Fisek Institute’s Approach Towards The Health Services Provided By Social Security Institutions

* Dated 04.16.1997, this report was prepared on account of the formal request of the Republic of Turkey-Presidential State Supervisory Committee.

As we examine the historical development of the concept of social security in Turkey, we notice that the two concepts, “social state” and “social security”, were presented in an intermingled way until 1950.

Furthermore, after 1924, the measures regarding working life as well as social security issues were given a special emphasis -as a result of the non-existence of a necessary Labour Law and the existence of an influential Ministry of Health- within the activities of the Ministry of Health and under the scope of the Law on the Protection of General Health. Such an evolution brought forth the birth of a “model” as differently from other countries. Especially for the regulations and applications regarding occupational health and safety issues, it was preconditioned that the two ministries (the Ministry of Health and of Labour -previously Economy) were to work in co-ordination. This co-operation is a fact that other countries have not ensured even today and which presents itself in the remoteness between the activities of the World Health Organisation and the International Labour Organisation.

However, unfortunately, when we come to the 1945’s during which the most harmful problems like contagious diseases were overcome, we notice that “insurance” practices were started just for the sake of a small group (workers) as opposed to the current developments in the world; and it was because of the budget deficiencies and of an approach nourished by the worries on international politics. It is also thought-provoking that during that time, these two ministries (health and labour) were involved in an undertaking for health insurance, and hence they adopted a competitive position against each other. Prepared by the Ministry of Health and Social Service in 1947, the Bill on Health Insurance was sent to the Turkish Grand National Assembly (TGNA); yet, in 1950, the Health Insurance practice was got started under the structure of the Worker’s Insurance Institution.

Even if it was condoned for a short period of time, this privilege bearing application was not complemented with a satisfying health service comprehending the society overall, and this increased the burden loaded over the Social Insurance Institution (SII). The institution, then, turned to be the target of various misuses, as it was clear from the complaints of a Vice-General Director of SII saying: “It is as if all the dialysis patients in Turkey were insured”.

In 1961, the “Law on the Socialisation of Health Services” aiming to put the “health for all” principle into practice also aimed to provide health services for each and every citizen without favouring any one. It became the first factor circumscribing the success of this implementation that the law started to be put into practice first in the east and south east provinces. If these provinces are compared with each other, in terms of which were comprehended by the practices on the “socialisation of health services” and on the “health insurance”, an exceedingly striking picture would come out that one may notice.

As you see, the divergence between these two practices were incited, rather than achieving their integration, in the name of conveying the necessary health services to the every nook and cranny of the country. Just in the same way, the insistent campaigns carried out in 1964-67 by the social parties of working life appeared as a pressure group in order to make them split into two.

Regrettably, the concern for “preventive health services”, as stated in the Article 114 of the SII Law, was left out meanwhile. Similarly, except for “family planning” services, it is not possible to talk about any SII implementation on preventive health services for today. Whereas, the most effective way to reduce the expenditures of insurance is not causing to arise the necessity of insured persons to utilise from these insurance branches ever, by utilising from the “self-defence mechanisms” brought forth by the Law No. 506.

Among other things, it should not be forgotten that there are two important SII enterprises for the provision of preventive health services. The first one of these is the TUM-SAB Project initiated in 1972, and the other is the experience regarding the Occupational Diseases’ Clinic initiated in 1976. The former aimed to establish bridges between the occupational physicians and SII, while the latter, by means of visiting and inspecting workplaces, intended to detect occupational disease cases at workplaces, which might be overlooked given the daily functioning of polyclinics. Unfortunately, the first experience ended in failure; and the second one, by being deviated from its objective, remained as three hospitals only evaluating the cases that were sent them “suspiciously” and providing a medical treatment service for them if it is needed. However, an institution like SII, which is only obliged to take care of workers and their families, should have appropriated a workplace and work-based approach as a guide for its actions. It should be the most significant characteristic of the organisations on general health differentiating them from the others.

These are the losses of great significance, and some of the trains about which it is said that SII missed.

It is one of the most critical weaknesses of SII that it has not formed an “institutional memory” throughout its 50 year-odd history. On that ground, it is a fairly significant starting point that the Economic and Social History Foundation of Turkey was made the “History of the Foundation” written. Concerning this historical study, it was underlined that Re-structuration Enterprises of the Institution should be investigated thoroughly and people should take lessons from the past experiences.

Another weakness is the inadequacy of the academic studies and publications supported by the institution. Nevertheless, it is only through “extrospective observations” the repetition of making the same mistakes (which are defined as “operational blindness” and which are supposed as if they are right) would be held back by allowing the institution to scrutinise its own implementations. In this regard, the “Co-operation Protocol” should be touched upon, which was proposed by the Ankara University- Faculty of Political Sciences Deanery for the interests of the SII General Directorate.

On the other hand, concerning different insurance branches from which premiums are collected separately, the insurance on occupational disease and accidents still counts much. These premium extras should be utilised in accordance with the “solemn agreements made during the collection”; however, SII employs them in order to meet its deficits. What should be done with these premium extras is the development of such systems that would reduce the occurrence rate of occupational accidents, and that would allow the occupational diseases to be ascertained. In this way, the insurance premiums regarding occupational diseases as well as “consumable” occupational accidents would be reduced as the years passed. Consequently, this would let the conditions of workplaces to be meliorated, and the number of insured persons having died or been maimed to be reduced. Therefore, the attainments would not be achieved individually only, but also socially.

For many years, the “Health Insurance” yielded a lot as well. However, it is due to the recent increase in the medicine prices and the high costs of technical reports (like advanced projection) that are purchased from extra-institutional sources. If these extras are spent for the improvement of “first-step services”, both individual and social attainments would be expanded.

Solving the problems of SII and social security institutions in general cannot be thought aside from the problems of social state. Behind the social security crisis that we live through today, there lies the spoiling of the social state’s functions. In order to compensate for the decrease in the social support of the state, insured persons are willing to resort to their financial potential; yet, since they are experiencing “income losses or expenditure increases”, they are not able to afford this desire. Consequently, they regard the social security system as responsible for this drawback. Therefore, the solution lies in the endeavours of social security system to reduce the expenditures through undertaking some of the burdens of social politics either by itself or in co-operation with the state. Beyond any doubt, employers would be expected to continue to provide some of the services they have been providing previously.

Defined in particular to SII, these principles could be applicable for both the Retirement Trust and Bag-Kur (Social Insurance Institution for the Self-Employed). While SII makes use of the occupational physicians, the Retirement Trust (or other public institutions paying premium to this institution) utilises from the institutional physicians. It is better for the ones affiliated with Bag-Kur, on the other hand, to be comprehended by the workplace or work-based service chains. Affiliated with various social security institutions, all “active insured” persons’ extra-work problems (in addition to the health problems of whom they are obliged to take care) could be resolved by channelling them to the health clinics.

The new model that we propose in regard to the health-social services provided by social security institutions features, first of all, focusing on the “first-step organisations” that are in order to eliminate the necessity felt for utilising from these services (Model Proposal-Table 1). As for the limited cases in which this is not achieved so, established mechanisms of the social security system are to be made use of. Concerning the Table demonstrating the Model Proposal, (A) denotes the “first-step organisations”, while (B) is for institutional mechanisms.


(A) (B)
Occupational (or Institutional) Medicine Health Clinics
The Centre of Geriatrics, Rehabilitation, Occupational and Environmental Polyclinics Hospital Centres
The Centre for Rehabilitation, Environmental and Occupational Protection and Geriatrics for aged people SII State Hospital
Occupational Diseases The Hospital for Occupational Diseases

The integration (unification and merger) of social security institutions is a matter that has been discussed for years. However, any progress has not been observed until so far. Such a step taken in health issues would be the first step of achieving this general integration.

Concerning this step, first-step health organisations bear a significant place. As it is clearly understood from the Table, occupational (institutional) medicines and health clinics constitute the first step of this model. As required by the Law on the Generalisation of Health Services, the population scale of a first-step organisation employing permanent physicians is 5.000 persons. This scale should be rendered valid for occupational and institutional medicines as well; and workplaces should headed towards the establishment of “shared” health centres.

The workplaces which are not required to maintain an occupational physician is the ones employing less than 50 workers; and they should be evaluated within the scope of these necessities, hence within these “shared” health units.

Regarding these health units, the necessary manpower and equipment standardisation should be made; and a multi-disciplinary approach (medical sciences, engineering, social sciences, and etc.) should be appropriated in accordance with the necessities of working life.

Preventive medicine approach should be determined as the fundamental duty concerning the first-step.

The establishment and management of the occupational and institutional medicines should be carried on by employers. If they request so, these employers should be given an opportunity to make use of these “shared” health units. Additionally, they should be encouraged through the supports like credit opportunities provided by the social security institutions.

With respect to these supports, the development and the cost-efficiency criteria should be taken into account.

Shared health units should undoubtedly comprehend all the issues like social development, human rights, community education, and the services for utilisation from leisure time activities and the provision of social counselling. Under the scope of these services, these should be given a special emphasis: children, women, disabled and middle-aged people that have not reached to the retirement age yet.

In addition to the unification of the “Ministry of Labour and Social Security”, the “Ministry of Health” and the “Ministry of State Responsible for Family and SHÇEK (Social Services and Child Protection Institute)” under a single structure, all these measures can come to a successful conclusion only as non-governmental organisations are given more active roles in practice.

Respectfully, and with our best wishes…