The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey
Abstract: 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 entre… Show more
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Photo by Engin Yapici on Unsplash ABSTRACT Medical tourism has excellent potential and downfalls, which this paper will extensively cover. While medical tourism has great economic benefits to the host country and calls for the increase of professionalism and skill of physicians, it also influences doctors locating to private hospitals and skewing healthcare costs and access for locals. Given the many weights and balances to consider, the discussion of expanding this type of healthcare into Turkey is ethically needed. INTRODUCTION I watched from the hotel lobby as a group of men with surgically wrapped heads strolled in line behind a young woman; she was speaking to them in English with a heavy Turkish accent. Across the room was another group like this one, but the women had bandages on their noses. As a Turk, this sight was not new to me: over the years, I witnessed the number of foreigners coming to Turkey for medical procedures increase by tenfold. And, I began to see how savvy Turkish tourist companies became over time, creating enticing packages for people to tour the beautiful city of Istanbul while receiving a hair transplant procedure or rhinoplasty. While I understood why individuals would come to Turkey for their procedure ― lower prices, expert physicians, and a lovely tourist destination ― I began to question whether profiting from the health care of others was ethical. This paper examines whether it is ethical for Turkey to invest in a growing medical tourism field, which has the potential for significant economic benefits yet could threaten health inequalities between locals and foreigners. Further, it will outline why tourists choose Turkey as a medical tourism destination, the reasons to favor medical tourism, and the reasons to oppose it. Finally, the paper will conclude that Turkey should cultivate and invest in medical tourism, with suggestions for expanding the field into a thriving market. ANALYSIS By definition, a medical tourist is an individual who travels to a foreign country to experience both cultural tourism and medical treatment.[1] Global medical tourism is a $55billion industry, and the industry in Turkey is experiencing an annual growth rate of 22.6 percent.[2] In 2017, more than one million individuals traveled to Turkey for medical tourism, putting approximately ten billion dollars of foreign currency into the economy.[3] Medical tourists who traveled to Turkey received, on average, more than one procedure during their stay.[4] Due to the increasing demand for medical tourism, the Ministry of Health in Turkey emphasized the expansion of medical tourism in its strategic plan, implementing initiatives to grow the industry.[5] These initiatives include improving the quality of Turkish hospitals and receiving Joint Commission International (JCI) accreditation, which is an internationally recognized quality healthcare index.[6] There are multiple reasons why individuals choose Turkey as their destination for medical tourism. First, it is easy to travel to: individuals need only an E-visa, which they can easily receive through an online application.[7] In addition, Turkey has lower prices compared to the Western hemisphere.[8] The Turkish government incentivizes medical tourism through lucrative advertising specials. For example, Turkish Airlines offers discounted airline ticket prices of 50 percent for patients who demonstrate a patient admission document from a Turkish-certified health institution.[9] Private hospitals have opened advertising offices in the Ataturk airport as well.[10] Lastly, hotels and hotel chains collaborate with hospitals to offer lucrative tourist packages for patients.[11] While these perks and incentives draw people to Turkey, the lack of insurance coverage, high cost of treatment, and long wait times in their home countries are the most significant reasons that tourists choose Turkey as their medical destination.[12] Arab tourists previously traveled to the United States and the United Kingdom for medical treatment, but due to the implementation of strict travel sanctions after the September 11 attacks, they have had to look elsewhere.[13] For Arab tourists, the similarity of culture and religion in Turkey, a predominantly Muslim country, is also an enticing factor.[14] And, while Thailand and Singapore offer lower health care costs than Turkey, the shorter distance from the home country plays an important role in choosing Turkey as a medical destination.[15] European tourists choose Turkey for different reasons. For example, some surgeries conducted in Turkey are not available in Europe.[16] Patients from the Balkans and Central Asia prefer Turkey because of Turkey’s highly trained physicians and brand new, well-equipped hospitals compared to those in their home countries.[17] Interestingly, the low costs rank lower in importance than cultural similarity among those seeking care in Turkey.[18] The most important factor for choosing Turkey was quality: most tourists came from countries with a healthcare system marred by a lack of expertise or technological advancement.[19] One Turkish physician stated, “[Turkey] really ha[s] practices, doctors, services, hospitals and treatments that are above world standards in terms of health care.”[20] l. Ethical Permissibility of Medical Tourism in Turkey Health tourism has the potential to make a significant impact on the economic and social life of countries.[21] As a developing country, Turkey cannot afford to overlook this economic possibility.[22] The expansion of medical tourism in Turkey has allowed the country to reform its healthcare system into one that competes with health care quality in the Western hemisphere. Since 2010, there has been a significant increase in patients traveling to Turkey for health care.[23] The AK Party in Turkey pledged to promote health tourism in its campaign in 2011.[24] This inspired health care reform in 2013, with Turkey instituting a publicly funded and organized healthcare system.[25] In 2013, the Turkish government created publicly funded city hospitals. These hospitals were formed for medical tourism, meeting quality levels never-before-seen in the country.[26] In 2014, the Ministry of Health began granting accreditation to medical providers for medical tourism services and supporting translation services, patient transportation, and marketing.[27] Additionally, strategic initiatives were implemented to increase the number of Turkish medical school graduates.[28] The number of private medical schools increased from five before 2013 to 24 by the end of 2015.[29] A 50 percent tax reduction was granted to healthcare institutions that provided health care to foreigners.[30] Finally, Turkey began reforming hospital systems to obtain JCI accreditation. The growth of medical tourism in Turkey has resulted in positive reform of Turkey’s healthcare system. Turkey has over ten city hospitals in Istanbul, with qualified professionals proficient in English and other languages.[31] These hospitals are public and thus open and available for use by the general Turkish community, offering excellent quality health care to the country’s citizens. However, private hospitals have also flourished and, in some cases, have drained some of the doctors from public hospitals. With the increase in quality measures and regulatory healthcare committees, such as the Health Tourism Coordination Council (SATURK), Turkey’s healthcare system rivals the West's with highly trained professionals, competitive medical schools, and modern medical facilities.[32] Turkey has even reached the forefront of medical advancement: the World Eye Hospital is renowned for its cutting-edge ophthalmology services.[33] The investment in medical tourism has allowed Turkey to invest more in its private sector as well: the total expenditure on health as a proportion of the GDP rose from 2.4 percent in 1980 to 6.1 percent in 2008,[34] with an almost $2 billion national income from medical tourism in 2010. ll. Arguments Against the Ethical Permissibility of Medical Tourism in Turkey While public city hospitals were opened with the potential to support the Turkish medical tourism industry, private hospitals support 83 percent of the medical tourism market, and the gap between private and public hospitals has been growing yearly.[35] Private hospitals have mostly opened in urban areas, such as Istanbul, Ankara, and Antalya.[36] As a result, there has been a “brain drain,” in which members of the health workforce have left rural areas and have moved to urban cities where they can make larger profits from the medical tourism industry.[37] In addition, the use of public city hospitals has been met with concern regarding whether inequalities in health care between foreigners and Turkish citizens will arise. The Ministry of Health pays rent for the city hospitals in US dollars, exacerbating inflation in the Turkish lira currency and increasing reliance on high-paying medical tourists to support the public hospital system.[38] Due to this pressure, the prices for medical services are not consistently kept at affordable levels for Turkish citizens.[39] The head of The Private Hospitals and Health Institutions Association, Resat Bahat, stated, “Turkish citizens must receive priority for public resources. You cannot treat a Libyan or a Dutch when your own citizen is shaking at home with pneumonia. You [the public sector] can perhaps engage in medical tourism if you have excess bed capacity. But it is hard to do this [medical tourism] with the public sector.”[40] Rapid growth has also compromised patient safety and health care quality. While clinics must receive medical tourism certificates to provide treatment, fraud has risen.[41] In 2016, six out of ten hair transplant clinics were operating illegally.[42] These clinics offered hair transplants for as low as $800 when the treatment costs approximately $2000 in a Ministry of Health authorized clinic.[43] International patients have complained of inadequate human resources, such as the inability to communicate appropriately and insensitivity to tourists’ cultural features and habits, as well as a lack of facilitators in hospital systems.[44] The most common complaint has been that medical tourism companies fail to direct patients well and follow up after procedures.[45] Furthermore, multiple Turkish physicians have cited cases of malpractice with foreign patients.[46] One Turkish physician highlighted the ethical dilemma of turning health care into a commodity: “It is important that healthcare should be provided in such a way that institutions can continue their business without turning into a commercial commodity, ignoring the health and the aspect of the event. All people should have access to health equally.”[47] A Turkish pulmonologist also supported the idea of the separation between health and tourism, claiming that health care is a subject that requires unique methods to meet its needs, which should be addressed separately from the tourism industry.[48] lll. The Case for Continuing Medical Tourism While the above arguments demonstrate the difficulties with medical tourism, I argue that it is ethically permissible to invest in and expand Turkish health tourism. From a utilitarian perspective, the benefits of medical tourism to Turkish citizens outweigh the costs of expansion. Since investing in medical tourism, the quality of Turkish health care on both public and private levels has increased drastically. Turkey has also moved towards implementing more regulations surrounding the quality of health care.[49] International standards for health care have been adopted as well allowing Turkish citizens to reap the benefits of the medical tourism industry through access to advanced and high-quality health care.[50] While access and affordability for local patients must improve, the very existence of high-quality care and care standards that are better regulated exemplify improvements. Investments in medical education have also allowed Turkish citizens to gain greater access to higher education throughout the country with more medical seats and the opening of multiple private medical schools.[51] In addition, the expansion of the health industry has increased the professional opportunities available in healthcare for Turkish citizens. There is no doubt that medical tourism has greatly benefited the Turkish economy. Turkey aims to be the leading country in medical tourism by 2023, opening economic opportunities within and beyond medicine. The financial benefit is not reserved for the hospital systems and could provide high-paying jobs in hospitality, food service, etc.[52] People coming to Turkey spend money sightseeing and enjoying hotels, nature, and cities. While concerns about fraud exist, the medical tourism industry in Turkey is still relatively new, dating back to 2013. Thus, fraud is not widespread, considering the rate at which the industry has grown and its remarkable milestones in quality and patient services. There is no doubt that Turkey will continue to reform to meet the demands of various patient populations without compromising the safety and quality of its healthcare commodities. The government has been adept at tracking the industry and can adopt new regulations and enforcement to discourage and punish fraud. In addition to the existing policy guiding the expansion of Turkey’s medical tourism industry, more can be done to expand the industry. Some argue that barriers to medical tourism growth include inadequate human resources, negative corporate images and perceptions of Turkey globally, lack of facilitators, and unsatisfactory quality of care for medical tourists.[53] While Arab tourists are more at ease in choosing Turkey as a health destination because of the shared religion and understanding of Islamic accommodations, marketing to European and Asian tourists should address the possibility that they may feel uneasy about cultural differences or even that their cultural needs will not be respected or met. Therefore, more effort must be directed toward training medical personnel to exercise cultural competency and make hospitals culturally welcoming. This may include offering diverse food choices and ensuring that translators are available during all aspects of the medical tourist experience, starting at the airport. County-specific environmental factors should also be considered before a private hospital can enter the medical tourism market.[54] For example, hospitals should offer tour vouchers to capitalize on the historical sites in Cappadoccia. In addition, hospitals in Gaziantep should be sure to have signs in Arabic, and Arab-speaking health personnel, to meet the needs of the large Arab population in the area. Turkey must also do more to control costs to prevent the exacerbation of inequalities between foreigners’ and citizens’ access to health care. For example, some clinics have been able to circumvent cost regulations by the Ministry of Health.[55] By appointing region-specific regulatory overseers, they can ensure that costs are not prohibiting the local population from seeking necessary health care. CONCLUSION Turkey has seen enormous expansion in its medical tourism industry in recent years. Through government support and collaboration between the tourism and healthcare sectors, the Turkish economy has amassed billions of dollars in revenue annually from medical tourism alone. The investment into the medical tourism industry has placed Turkey at the forefront of quality and cutting-edge health care. While medical tourism has contributed enormous benefits to communities and the economy, there is more to do to ensure that health care inequalities between foreigners and Turkish citizens do not rise. The medical tourism industry in Turkey is not yet perfect; however, the potential is enormous. All things considered, medical tourism stands to help Turkey’s economy both through hospital systems and the increased tourism that coincides with travel for medical care. Due to expanded demand for services, medical tourism has led Turkey to develop its healthcare system and expand the number of people who can become physicians. Yet, more must be done to prevent fraud, ensure fair prices that Turkish locals can afford, and help public hospitals maintain some of the tourism market shares. Overall, medical tourism stands to benefit the people of Turkey and is an ethical way to expand the economy. - [1] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [2] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031; Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [3] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [4] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [5] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [6] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79; Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475; Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [7] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [8] Ibid. [9] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [10] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [11] Ibid. [12] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [13] Ibid. [14] Ibid. [15] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [16] Ibid. [17] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [18] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [19] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [20] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [21] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [22] Ibid. [23] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3). [24] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [25] Ibid. [26] Ibid. [27] Ibid. [28] Ibid. [29] Ibid. [30] Ibid. [31] Ibid. [32] Ibid. [33] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [34] Ibid; Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [35] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3); Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [36] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [37] Ibid. [38] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [39] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [40] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [41] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [42] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [43] Ibid. [44] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [45] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [46] Ibid. [47] Ibid. [48] Ibid. [49] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism; Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [50] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: Case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [51] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [52] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3). [53] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [54] Ulaş, D., & Anadol, Y. (2016). A case study for medical tourism: investigating a private hospital venture in Turkey. Anatolia: An International Journal of Tourism & Hospitality Research, 27(3), 327–338. https://doi-org.ezproxy.cul.columbia.edu/10.1080/13032917.2016.1191763 [55] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318.
Photo by Engin Yapici on Unsplash ABSTRACT Medical tourism has excellent potential and downfalls, which this paper will extensively cover. While medical tourism has great economic benefits to the host country and calls for the increase of professionalism and skill of physicians, it also influences doctors locating to private hospitals and skewing healthcare costs and access for locals. Given the many weights and balances to consider, the discussion of expanding this type of healthcare into Turkey is ethically needed. INTRODUCTION I watched from the hotel lobby as a group of men with surgically wrapped heads strolled in line behind a young woman; she was speaking to them in English with a heavy Turkish accent. Across the room was another group like this one, but the women had bandages on their noses. As a Turk, this sight was not new to me: over the years, I witnessed the number of foreigners coming to Turkey for medical procedures increase by tenfold. And, I began to see how savvy Turkish tourist companies became over time, creating enticing packages for people to tour the beautiful city of Istanbul while receiving a hair transplant procedure or rhinoplasty. While I understood why individuals would come to Turkey for their procedure ― lower prices, expert physicians, and a lovely tourist destination ― I began to question whether profiting from the health care of others was ethical. This paper examines whether it is ethical for Turkey to invest in a growing medical tourism field, which has the potential for significant economic benefits yet could threaten health inequalities between locals and foreigners. Further, it will outline why tourists choose Turkey as a medical tourism destination, the reasons to favor medical tourism, and the reasons to oppose it. Finally, the paper will conclude that Turkey should cultivate and invest in medical tourism, with suggestions for expanding the field into a thriving market. ANALYSIS By definition, a medical tourist is an individual who travels to a foreign country to experience both cultural tourism and medical treatment.[1] Global medical tourism is a $55billion industry, and the industry in Turkey is experiencing an annual growth rate of 22.6 percent.[2] In 2017, more than one million individuals traveled to Turkey for medical tourism, putting approximately ten billion dollars of foreign currency into the economy.[3] Medical tourists who traveled to Turkey received, on average, more than one procedure during their stay.[4] Due to the increasing demand for medical tourism, the Ministry of Health in Turkey emphasized the expansion of medical tourism in its strategic plan, implementing initiatives to grow the industry.[5] These initiatives include improving the quality of Turkish hospitals and receiving Joint Commission International (JCI) accreditation, which is an internationally recognized quality healthcare index.[6] There are multiple reasons why individuals choose Turkey as their destination for medical tourism. First, it is easy to travel to: individuals need only an E-visa, which they can easily receive through an online application.[7] In addition, Turkey has lower prices compared to the Western hemisphere.[8] The Turkish government incentivizes medical tourism through lucrative advertising specials. For example, Turkish Airlines offers discounted airline ticket prices of 50 percent for patients who demonstrate a patient admission document from a Turkish-certified health institution.[9] Private hospitals have opened advertising offices in the Ataturk airport as well.[10] Lastly, hotels and hotel chains collaborate with hospitals to offer lucrative tourist packages for patients.[11] While these perks and incentives draw people to Turkey, the lack of insurance coverage, high cost of treatment, and long wait times in their home countries are the most significant reasons that tourists choose Turkey as their medical destination.[12] Arab tourists previously traveled to the United States and the United Kingdom for medical treatment, but due to the implementation of strict travel sanctions after the September 11 attacks, they have had to look elsewhere.[13] For Arab tourists, the similarity of culture and religion in Turkey, a predominantly Muslim country, is also an enticing factor.[14] And, while Thailand and Singapore offer lower health care costs than Turkey, the shorter distance from the home country plays an important role in choosing Turkey as a medical destination.[15] European tourists choose Turkey for different reasons. For example, some surgeries conducted in Turkey are not available in Europe.[16] Patients from the Balkans and Central Asia prefer Turkey because of Turkey’s highly trained physicians and brand new, well-equipped hospitals compared to those in their home countries.[17] Interestingly, the low costs rank lower in importance than cultural similarity among those seeking care in Turkey.[18] The most important factor for choosing Turkey was quality: most tourists came from countries with a healthcare system marred by a lack of expertise or technological advancement.[19] One Turkish physician stated, “[Turkey] really ha[s] practices, doctors, services, hospitals and treatments that are above world standards in terms of health care.”[20] l. Ethical Permissibility of Medical Tourism in Turkey Health tourism has the potential to make a significant impact on the economic and social life of countries.[21] As a developing country, Turkey cannot afford to overlook this economic possibility.[22] The expansion of medical tourism in Turkey has allowed the country to reform its healthcare system into one that competes with health care quality in the Western hemisphere. Since 2010, there has been a significant increase in patients traveling to Turkey for health care.[23] The AK Party in Turkey pledged to promote health tourism in its campaign in 2011.[24] This inspired health care reform in 2013, with Turkey instituting a publicly funded and organized healthcare system.[25] In 2013, the Turkish government created publicly funded city hospitals. These hospitals were formed for medical tourism, meeting quality levels never-before-seen in the country.[26] In 2014, the Ministry of Health began granting accreditation to medical providers for medical tourism services and supporting translation services, patient transportation, and marketing.[27] Additionally, strategic initiatives were implemented to increase the number of Turkish medical school graduates.[28] The number of private medical schools increased from five before 2013 to 24 by the end of 2015.[29] A 50 percent tax reduction was granted to healthcare institutions that provided health care to foreigners.[30] Finally, Turkey began reforming hospital systems to obtain JCI accreditation. The growth of medical tourism in Turkey has resulted in positive reform of Turkey’s healthcare system. Turkey has over ten city hospitals in Istanbul, with qualified professionals proficient in English and other languages.[31] These hospitals are public and thus open and available for use by the general Turkish community, offering excellent quality health care to the country’s citizens. However, private hospitals have also flourished and, in some cases, have drained some of the doctors from public hospitals. With the increase in quality measures and regulatory healthcare committees, such as the Health Tourism Coordination Council (SATURK), Turkey’s healthcare system rivals the West's with highly trained professionals, competitive medical schools, and modern medical facilities.[32] Turkey has even reached the forefront of medical advancement: the World Eye Hospital is renowned for its cutting-edge ophthalmology services.[33] The investment in medical tourism has allowed Turkey to invest more in its private sector as well: the total expenditure on health as a proportion of the GDP rose from 2.4 percent in 1980 to 6.1 percent in 2008,[34] with an almost $2 billion national income from medical tourism in 2010. ll. Arguments Against the Ethical Permissibility of Medical Tourism in Turkey While public city hospitals were opened with the potential to support the Turkish medical tourism industry, private hospitals support 83 percent of the medical tourism market, and the gap between private and public hospitals has been growing yearly.[35] Private hospitals have mostly opened in urban areas, such as Istanbul, Ankara, and Antalya.[36] As a result, there has been a “brain drain,” in which members of the health workforce have left rural areas and have moved to urban cities where they can make larger profits from the medical tourism industry.[37] In addition, the use of public city hospitals has been met with concern regarding whether inequalities in health care between foreigners and Turkish citizens will arise. The Ministry of Health pays rent for the city hospitals in US dollars, exacerbating inflation in the Turkish lira currency and increasing reliance on high-paying medical tourists to support the public hospital system.[38] Due to this pressure, the prices for medical services are not consistently kept at affordable levels for Turkish citizens.[39] The head of The Private Hospitals and Health Institutions Association, Resat Bahat, stated, “Turkish citizens must receive priority for public resources. You cannot treat a Libyan or a Dutch when your own citizen is shaking at home with pneumonia. You [the public sector] can perhaps engage in medical tourism if you have excess bed capacity. But it is hard to do this [medical tourism] with the public sector.”[40] Rapid growth has also compromised patient safety and health care quality. While clinics must receive medical tourism certificates to provide treatment, fraud has risen.[41] In 2016, six out of ten hair transplant clinics were operating illegally.[42] These clinics offered hair transplants for as low as $800 when the treatment costs approximately $2000 in a Ministry of Health authorized clinic.[43] International patients have complained of inadequate human resources, such as the inability to communicate appropriately and insensitivity to tourists’ cultural features and habits, as well as a lack of facilitators in hospital systems.[44] The most common complaint has been that medical tourism companies fail to direct patients well and follow up after procedures.[45] Furthermore, multiple Turkish physicians have cited cases of malpractice with foreign patients.[46] One Turkish physician highlighted the ethical dilemma of turning health care into a commodity: “It is important that healthcare should be provided in such a way that institutions can continue their business without turning into a commercial commodity, ignoring the health and the aspect of the event. All people should have access to health equally.”[47] A Turkish pulmonologist also supported the idea of the separation between health and tourism, claiming that health care is a subject that requires unique methods to meet its needs, which should be addressed separately from the tourism industry.[48] lll. The Case for Continuing Medical Tourism While the above arguments demonstrate the difficulties with medical tourism, I argue that it is ethically permissible to invest in and expand Turkish health tourism. From a utilitarian perspective, the benefits of medical tourism to Turkish citizens outweigh the costs of expansion. Since investing in medical tourism, the quality of Turkish health care on both public and private levels has increased drastically. Turkey has also moved towards implementing more regulations surrounding the quality of health care.[49] International standards for health care have been adopted as well allowing Turkish citizens to reap the benefits of the medical tourism industry through access to advanced and high-quality health care.[50] While access and affordability for local patients must improve, the very existence of high-quality care and care standards that are better regulated exemplify improvements. Investments in medical education have also allowed Turkish citizens to gain greater access to higher education throughout the country with more medical seats and the opening of multiple private medical schools.[51] In addition, the expansion of the health industry has increased the professional opportunities available in healthcare for Turkish citizens. There is no doubt that medical tourism has greatly benefited the Turkish economy. Turkey aims to be the leading country in medical tourism by 2023, opening economic opportunities within and beyond medicine. The financial benefit is not reserved for the hospital systems and could provide high-paying jobs in hospitality, food service, etc.[52] People coming to Turkey spend money sightseeing and enjoying hotels, nature, and cities. While concerns about fraud exist, the medical tourism industry in Turkey is still relatively new, dating back to 2013. Thus, fraud is not widespread, considering the rate at which the industry has grown and its remarkable milestones in quality and patient services. There is no doubt that Turkey will continue to reform to meet the demands of various patient populations without compromising the safety and quality of its healthcare commodities. The government has been adept at tracking the industry and can adopt new regulations and enforcement to discourage and punish fraud. In addition to the existing policy guiding the expansion of Turkey’s medical tourism industry, more can be done to expand the industry. Some argue that barriers to medical tourism growth include inadequate human resources, negative corporate images and perceptions of Turkey globally, lack of facilitators, and unsatisfactory quality of care for medical tourists.[53] While Arab tourists are more at ease in choosing Turkey as a health destination because of the shared religion and understanding of Islamic accommodations, marketing to European and Asian tourists should address the possibility that they may feel uneasy about cultural differences or even that their cultural needs will not be respected or met. Therefore, more effort must be directed toward training medical personnel to exercise cultural competency and make hospitals culturally welcoming. This may include offering diverse food choices and ensuring that translators are available during all aspects of the medical tourist experience, starting at the airport. County-specific environmental factors should also be considered before a private hospital can enter the medical tourism market.[54] For example, hospitals should offer tour vouchers to capitalize on the historical sites in Cappadoccia. In addition, hospitals in Gaziantep should be sure to have signs in Arabic, and Arab-speaking health personnel, to meet the needs of the large Arab population in the area. Turkey must also do more to control costs to prevent the exacerbation of inequalities between foreigners’ and citizens’ access to health care. For example, some clinics have been able to circumvent cost regulations by the Ministry of Health.[55] By appointing region-specific regulatory overseers, they can ensure that costs are not prohibiting the local population from seeking necessary health care. CONCLUSION Turkey has seen enormous expansion in its medical tourism industry in recent years. Through government support and collaboration between the tourism and healthcare sectors, the Turkish economy has amassed billions of dollars in revenue annually from medical tourism alone. The investment into the medical tourism industry has placed Turkey at the forefront of quality and cutting-edge health care. While medical tourism has contributed enormous benefits to communities and the economy, there is more to do to ensure that health care inequalities between foreigners and Turkish citizens do not rise. The medical tourism industry in Turkey is not yet perfect; however, the potential is enormous. All things considered, medical tourism stands to help Turkey’s economy both through hospital systems and the increased tourism that coincides with travel for medical care. Due to expanded demand for services, medical tourism has led Turkey to develop its healthcare system and expand the number of people who can become physicians. Yet, more must be done to prevent fraud, ensure fair prices that Turkish locals can afford, and help public hospitals maintain some of the tourism market shares. Overall, medical tourism stands to benefit the people of Turkey and is an ethical way to expand the economy. - [1] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [2] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031; Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [3] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [4] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [5] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [6] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79; Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475; Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [7] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [8] Ibid. [9] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [10] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [11] Ibid. [12] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [13] Ibid. [14] Ibid. [15] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [16] Ibid. [17] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [18] Yıldız, M. S., & Khan, M. M. (2019). Factors affecting the choice of medical tourism destination: A case study of medical tourists from the Arab Region in Turkey. Journal of Health Management, 21(4), 465-475. [19] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [20] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [21] Sag, I., & Zengul, F. D. (2019). Why medical tourists choose turkey as a medical tourism destination? Journal of Hospitality and Tourism Insights, 2(3), 296-306. doi:http://dx.doi.org/10.1108/JHTI-05-2018-0031 [22] Ibid. [23] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3). [24] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [25] Ibid. [26] Ibid. [27] Ibid. [28] Ibid. [29] Ibid. [30] Ibid. [31] Ibid. [32] Ibid. [33] Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [34] Ibid; Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [35] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3); Buljubasic, E. (2019). Evaluation of GCC Patients' Service Quality Perception Towards Medical Tourism and Turkey as a Medical Tourism Destination (Doctoral dissertation, Marmara Universitesi (Turkey)). [36] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [37] Ibid. [38] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [39] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [40] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [41] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [42] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [43] Ibid. [44] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [45] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism. [46] Ibid. [47] Ibid. [48] Ibid. [49] Both an Opportunity and Threat to Turkey Health Tourism. TurkeyMedicals.Com, Turkey IHealth , 2022, https://turkeymedicals.com/health-tourism; Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [50] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: Case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [51] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318. [52] Akgün, S. (2015). Medical tourism in Turkey: past, present, and future. Seval Akgün. European Journal of Public Health, 25(suppl_3). [53] Cavmak, D., & Cavmak, S. (2020). Using AHP to prioritize barriers in developing medical tourism: case of Turkey. Int J Travel Med Glob Health, 8(2), 73-79. [54] Ulaş, D., & Anadol, Y. (2016). A case study for medical tourism: investigating a private hospital venture in Turkey. Anatolia: An International Journal of Tourism & Hospitality Research, 27(3), 327–338. https://doi-org.ezproxy.cul.columbia.edu/10.1080/13032917.2016.1191763 [55] Yılmaz, V., & Aktas, P. (2021). The making of a global medical tourism destination: From state-supported privatisation to state entrepreneurialism in healthcare in Turkey. Global Social Policy, 21(2), 301-318.
Universal Health Coverage with Private Options: The Politics of Turkey’s 2008 Health Reform
Over the past decades, countries across the Global South have been adopting expansionary health reforms and are increasingly doing so under the banner of promoting universal health coverage. But countries have taken notably different approaches regarding the inclusion of private actors in their expanding healthcare systems. In this article, we explore the political causes and consequences of partial privatization in the context of healthcare expansion. We conduct a case study of Turkey’s 2008 health reform, which coupled substantial coverage expansion with the introduction of private options in provision and financing—and has since been branded as a global “success story” of achieving universal health coverage. Specifically, we seek to explain why Turkey introduced private options with its expansionary health reform and what kind of policy feedback effects this has triggered. We find that private options were incorporated into the reform as the result of persistent business lobbying and pro-market changes in the leadership of the health ministry and not because of any international coercion, e.g., by the World Bank. The introduction of these private options has since led to the growth of private hospital and insurance markets and the political entrenchment of partial privatization.
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