Objective: 224 Instead of 506*

By Prof. Dr. A. Gurhan Fisek

* This article was published in Working Environment Periodical, No. 5, November 1992.

The most significant indicator proving the success of a health service is that the service area does not experience any problem after the provision and that it does not pave a way for the complaints of society. It also proves its reliability on the condition that it finds solutions for problems that may arise in the future by providing “fast” and “satisfying” services for individuals.

When we appropriate this criteria, we notice that the grade society gives to the health services of the Social Insurance Institution (SII) is “failed”. Since, these services are not what is expected from an institution that comprehends almost half of the total population (including the ones of whom insured people are obliged to take care), and that absorbs one third of Turkey’s medicine consumption.

Why is that so?

First of all, the point under consideration is the fact that the problem has not started with the recent government. However, the recent government strives to maintain the policy that has been dominating SII for years.

Causing SII to be disgraced in the eyes of people, this wrong policy is based upon an indemnificatory-compensative approach. In other words, it is such an approach that tells people “First, get sick; then come. I try to treat; then, pay you the cost of your loss”. It is exactly what Bismarck the Prussian told, who desired to impede the social activeness in the 19th century. After a hundred and ten-odd years passed, what an outdated approach is this in such a world in which giant steps were taken for the sake of respect for human beings.

SII missed the train of contemporary living two times. The first one happened in 1950, and the other in 1964.

Affecting the society and the world in 1950, the democratic wave was employed in order to “save” one group as a result wrong evaluations and the digression of the target. In such a period, during which worker-civil servant division was still on the agenda and a progress guaranteeing “health for all” was needed, the “Health Insurance Law” was passed only for the manual labourers. In this period, “individual release” of the workers was aimed, and they were encouraged to behave accordingly. In this way, both occupational health-safety oriented functions were suffered loss, occupational disease related hospitals were closed down and the progress orienting all segments of society was postponed. It was also this encouragement lying behind the insistence of labour unions to defend SII model and their disinterest in the applications of the Ministry of Health. This is a train missed.

As a part of the social justice approach becoming a current issue after the 1960 coup d’état, health services were appraised in a way to comprehend all; and in this period, many progresses were made which may be even reckoned as a “revolution”. By the Law No. 244 on the socialisation of health services, a model through which preventive and therapeutic health services were integrated was conveyed throughout the country including the smallest allocation units.

This law made all institutions providing health services be obliged to integrate with each other and to be administered under the control of a single authority; yet the dominant approach infusing into SII and labour circles insistently objected to this formation. In the same way, in 1964, the Social Insurance Law (Law No. 506) was enacted in order to unite all insurance branches under the same legal roof.

During the time the law was passed, an article was appended to the law as a result of the consultations to various ministries. Accordingly, the Ministry of Health and Social Services made a formal request for the inclusion of an article stating that “Social Insurance Institution was to provide preventive medicine services also”. SII authorities, then, reacted enormously this time. In regard to health issues, all these were the endeavours of the socialisation architects in order to append the requirements of contemporary medicine approach into the SII Law.

This provision, however, was “reluctantly” appropriated under the threat of the Ministry of Health and Social Services that it was not to ratify the law. Yet, this law was implemented until so far except for very few exceptions. Therefore, SII decided not to defence both itself and the insured people under its protection. Consequently, SII applications appropriated an “indemnificatory and compensative” approach till today, rather than an universal approach as is due to the contemporary medicine approach (as well as the approach comprehending preventive and therapeutic health services in a balanced way).

This is the second train missed.

In addition to all these, it should be noted that the opportunities that we may call as the “self-defence mechanisms” of SII (Article 15; 26; 41; 74-75; 130) have not been utilised ever during the past years; and this is one of the reasons of deadlock that our country lives through today.

Nevertheless, this deadlock, rather than incompetence of some managers, has been due to the failure in the basic choice. In other works, the solution has been sought by means of insurance approach. The same fault, this time, is tried to be put forth by the Ministry of Health. Considered as an extension of the “free market economy”, through General Health Insurance (GHI) and family medicine model, this approach has been aimed to be throughout the society. This causes us to consider that the insistence over this formulation is entirely due to the ideological concerns, especially in an environment where SII experience is clear for all of us.

What is the butt of this ideological assault is the system brought forth through the Law on the Socialisation of Health Services (Law No. 224). When we elaborate the system, we see that socialisation of health services is a universal approach requiring all these together: team work, multi-disciplinary approach, the mosaic of politics, social development, social participation, preventive and therapeutic health approach. Additionally, it appropriates various current concepts such as stepped propulsive chain; centralisation of the services; health as a human right, and etc.

This ideological assault aims to destroy the social state. In fact, both the 1961 Constitution and the “Law on the Socialisation of Health Services” passed in the same year and sharing common ideals with the Constitution almost shared the same fate. The law was spoiled by various amendments made here and there; and it was put into force by ignoring the various articles it contained. However, no government took courage to invalidate this law, even during the period of military regimes in which democracy was put aside.

The third train: In 1992, it now waits at the platform.

There are two choices in the presence of the recent government: Choosing the outdated or contemporary. If it chose the outdated one, though this is what Mr. Yildirim Aktuna is prepared for, SII’s unfavourable experiences would be put into practice at the national scale, by being known as GHI and by dissolving GHI into its structure; hence, the train would be missed again.

If it prefers the contemporary one, all health units, especially the health services provided by SII, would be integrated through the means of socialised health services. The organisational structure proposed by the Law No. 224 would be re-structured without a change in its draft phase but having been developed regarding its participatory characteristics. As to this re-structuration, its monetary resources would also be guaranteed; hence, and it would acquire a “autonomous” character.

In this case, we would be able to say “it is a delayed progress; but still favourable”.

In order to be able to say this, a pressure group should be formed including altogether physicians, labourers, retired people, entrepreneurs, sick and health people, and hence all individuals and institutions that appropriate the ideals of contemporary living and that esteem the lives of human beings.