Objective The restructuring of healthcare provision for the coronavirus disease 2019 (COVID‐19) pandemic caused disruptions in access for patients with chronic or rare diseases. This study explores the experiences of patients with chronic or rare diseases in access to healthcare services in Turkey during the COVID‐19 pandemic. Methods Semi‐structured interviews were conducted with representatives (n = 10) of patient organisations (n = 9) based in Istanbul. Thematic analysis with an inductive approach was conducted to analyse the responses obtained through the interviews. Results The lack of clinical information at the beginning of the pandemic caused fear among patients with chronic or rare diseases. Patients experienced obstacles in access to healthcare services because of the overcrowding of hospitals with COVID‐19 patients. Some treatment procedures were cancelled or postponed by physicians. Of these procedures, some were medically vital for those patients, leading to or exacerbating further health problems. The most positive measures that patients identified were where the Social Security Institution introduced regulations to facilitate access to prescribed medicine for chronic patients. Information exchange between the doctors and their patients was important to alleviate the uncertainty and reduce the anxiety among patients. Discussion Access problems experienced by patients during the COVID‐19 pandemic were a complex mix of factors including shortages and physical barriers, but also perceptions of barriers. The findings of this study show that patient organisations can provide insights on disease‐specific experiences and problems that are very valuable to improve access to healthcare services to achieve the universal health coverage target. Hence, this study emphasises the inclusion of patient organisations in decision‐making processes during times of health crises. Public Contribution Representatives of patient organisations participated in the interviews.

Examining medical tourism, especially in countries with publicly funded and organised healthcare systems, offers a gateway into an understanding of the changing role of the state in contemporary societies. Drawing on a comprehensive documentary review, this article examines the evolving role of the state in transforming Turkey into a global medical tourism destination. The article identifies two stages of state involvement in medical tourism: the period after the 2003 healthcare reform and the rise of an entrepreneurial healthcare state since 2013. The article suggests that the state, in the first period, performed a facilitator role by supporting privatisation in healthcare provision; in the second period, it assumed an entrepreneurial role, establishing large hospital complexes through a public-private partnership and created a public corporation to capitalise on the export of healthcare services. The Turkish case demonstrates that the role of the state in medical tourism is subject to change over time, depending on shifts in governmental strategies for healthcare and government-business relations. The article also offers evidence on the continued relevance of the multidimensional engagement of the state in healthcare that cuts across economic and social policy commitments. This engagement has recently extended into the domain of healthcare provision in the context of medical tourism.

Hospital reimbursement models might have unintended consequences for medical practice. In Turkey, a mixed reimbursement scheme, based on the diagnosis-related group (DRG) model and global budget, was gradually introduced as part of the country's 2003 healthcare reforms. This article examines the impacts of the DRG model on medical practice in Turkey, as perceived by physicians working in public and private hospitals. This study draws on an analysis of 14 interviews with physicians. The findings reveal that the implementation of the DRG has transformed medical practice into a process of cost-benefit optimisation which involves balancing the income and expenses of hospitals against patients' medical needs. To mitigate the negative effects of the DRG, the current model may need to be reformed, particularly to grant exemptions from the standard reimbursement structure for patients who are experiencing complications and/or multiple health conditions.

PurposeNew Public Management-informed pay-for-performance policies are common in public sectors internationally but can be controversial with delivery agents. More attention is needed on contingent forms of bottom-up implementation of challenging policies, in emerging market economies, for professionals who face tensions between policies and their codes of practice. Street-level bureaucrats (SLBs) mediate policy implementation through discretionary practices; health professionals have enhanced space for discretion based on autonomy derived from professional status. The authors explore policy implementation, adaptation and resistance by physicians, focusing on payments for health workers in Turkey.Design/methodology/approachThe researchers conducted semi-structured qualitative interviews with 12 physicians in Turkish hospitals and thematic analysis of interview transcripts, using a blended (deductive and inductive) approach.FindingsThe policy fostered discretionary behaviours such as cherry-picking (high volume, low risk procedures) and pro-social rule-breaking (e.g. “upcoding”), highlighting clinical autonomy to navigate within policy restrictions. Respondents described damage to relationships with patients and colleagues, and dissonance between professional practice and perverse policy incentives, sometimes leading to disengagement from clinical work. Policymakers were perceived to be detached from the realities experienced by SLBs. Tensions between the policy and professional values risked alienating physicians.Research limitations/implicationsThis study utilises participant self-reported perceptions of discretionary behaviours. Further work may adopt alternative methods to explore the relationship between self-reporting and observed practice.Originality/valueThe authors contribute to research on differentiated, contingent roles of groups with high scope for discretion in bottom-up implementation, pointing to the potential for policy-professional role conflicts between top-down P4P policies, and the values and codes of practice of professional SLBs.