacity [3]. e
extremely high cost burden can be seen
more clearly if it is considered that rent-
als will be paid for a period of 25 years and
it will further increase with each new city
hospital. While the exchange rate was set
as 1 USD=1.5 TL in preliminary feasibility
reports for hospitals, the present exchange
rate is well over 1 USD=6 TL. Given that
the Turkish lira is recently losing value
against foreign currencies including dol-
lar and euro in the rst place, it is a great
risk for the country that rentals have to be
paid based on USD. Economists warn that
initiatives in public-private partnership will
further deepen the present economic crisis
faced by Turkey.
Worldwide, suppositions that once laid
the basis of arguments about the “ratio-
nality” and “legitimacy” of privatizations
through public-private partnerships and
other methods are collapsing while argu-
ments and struggle for the delivery of pub-
lic services publicly and for the benet of
public are getting stronger. e call made
by more than 150 organizations throughout
the world with a Manifesto addressed to
the World Bank and IMF was an impor-
tant stage in this process. Upon reactions,
the World Bank had to update its criteria
related to Environmental and Social Im-
pact Assessment [4]. In the same vein, a
revised text related to counselling services
in initiatives supported by the International
Bank for Reconstruction and Development
(IBRD) and International Development
Association (IDA) was issued in July 2014.
e point that is emphasized in modica-
tions made is that relevant reports should go
into the essence beyond what is formal and
include realistic assessments. A statement
made by the World Bank openly admits the
presence of manipulations in environmental
and social impact assessment reports com-
ing from the eld in relation to projects that
it will fund and concedes that its local units
have to be more meticulous on such mat-
ters.
e rst one being in April 2011, tenders
based on the PPP method and their legis-
lative basis was carried out in a way closed
to all relevant stakeholders. Infractions and
irregularities in the process include the fol-
lowing: Change in companies involved in
tendering process; continuation of price re-
lated discussions even after the completion
of tenders; failure in making deliveries on
committed dates; revision of contracts over
and over again; and deeming the procedure
of tendering practically non-functional
through transfer of shares of the main com-
pany as a method having no place either in
legislation or in relevant regulation. e es-
sential point in any tender is to nd a com-
pany best suited to perform a specic work
in compliance with some specications and
award it in a way to uphold public benet.
In the method mentioned above, however,
even companies not participating to tender
process were awarded by moving out of the
inspection of tender commissions. is is
openly in contrast with the Law on Public
Tendering and the Law No. 6428 on Build-
ing and Renewal of Facilities and Delivery
of Services through Public-Private Partner-
ship Model by the Ministry of Health.
In relation to PPP practices known as “city
hospitals” tendered in Turkey since 2011,
various consulting rms solicited the opin-
ion of the Turkish Medical Association in
the context of environmental and social
impact assessment. Resulting opinions were
placed on internet pages of the organiza-
tion. Retrospective visits to World Bank’s
project evaluation and promotion pages
showed that opinions of the TMA were
not incorporated into reports and the only
mention of the TMA was about its lawsuit
requesting the nullication of tenders.
Yet, opinions forwarded by the TMA had
pointed out to many defects and irregulari-
ties in relevant procedures and processes in-
cluding the following: practices, including
those under the relevant legislation in the
rst place, totally out of public informa-
tion and scrutiny; absence of Environmen-
tal Impact Assessment (EIA) in any project
though it is compulsory under the existing
Environment Law; development of projects
out of international criteria related to e-
ciency; existence of building projects leading
to implicit incremental costs; threat to peace
in working life as a result of status dier-
ences of personnel to be employed in hospi-
tals; negative implications on education for
specialty in medicine as a result of arrange-
ments not considering the requirements of
this education; threats to medical autonomy
in the absence of rules on doctor-private
company relations; increased possibility of
companies shifting risks to public and pub-
lic employees as a result of ambiguities in
risk sharing; non-compliance of preliminary
feasibility reports on projects with criteria
set by the World Bank, OECD, European
Bank for Reconstruction and Development
(EBRD) and European Investment Bank;
absence of any value for money (VfM) anal-
ysis complying with international standards;
and neither including nor taking the opin-
ion of trade unions and professional orga-
nizations at any stage in the process. Hence,
the process operating so far in Turkey as a
whole runs counter to all environmental and
social impact assessment criteria.
In Turkey there are also some technical
problems associated with city hospitals such
as high number of beds and large size of in-
door space per bed.
e average number of beds in a city hos-
pital in Turkey is 1,311. is number, how-
ever, may be as high as 3,704 in the case of
Ankara-Bilkent City Hospital for instance.
e number of beds in a hospital is accepted
as an important indicator with respect to ef-
ciency. e outcomes of a systematic study
on the eciency and optimal size of hos-
pitals show that hospitals with bed capac-
ity under 200 and over 600 are inecient
Health Care TURKEY
BACK TO CONTENTS
47
[5]. e high number of beds preferred for
city hospitals confronts Turkey as a source
of ineciency as proven by past experience
and scientic studies. While large hospitals
are being abandoned throughout the world
for their ineciency, the Ministry of Health
targets launching such hospitals with thou-
sands of beds.
In city hospitals in Turkey, the average in-
door space per bed is 287 m2 than can be
as high as 350 m2 in some hospitals. It is
observed that this space is generally around
150-200 m2 in new hospitals built in de-
veloped countries. is means that indoor
space per bed in city hospitals in Turkey
is larger by about 40 per cent than what is
recently preferred in modern hospitals. e
point is that larger the indoor space per bed
is, higher the costs of energy, cleaning, re-
pair and maintenance are.
As far as health workers are concerned, city
hospitals rst of all created problems related
to their employment. While it is accepted to
transfer sub-contracted workers in Ministry
of Health hospitals to permanent employ-
ment status, those working in city hospitals
as well as workers in public hospitals to be
closed for these hospitals are excluded from
this arrangement.
e practice of city hospitals that under-
went auditing by the Court of Accounts for
the rst time in 2018 since 2005 presents a
dire picture. e report by the Court of Ac-
counts observes the following: Hospitals are
delivered with yet uncompleted construc-
tion and equipment; operations favouring
companies in payment schedules even when
guarantees are given for changes in foreign
exchange and ination rates; deletion of
records of aws by companies that are also
awarded hospital information management
systems; or administrations that have to
conduct inspection only on databases pro-
vided by companies; possibility of revising
all contracts to the benet of companies
upon the request of companies and credit
institutions; and while in legislative terms
it is only the Treasury that can undertake
debts on behalf of public, top sta in the
Ministry of Health committing to com-
pensate companies in cases of termination
of contracts even when companies are the
breaching party and undertake the repay-
ment of debts incurred by companies [6].
To sum up, the major problem areas related
to “City Hospitals” in Turkey can be listed
as follows:
Method of nancing (extremely high cost
to the public, payment diculties faced
by public hospitals to move, ways to be
pursued in relation to treasury guarantee
and cases like bankruptcy),
Site selection (opening of farmland to
development and constructions on sites
under the threat of oods),
Problems of physical access resulting
from the closure of hospitals located at
city centres (geographical/economical ac-
cessibility),
Status of sites to be vacated by public
hospitals moving elsewhere (their trans-
fer to contracting companies is at issue),
Concessions for the delivery of both
health and support services in public hos-
pitals to move and
Issues related to the employment and
rights of health workers [7].
Stance of Turkish
Medical Association
It is known that the PPP is a method of
privatization creating new market opportu-
nities in countries where it is implemented
in the eld of health and that its purpose is
not public benet. Hospitals operating in
the context of PPP deliver private and prot
seeking services that erode the system of
healthcare. e focal point of service here is
not human health but what accrues as prot.
e Turkish Medical Association closely
follows the process of city hospitals and
wages a struggle in both organizational and
legal terms against public-private partner-
ship initiatives in the eld of health up-
holding the interests of health workers and
public benet. In 2012, the TMA carried
the issue of public-private partnership/city
hospitals to the top of its agenda and de-
ned it as a strategic work given that the
process will eventually lead to the full priva-
tization of healthcare and leave doctors and
health workers with no other option but be-
ing employees of international consortiums.
e TMA Central Council established its
City Hospitals Monitoring Group in April
to steers eorts and initiatives in this area.
Despite the promotion of city hospitals as
new and modern buildings that public hos-
pitals will nally enjoy, it is clear that such
campuses built through public-private part-
nerships have in fact no ties with what is
actually public. It appears that city hospitals
will be the means of transferring new and
large resources to global capital under the
pretext of “public”. e people of Turkey are
now confronted in the eld of health a form
of privatization even more destructive than
what has been experienced so far.
References
1. Current Concerns, accessed August 8, 2018,
https://www.zeit-fragen.ch/en/numbers/2016/
no-12-28-may-2016/ttip-international-arbitra-
tion-courts-an-assault-on-democracy-and-the-
state-of-law.html .
2. Ministry of Development (2017), Report on
Developments Related to Public-Private Part-
nership Practices in the World and in Turkey
2016, General Directorate of Investment Pro-
gramming, Monitoring and Evaluation, 2017.
3. Northern Anatolia Development Agency Pri-
vate Hospital Preliminary Feasibility Report
(2016), accessed April 22, 2018, https://www.
kuzka.gov.tr/paylasim/01_ozel_hastane_(on_
zibilite).pdf
4. WORLD BANK Environmental and Social
Framework Setting Environmental and So-
cial Standards for Investment Project Financ-
ing, 2016, accessed August 8, 2018, http://
consultations.worldbank.org/Data/hub/files/
consultation-template/review-and-update-
world-bank-safeguard-policies/en/materials/
third_draft_esf_for_disclosure_july_20_2016.pdf
5. Giancotti, M., Guglielmo, A. and Mauro, M.
(2017), “Eciency and Optimal Size of Hos-
Health Care
TURKEY
BACK TO CONTENTS
48
pitals: Results of a Systematic Search”, PLoS
ONE, 12 (3): e0174533.
6. Court of Accounts, 2017 Inspection Report on
Public Hospitals in Turkey.
7. Pala, K. High Cost of City Hospitals is Con-
cealed, Bianet; 2017, accessed April 15, 2018,
https://bianet.org/bianet/siyaset/183006-sehir-
hastanelerinin-yuksek-maliyeti-gizleniyor .
Kayihan Pala, Professor of Public Health,
Turkish Medical Association, member
of City Hospitals Monitoring Group
Ozgur Erbas, Lawyer,
TurkishMedical Association,
member of City Hospitals
Monitoring Group
Eris Bilaloglu, Biochemistry specialist,
Turkish Medical Association President
of Central Council (2010–2012),
Turkish Medical Association, member
of City Hospitals Monitoring Group
Bayazit Ilhan, Ophthalmologist,
Turkish Medical Association President
of Central Council (2014–2016),
Turkish Medical Association, member
of City Hospitals Monitoring Group
Rasit Tukel, Professor of Psychiatry,
Turkish Medical Association President
of Central Council (2016–2018),
Turkish Medical Association, member
of City Hospitals Monitoring Group
Sinan Adiyaman, Professor of
Orthopaedics and Traumatology,
Turkish Medical Association President
of Central Council(2018-2020),
Turkish Medical Association, member
of City Hospitals Monitoring Group
E-mail: ttb@ttb.org.tr
Welcome speech by
Dr. Ravindran R.Naidu–
president of the Cmaao 2018–2019
“Friends, it is an absolute honour and privi-
lege to stand before you on this graceful oc-
casion and utter the most awaited words “Yes,
I accept to be the President of CMAAO for
the year 2018–2019, an organisation with a
proud past and an exciting future. A single
head achieves nothing, so Iam counting on
your support to achieve the growth and goals
of CMAAO. is is truly a moment to be
honoured and cherished. I accept this ap-
pointment with pride and will give my best
eorts to make you proud. With the grace of
god and the cooperation of fellow members,
I will devote my time and myself to the obli-
gations and duties of this post.
Currently comprised of 19-member Na-
tional Medical Associations (NMAs), the
Confederation of Medical Associations in
Asia and Oceania (CMAAO) has more
than 50 years of history. Its establishment
was proposed in 1956 by Dr. Rodolfo
P. Gonzalez, then President of the Phil-
ippine Medical Association at the third
meeting of the Southeast Asian Medical
Confederation. In 1959, CMAAO was in-
augurated at the rst Congress and Council
Meeting held at the Imperial Hotel in To-
kyo. ere were 11-member NMAs at the
time of inauguration, of which 6 were pres-
ent at the rst congress.
e Secretariat, which was originally in the
Philippine Medical Association, moved
to Malaysia (1993), ailand (1997), New
Zealand (1999), and since 2000 it has been
in Japan. e role of CMAAO Secretary
General was also passed to the JMA.
is is a history that should never be forgot-
ten, and we, the current generation of mem-
bers, owe it to all the organisation’s past
members to keep this great organisation
strong and vibrant as we face the challenges
of the medical profession that confront us
now and into the future.
Over the next one year we will continue to
build on our strengths, but also take on new
directions.
We will continue our programs that
strengthen our professionalism. We will also
retain our commitment to solidarity, ensur-
ing that our members that are less resourced
can have more opportunities and assistance
to be part of this organisation and promot-
ing exchange of information and activities
aimed at improving the health of all in the
Asia Pacic region. To ensure that all of us
can perform our critical role and be a part of:
CMAAO Resolution on Ensuring Food
Safety,
CMAAO Resolution on Ethical Frame-
works for Health Databases and Health
genetic databases,
CMAAO Delhi Resolution on the Pre-
vention of Child Abuse,
Ravindran R Naidu
Confederation of Medical Associations in
Asia and Oceania (CMAAO)
NMA News MALAYSIA
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... Makalede şehir hastanelerinin "kamu" adı kullanılarak, küresel sermayeye yeni ve büyük bir kaynak aktarmanın aracı olduğu vurgulanırken, Türkiye toplumunun sağlık alanında oldukça yıkıcı yeni bir özelleştirme ile karşı karşıya olduğu uyarısında bulunulmuştur. 13 Sağlık hizmeti kullanıcılarının nasıl adlandırılacağı konusunda çeşitli durumlar rol oynayabilir. Örneğin sağlıklı olup sağlık hizmeti kullanan kişilerin hasta olarak adlandırıldıklarında kendilerini nasıl hissettikleri (örneğin kontrol amaçlı görüntülemeyi kullanan sağlık kişilerin nasıl hissettikleri) de göz önünde bulundurulmalıdır. ...
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Günümüzde bilgiye erişimin kolaylaşması, teknolojideki gelişmeler, eğitim düzeyinin ve sağlık okur-yazarlığın artması gibi çeşitli nedenlerle sağlık hizmeti kullanıcılarının profili değişmiştir. Sağlık hizmeti kullanıcıları sağlık kurumlarından ve sağlık çalışanlarından daha fazla beklentiye sahip olup, kendileri ile ilgili kararlara daha aktif olarak katılmak istemektedirler. Kişilerin bu beklentilerini karşılayarak rekabet avantajı elde etmek isteyen sağlık kurumları ise sağlık hizmeti almak için gelen kişilere hasta yerine müşteri gibi davranabilmektedirler. Bazı kişilerce bu durumun sağlık hizmetinin sunumunda kaliteyi geliştireceği düşünülmekle birlikte, bazı kişiler ise sağlık hizmeti alan kişilere müşteri olarak yaklaşmanın, sağlık kurumlarının kendine has bazı özellikleri nedeniyle, etik konular da dahil olmak üzere, bazı sıkıntılara yol açabileceğini belirtmektedir. Bu çalışmada bu konudaki farklı bakış açıları ve yaklaşımlar ele alınarak tartışmak amaçlanmaktadır. Bu doğrultuda sağlık hizmeti kullanıcılarını ifade etmek için kullanılan çeşitli terimler, bu terimlerin kelime anlamları, sağlık hizmeti kullanıcılarının kendilerinin nasıl adlandırılmak istedikleri ve bu konudaki farklı görüşlere yönelik literatür derlemesi yapılmıştır. Yapılan incelemeler sonucunda, sağlık hizmetine ihtiyaç duyan kişilerin tümüne ihtiyaçları olan sağlık hizmetinin sunumunda onları dinleyen, onlarla ilgilenen, para kazanmaktan çok iyileştirmeyi amaçlayan, yanlış yönlendirmeyen tıbbi hizmetlerin sunulması açısından "hasta" yaklaşımının; hastaların beklentilerini izleyen, tatmin düzeylerini ölçen pazarlama faaliyetleri ve onlara kaliteli bir hizmet sunma konusunda yapılacak iyileştirme faaliyetleri açısından ise "müşteri" yaklaşımının benimsenmesi gerektiği sonucuna varılmıştır. ABSTRACT Today, the profile of health care users has changed due to various reasons such as easier access to information, developments in technology, and increased education and health literacy. Health care users have more expectations from health institutions and healthcare workers and they want to participate more actively in decisions about themselves. On the other hand, health institutions that want to gain competitive advantage by meeting these expectations of the people can treat the people who come to get health services as customers instead of patients.While some believe that this will improve the quality of health care provision, others say that approaching healthcare users as a customer may lead to some problems, including ethical issues, due to the specific characteristics of health care institutions. This study aims to discuss different perspectives and approaches on this subject. In this respect, literature review have been made about various terms used to express health service users, word meanings of these terms, how health service users want to be named and different opinions on this subject.As a result of the examinations, the "patient" approach should be adopted in terms of providing non-misguided medical services to all the people in need of health care, listening to them in the provision of health care, taking care of them, aiming to cure them rather than making money; and "customer" approach should be adopted in terms of marketing activities that follow the expectations of the patients and measure their level of satisfaciton, and measuring their level of satisfaction and improvement activities about providing them a quality service.
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A huge-scale transformation and neoliberalization of the Turkish healthcare system is happening under the rule of AKP, and the city hospitals as a public-private partnership model constitutes the centerpiece of this transformation. The “effectiveness” argument is utilized both by politicians and financial actors to promote the role of the private sector in the management of public services as in the case of city hospitals. This paper argues that the McDonaldization thesis of George Ritzer can help analyze the transnational nature of neoliberalization of the Turkish healthcare system, and features of McDonaldization, most notably the irrationality of rationality through the argument of effectiveness can explain the transformative role of city hospitals in the healthcare system. Moreover, as a general theoretical observation, it is argued that neoliberal transformation and McDonaldization of public services lead to broader sociopolitical consequences by deteriorating the public service ethos.
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Health policies and systems are determined by the changes in the world"s economic policies. Therefore, the role and the responsibilities of governments in the health sector are also susceptible to change. In this study, given the/ in the framework generated by/ taking into account the implementation of the last 40 years policies in the world, there have been evaluated the transformation process, the finances and the services provided by the public health system, through the lens of the political economic approaches for the health system in Turkey. The transformation of the health system has been seen as a reflection of economic policies that were shaped by the social relations. The focus of this study is the marketisation process of the healthcare system in Turkey.
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Background National Health Systems managers have been subject in recent years to considerable pressure to increase concentration and allow mergers. This pressure has been justified by a belief that larger hospitals lead to lower average costs and better clinical outcomes through the exploitation of economies of scale. In this context, the opportunity to measure scale efficiency is crucial to address the question of optimal productive size and to manage a fair allocation of resources. Methods and findings This paper analyses the stance of existing research on scale efficiency and optimal size of the hospital sector. We performed a systematic search of 45 past years (1969–2014) of research published in peer-reviewed scientific journals recorded by the Social Sciences Citation Index concerning this topic. We classified articles by the journal’s category, research topic, hospital setting, method and primary data analysis technique. Results showed that most of the studies were focussed on the analysis of technical and scale efficiency or on input / output ratio using Data Envelopment Analysis. We also find increasing interest concerning the effect of possible changes in hospital size on quality of care. Conclusions Studies analysed in this review showed that economies of scale are present for merging hospitals. Results supported the current policy of expanding larger hospitals and restructuring/closing smaller hospitals. In terms of beds, studies reported consistent evidence of economies of scale for hospitals with 200–300 beds. Diseconomies of scale can be expected to occur below 200 beds and above 600 beds.
Report on Developments Related to Public-Private Partnership Practices in the World and in Turkey
  • Ministry
  • Development
Ministry of Development (2017), Report on Developments Related to Public-Private Partnership Practices in the World and in Turkey 2016, General Directorate of Investment Programming, Monitoring and Evaluation, 2017.
High Cost of City Hospitals is Concealed
  • K Pala
Pala, K. High Cost of City Hospitals is Concealed, Bianet; 2017, accessed April 15, 2018, https://bianet.org/bianet/siyaset/183006-sehirhastanelerinin-yuksek-maliyeti-gizleniyor.