By Prof. Dr. A. Gurhan Fisek
Each re-structuration enterprise must bear the traces of experiences and necessities of that field. Sure enough, SII (Social Insurance Institution) has been one of the institutions about which it has been discussed most. This statement is valid with regard to two different aspects. First of all, the premium claims of SII and its budget amount to quadrillions; and it is equal to one third of the budget of the Republic of Turkey. Additionally, after undertaking the health care services provided for Bag-Kur (Social Insurance Institution for the Self-Employed) employees, it provides its services, as stated by the minister, for 53 % of the population. Secondly, “social security” is one of the most fundamental necessities of human beings, and this has a crucial influence over people’s lives.
Concerning such a significant field, every arrangement made and step taken do have an impact over both today and future of the society; despite the fact that SII is not aware of this significance…
Each re-structuration process has a self-statement (mission) of its own. This self-statement is in order to overcome the obstacles confronted in the previous periods. Constituting most of the SII expenditures, accidents and diseases attract the attention of society due to its “preventable” character. Genuinely, “preventability” is one of the matters that has been treated during “occupational health and safety weeks”, and the campaigns on the “prevention of traffic accidents” and on “vaccination”. Furthermore, there is a slogan that we already know by heart, that is “preventing is easier than paying”.
However, there is an important point to be paid attention at that point. The ones who are held responsible for paying and preventing do constitute two different segments of the society. As stated in laws and international conventions on the prevention of disease and accidents, public offices must be held accountable for monitoring whether the necessary precautions have been taken or not (such as the Ministry of Labour and Social Security, SII, the Ministry of Health, the Ministry of Internal Affairs, the General Directorate of Security, and etc.). On the other side, the ones who are paying or who will not be able to pay at all are the individuals (employers-employees) paying premiums to social security institutions, and their relatives.
SII has a unique character differentiating it from the social security institutions both in Turkey and in various developed countries; and that is its combining its premium collection and service provision functions under the same roof. What is commonly observed, on the other hand, is a system through which these services are purchased from various establishments by the financial source collecting premiums. For instance, the Retirement Trust turns to such a method for its participants. However, if the cost prices are to be regarded as the only criterion, it can be noticed that the unit cost paid for per patient by SII is 100, while it is 183 when paid by the Retirement Trust. Moreover, SII has a particular health organisation under its authority; and this gives itself an opportunity, different from other social security institutions, to provide preventive health services and to co-operate with the Ministry of Health working in the same direction.
Since 1964, the Social Insurance Law stated that the institution may undertake preventive health services if necessary (Article 124). However, the institution has not been involved in such an enterprise, and this has caused it to be criticised accordingly. As to these criticisms, it has been pointed out that the institution has appropriated an outdated (indemnificatory) philosophy. Indemnificatory philosophy is such an approach that tends to wait, without turning a hair, until an individual or his/her family suffer loss, and to compensate the occurring loss (according to the determined directions).
Concerning the re-structuration of SII, one can hardly observe a worry like reducing the risks to a minimum (preventive approach).
This can be compared with filling a bucket up with water (premium), which is punctured at the bottom. Contemporary social security approach aims to plug this puncture; and for this, it makes good use of the community medicine approach (the system that takes up preventive, therapeutic, and rehabilitative services with an universalistic approach) that is part of the social policies.
We wonder whether SII’s Presidential Model organisation has appropriated contemporary approach instead of this.
In the name of preventive health services, these can be observed in the new institutional law:
Taking place in the content of the Statutory Decree No. 616, several raw-headings point the only way out that would render the re-structuration of SII expressive.
Occupational Medicines: The establishment of occupational medicines and occupational health organisations is compulsory for the workplaces employing 50 or more workers. On the other hand, for the workplaces employing less than 50 workers, these may be established voluntarily and collectively. The actual function of these establishments is related with preventive medicine approach; however, they generally treat the patients transferred by SII (and in the name of SII) as they are authorised to do so. Also, these establishments may be regarded as the first-step health facilities from the point of view of SII; yet, do not get any support except for medicaments, and do not exchange information with the SII hospitals. Besides, any discrimination is not made between the patients transferred by SII and who directly resort to SII hospitals. However, these are not even discussed that these establishments provide preventive medicine services; reduce the burden loaded over SII in regard to occupational diseases and accidents in particular, and diseases in general; and would brought about various gains through early diagnosis opportunities. Unfortunately, there is not any hope or a sign for finding solutions to these issues that have been discussed approximately for 50 years. The only sentence stated in this regard is the “promulgation of the regulation that is related with the institutional implementations on occupational medicine”. Also, it is probable that this necessity would be due to the problems experienced among medical associations, occupational physician, employers and SII during the authorisation process of occupational physicians.
Provision of preventive health services by the institution:
According to the Social Insurance Law No. 506, Article 124, and by the Department of Health and Disability Operations, taking necessary precautions on preventive health services, and determining the applications, methods and principles (Article, 36/a);
Providing children health, family planning and immunisation services for the right holders as the institutional opportunities allow (33/f).
In Turkey, preventive medicine practices have an approximately eighty-year-old history. They have put their signature on various successful enterprises, especially the ones on contagious diseases which are among the most frequently observed, most mutilating and the most fatal diseases. However, above mentioned quotations demonstrate that the re-structuration process reflects a limited practice, rather than being built on the accumulations under consideration. Since SII offers social insurance services for regularly salaried employees, prevention of occupational disease and accidents and of traffic accidents should be come to one’s mind, when preventive services are talked of. Concerning these quotations, there is not such a sign complying with this criterion. “Early diagnosis” is one of the most noteworthy means of preventive services. As required by the law, employers are obliged to provide check-up services for their employers annually, and this is a convenient condition for early diagnosis. There is also a possibly of both increasing the quality of these check-ups and coming out ahead (from the point of view of both individuals and the institution) through this early diagnosis. And both of the two can be achieved through offering mobile support units for occupational physicians. Nevertheless, above mentioned quotations do not give us a cause to hope for such a comprehensive approach.
Inspections, carried out by insurance inspectors, on whether occupational health and safety precautions are taken: In order to prevent occupational disease and accidents occurring at workplaces, it appears as one of the most important steps that workplaces should be inspected with respect to the implementation of the laws. At that point, it is fairly significant that the insurance inspectors having the sanctioning power in this regard should concern themselves with this matter. This was something mentioned in the previous regulation; yet, it was not put into practice. Before all else, in order to put this into practice, these social science origin inspectors should be knowledgeable about the tendencies of different sciences in this regard; and be supported through lab opportunities for making objective evaluations. In practice, there is not any sign with respect to these matters as well.
When we take a look at the new institutional law, we notice that health and insurance services are treated separately. This makes the structure vulnerable. Because, when we observe the departments bound to the Directorates General of Health and Insurance Affairs, we come across with a symmetry. That is to say, for example, in each directorate general, there are separate Departments of Data Processing and supplementary units (Departments of Personnel-Training, Accounting-Financial Affairs, Construction-Immovable Goods, Purchasing-Supplies-Administrative Affairs, Archive, and etc.).
On the other hand, the vulnerability of the new structure proves the fact that one of the most striking self-statements of this re-structuration is the privatisation of the institution. Because, for al long time, one of the most noteworthy objectives of the policy makers appropriating the “privatisation of health” discourse has been a such transformation by which SII, like other social security institutions, turns to an institution purchasing health services rather than producing them.
This objective is the extension of an approach that considered, in the 1930’s, state interventions to the economic sphere as a transformation period and that asserts that such necessities requiring this intervention are not valid for today. Because, in 1950, there was not any chance for Turkey to make the hospitals widespread and operate them by the hand of the private sector. Even in Istanbul, the number of hospitals was so few that one can count them on the fingers of one hand. Under the circumstances peculiar to that period, the state, hence, headed towards some workers’-employers’ circles who were able to afford these premiums as a result of its incapacity to take on this burdensome responsibility.
During the same period, there was not any medicine factory in our country to back the therapeutic health services up. Although the establishment of a medicine factory was proposed by the General Assemblies of SII in these years, it was preferred that the medicine industry was to be developed through the “law for promotion of foreign capital (1953)”. However, these two choices became a beginning of the end for the ones maintaining that health services should be operated by the public sector. Because, through the adoption of the “Law for Promotion of Foreign Capital”, 80 % of the foreign capital was invested in the chemical industry; and the most important extension of these investments became the establishment of international medicine factories.
It was in 1964 during which the ones maintaining that health services should be operated by the public sector lost the battle unequivocally. Because, this year was the one when the first proposal on the “re-structuration of SII” was refused. In this period, these were also impeded through the support of labour unions: the “Law on the Socialisation of Health” which reckoned health services as a whole without discriminating healthy and unhealthy people, and an articulation among SII health organisations based on “sharing and solidarity”. The tendency predominating the Statutory Decree No. 616 seemed compatible with a sentence uttered by Bulent Ecevit at this time, that is “What should be discussed is the transfer of the Ministry of Health’s hospitals to SII, not of SII’s health facilities to the Ministry of Health”. Initiated in 1947, these plans on “General Health Insurance” have remained as a current issue till that date; nonetheless, they have not been generalised yet due to their incompatibility with the conditions in Turkey.
Beside the formation of a vulnerable structure between these two general directorates, the traces of intentions on the privatisation of health affairs can also be encountered with in the regulations based on the Statutory Decree No. 616. These can be enumerated as follows:
The first striking thing is the formation of two separate departments, that are the Department of Health Facilities Administration and the Health Services-Department of Purchasing, and the formation of Health Enterprises in the provinces;
The formation of a dispatching chain for patients between the facilities within and outside the institutions, by the Department of Therapeutic Services, and the determination of the steps of health services in accordance with this objective (Article 33-I);
By the Department of Health Facilities Administration, ensuring the organisation and operation of services like cleaning, security, nourishment, heating, laundry, communication, transportation, social services, public relations, provided in health organisations; and the organisation of the medical discharge management (Article 35);
The responsibilities of the Health Services-Department of Purchasing are;
Determining the methods and principles related with the purchasing of health services from any kind of health organisations and related individuals; preparing the protocols; and practising them after approval (37/a);
Determining the methods and principles related with the provision of health services, in the health organisations bound to the institution, for organisations and individuals rather than insured persons and right holders; and practicing them after approval (37/b);
Preparing the schedule of prices related with the health services provided by the institution; and putting them into practice (37/c);
Planning the works on the purchasing of health services from public institutions and enterprises; preparing the related protocols and putting them into practice; inspecting the services produced by the seller organisations in terms of both quality and quantity, and in accordance with the protocols prepared (37/d).
The transformation of SII hospitals into an enterprise has been something discussed for a while. In accordance with the principle of “getting by on one’s own means”, these discussions have been setting forth a tendency including a monetary content instead of a social approach, particularly about “selling these services to the ones that are not insured”, and about the “operation of hospitals by individuals’ private enterprises”.
Health Enterprises (Article 46):
“The Institution, with the common proposal of the SII Directorate-Directorate General of Health Affairs and its Chairman and with the decision of the Board of Directors, can establish health enterprises having a public legal personality and having an administrative and financial autonomy; or transform the existing health facilities into a health enterprise.”
“For the purpose of providing health services for the individuals whom the institution is obliged to provide as required by the related laws, re-modernisation and organisation of the health enterprises can be realised by legal or real persons; and their operation can be permitted after the proposal of the Board of Directors and approval of the Ministry.”
As we have stated in the previous article on the administrative components of the re-structuration process, the manager of a business enterprise is among the persons directing the Health Enterprise’s Executive Committee, and s/he is appointed by the Directorate.
These are among the responsibilities of the manager of an enterprise: Within the limits determined by the Board of Directors, signing contracts with individuals and organisations for the services provided or purchased by the enterprise; and as to the issues that are under the responsibility of the Health Enterprise’s Executive Committee, signing contracts according to the authority vested.
In the case the management of such an enterprise is given to a “physician”, the opportunity given to that physician to set up a surgery is something to be discussed separately. If a person is authorised to purchase health services from the private sector, and to turn this hospital over the hand of the private sector if necessary, but at the same time is involved in the public sector, this would clearly reflect his/her real intention. Here, the intention is not the strengthening and improvement of the public sector, but rather climbing the steps of the privatisation process.
When we consider the re-structuration of SII in accordance with the Statutory Decree No. 616, together with the vulnerable structure formed through these enterprises as well as the activities based on monetary concerns, we notice that this re-structuration bears the self-statement on the privatisation of “hospital”isation services.
For the services apart from hospitalisation, “profit” and “revenue” are more troublesome issues. For this reason, no one talks about the privatisation of preventive services. Regrettably, this fact is forgotten that preventive, therapeutic and rehabilitative services are integral. On that ground, contemporary health approach aims to perform all these services in an integral manner; and this is also called “universal approach” or community medicine approach”. Sadly enough, the provision of necessary health services are approached through an out-dated approach that has a dominant influence also on the re-structuration of SII and that has a potential to influence our social security system overall.