Downsizing as a Public Policy and Downsizing Practices in the Health Sector: The Case of Turkey

Introduction

Along with the understanding of the social welfare state that prevailed internationally after World War II, states developed and implemented policies to protect the health of their citizens, ensure that people are not sick, and raise the health level of society. Over time, the growing population, society's demand for more and better healthcare services has led to an increase in health spending. This increase, along with another public spendings, has begun to strain the budgets of states. Each year, states allocate a specific amount from their budgets to health expenditures. Although this share varies depending on the development level of the countries and the health policies implemented in the country, it represents a significant proportion. Health expenditure worldwide increased by 3.9% between 2000-2017. Health spending in middle-income countries increased by 6.3% per year between 2000-2017 and 7.8% per year in low-income countries (WHO, 2019). For Turkey, this situation is no different. While total health expenditures in 2002 were approximately 8.7 million US dollars (3.7% of GDP), this reached 27.6 million US dollars in 2019 (SB, 2019).

After the oil crisis in the 1970s, the welfare state began to be questioned. Keynesian policies came to the international agenda after the Great Depression in 1929 began to be abandoned after a crisis again and were replaced by liberal economic policies. Since the 1980s, neoliberal policies that put competition, quality and effective service delivery at the forefront have started to come to the agenda under the influence of globalization. According to the neoliberal approach, the public sector which is growing excessively and become cumbersome is responsible for crises. So the state should withdraw from the economic sphere, return to its main duties and leave the market to the private sector. In parallel with this understanding, public services previously offered by the state from the 1980s to the present have now started to be offered by the private sector or by private sector-public cooperation. Health, a public service, was also affected by this policy. Constantly increasing health spending and the financial burden it poses on the budget have led to debates about the role of the state in the provision of healthcare services. As a solution, privatization of healthcare services has been proposed. The World Bank (WB) and the International Monetary Fund (IMF) have a great influence on this policy. These twin brothers specifically stipulated the privatization of health services as a condition of lending to underdeveloped countries. Turkey, which has a turbulent political history and has experienced frequent administrative and economic crises, has also been affected by this process.

Health services in Turkey, which progressed in the process of institutionalization until the 1950s, were seen as a government duty after 1961. By the 1980s, a policy shift had begun, and health had ceased to be the only service offered by the state. As a result of contact with WB, several reform movements in health were initiated. The focus of these reforms was to reduce the role of the state in the health sector and to further encourage the private sector, to pay the health expenditures of the group other than the low earners themselves, to implement the family medicine model, to reduce the number of staff or to increase the employment of contract personnel, to turn the Ministry of Health (MoH) into a regulatory and supervisory structure. The vast majority of these were not implemented until 2003. Steps for downsizing the health sector have started to be taken together with the Health Transformation Project (HTP) since 2003. This study aims to discuss the effects of transformation in health policies after 1980 on downsizing and the practices on behalf of downsizing in health and to contribute to the health sector dowsizing literature. The chapter is structured as follows:, First, authors will give a background information about downsizing and public sector downsizing. Then, downsizing in Turkish health sector will be discussed under two periods: before 2003 and after 2003. In this subtitle steps taken for downsizing in the health sector since 1980 will be analysed. Finally, under the last section there will be a discussion on whether there is really a downsizing or not ın Turkish health sector by looking at the data.