Picture: Ankara Bilkent City Hospital – the largest of Turkey’s ‘health campuses’. Credit: Metuboy, via Wikimedia Commons

Governments are searching for new ways to engage in global healthcare markets and to commercialise on successes in their healthcare systems. In this blogpost, Volkan Yilmaz shares findings from a recent article in Global Social Policy in which he and Puren Aktas argue that trends in Turkey’s healthcare system suggest an increasingly entrepreneurial approach to public healthcare that stands to reshape state-citizen relations for the future.   

Healthcare and the state

For those of us in our adult years, many were born in countries where healthcare has predominantly been seen as a public service, albeit one with long waiting times to service shortages. Leaving aside the comparatively exceptional experience of countries with heavily marketised systems such as the USA and India, we have been accustomed to seeing the public sector or not-for-profit organisations taking a major role in the financing of healthcare, its provision, or both. The state has been responsible for organising healthcare for its citizens, but what happens when states turn their attention to citizens of other countries?

It is in response to this question that Puren Aktas (University of Manchester) and I examined the evolving role of the state in transforming Turkey into a global medical tourism destination. Medical tourism, which refers to the cross-border mobility of persons to receive healthcare service, is challenging our spatially bounded understanding of healthcare. It has been symbolised by the birth of a global market for healthcare services, where those willing and able to purchase services in other countries can do so. People participate in this market because they live in countries where healthcare is already a costly service; others in countries where public service is available but getting a timely and/or quality service is complicated. This travel has attracted the attention of various scholars, yet research has tended to focus on ‘demand-side’ factors: why do people choose to cross borders to receive healthcare, and how they decide where to go? We instead examined the ‘supply-side’, using a comprehensive documentary review to identify a shift in the mode of Turkish state involvement in medical tourism, from facilitator to entrepreneur.

Many faces of the state in medical tourism

Although medical tourism is often centred in private healthcare settings, in many contexts the state has been present from the very beginning. Ormond and Mainil identify three forms of state involvement in medical tourism: facilitators, regulators, or providers. Traditionally, the state has taken facilitator and regulator roles in medical tourism, while the private sector has assumed a provider role. However, in some settings the state has become more directly involved in the provision of services – this is a recent phenomenon and may be the harbinger for a substantial reorganisation of some state healthcare systems towards global markets. To describe this more active involvement in the trading of healthcare services, Jarman coins the term ‘entrepreneurial’ healthcare state.

Turkey’s rise as a medical tourism destination has been rendered possible by an unprecedented increase in private sector engagement in healthcare provision in the 2000s. The state played a facilitator role in healthcare market development in those years mainly by incentivising and subsidising private sector provision for domestic consumption. However, relatively low rates of public reimbursement for private services and the private sector motivation to increase its profit margins led to calls for stronger state support for inbound medical tourism. The state response was largely affirmative, which even included a plan to establish a healthcare version of export processing zones where the private sector would take the lead.

However, in the 2010s the state seems to have shifted its medical tourism strategy towards a more entrepreneurial version where the public sector role would go beyond facilitation and regulation. Currently, the state in Turkey is involved in establishing large hospital complexes through a series of public-private partnerships that will serve medical tourists alongside the citizens. In the financing model used for these hospitals, medical tourism revenues would decrease the burden these hospitals bring to the public purse. To this end the government founded a public corporation that could capitalise on the export of healthcare services. These changes have been assigning a new provider role to the public sector, which puts it in competition with the private sector in medical tourism. In our article we demonstrate how this form of state presence in medical tourism has created tension between the public and private sectors and led to the private sector lobbies calling for a return to the previous division of responsibilities.

International customers for your public services

The intriguing character of state involvement in attracting demand for medical care and selling public sector produced healthcare to medical tourists originates from its implications for the relationship between the state, healthcare and its citizens (alongside residents, refugees and asylum seekers). In some cases, such as the UK and Israel, the austerity context pushes public service managers to get more involved in medical tourism. In others similar to Turkey, such as Colombia and Thailand, the impetus comes directly from the central government. State involvement in the provision side of medical tourism in these middle-income countries deserves further attention because the healthcare system capacity in these countries is comparatively limited and failing to meet the needs of the citizens. Therefore, the implications of opening up public services to medical tourism for access and equity in these countries may be more pronounced than others.

The research described in this blogpost was part of a broader project – Regulatory initiatives and challenges in pluralistic healthcare systems: the case of Turkey – which was funded by a Newton Advanced Fellowship from the British Academy and was hosted by King’s College London Department of International Development. The blogpost is based on a article published in Global Social Policy in December 2020. The full article is available here.