Explaining Large-Scale Policy Change

in the Turkish Health Care System:

Ideas, Institutions, and Political Actors
T u b a I. A g a r t a n
Providence College

A bstract Explaining policy change has been one of the major concerns of the health
care politics and policy development literature. This article aims to explain the spe­
cific dynamics of large-scale reforms introduced within the framework of the Health
Transformation Program in Turkey. It argues that confluence of the three streams—
problem, policy, and politics— with the exceptional political will of the Justice and
Development Party’s (JDP) leaders opened up a window of opportunity for a large-scale
policy change. The article also underscores the contribution of recent ideational per­
spectives that help explain “why” political actors in Turkey would focus on health care
reform, given that there are a number of issues waiting to be addressed in the policy
agenda. Examining how political actors framed problems and policies deepens our
understanding of the content of the reform initiatives as well as the construction of the
need to reform. The article builds on the insights of both the ideational and institu­
tionalist perspectives when it argues that the interests, aspirations, and fears of the JDP,
alongside the peculiar characteristics of the institutional context, have shaped its pri­
orities and determination to carry out this reform initiative.

K eyw ords health care reform, Turkey, window of opportunity, ideational perspec­
tives, institutionalism

In t r o d u c t i o n

Since 2003 the Turkish health care system has been undergoing a major
transformation, described in a recent Lancet commentary as a “remarkable

I would like to thank Jason Beckfield, Daniel Beland, Ana M. Guillen, Deborah Levine, and
Jessica Mulligan for their valuable comments. The research reported here has received financial
support from the Social Policy Forum, Bogazi?i University, Turkey.
Journal o f Health Politics, Policy and Law, Vol. 40, No. 5, October 2015
DOI 10.1215/03616878-3161174 © 2015 by Duke University Press
972 Journal o f Health Politics, Policy and Law

revolution in health” (Horton and Lo 2013: 3). This was no exaggeration,

since the reforms introduced within the framework of the Health Trans­
formation Program (HTP) introduced changes in the financing, delivery,
and regulation of health care services. This major reorganization of the
health care system was accompanied by a new division of labor among the
public and private sectors: the state has been gradually withdrawing from
provision of services while strengthening its role in financing and regu­
lation. This transformation can be analyzed in terms of what Lars Thorup
Larsen and Deborah Stone (2015) call the “two faces of neoliberalism”:
The idea that money follows the patient is institutionalized by allowing
publicly insured citizens to choose among private and public providers (the
first face of neoliberalism). In this process, the role of the private sector in
service provision has expanded, but it has not been accompanied by a
weakening of the state. Indeed, the state gains some degree of leverage
over the private sector because it can now play a more regulatory role and
sets the rules for both the private and the public sectors (the second face
of neoliberalism). Moreover, the reforms have introduced a new mecha­
nism whereby public hospitals are governed by economic incentives, often
described in the health reform literature in terms of the public manage­
ment paradigm (again, the second face of neoliberalism). Thus, similar
to reform policies in Denmark and the United States, the HTP demon­
strates how neoliberal reforms “seek” and “make” the health care system
more governable.
The dynamics of policy change have been analyzed from a range of
perspectives in the past few decades as reforms were introduced in many
health care systems. Recent institutionalist scholarship has recognized that
path dependency can be disrupted and change may take place in two
ways— incrementally and rarely through critical conjunctures or win­
dows of opportunity. This article examines the dynamics of this rare or
remarkable health care system change by combining three theoretical
approaches— John W. Kingdon’s streams approach, institutionalist schol­
arship, and ideational perspectives. Building on Kingdon's (2011) streams
approach, it argues that a rare “window of opportunity” for policy change
was opened when a majority government was formed in Turkey in 2002
after years of coalition governments and right after a major economic crisis.
This window opened at a time when the problems of the health care system
were well known and were seen as a public matter requiring attention
(problem stream), and possible solutions such as establishing a national
health insurance or redefining the responsibilities of the Ministry of Health
(MOH) had been proposed in the preceding two decades (policy stream). In
 Agartan ■ Policy Change in Turkish Health Care 973

addition to the coupling of these three streams, the Justice and Develop­
ment Party (JDP) government, since the early days of reform, has dem­
onstrated an extraordinary mobilization of political authority and will,
crucial to bringing about policy change.
The availability of policy solutions pressed by policy actors and the
opening up of a window of opportunity help explain “when” the time of
health care reform had come as well as the dynamics of agenda setting
(“how” it had taken place). However, why health care was assigned such
importance in the JDP’s policy agenda and why the party leaders were so
determined to implement it still need to be accounted for. Recent ideational
perspectives (Beland 2005; Beland and Cox 2011; Mehta 2011) offer
answers to these questions by bringing the identity and individuality of the
agent back into the analysis of policy change. This perspective can help
(1) analyze large-scale, path-departing change through a dynamic under­
standing of the relationship between actors and institutions; (2) explain
why it took the form that it did (the particular content of the reform pro­
gram); and (3) identify the factors that could explain why political actors
would focus on health care reform, given that there were a number of issues
waiting to be addressed in the policy agenda. A key question that I explore
in this article is how and why the JDP leaders perceived health care reform
as a policy that would benefit them.
This article hypothesizes that, in addition to the confluence of the three
streams, the interactions among the institutional environment and per­
ceived interests of the JDP have shaped its priorities and its determination
to carry out this reform initiative. On the one hand, this article views policy
change as largely the result of “the interaction between strategic conduct
and the strategic context within which it is conceived and in the later
unfolding of its consequences, both intended and unintended” (Hay 2011:
68). Accordingly, reform in the health care system took place in this par­
ticular way because the JDP leaders assigned it a high priority. And they
assigned such a high priority not only because major problems of the health
care system and their solutions were well defined but also because they
perceived the reform to be in their best interest. On the other hand, the
institutionalist perspective argues that existing institutional settings create
obstacles and opportunities that are likely to affect the behavior of policy
actors. Key features of the peculiar institutional context in Turkey, such as
the hostility and struggle among the JDP and the Kemalist-secularist
establishment, have significantly shaped the JDP leaders’ perceptions about
what is feasible, desirable, and legitimate and therefore influenced their
strategic conduct. Turkey’s health care reform experience thus highlights the
974 Journal o f Health Politics, Policy and Law

importance of analyzing the relationship among ideas, institutions, and

policy change.
In the next section I lay out the theoretical framework of the article
and review the debates in the institutionalist literature on policy change,
Kingdon’s (2011) streams approach, and ideational perspectives. I then
provide a description of the structure of the Turkish health care system in
the two decades preceding the HTP and identify the policy and problem
streams. Next, I focus on the reform initiative, the HTP. After describing
its major achievements, I analyze how the problem, policy, and politics
streams come together to open up a window of opportunity. Turkey’s health
reform initiative is interesting from a historical institutional perspective
not only because it represents a rare occurrence of a window of opportunity
for reform but also because it demonstrates the unusual determination of
the JDP leaders to carry out major public-sector reforms, which must be
examined in relation to the institutional context.

M e th o d s

This case study aims to investigate how change has occurred during a single
reform effort that began in 2002. Policy change here is defined as “large-
scale” due to the magnitude of change in all three functions of the health
care system, rather than the goals or direction of reforms. In other words,
the HTP was not radical, nor can it be described as innovative, but it
included many of the familiar ideas from previous reform initiatives. Thus
the study also explores continuities and, adopting Kingdon’s perspective,
aims to identify whether problem definitions and solutions were available
to the JDP leaders. The first step in the research was to identify reform
initiatives since the 1980s, when Turkey experienced a major political
economic transformation (summarized in table 1). From 2005 to 2009, I
tracked down major reform documents as well as analyses of these reforms
through the websites of key organizations (the MOH, the Turkish Medical
Association [TMA], the World Bank, the Organisation for Economic
Co-operation and Development [OECD], the World Health Organization
[WHO], and Turkey’s State Planning Organization [SPO]) and through
professional networks. In 2005 I also visited various offices at the MOH
and SPO as well as the headquarters of the TMA and three major labor
unions in Ankara to collect hard copies of these reform documents (such as
the Price Waterhouse report [SPO 1990] and the MOH progress reports
[MOH 2011]). Additionally, an online database search was conducted to
find academic articles published on current and previous reform initiatives.
 Agartan ■ Policy Change in Turkish Health Care 975

In this time span I was also able to identify key informants and key
members of the HTP reform team. Six interviews were conducted in 2005
with members of the reform team (active bureaucrats), and two members
were interviewed again in 2009. These were semistructured interviews
with open-ended questions. During the interviews, I asked the interviewees
whom they consulted with during the drafting stage and who else was on
the reform team. I secured appointments through referrals from the ini­
tial interviewees, and in this way I was able to interview in 2005 two
ex-bureaucrats who worked on the previous reform initiatives.
Nine more interviews were conducted with key stakeholders, including
representatives from the TMA, major labor unions, and the World Bank
in the spring of 2005. These interviewees were identified with the help of
the initial document analysis and, more particularly, a stakeholder report
prepared for the MOH (Gonzalez Rossetti 2004). Finally, another round of
document search was conducted in 2013 to identify more recent reports,
academic publications, as well as newspaper articles that focused on the
implementation stage. The documents and interviews were analyzed man­
ually by tracking the following rhetorical elements: the problems of the
health care system; the goals of reforms; the solutions offered (the contents
of reform proposals were categorized into market-based, state interven­
tion, and managerial); descriptive statistics; and reference to previous reform
initiatives. I paid particular attention to how interviewees framed the need
for reform as well as its outcomes.

Ideas, Actors, Institutions: Explaining Change

in the Turkish Health Care System
Theoretical Background: Explaining Policy Change
Historical institutionalist theories claim that institutions shape both the
goals and the strategies of actors and thus push policy along particular
paths. Deviating from these particular paths, as Jacob S. Hacker (2002)
points out, is very unlikely when institutions benefit important organized
interest groups that use “veto points” (Immergut 1992) to thwart change,
when institutions reflect broader values of a society, or when large social
programs or institutions create “lock-in effects” that favor the continuation
of the status quo (Pierson 1996). Such an emphasis on path dependency and
policy legacies, however, has been criticized for narrowing the analytical
focus to stability and continuity. In response, some institutionalist scholars
have taken on the challenge of explaining institutional change and
976 Journal o f Health Politics, Policy and Law

distinguishing its specific mechanisms. According to this recent institu­

tionalist scholarship, change may take place in two ways— incrementally
(Crouch and Farrell 2004; Hacker 2004; Streeck and Thelen 2005; Clegg
2007) or at critical conjunctures.
The discussion on critical conjunctures focuses on a major “exogenous”
event, such as an economic or military crisis, a change in the political
system, a technological development, or a demographic change (Thornton
and Ocasio 1999; Dobbin and Dowd 2000; Schneiberg 2005). This type
of change— described with various terms including radical, major, profound,
striking, drastic, pathbreaking, trajectory inflecting, and disruptive— was
associated with institutional breakdown or innovation. In this punctuated
equilibrium model, history is marked by critical junctures or ruptures in
which equilibrium is disrupted: old routines lose their force, the effects of
political institutions are comparatively minimized, or vested interests are
subverted, thus leaving more room for agency. According to David Wilsford
(2010: 675-76), the actions of major policy actors like the charismatic
leader and the quality of the decisions in these critical contingencies will
then determine both the particular content of reforms and the direction of
change as well as whether the opportunity is seized or missed.
Although distinct from historical institutionalism, some studies that aim
to examine reform initiatives in various areas of health care systems have
adopted Kingdon’s (2011) concept of the “window of opportunity” (Tuohy
1999; Lush, Walt, and Ogden 2003; Surjadjaja and Mayhew 2011). His
framework of agenda setting has also been appealing for its potential to
explore the interplay of institutions, interests, and ideas (Beland 2005;
Leiber, Gress, and Manouguian 2010). Kingdon (2011: 16-17) suggests
that in any setting there are many problems that require attention and that
these constitute the “policy agenda” or the “problem stream.” Yet many of
these problems are not addressed by key policy makers. An idea’s time
comes— that is, the problem attracts policy makers’ attention— only when
different solutions or alternatives (policy stream) are available. These
solutions or proposals floating in the policy stream are coupled with the
recognized problems particularly during a major event, or a “window.”
Kingdon (2011: 168) explains that a change in administration— that is, a
change in the political stream— is “probably the most obvious window,”
but he argues that a window may also open “because a new problem
captures the attention of governmental officials and those close to them.”
During these windows or moments of opportunity, policy entrepreneurs—
“people who are willing to invest their resources in pushing through their
 Agartan ■ Policy Change in Turkish Health Care 977

pet proposals or problems”— play an important role in coupling proposals

with certain problems and pushing for the adoption of their proposals, thus
bringing these three streams (problem, policy, and politics) together
(Kingdon 2011: 20).
Kingdon’s streams approach offers a valuable framework to explain
large-scale change in the Turkish health care system. The term large-scale
refers to the magnitude of the changes observed in all three functions of the
health care system, that is, in financing, provision, and regulation. Thus
large-scale does not imply significant shifts in policy strategies and goals.
Nor does it refer to direction of change, because the 2003 reform does not
represent an innovative departure from previous directions. This article
argues that a rare “window of opportunity” (Kingdon 2011) for policy
change was opened when a majority government was formed in 2002 after
years of coalition governments (politics stream). This window opened at a
time when the problems of the health care system were well known and
were seen as a public matter requiring attention (problem stream), and
possible solutions had been proposed in the preceding two decades (policy
stream). But is the availability of policy solutions or proposals pressed by
policy entrepreneurs and/or political leaders or the opening of the window
of opportunity enough to explain the particular content of the reforms or
why the JDP leaders decided to carry out a health care reform?

W hat Makes Reforms Happen? The Three Streams, Ideas,

and Political W ill

In Kingdon’s work (2011: 179-84) it is the combination or “coupling” of

the three streams that brings about major policy change, and the policy
entrepreneurs are assigned a key role in this process of coupling. Key policy
entrepreneurs might be career bureaucrats, members of the legislature,
lobbyists, academics, or experts working for a think tank. The parlia­
mentary structure and dominance of the political elite in the policy-making
tradition in Turkey (Heper 1985) meant that the government enjoyed
concentrated authority that left little scope for the emergence of powerful
policy entrepreneurs. Although some policy experts— ex-bureaucrats who
acted as consultants to the reform team and current bureaucrats appointed
by the JDP leaders— played important roles in the drafting of the reform
blueprint, the HTP, more research is needed to explore whether and in
what ways they were instrumental in the policy and problem streams.
Therefore, this study focuses mostly on the role of major policy actors such
978 Journal of Health Politics, Policy and Law

as the political leaders in the JDP and the reform team led by the minister
of health.
The role of political actors in bringing about institutional change has
been explored by ideational perspectives (Beland 2005; Beland and Cox
2011; Hay 2011; Mehta 2011). Ideational scholars move beyond the search
for an “exogenous factor” that would drive policy change: they propose an
analytical framework that explores large-scale change through a dynamic
understanding of the relationship between actors and institutions. This
understanding is “agency-centered” because it views change as largely the
result of choices actors make. As Daniel Beland and Robert H. Cox (2011:
12) put it: “The unique claim of ideational scholars is that these choices are
shaped by the ideas people hold and debate with others. These ideas, in
turn, are based on interpretations people have of the world and of those
around them.” In this article, I focus on interests as one form of ideas.
Following Colin Hay (2011:67,69), this article views actors as “strategic,
seeking to realize certain complex, contingent, and constantly changing
goals” and defines interests as “constructions” that are “inherently nor­
mative and subjective/intersubjective conceptions of self-good— of what it
would advantage the individual to do or to have done.” In this definition,
constructions reflect “subjective preferences regarding the things the actor
values and the relative values the actor assigns to the desires he or she can
imagine” (Hay 2011:79). Then, a central question for this article is how and
why the JDP leaders conceived health care reform of a higher value and
perceived it as a policy that would benefit them.
The answer to this question is not that the political leaders gave priority
to health care reform because they were pursuing their objective material
interests like winning the elections and increasing political support, as
materialist approaches would argue. Rather, these leaders had “percep­
tions” about what was possible, feasible, and desirable that were “shaped
both by the institutional environment in which they fjound] themselves and
by existing policy paradigms and worldviews” (Hay 2011: 69). Therefore,
in the analysis section I examine the perceptions of the JDP leaders to
explain why they conceived of health care reform as a high-priority policy.
Such a framework also helps explain the political will that the JDP dem­
onstrated at the implementation stage. In addition, to understand the par­
ticular content of the reform proposal, the HTP, I examine how these
perceptions were shaped by the existing policy paradigms and worldviews,
which include domestic as well as global elements such as the new public
management (NPM) paradigm. Especially since the mid-1990s, many
 A g a rta n ■ P o lic y C h a n g e in T u r k is h H e a lt h C a r e 979

scholars have highlighted the role of epistemic communities and networks

in health policy (Beyeler 2004) and examined mechanisms of cross­
national policy learning and policy transfer (Klein 1997; Marmor, Free­
man, and Okma 2005; Weyland 2005). This growing literature encourages
us to explore the interactions among domestic and global policy paradigms
and to trace the influence of ideas and worldviews developed in other
countries and in relevant international institutions such as the World Bank,
WHO, or the OECD.
Before exploring these arguments further, I review in the next section the
evolution of policy and problem streams until the recent reform initiative
and identify dominant policy ideas and paradigms. The discussion focuses
on the post-1980 period because the 1980 military coup represents a
turning point whereby market reforms that transformed the role of the state
were implemented.

The Turkish Health Care System before the HTP

(1 9 8 0 -2 0 0 3 )

A defining feature of the social insurance system in the 1980s was its
nonegalitarian nature: reflecting the segmented nature of the labor market,
the three social security funds had significant differences in terms of benefit
packages, premium rates, access to public and private facilities, and the
quality of services provided. At the top of the hierarchy were active state
employees and members of the Emekli Sandigi (Retirement Fund), fol­
lowed by members of the Sosyal Sigortalar Kurumu (Social Insurance
Institution; SSK) and members of the Bag-Kur (Social Insurance Institu­
tion for Craftsmen and Artisans and Other Self-Employed). This hierarchy
was not based on the level of individual contributions. In the context of the
national developmentalist project directed by the central state bureaucracy,
the hierarchy was based on “closeness to the state” and “employment
status” (Ustiindag and Yoltar 2007).' Therefore, policy makers and polit­
ical leaders were not concerned with the nonegalitarian and fragmented
nature of the social security system, which was highly popular among the
civil servants and industrial workers.
Two economic crises— in 1994 and 2001— brought about a major
change in the balance of power in Turkey’s political economy by strength­
ening the “pro-reform coalition” (Oniy 2007: 252). While the crisis created
public support for the reform process domestically, at the same time it
provided a context whereby international institutions such as the International

l . Unless otherwise noted, all translations are mine.

980 Journal o f Health Politics, Policy and Law

Monetary Fund (IMF), the World Bank, and WHO as well as the European
Union emerged as legitimate actors that pushed for reform (Bugra and
Keyder 2006; Bugra and Adar 2008).
In the problem stream, discussions centered on expansion of insur­
ance coverage and problems with resource raising and allocation. While
establishing a single-payer plan remained a distant target, the reform ini­
tiatives during the 1990s framed creating additional financing organiza­
tions as a step toward the single-payer system. Examples of this can be seen
in the draft law establishing individual health insurance in 1998 as well as
the means-tested scheme Ye§il Kart (Green Card) in 1992. This scheme for
low-income citizens quickly expanded to provide coverage for inpatient
services. Main policy documents of the time such as the government
programs, letters of intent submitted to the IMF, or the five-year devel­
opment plans were also concerned with the low levels of public spending
on health— public expenditure on health during the 1980s ranged between
1.3 and 1.8 percent and during the 1990s between 2.2 and 3.3 percent (SPO
1990: 123)— and the limited capacity of the Turkish state in terms of
collecting the contributions (SPO 1990: 107). What is notable in this dis­
cussion on resource raising is the omission of the option of financing
through taxes, quite in line with the emerging neoliberal policy paradigm.
Major reform proposals such as the 1996 Health Care Reform suggested a
purchaser-provider split and aimed to establish a public fund (so-called
individual health insurance) to expand insurance coverage to the unin­
sured, who were expected to contribute based on their income (table 1).
Post-1980 debates in health policy witnessed the emergence of an
alternative policy paradigm influenced by ideas of privatization and the
NPM. Certain elements of this new paradigm can be seen in the debates
surrounding the 1987 Basic Health Law. On the one hand, strict controls
on private-sector activity gave way to a policy of encouragement of pri­
vate provision of health services. On the other hand, the highly central­
ized command-and-control tradition of administering health services was
identified as a major source of inefficiency and waste, and, as a solution, a
restructuring of the MOH was proposed. Despite limited implementation,
the 1987 Basic Health Law was crucial in shaping the problem definitions
and policy solutions offered by subsequent reform attempts (table 1).
Organizational problems such as “wasteful duplication due to poor plan­
ning and overlapping functions among different facilities,” “conflicts
between the central and provincial levels of administration and continual
referral of even minor matters to higher authorities,” and “low management
capacity” were highlighted in a key policy document, the “Master Plan
Study” (SPO 1990: 4—7).
T ab le 1 M a jo r Reform In itia tive s and W o rld Bank Projects in Turkey, 1987-2003: Problems Id e n tifie d
and S olutions Proposed

Plans/Projects Problems Solutions / Policy Agendas

1987 Basic ■ Highly centralized command-and-control tradition of ■ Encourage private provision of services and
Health Law administering health services creates inefficiencies and competition among service providers
waste, lack of planning, and effective regulation ■ Reorganize the responsibilities of the Ministry of
Health (MOH) and transform it into a planning and
managing agency
■ Hospital autonomization
■ Create regulatory institutions responsible for managing
certain areas of health policy such as drugs or medical
devices
1990 first World ■ Higher-than-average fertility, poor ante- and postnatal ■ Develop health infrastructure in eight provinces (pilot)
Bank project, care, unsafe deliveries, and improper birth spacing; and the rest of the provinces including construction
1989-99 malnutrition among children especially in rural areas of new facilities or upgrading of existing ones,
and eastern Turkey strengthening of provincial management,
* Inefficient public health system: (a) neglect and reorganization of referral procedures, and provision of
underfunding of public health facilities and (b) poor equipment and vehicles
managerial capability of the MOH ■ Implementation of fifteen health programs targeted at
■ Large regional disparities of access and quality maternal care, child care, control of communicable
diseases, and improved frontline curative care
■ Reorganize the MOH, develop its managerial capacity
and ability to conduct operational research
(continued)
T ab le 1 M a jo r Reform In itia tive s and W o rld Bank Projects in Turkey, 1987-2003: Problems Id e n tifie d
and S olutions Proposed (c o n tin u e d )______________________________________________________________
Plans/Projects Problems _____________________________Solutions / Policy Agendas

1 9 9 4 -2 0 0 4 ■ High burden of disease due to avoidable illness and ■ Upgrade the training of primary health care personnel
Second disability * Expand basic health care interventions known to be
World Bank ■ Inequities in access to essential health services cost-effective
project ■ Low quality of health care management ■ Strengthen the network of health care facilities
■ Restructure the MOH by
o upgrading the training of staff in policy making,
planning, and management
o monitoring and evaluation
o decentralizing and restructuring management
responsibility in six pilot hospitals
o introducing basic management support systems in
provincial health directorates and selected hospitals
in the project provinces, as well as evaluating a more
comprehensive management information system in
one urban pilot hospital in western Turkey
Table 1 (continued)
Plans/Projects Problems Solutions / Policy Agendas
1996 Health Poor health outcomes—infant and maternal mortality Expand insurance coverage
Reform are high Introduce a purchaser-provider split and establish a
proposal Lack of universal coverage single fund/payer
Many financing and provision organizations have Create autonomous health enterprises
overlapping functions Reform primary care system with the introduction of
Inefficiencies and waste in service provision family physician model
No emphasis on preventive care and health promotion Restructure the MOH into a planning and managing
services; inefficient provision due to emphasis on agency
curative care; lack of an effective referral system Initiate management training program
Barriers to accessing care in rural areas lead to low Introduce reforms in the management of human
rates of utilization resources and health information systems
Too much centralization in the management of health Introduce new payment mechanisms to attract health
services, administrative positions are held by workers to health facilities in underdeveloped regions
physicians, and there is a shortage of professional Improve educational standards in nursing schools
managers Introduce new in-service training opportunities to
Imbalances in the distribution of health personnel and health personnel
inadequate functional mix (nurse, midwife, doctor
ratios)
(continued)
T ab le 1 M a jo r Reform In itia tive s and W o rld Bank Projects in Turkey, 1987-2003: Problems Id e n tifie d
and S olutions Proposed (c o n tin u e d )

Plans/Projects Problems Solutions / Policy Agendas

2003 Health Poor health outcomes— high infant and child mortality Strengthen mother-child health care services
Transformation rates Establish General Health Insurance (GSS) and a single
Program (HTP) Lack of universal coverage benefits package
Many financing and provision organizations have Introduce a purchaser-provider split and establish a
overlapping functions single fund/payer (the Sosyal Giivenlik Kurumu
Inefficiencies and waste in service provision [Social Security Institution; SGK])
No emphasis on preventive care and health promotion Create autonomous health enterprises, building a
services; lack of an effective referral system health city/campus for each region
Inequalities in rural areas especially in eastern and Reform primary care system with the introduction of
southeastern regions of the country the family physician model
Too much centralization in the management of health Build new facilities; expand 112 emergency services
services Restructure the MOH into a planning and managing
Shortage of facilities, technology, and skilled health agency
workers Investment in health information systems
Lack of physicians and prevalence of corruption due to Full-time employment of public-sector doctors; expand
policy of private practices of publicly employed performance-based supplementary payments
doctors National drug policy; new medicine pricing system
Sources: 1987 Basic Health Law; MOH 1996; World Bank, StaffAppraisal Report: Turkey— Second Health Project; Essential Health Services and Management
Development in Eastern and Southeastern Anatolia (Washington, DC: World Bank, 1994); World Bank, Staff Appraisal Report: Republic o f Turkey— Primary
Health Care Services Project, Report No. 16374-TU (Washington, DC: World Bank, 1997); World Bank, Implementation Completion Report: Republic o f Turkey—
First Health Project, Report No, 19477-TU (Washington, DC: World Bank, 1999); MOH 2003, 2010
 Agartan ■ Policy Change in Turkish Health Care 985

Building on these analyses and the 1987 Basic Health Law, the next
reform initiative— the 1996 Health Reform— proposed creating autono­
mous hospitals and health enterprises and reforming the primary care
system with the introduction of the family physician model. Furthermore,
the 1996 Health Reform aimed to address regional disparities in the dis­
tribution of health professionals and personnel shortages— a challenge that
could not be overcome since the early days of the republic (MOH 1996). A
third World Bank project— the Primary Health Care Services Project—
was initiated in 1997 to support the development of the role of the family
physician and to create an integrated primary health care system. However,
none of these proposals initiated by the 1996 Health Reform could be
passed in Parliament, and all were shelved until the next reform initiative.
An interesting feature of the reform discourse during the late 1980s and
1990s— which is also seen in the 2003 HTP reform— is the attempt to
balance the requirements of the liberal market economy with the obliga­
tions of the “social state” and to strike a new division of labor among the
state and markets whereby the state assumes the responsibility of planning
and regulating the provision of services, establishing and monitoring
standards, and focusing on preventive health services (Ozsan 1998). This
definition of state-market relations helps us understand what Larsen and
Stone (2015: 947) call the “two-sided dynamic” of neoliberalism. Espe­
cially the 1987 Basic Health Law marks the beginning of the marketization
and managerialism reforms in the Turkish health care system. For the
first time, ideas like “efficiency” and “competition” were introduced in the
health care system, which was now seen as a “field of economic activity or
business” (Basic Health Law on Health Services 1987, preamble). The
reformers advocated for leaving the provision of health care services to
private hospitals and autonomous health enterprises. Additionally, one of
the most frequently cited mottoes of the neoliberal discourse, that one
should not expect everything from the “father” state, was often mentioned
to justify the marketization reforms. However, at the same time, the second
dynamic or face of neoliberalism was evident in the acknowledgment of
the state’s responsibility in financing and regulation. The next section
traces these ideas in the new reform initiative, the HTP.

T h e JDP a n d H e a lth C a re R e fo rm : F ra m in g P ro b le m s
a n d t h e P o lic y A g e n d a in t h e HTP

The JDP was founded in 2001 and elected into office in 2002. Health care
was mentioned briefly in major policy documents of the party mostly in
986 Journal o f Health Politics, Policy and Law

terms of goals that needed to be achieved. Both the party program (JDP
2002a) and the Urgent Action Plan (JDP 2002b), which served as a road
map summarizing the main targets and policies of the new government,
promised to establish universal coverage. The main policy document that
provided the details of how to reach this goal was announced one year later,
in December 2003. The HTP booklet defined reforming the health care
system as a major public policy priority (MOH 2003). Besides describing
its main features, 1 examine in this section the JDP’s reform discourse.
An interesting feature of this discourse was its emphasis on consensus or
continuity, which was used to highlight similarities between the way the
JDP and previous governments have viewed the problems of the health
care system.
References to continuity can easily be found in the policy documents as
well as in the speeches of the minister of health, Recep Akdag. For instance,
in his introduction to the HTP booklet (MOH 2003) Akdag explains the
dynamics of the policy learning process, recognizing that the program
does not claim to be starting from point zero. Rather, as Akdag states, it
acknowledges “all the previous works, law drafts and formed opinions as a
step. We are trying to build a new future not by refusing the past, but by
evaluating the past” (MOH 2003: 3). This idea of evaluating or building on
past experience was also mentioned by some high-level MOH bureaucrats
during the interviews that I conducted as part of this study. One of the key
bureaucrats of the reform team discussed how the team studied the earlier
reform initiatives carefully. He also admitted to consulting with some
ex-bureaucrats who occupied leadership positions during the World Bank
health projects in the 1990s and the 1996 Health Care Reform. One of these
ex-bureaucrats, during the interview I conducted with him, asserted that
he himself had been among the key individuals who had drafted the
HTP booklet.
A quick comparison of the problems listed in the HTP booklet and the
problems highlighted by the reform programs since the 1987 Basic Health
Law (table 1) demonstrates the similarities in the definition of problems.
The HTP highlights poor health outcomes such as high infant and maternal
mortality rates; claims that the existing health system has become inac­
cessible, inefficient, and unresponsive to growing needs; and identifies
rising costs, which are explained mostly by waste and corruption in the
system. It cites the lack of insurance coverage for a significant percentage
of the population (around 32 percent in 2002); equity problems due to
differences among the insurance funds; regional and rural-urban disparities
in the distribution of resources and health personnel; problems in the
 Agartan ■ Policy Change in Turkish Health Care 987

provision of primary care services such as lack of an effective gatekeeping

system; and centralized decision making in the MOH as well as in public
and SSK hospitals, which has contributed to inefficient management,
waste, and corruption (MOH 2003). The reform team justified the need to
reform by pointing to these long-standing problems of the health care
system, which “got worse with each passing year” (MOH 2003: 3). Table 1
demonstrates the extent to which policies proposed in the HTP were similar
to earlier reform initiatives. In the HTP, market elements such as compe­
tition, choice, and financial incentives were accompanied by a redefinition
of the role of the state that involved limiting its capacity to regulate or
“steer” private-sector activity. As I discussed in the preceding sections,
many of the policies that were proposed by governments during the
1990s— such as establishing a single-payer system, granting autonomy to
public hospitals, and redefining the role of the MOH— reflected such
redefinition of the roles of the state and market. This list of common
policies and a dominant policy paradigm that combines market elements
with universalism suggest that policy solutions were available to the JDP
leaders when they took office (table 1). As the window opened in the
politics stream with the 2002 elections, the JDP leaders played an active
role in coupling problems with policies and constructed the need to reform
by referring to the list of problems waiting to be addressed since the early
1990s. They justified the content of their reform program by highlighting
the continuities with previous reform initiatives. Thus they successfully
framed the necessity to carry out this particular reform program at this
particular time. I turn now to the last element of the confluence argument:
as the JDP leaders themselves indicated on numerous occasions, the main
difference in this reform attempt was a new government that would bring
the political will and commitment to reform.

" F ro m N o w o n . N o th in g W ill Be t h e S a m e as B e fo re " :

P a th b r e a k in g R e fo rm s a n d P o litic a l W ill

The two decades leading up to the 2002 general elections were charac­
terized by unstable coalition governments and frequent economic crises.
Earlier reform proposals could not be passed in Parliament or implemented
due to political instability. Therefore, the 2002 general elections repre­
sented a turning point where the JDP won 34 percent of votes and formed a
single-party government controlling a majority of the seats in the Turkish
Assembly. The following elections in July 2007 also resulted in a landslide
victory for the JDP, as its percentage of votes increased to 46.5 percent. The
988 Journal o f Health Politics, Policy and Law

party received a record level of support in the 2011 general elections with
49 percent of votes and established the third majority government. In the
Turkish parliamentary system, this meant significant power for the JDP
and its leader, who simultaneously serves as the chief of the executive
branch— the prime minister— and the leader of the party occupying the
majority of seats in the assembly. The top-down tradition of policy making
and party-line voting also made it easier for the party leaders to garner
support for their legislation in Parliament.
In addition to a swift policy-making process, the JDP leadership dem­
onstrated continuous political commitment to health care reform and
steadfast implementation. Health minister Akdag presided over the reform
process from 2002 to 2013 (a record tenure of eleven years) and with his
reform team ensured that most elements of the reform proposal were
implemented consistently. Indeed, a recent article in the British Medical
Journal described the Turkish health care system’s transformation as
moving “from laggard to leader” and argued that other countries can
learn from Turkey’s success story, which demonstrated the importance
of “political commitment at the highest level,” “leadership,” and “the
determination to follow through policy implementation” (Bari$, Molla-
haliloglu, and Aydin 2011: 581). This section aims to explain why health
care reform was assigned such a priority in the JDP’s agenda and what
motivated this commitment and determination to implement the reform.
To do so requires going beyond the three streams approach, which tells us
that the time of the HTP has come and to rely on ideational perspectives to
help place the actor, the JDP, at the center of analysis. I first examine the
ideology of the JDP to explain its role in shaping the content of the reform
program and its determination, and I then turn to the question of why the
HTP was assigned such a priority.

The JDP's id e o lo g y a n d th e HTP

One possible explanation of political will and determination is the fit of the
reform package with a self-constructed image of the JDP as the reformist
actor and its ideology. From day one, the JDP leaders claimed that “nothing
will be the same as before” (JDP 2002b). They announced that it is the
reformist actor in Turkish history who has achieved transformations that
predecessors could not. In the main party documents as well as in the
media, the party presented itself as a center-right party with a conserva­
tive democrat identity, which was defined as a mix of economic liberal­
ism and social conservatism (Gumuscu and Sert 2010: 55). The party was
 A g a rta n ■ P o lic y C h a n g e in T u r k is h H e a lt h C a r e 989

committed to improving social welfare and economic growth while simul­

taneously endorsing “a moral order encompassing agricultural society
and its traditional values, mores, and customs, among which religiosity
is definitely predominant” (Kalaycioglu 2007: 240).
As soon as it came to power, the party embarked on a range of economic
and social reforms. The party was committed to macroeconomic stability
and fiscal discipline and to encouraging private investment in all sectors.
Especially during its first term, the JDP was a major proponent of full
membership to the European Union and passed laws aimed at improving
gender equality and democratization alongside its reform efforts in health
care, social security, and education. This mix of economic and social
policies has been described by Ziya Oni^ (2012: 142) as “a kind of com­
munitarian, a ‘third-way’ response to neo-liberal globalization” or “social
and regulatory neo-liberalism,” which “allowed it to transcend the bound­
aries of class politics and construct broad-based cross-class coalitions of
political support which would not have been possible under the old-style,
Washington Consensus based neo-liberalism.” This description highlights
the complexity and the dual nature of neoliberalism, which, as Larsen and
Stone (2015: 966) argue, “can use the public and private sectors to keep each
other in check.”
The health reform agenda (the HTP) clearly reflects this social neoliberal
approach, since it combines encouragement of private provision with
increased state regulation and universalism (Agartan 2012). On the one
hand, market elements, like competition and choice, have been introduced
into the health care system. I highlight three policies here. First, as part of
the introduction of the purchaser-provider split, health facilities owned and
operated by various public agencies were transferred to the MOH in 2005.
In the next step, competition among public and private providers was
encouraged by assigning to the single payer, the Sosyal Giivenlik Kurumu
(Social Security Institution; SGK), the authority to selectively contract
with all types of providers. However, such choice among public and private
providers was limited to financially well-off patients, because the HTP
allowed private facil ities to charge higher fees that would be covered by the
patients themselves. Second, reflecting the party’s commitment to the
entrenchment of the market economy, the JDP leaders encouraged private
investment in the health care system, particularly in the hospital sector.
Prime Minister Recep Tayyip Erdogan stated that “free markets should be
established in health care as in other sectors” (quoted in Hiirriyet 2006). As
a result, the number of private hospitals has almost doubled in ten years,
from 271 in 2002 to 541 in 2012 (MOH 2013: 65). Third, in line with
the NPM paradigm, the role of the MOH was redefined to assume a
990 Journal o f Health Politics, Policy and Law

“stewardship function, planning and supervising both the public and the
private sector” (Tatar et al. 2011: 151). Such a stewardship role implied
gradual withdrawal from the provision dimension through decentralization
and granting financial and administrative autonomy to public hospitals “as
part of anew competitive environment” (OECD 2008; Tatar et al. 2011: 152).
On the other hand, emphasizing universalism and solidarity as among
its major priorities, the HTP defined equity as “access to health care ser­
vices according to need and contribution to the health care financing sys­
tem according to income” (MOH 2003; Tatar et al. 2011: 150). The party
leaders highlighted difficulties experienced by low-income groups in acces­
sing care, and the prime minister even shared publicly his own experiences
as a low-income child. An important step toward achieving universal
access and improving solidarity was the creation of the single-payer system
that united all public funds under the SGK. Disparities among members of
different funds in terms of contribution levels, access to health care pro­
viders, and coverage were effectively addressed: the public insurance
system was financed through compulsory social contributions that were
earnings based, and a single comprehensive benefits package was intro­
duced. In this way, the reforms tried to improve redistribution among the
poor and the rich, the sick and the healthy (MOH 2003). Although many of
the recent analyses of the HTP praise these policies that aim to improve
equity (Bari§, Mollahaliloglu, and Aydm 2011; OECD 2008; Yildirim
and Yildirim 2011), other studies highlight the challenges of achieving a
balance with market elements and ensuring equal access (Agartan 2012)
and the emergence of new inequalities based on income (Yilmaz 2013).

Why Health Care Reform? Interests and Institutional Context

Looking closely at the contents of the HTP and how it relates to the
ideology of the JDP— as defined by the party since its establishment in
2001— allows us to examine the role of agency. The main argument
explored in this section is that the choice of the JDP leaders to carry out the
HTP is complex and involves several contingent goals based on their
perceptions of what is possible, legitimate, and feasible in that particular
strategic context. The JDP leaders conceived the reform to benefit them in
ways that were closely related to their concerns about legitimacy and
survival: (1) to garner popular support in the next elections and (2) to
transform bureaucratic state structures. Both of these constructions of interests
are shaped by the hostile institutional environment that characterized the
Turkish polity since 2002 as well as by existing policy paradigms like
the NPM.
 A g a rta n ■ P o lic y C h a n g e in T u r k is h H e a lt h C a r e 991

First, the JDP leaders considered especially the universalist aspect of

the FITP as beneficial to gamer electoral support. Redistributive policies,
especially those that entail expansion of benefits or improving access to
services like health care and education, have been discussed in the Turkish
context within the framework of “populism” that aimed to “ease some of
the social tensions, unemployment pressures, and growing inequalities”
(Eder 2010: 182). While the JDP’s success especially in 2007 has been
attributed to its management of economic stability during its first term in
office ((^arkoglu 2007; Gumuscu and Sert 2010), “providing for rapid
improvement in socioeconomic welfare” to those who otherwise would
have a much smaller chance of upward social mobility (Kalaycioglu 2007)
is another factor discussed by recent analyses of the JDP’s success. Health
care reform is one important item in this social welfare improvement
agenda, and recent electoral surveys support this argument. When asked
about which policies of the JDP they found satisfactory, participants of a
recent survey stated that they were very happy with direct access to private
hospitals, easy access to affordable prescription drugs, and access to other
services like free transport for dialysis patients (Giir 2011).
While increasing votes is a common concern for all political parties, it
is not viewed here as a material, objective interest that shapes the behav­
iors of political actors. Rather, garnering electoral support was assigned a
high value and thus was conceived by the JDP as being in the party’s
interest because of its major struggle with the dominant institutions and
actors in the Turkish polity. The challenge from the “Kemalist-secularist
establishment”-— which comprised the main opposition party, the Repub­
lican People’s Party (Cumhuriyet Halk Partisi; CHP); the high ranks of the
army; and some part of the civil bureaucracy including the high courts—
was serious, since it highlighted the JDP’s “Islamist” roots in the National
Outlook (Milli Gorii§) movement and voiced its fears that the party would
dismantle secularism (Qnar 2006; Gumuscu and Sert 2010). Reflecting
these concerns, a memorandum was issued in April 2007 on the web pages
of the Turki sh armed forces that voiced their concerns about threats against
secularism and other national values of the polity. The struggle among the
JDP and the Kemalist establishment continued with an attempt to ban the
party in the Constitutional Court in March 2008 on the basis of its activities
against secularism.
In response to these serious challenges, the JDP refrained from crit­
icizing the principle of secularism and avoided confrontation on reli­
gious issues (Qnar 2006). Instead, the party embraced a reformist political
992 Journal o f Health Politics, Policy and Law

agenda consisting of democratization (Qinar 2006; Gumuscu and Sert 2010),

integration with the European Union, economic liberalism, and reforms
aimed at transforming the public administration. The health reform ini­
tiative, with its expansionist features, was part of this political agenda
and was perceived by the JDP as a way to boost its legitimacy in the eyes of
the Turkish people. The threat of a military coup and being banned from
political life was very serious at the time, and if the party were to be
recognized as a legitimate political actor that delivered real benefits to the
electorate (and thus remained popular), it would not be that easy for the
Kemalist-secularist establishment to get rid of it. In sum, the JDP leaders’
fear of elimination and their particular perception of the institutional con­
text as hostile have shaped their conception of interests and thus provided
the motivation for conduct— to carry out this particular health reform
package immediately.
Moreover, the emphasis on continuity that was discussed in the previous
section becomes more meaningful when considered against this back­
drop of conflict with the secularist establishment. The JDP leaders made a
conscious effort to highlight continuities in the content of proposed health
care reforms since the early 1990s and presented the HTP as a culmination
of these earlier initiatives. This particular way of framing the HTP can be
considered part of a broader strategy that aims to legitimize the JDP as a
political actor with no “hidden” purposes or different agendas and thus
normalize its existence in the secular political system.
Second, the JDP leaders conceived the reform to benefit them by
transforming bureaucratic state structures. The HTP presented a unique
opportunity for the JDP leaders to dismantle bureaucratic state structures
in the health care system through marketization and managerialism. Since
its early days in office, the JDP viewed bureaucratic state structures as
a challenge to governing the country effectively. Therefore, it tried to
transform these structures in two ways: (1) through partisan appointments,
which turned the bureaucracy into a site of legal battles between the secular
establishment and the government (C^inar 2008; Heper and Berkman 2009),
and (2) through downsizing the bureaucracy. As discussed above, the JDP
leaders adopted the NPM discourse and argued that the state should be lean
to steer the country efficiently. In the health care system this implied
encouraging private providers, withdrawing the state from provision
(through policies such as the purchaser-provider split and granting public
hospitals autonomy), and focusing on regulatory functions. The party’s
perceived interests were clearly shaped by this ideological position, but
 Agartan ■ Policy Change in Turkish Health Care 993

they also arose out of an ongoing interaction with the hostile institutional
context: the party would strategically benefit from the dismantling or down­
sizing of the bureaucratic state structures that were part of the Kemalist-
secularist establishment threatening its very existence. Additionally, these
managerial reforms weakened their critics such as trade unions, which lost
control over the insurance fund for workers (the SSK) and hospitals owned
by this fund.
In sum, the HTP, with its particular content that combines universalism
with elements of marketization and managerialism, was drafted, passed in
Parliament, and implemented with unprecedented leadership and deter­
mination because of the way the JDP conceived its interests in relation to
the strategic institutional context. The JDP leaders perceived health care
reform as legitimate and feasible given the availability of problem defi­
nitions and solutions and assigned it a high priority, believing that the
reforms would boost its legitimacy and help it survive in this hostile
institutional environment.

Conclusion
Explaining policy change has been one of the major concerns of the health
care politics and policy development literature. Recent institutionalist
scholarship has recognized that path dependency can be disrupted and
change may take place in two ways— incrementally and through critical
conjunctures or windows of opportunity. The above analysis aimed to
explain the specific dynamics of large-scale reforms introduced within the
framework of the HTP in Turkey. It demonstrated that the confluence of the
three streams— policy, problem, and politics— combined with the excep­
tional political will of the JDP leaders opened up a “window of opportunity”
(Kingdon 2011) for this large-scale policy change. Building on recent ide­
ational perspectives (Beland 2005; Beland and Cox 2011; Hay 2011; Mehta
2011), the article explained how and why health reform was assigned
such priority and why political leaders demonstrated such political will in
implementing the reform.
The JDP was able to put forward a culturally and ideologically resonant
discourse that highlighted continuity with previous reforms, emphasized
the need for change, and justified the urgency of reforms. This discourse
was crucial in legitimizing its reform initiative, the HTP. It is in this sense
that ideological frames can help particular actors make a strong case for
reform and thus facilitate policy change (Cox 2001; Beland 2010). While
this article examined this reform discourse critically, it could not engage in
994 Journal o f Health Politics, Policy and Law

a deeper analysis of the role of the peculiar characteristics of the JDP such
as its religious values. Some scholars who examine reform initiatives
especially in social assistance policies discuss the influence of the party’s
Islamist heritage and its sensitivity to the poor. For instance, Ay§e Bugra
(2007: 46) explains how, under JDP rule, public assistance programs
have been undermined by “the mutually reinforcing role of Islam and
neoliberalism.’’ More research is needed that critically examines the role
of religious values in the health policy discourse, perhaps to compare it to
other policy areas such as social assistance or income-maintenance poli­
cies, to see whether and in what ways these values shape problem recog­
nition and policy solutions.
This case study demonstrates how ideas and institutions interact to shape
the behavior and decisions of key policy actors. Institutionalist scholars
have demonstrated how political institutions influence the strategies of
policy actors and reinforce existing policies. As discussed in the preceding
sections, the JDP leaders emphasized continuity with the health policies
proposed in the 1990s while at the same time complaining about the
functioning of previous programs and their perceived economic or social
implications. More in-depth studies focusing on the reform discourse are
needed that would shed light on how earlier policies shape the definition of
policies in the current reform. Moreover, the institutionalist perspective
argues that existing institutional settings create obstacles and opportunities
that are likely to affect the behavior of policy actors. In the Turkish context,
the hostility and struggle among the JDP and the Kemalist-secularist
establishment have significantly shaped the behavior and key decisions of
the JDP leaders in many policy areas including that of health care reform.
Clearly, institutionalist scholarship is quite important to explaining the
Turkish health care reform; however, this article aims to place political
actors at the center of its analytical framework. It argues that while the
window of opportunity and the existence of policy solutions provide an
opening for large-scale change, political actors make choices, which could
be “reactive to changing circumstances, but often [are] a proactive effort by
political actors to reexamine their surroundings, reconsider their positions,
and develop fresh approaches” (Beland and Cox 2011: 11). In the Turkish
case, choices made by actors are equally important, since the JDP leaders
assigned a high value to health care reform and demonstrated unprece­
dented determination to implement it. They perceived health care as a
unique opportunity to boost their legitimacy and transform bureaucratic
state structures in their struggle with the Kemalist-secular establishment. In
this framework, the political institutions and policy discourse adopted by
 A g a rta n ■ P o lic y C h a n g e in T u r k is h H e a lth C a re 995

the Kemalist-secularist establishment can be considered both an obstacle

and a factor that motivates political actors to act. Ideational analysis can
help us study the perceptions of policy actors about political institutions
and especially the role of the state and the markets. In this way, we may be
able to examine the complex interactions between policy ideas, dominant
values, actors, political institutions, and vested interests and observe how
exogenous events interact with choices of policy actors to bring about
large-scale change.

Tuba I. A g artan is associate p ro fe s s o r o f h e a lth p o lic y a n d m a n a g e m e n t a t P ro v i­

d e n ce C o lle g e . H e r research in te re s ts a re a t t h e in te rfa c e o f social p o lic y a n d s o c io lo g y
w i t h a fo c u s o n c o m p a ra tiv e h e a lth p o lic y , p ro fe s s io n s a n d h e a lth care re fo rm , a n d
g lo b a l h e a lth a n d g o v e rn a n c e . H e r re c e n t p u b lic a tio n s in c lu d e "S o c ia l H e a lth In s u r­
an ce w i t h o u t C o rp o ra te A c to rs : P a tte rn s o f S e lf-R e g u la tio n in G e rm a n y , P o la n d , a n d
T u rk e y ," w it h Claus W e n d t a n d M o n ik a -E w a K a m in s k a {SocialScience a n d M edicine,
2013), a n d " M a r k e tiz a tio n a n d U n iv e rs a lis m : C r a ftin g th e R ig h t B alan ce in th e
T u rk is h H e a lth c a re S y s te m " {C u rre n t Sociology, 2012).

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