Impact of Market Economy on Health: Global View from Türkiye’s Perspective and the Role of WHO ()
1. Introduction
Health inequalities are ahead of us in diseases, deaths, and disabilities interest. The apparent reasons are poverty, migration, unemployment, lack of education, wrong traditions/beliefs, hunger, unhealthy food, homelessness, war, terrorism, climate change, work accidents, and reasons such as occupational diseases. However, when considering the root causes, issues such as income distribution, poverty, migration disorders, work accidents, and occupational diseases appear to originate from these conditions. More importantly, looking at the origin of all causes, the main reason is capitalist production relations, and it is seen that there is a class structure in society [2].
Several world health problems that have been discretely considered in the past are viewed in this paper as interwoven with each other and the functioning of the capitalist political-economic world system. Thus, climactic explanations and even poverty, when conceived in cultural terms or as a structural problem resident entirely within a single nation, are seen as inadequate for understanding any or all of the problems discussed briefly here: poor general health levels in peripheral and semi-peripheral nations, significantly rising infant mortality rates in countries such as Brazil [3] artificial and artificial malnutrition; dumping and exploitative sale of drugs, pesticides and other products banned or restricted in core nations; genocidal and other threatening approaches to population control; export of hazardous and polluting industry to peripheral and semi-peripheral nations; similar export of human experimentation; the sale of irrelevant, high medical technology to countries lacking basic public health measures; the “brain drain”; and medical imperialism. Also discounted are moralistic inveighing, complaints about inadequate information and its transfer, discussions of bureaucratic bumbling or inter-agency politics and professional rivalries, various forms of victim-blaming, and other explanations and corrective approaches that ignore class structures and the control, distribution, and appropriation of resources in nations and the world-system. The framework suggests the importance of a worldwide cultural hegemony, including a medical cultural hegemony established by and in the service of the ruling classes. Socialist-oriented nations, which are quasi-independent of the capitalist world system, are seen as suffering less from its effects. This suggests we should conceive of world socialist and capitalist health rather than any unified phenomenon called “international health” [4].
As can be observed in its most concrete form in the last 30 - 35 years, no basic-determining health policy and practice has been encountered in Türkiye in previous periods other than the dominant health policies in the capitalist World [5].
Leftist criticism of worldview holders is believed that WHO is now favoring capitalism and turning to liberal policies. Themselves with an understanding of our country. For some who describe themselves as right-wing or conservative, internationally controlled by vested interests as an organization, our national interests’ voices of concern about harm started to rise [6].
Recent studies of medical errors have estimated that mistakes may account for as many as 251,000 deaths annually in the United States (U.S.), making medical errors the third leading cause of death [7]. From 2007 to 2009, 708,642 patient safety events were reported to have contributed to the deaths of 79,670 hospitalized Medicare beneficiaries in the United States of America [8] [9]. If we project this data to the world, we can estimate that 8 million people die every year due to medical care.
The incidence of iatrogenic deaths in the Finnish cause-of-death statistics; a retrospective study has been reported by Kuvaja [10].
The total number of iatrogenic deaths comprises only less than 0.4% of deaths annually and 1.4% of the total volume of medico-legal autopsies annually.
The iatrogenic cause is quite often suspected or is the reason for police investigation and medicolegal autopsy.
2. Step by Step Collapsing
According to OECD’s 2019 data, current price and purchasing power parity, total health expenditures per capita in US Dollars were 1337 dollars in Türkiye. Compared to other countries, less money was spent only in Mexico and Colombia, with 1153 and 1212 dollars, respectively. Türkiye is at the bottom of the list regarding health expenditures per capita [11].
Although health expenditures do not show that the country’s health system is effective, the expenditure gap is essential in showing the differences. Values according to OECD 2022 data are as follows (US Dollars/capita): USA 12,550, Switzerland 8050, Germany 8011, Norway 7771, Austria 7275, France 6629, Sweden 6437, Australia 6372, Canada 6319, Denmark 6280, Ireland 6050, UK 5492, Japan 5250, Spain 4431, Italy 4290, Portugal 4162, Latvia 3445, Greece 3015, Chile 2699, Türkiye 1827, Mexico 1181 [12].
The USA is again at the top of the table, with $12,550 per capita spent on health. It is followed by Switzerland, with $8050, and Norway, with $7771. The OECD average is 4500 dollars, which is at least three times the money Türkiye spends per capita.
Japan’s health data, which is almost one-third of the United States’s health expenditures, is in much better condition than that of the United States. This also applies to Scandinavian countries. How effectively these expenditures are used is as crucial as health expenditures. However, it should also be noted that the degree to which countries attach importance to health is also vital. For example, while Türkiye is the last country that spends the least on health per capita, it is among the top 20 countries in the budget spent on armament [13].
It will be helpful to examine the changes step by step to understand how the same government destroyed our health system in Türkiye, which has been trying to be established step by step for 100 years and reached a perfect place in the early 2000s.
Four main periods in health policies during the hundred-year Republic period are distinguishable from other periods. It is helpful to see the characteristics of these periods.
1-Period 1920-1945: During this period, preventive health services were established on solid foundations, Tuberculosis and Malaria were eradicated, and smallpox vaccines were produced.
2-Period; 1961-1980 Capitalist but pretending Social Welfare State. There was a turn from preventive health services to curative health services, a foreign-dependent health service provision was introduced, and imitation of America developed.
3-Period 2002-2016: Patriarchal Neoliberal Era Hidden Under the Mask of the Social State. During this period, liberal policies were organized under the guise of preventive health services, doctors were devalued, university hospitals faced financial difficulties, and private centers became widespread.
4-Period 2016-2024: Predatory brutal neoliberal policies without the mask. During this period, wrong practices, such as using public facilities allocated to the relatives of the political administration, the private hospitalist, and the minister of health, became public. Relatives and political cronies were allowed to import medical supplies and vaccines at unnecessary and excessively high prices. Illegals, who did not even know if they had a diploma, began to practice medicine. As thousands of doctors went abroad as a result of ill-treatment, state hospitals became unable to make appointments, and there was a collapse in therapeutic approaches as well as preventive health approaches.
2.1. Privatization of Health System and Private Public
Partnerships (PPP) and Mega Hospitals
Even though a development can be observed in the health statistics, there are significant differences
between the educated and uneducated, urban and rural, and western and eastern provinces of Türkiye [14].
The name of the government in Türkiye was “capitalist republic” except for the first 20 and the last 20 years. Definable. Health in Türkiye in the 100 years policies, particularly the financing, organization, service delivery, and labor of health services. While it cannot be denied that capitalism is decisive in the areas of power, the main outlines of the process, It can be predicted that it will parallel the world capitalist system. The first 20 years can be called a complete social welfare state, and the last 20 years can be called a brutal patriarchal exploitation system.
The health sector in Türkiye whets the private sector’s appetite due to unfairly obtained rents and payment and import policies carried out with unethical relations with the political authority.
According to the Presidential Investment Program, 130 billion 767 million 346 thousand TL (app 5 billion EURO) will be spent on rent for city hospitals from 2017 to 2024. In the 2024 budget, 83.7 billion TL (3.5 billion EURO) will be paid to companies for rent and service procurement for mega city hospitals, which is typical PPP [15]. At the highest point, the total usage fee is 27.5 billion euros for all city hospitals except Kütahya. The figure to be given for one square meter is 2 thousand 421. The cost per square meter of the city hospital, including the device and infrastructure, is 1465 euros in today’s money. Almost all of these payments are made by pro-government businessmen. The state pays rent to companies for 25 years. There are some very striking elements here. The amortization period of the investment does not exceed 3 - 4 years. For the remaining 20 - 21 years, rents are paid from public resources in amounts that will often exceed the investment cost. According to the Ministry’s report, 18 cities with today’s prices Companies invested 10 Billion US Dollars in the hospital and completed it in 25 years. They will generate revenue of 30 Billion US Dollars [16].
For a sufficient PPP study to benefit public health, the system needs to regulate the expansion of the private sector, reduce costs, and enhance the effectiveness of service provision. Second, substantial improvements in enforcing laws and regulations about the registration, licensing, and accreditation of medical care practitioners and various medical care institutions are urgently needed. Rational expansion and establishment of medical care facilities are critical sample data demonstrating the abundance of care providers in urban compared to rural areas. In addition, far greater attention must be paid to the quality of care provision [17]. Otherwise, the desperate economic devastation that Türkiye is in will emerge.
Brambilla’s study shows that Turkish cases generally get lower scores than European ones in terms of Construction Density and Community Connectivity (28%; 50%), Alternative Transportation (18%; 50%), and Site Development (26%; 38%). Connection to Natural World (30%; 52%) and Heat Island Effect (33%; 43%). The score was only higher in the Development Density criteria (30%; 16%). It also emerged that the gross floor area per bed ratio is much more significant for Turkish cases (334 m2/bed; 198 m2/bed), which can be interpreted as one of the weaknesses related to oversizing such infrastructures. However, planned, scheduled, budget-friendly, and ethical PPP studies can contribute to health stability [18].
2.2. The Doctors under the Pressure of Business Capitals
In a speech he made in March, President Recep Tayyip Erdoğan said about doctors, “I am being frank: if they leave, let them go, we will employ our doctors who have just graduated from university. We will continue to work here with our assistant doctors. I go even further; we will ensure the return of those who want to return from abroad and work here.” “We will assign it,” he said. Due to this ignorant and inferiority complex approach, many doctors went abroad [19].
One essential reason hospital owners pressured doctors was the wrong policies of health ministers in the private sector.
The Ministers of Health and the characteristics of the AKP governments that have been in power since 2002 are as follows (See Table 1).
Table 1. The private sector.
Recep Akdağ |
2002-2013 |
MD, Academician |
|
2016-2017 (Second Term) |
Recep Akdağ was dismissed from his first term duty because he did not allow President Erdoğan’s special Project Mega City Hospitals; during his term, he made significant progress in the country, especially in preventive health services |
Mehmet Müezzinoğlu |
2013-2016 |
MD, Private Hospital Owner |
Ahmet Demiircan |
2017-2018 |
MD |
Fahrettin Koca |
2018-2024 |
MD, Private Hospital, and Private University (Medipol) owner |
Kemal Memişoğlu |
2024- |
MD, Academcian |
According to the report of the Court of Accounts, Medipol, which built a VIP hospital owned by the Minister of Health Fahrettin Koca with the Build-Operate-Transfer model on the land belonging to the Foundations, was given an extra operating period despite the explicit provision in the contract. The operating period of the VIP hospital that Medipol will open in Istanbul has increased from 17 years to 33 years. It was revealed that large areas of public land were allocated to the Medipol group, founded by the Minister of Health Fahrettin Koca and managed for about 20 years by the General Directorate of Foundations in Ankara [20].
The prominence of the private sector in health, the foundations of which were laid during the Recep Akdağ period, gradually increased under other ministers. The state’s ability to receive service from private hospitals, which started as a necessity for expanding health services during Recep Akdağ, later became unlimited. The undisciplined, limitless, and excessively expanded private health sector gradually made public health services more complex and increased costs.
3. The World Health Organization (WHO) Supposedly
Protects Health
The approved Biennium Program Budget for the World Health Organization (WHO) for 2022-2023 is 6.72 billion USD. Current estimates suggest the total program budget reaches up to 8.9 billion USD. The organization’s budget generally includes health expenditures from governments, households, and donations. However, most money is spent on personnel, meetings, staff, and management expenses (https://www.who.int/). Unfortunately, effective programs cannot be carried out [21].
Currently, the approach that the World Health Organization most influences is the capitalist liberal view [22]. Since the first day of the coronavirus epidemic, relations between China and the World Health Organization have been constantly questioned.
US President Donald Trump argued that the World Health Organization acted in line with China’s wishes and decided to cut off aid. WHO openly defended itself as China’s spokesperson after this money decision. Following the developments, China donated 30 million dollars to WHO [23].
Unfortunately, WHO has been used as a tool in committing many abuse crimes. World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus apologized after it was determined that “sexual abuse” was committed against women by United Nations staff in the Democratic Republic of Congo (DRC) [24]. Ghebreyesus said, “This is a dark day for the WHO. I take ultimate responsibility” after the independent investigation commission announced its report.
WHO Director-General stated that the contracts of 4 people working in the institution were terminated with the report’s announcement. He said that the investigation continues for other employees. “Women were offered jobs in exchange for sexual intercourse.”
The commission interviewed 210 people one-on-one who said they were offered a job in exchange for sexual intercourse or were victims of rape during the fight against the Ebola virus in 2018-2020. Seventy-five of them claimed to be victims of sexual abuse.
The cost of 15 billion doses of the COVID-19 vaccine is 21.5 USD. In other words, the price of the COVID-19 vaccine is:
21.5 EURO × 15 billion doses: 375 billion EURO (only 200 billion EURO was spent on weapons in the war between Ukraine and Russia).
However, the additional medical expense savings for the USA with the vaccine are only 11 million USD. It is difficult to say that the vaccine is economically effective [25].
4. Conclusions
Health inequalities can be defined as avoidable and unacceptable disruptions in the health of individuals or communities caused by social factors and deficiencies in the organization of the health system. It has become one of the main political and social topics today, especially after the spread of neoliberalism. There are two primary components of health inequality: inequality in the social determinants of health and inequality in health care [26].
Although biological factors affect human health, their impacts are mediated by social processes. The social determinants of health (SDH) approach rightly stresses this [27].
Privatization, one of the capitalist system’s significant destructions, reflected in health also leads to severe decay. However, planned, scheduled, budget-friendly, and ethical PPP studies can contribute to stability in health.
There is no chance for health to improve, like other degenerated institutions, before the 24-year AKP rule and dictatorship in Türkiye ends. The only possibility of recovery is the re-democratization of the regime and the establishment of the rule of law.
Healthcare privatization is a policy of transferring the provision of public services to private individuals or companies. Many nationalized healthcare services have pursued privatization since the 1980s in the hope that mixed markets and the inclusion of private sector interests can improve the quality of care at a cheaper cost than the public sector. Private sector providers might also bring with them competition effects, improving performance across the entire health system as all providers are incentivized to deliver improved quality services if they are to win the custom of the commissioning bodies. Competitive markets might even discourage providers from revealing service quality information. The result of competition, especially cost-based competition, in the healthcare sector can cause severe deadlock or harm. The shift to private funding in the USA via the privatization of the Medicare program has resulted in more expensive plans but unclear effects on the quality of care [28].
Quality of Health Care has weakened in almost every country where privatization of Health Services has been carried out [29].
As a public service, health must be removed from being a means of profit. Healthcare privatization has rarely positively affected the quality of care.
For WHO to return to its intended role:
1—It must shrink.
2—Spend its expenses in line with its objectives.
3—Focus on public health and preventive health services.
4—Abandon initiatives related to the liberal economy.
5—Be transparent in all its activities, including budget expenditures.
6—The institution should be removed from the monopoly of some countries.
This report highlights the profound impact of transitioning to a market-oriented healthcare system in Türkiye, emphasizing the challenges faced by the public health sector and professionals. It underscores the importance of retaining a balanced approach to health policy that considers both public welfare and economic efficiency. Moving forward, Türkiye and other nations must carefully evaluate the implications of privatization and seek to develop health policies that are equitable, sustainable, and centered on public health needs.
For effective and beneficial public health service delivery, it is crucial to keep imperialist and capitalist forces away from the health sector.
Conflicts of Interest
The author declares no conflicts of interest.