When the poor need health care: Ethnography of State and Citizenship in Turkey

Middle Eastern Studies

Volumn 45, Issue 5, 2009, Pages 769-782

  Yoltar, Çaǧri ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

CITIZENSHIP; HEALTH CARE; SOCIOECONOMIC CONDITIONS; SOCIOECONOMIC STATUS;

EURASIA; TURKEY;

EID: 70449396768     PISSN: 00263206     EISSN: 17437881     Source Type: Journal    
DOI: 10.1080/00263200903135562     Document Type: Article

References (34)

1. A. Gupta, 'Blurred Boundaries: The Discourse of Corruption, the Culture of Politics, and the Imagined State', American Ethnologist, Vol.22, No.2 (1995), p.378.
2. 2008 saw a comprehensive overhaul of the public insurance system. In recent years the current AKP (Adalet ve Kalkinma Partisi - Justice and Development Party) introduced a comprehensive proposal that aims to reform the health care system in Turkey. Preparations under this reform agenda are already at work. For detailed analyses on the recent health care reform attempts in Turkey see T. Agartan, 'Turkish Health System in Transition: Historical Background and Reform Experience' (PhD thesis, Binghamton University, 2008); C. Keyder, N. Ustundag, T. Agartan and C. Yoltar (eds.), Avrupa'da ve Türkiye'de Sagli{dotless}k Politikalari{dotless} [Health Care Policies in Europe and Turkey] (Istanbul: Iletisim, 2007). One of the main pillars of the proposed reform is the establishment of a premium-based General Health Insurance (GHI) scheme, to replace the fragmentary structure of separate public insurance schemes. The Law regulating this new GHI Scheme was passed by the parliament in 2006, and after some modifications it was put into practice by 1 Oct. 2008. According to the GHI law, three separate public health insurance schemes are unified under one GHI Scheme; all citizens in Turkey will be covered under GHI regardless of their employment status, and they are required to contribute to the GHI Scheme with respect to their financial capacities. Sosyal Sigortalar ve Genel Sagli{dotless}k Sigortasi{dotless} Kanunu [The Law on Social Security and General Health Insurance Scheme], Resmi Gazete [Official Gazette], No.5510 (31 May 2006).
3. As of 2004, 52% of the workforce in Turkey was not covered by any of the public insurance scheme. Cali{dotless}sma ve Sosyal Guvenlik Bakanli{dotless}gi{dotless} [Ministry of Labour and Social Security], Proposal for Reform in the Social Security System (Ankara: Cali{dotless}sma ve Sosyal Guvenlik Bakanli{dotless}gi{dotless}, 2004).
4. As such the Green Card Scheme came as a novelty. Its organizing logic is not employment status of the beneficiaries, but their relative poverty, defined in terms of certain criteria. At the time of its establishment, the Green Card Scheme was considered as a provisional arrangement on the way to a more general and universal health insurance system. For a detailed historical analysis of transformations in the health care system in Turkey see A. Gunal, 'Health and Citizenship in Republican Turkey: An Analysis of the Socialization of Health Care Services in Republican Historical Context' (PhD thesis, Bogazici University, 2007). Although the GHI system was established with the law published in 1 Oct. 2008, those citizens who would be 'unable to contribute' - because of their lack of means - will continue to be covered by the Green Card Scheme until it is replaced with new legislation, Primsiz Odemeler Yasasi{dotless} [The Law on Without Premium Payments], by the end of 2010. For the time being, only a draft version of this legislation is available. I will not get into details regarding this new legislation to replace the Green Card Scheme, but it is important to note that the envisioned workings of the GHI Scheme reveals a continuity in the way the Turkish state deals with the provision of health care services to its 'poor citizens' under the Green Card Scheme.
5. Odeme Gucu Olmayan Vatandaslari{dotless}n Tedavi Giderlerinin Yesil Kart Verilerek Devlet Tarafi{dotless}ndan Karsi{dotless}lanmasi{dotless} Hakki{dotless}nda Kanun [The Law on the Covering of the Treatment Expenses of the Citizens with Insufficient Financial Means by the State through Green Card], Resmi Gazete [Official Gazette], No.3816 (18 June 1992).
6. As of 15 Nov. 2007, the exact number of Green Card holders in Turkey was 8,837,506. See Yesil Kart Bilgi Sistemi [Green Card Information System], http://sbu.saglik.gov.tr/yesil/ (accessed 15 Nov. 2007).
7. For detailed studies on ethnography of the state, see for example B. Aretxaga, 'Maddening States', Annual Review of Anthropology, Vol.32 (2003);
8. V. Das and D. Poole (eds.), Anthropology in the Margins of the State (Santa Fe, NM: School of American Research, 2004);
9. A. Gupta and J. Ferguson, 'Spatializing States: Towards An Ethnography of Neoliberal Governmentality', American Ethnologist, Vol.29, No.4 (2002);
10. T.B. Hansen and F. Stepputat (eds.), States of Imagination: Ethnographic Explorations of the Postcolonial State (Durham, NC and London: Duke University Press, 2001);
11. C. Krohn-Hansen and K.G. Nustad, State Formation: Anthropological Perspectives (London: Pluto Press, 2005);
12. M. Nuijten, Power, Community and the State: The Political Anthropology of Organisation in Mexico (London: Pluto Press, 2003);
13. A. Sharma and A. Gupta (eds.), The Anthropology of the State: A Reader (Oxford: Blackwell Publishing, 2006);
14. M. Trouillot, 'The Anthropology of the State in the Age of Globalization', Current Anthropology, Vol.42, No.1 (2001), pp.125-37.
15. A. Sharma and A. Gupta, 'Introduction: Rethinking Theories of the State in an Age of Globalization', in Sharma and Gupta (eds.), The Anthropology of the State, p.8.
16. Aretxaga, 'Maddening States', p.398.
17. Trouillot, 'The Anthropology of the State'.
18. Sharma and Gupta, 'Introduction', p.9.
19. Sharma and Gupta, 'Introduction', p.9;
20. C. Shore and S. Wright, 'Policy: A New Field of Anthropology', in C. Shore and S. Wright (eds.), Anthropology of Policy: Critical Perspectives on Governance and Power (New York: Blackwell Publishing, 1997).
21. V. Das and D. Poole, 'State and Its Margins: Comparative Ethnographies', in Das and Poole (eds.), Anthropology in the Margins of the State, p.3.
22. V. Das and D. Poole, 'State and Its Margins: Comparative Ethnographies', in Das and Poole (eds.), Anthropology in the Margins of the State, p.8.
23. T. Asad, 'Where Are the Margins of the State?', in Das and Poole (eds), Anthropology in the Margins of the State, p.279.
24. Statistics are gathered from local social security institutions in Adi{dotless}yaman.
25. Yesil Kart Bilgi Sistemi [Green Card Information System], http://sbu.saglik.gov.tr/yesil/(accessed 15 Nov. 2007).
26. According to the legislation, the sources of income to be considered in calculating the monthly income of household are as follows: cash payments for services; cash agricultural revenues; rent from estates or interests; cash transfers or grants from public, private institutions or other people; and in-kind income in any form above. Regarding the income sources mentioned above, the total monthly income of the household - including spouses, children, parents, as well as relatives up to third lineage living in the same household - is calculated and divided into the number of people in the household, and if the monthly income per household member is lower than one-third of the net minimum wage, he has right upon a Green Card. Odeme Gucu Olmayan Vatandaslari{dotless}n Tedavi Giderlerinin Yesil Kart Verilerek Devlet Tarafi{dotless}ndan Karsi{dotless}lanmasi{dotless} Hakki{dotless}nda Yonetmelik [The Decree on the Covering of the Treatment Expenses of the Citizens with Insufficient Financial Means by the State through Green Card], Resmi Gazete [Official Gazette], No.21314 (13 Aug. 1992).
27. During the application process, in Adi{dotless}yaman the applicants are expected to declare the following information required by the forms: personal information of the applicant; personal information of the applicant's dependants and the other persons in the household (even in the case that they do not apply for the Green Card); social security status of each person in the household; and income of each person in the household. The forms should be authorized by muhktars of the district (to confirm the residence address and the household information); the population bureau (to confirm the household information); the tax office (to check information related to taxation, hence income); the land office (to check information related to estate ownership); and the district municipality (to check income information). In addition, the social security statuses of household members are verified through information from social security institutions. In the decree regulating the Green Card scheme, it is also mentioned that in cases of necessity the police or the gendarmerie can investigate the living conditions of the applicants, and if they find out any unregistered information pertaining to the economic or financial conditions of the applicant, they are to declare it on the form.
28. V. Das, 'The Signature of the State: The Paradox of Illegibility', in Das and Poole (eds.), Anthropology in the Margins of the State, p.230.
29. For further discussion on subjunctivity see S. Reynolds-Whyte, 'Subjectivity and Subjunctivity: Hoping for Health in Eastern Uganda', in R. Werbner (ed.), Postcolonial Subjectivities in Africa (New York: Palgrave, 2002), pp.171-90;
30. B. Good, Medicine, Rationality, and Experience: An Anthropological Perspective (Cambridge and New York: Cambridge University Press, 1994).
31. Das and Poole, 'State and Its Margins: Comparative Ethnographies', p.10.
32. M. De Certeau, The Practice of Everyday Life (Berkeley: University of California Press, 1984).
33. M. De Certeau, The Practice of Everyday Life (Berkeley: University of California Press, 1984) p.xix.
34. P. Chatterjee, The Politics of the Governed: Reflections on Popular Politics in Most of the World (New York: Columbia University Press, 2004), p.66.