Вот такая оценка происходящего:
Модернизация в основном направлена на приватизацию медицинских услуг, предписанную в докладе Всемирного банка в 1993 году «Инвестиции в здоровье», предполагавшем, что экономическая эффективность, конкуренция, децентрализация, удовлетворение потребностей-клиентов, и зарплата, зависящая от продуктивности (performance) являются ключевыми для снижения затрат и повышения качества.(3)
Наш случай … пример страны, проводящих реформы для достижения всеобщей доступности медицинской помощи. Тем не менее, я твердо верю, что моральный аспект реформы должны быть принят во внимание.
Приватизация здравоохранения для повышения равенства, справедливости и права на здоровье — оксюморон. Экономическая эффективность и критерии возмещения основаны на денежных затратах, а не потребности пациентов. Финансирование услуг несправедливо. Люди платят страховые взносы для ОМС в качестве второго налога за получение той же помощи. ОМС покрывает лишь определенный пакет услуг, который становится все меньше с нынешней реформой.
Права пациентов становятся частью деловой подхода и преобразуются в права потребителей. Значение, которое придается праву выбора врача, является хорошей иллюстрацией этой тенденции. … Информированное согласие является письменным договором между заказчиком и поставщиком. …Пациенты, диагностические тесты, операции, любые медицинские вмешательства — в настоящее время все девальвировано в услуги и оплату. Врачи испытывают враждебность населения. Условия общественного договора между обществом и медицинской профессией подвергаются сомнению с обеих сторон. Трансформация медицинских услуг в еще один вид товара также изменяет традиционный статус врачей в обществе. Общественное доверие к медицине как социальной организации и доверие в отношениях пациент — врач разрушается….
Теперь признаюсь. Текст этот – не про Русь, а про Турцию. Рифат Атун написал статью (1), где описал, как реформа хорошо продвигается в Турции, а академик турецкий ему ответил. Ответ этот я и привел выше, заменив только турецкие названия на русские. Ниже чуть сокращенное письмо М. Чиванера и, далее – ответ ему Р. Атуна с соавторами
В. Власов
M Murat Civaner. Health-care reform in Turkey: far from perfect. Lancet, The, 2014-01-04, Volume 383, Issue 9911, Pages 26-26
The HTP basically aims to privatise health-care services following the 1993 World Bank landmark report, Investing in Health, which suggests that cost-effectiveness, competition, decentralisation, customer satisfaction, and performance-based incentives are key for decreasing costs and improving quality. 3
The Turkish case is presented as an example for countries pursuing reforms to achieve universal health coverage. However, I strongly believe that the moral dimension of the HTP must be taken into consideration.
Privatision of health care to enhance equity, fairness, and right to health is an oxymoron. Cost-effectiveness and criteria for reimbursement are based on monetary costs, not patients’ needs. The financing of the services is unfair. People pay premiums for general health insurance as a second tax to receive the same care. Insurance payments cover only a particular package of services, which is getting smaller with the current reform.
Patient rights are becoming part of a business approach and are being transformed into customer rights; the importance given to the right to choose a doctor is a good illustration of this trend. Moreover, medical information no longer belongs to the patient, but to health-care corporations. Confidentiality now protects the rights of corporations, not those of the patients. Informed consent is a written contract between customer and provider that defines the terms of the service. The consequences are worrying: the harm caused by the service is now defined as a fault caused by the worker who touched the patient last. This blame culture is dangerous; it pushes practioners towards defensive medicine. It also limits the time per patient because of performance-based incentives. Patients, diagnostic tests, operations, any medical interventions are now all devalued into bonus points. Physicians are experiencing alienation. The terms of the social contract between society and the medical profession are being questioned on both sides. Transformation of health-care services into just another kind of commodity also changes physicians’ traditional status in society. Public trust in medicine as a societal institution and trust in patient–physician relationships erodes. Medicine is moving away from its traditional roots and virtues; health-care workers are contracted workers in a new environment operated by corporate rules and market dynamics. Market demands make prioritisation of patients’ best interests and protection of professional independence more difficult.
The social contract, which is the fundamental justification of professional duty to provide care, is dissolving in front of us. It is deeply worrying, especially in terms of right to health. Medicine and health should not be mere subjects for business.
1. Atun R, Aydın S, Chakraborty S, et al: Universal health coverage in Turkey: enhancement of equity. Lancet 2013; 382: 65-99
2. : Project in Support of Restructuring of Health Sector. http://www.worldbank.org/projects/P102172/health-transformation-social-security-reform-project?lang=en(accessed June 5, 2013).
3. : World development report: investing in health. New York: Oxford University Press, 1993
Rifat Atun et al. Health-care reform in Turkey: far from perfect – Authors’ reply. Lancet, The, 2014-01-04, Volume 383, Issue 9911, Pages e1-e1
We are delighted with the discussion generated by our report Universal health coverage in Turkey: enhancement of equity. 1
In analysing the effects of the Turkish health reforms, we were careful to use reliable data from the Turkish Demographic and Health Survey (TDHS) 1993, 1998, 2003, and 2008; the Turkish Household and Budget Surveys (THBS) 2003–11 done annually by the Turkish Statistical Institution; and the health expenditure and health insurance coverage data from the Social Security Institution. We used WHO data for life expectancy in Turkey and European (E7) countries; Organisation for Economic Co-operation and Development (OECD) data for economic indicators; OECD Health data and World Bank data for health expenditures and health system performance of E7 countries; Maternal Mortality Estimation Inter-Agency Group estimates for maternal mortality ratios in E7 countries in 1990–2010; and UN Inter-agency Group for Child Mortality Estimation for under-5, infant, and neonatal mortality in E7 countries. These data are publicly available and offer the opportunity for scholarly analysis to provide scientific basis for hitherto unsupported assertions. We also used Ministry of Health human resources data. The report’s appendix (pp 2–13) 1 details the data sources and study methods.
The TDHS sample used in our analysis consists of children younger than 5 years for antenatal visits, births in a health facility, and births attended by trained staff (TDHS reports sample consisting of children who were born within 5 years before the survey date), and children aged 12–24 months for immunisation rates (for 2008, the TDHS report used a cutoff of 15–26 months). For mortality rates, we used different timeframes for our sample than in TDHS reports. Although between 1993 and 2008 in eastern regions, the infant mortality rate might have declined less (in percentage) than that in western regions, our analysis shows that inequality across urban versus rural regions and across asset groups decreased. We could not find a publication supporting Onur Hamzaoglu’s assertion that in 1993–2008 preventable deaths increased in all infant mortality. We found no evidence supporting the assertions that the Health Transformation Program (HTP) led to privatisation of the Turkish Health System, as stated by Murat Civaner, Ozdemir Aktan and colleagues, Feride Aksu Tanik, and Bulent Kilic in their Correspondence. HTP is publicly financed—the public sector provides 83% of health services. 1 Moreover, we could not find evidence supporting violation of right to health, mentioned by Civaner. Indeed, by contrast with Kayihan Pala’s and Kilic’s claims, our analysis of THBS shows that insurance coverage has increased more rapidly for the poor, with 84% of the poorest decile covered by some kind of insurance in 2011 compared with 24% in 2003. We could not find evidence supporting Kilic’s assertions that the General Health Insurance fails to protect the poor, that several treatments are not covered by the scheme, or that out-of-pocket health expenditures increased from 16% to 26%. Our analysis that used THBS data shows that out-of-pocket expenditures decreased from 2·2% to 1·9% of total household spending, and from 3·1% to 2·4% of the total non-food spending between 2003 and 2011. As public spending on health increased by around 110% (in US$ purchasing power parity adjusted) between 2003 and 2008 and real out-of-pocket expenditures at the household level increased by 49% between 2003 and 2011 (according to THBS data), 2 it is difficult to see how the share of out-of-pocket expenditures would have increased in overall health spending in Turkey through the HTP.
In identifying current challenges in the Turkish health system, we note the increased workload for health professionals and the opposition from the Turkish Medical Association to elements of HTP, including performance-related pay for health staff, which are used in health systems globally. 3 4 We stress the importance of managing public expectations and expanding opportunities for professional development to create a committed and well-trained health workforce. 1
Finally, violence against health staff is unacceptable in Turkey or elsewhere. The Commission established by the Turkish Grand National Assembly to investigate violence against health staff is very timely and welcome.
RiA has acted as an adviser and a consultant to the Ministry of Health of Turkey, including in the Health Transformation Program, and has undertaken consulting assignments in Turkey for the Ministry of Health of Turkey, WHO, and the World Bank. SA was the Undersecretary of the Ministry of Health of Turkey from 2002 to 2009. MA and IG have undertaken analytical consulting assignments for the Ministry of Health of Turkey. SC works for the World Bank and was involved in the World Bank-funded Health Transition Project in Turkey. ReA was the Minister of Health of Turkey from 2002 to 2012.
