The Problems of Public University Hospitals: The Case of Çapa and Cerrahpaşa

The Problems of Public University Hospitals:
The Case of Çapa and Cerrahpaşa

Abstract

İstanbul University Çapa and Cerrahpaşa Hospitals, which have been the most important and reputable medical institutions since the establishment of our republic, are facing serious problems today due to the disrepair of buildings, shortage of staff and lack of funds. Restrictive laws, the process starting with the Health Transformation Programme, unfair competition of foundation hospitals and private sectors that have been incentivised by the government, the Sosyal Güvenlik Kurumu’s failure to pay (Social Security Institution) (SGK) the hospital costs have played a role in the emergence of these problems. The inadequacy of executives on problem solving and the disinterest of academics are other aspects of this adverse process.

I. Introduction

İstanbul University is the first university of our country and has a deep-rooted history. Following the establishment of our Republic on 21st April, 1924, the legal entity of Istanbul Darülfünun was recognised and all its madrasas (medreses) have been transformed into faculties on 7th November, 1925.[1] In 1932, the Swiss pediatrician Professor Dr. Albert Malche gave advice about modernisation by preparing a report on the subject of university.[2] In these years, many invaluable scientists coming from Hitler’s Germany made a great contribution to the medical faculty and raised a number of students. Çapa and Cerrahpaşa Hospitals of İstanbul University continued to have the best medical staff, the most advanced equipment and had been the favourite hospitals of our country until the 1970s. After that time, due to changing circumstances and internal dynamics in our country, these hospitals have begun to experience problems and have been pushed into an adverse process rapidly after the Health Transformation Programme[3] in 2002. On 6th August, Cumhuriyet (Republic) Daily published a news report entitled “Turkish Medicine’s Two Giants on the Verge of Bankruptcy,”[4] after which the Minister of Health confirmed the report by announcing that two hospitals were in debt amounting to 650 million TL.[5] In the same news report, it was also stated that the debt of 60 public university hospitals increased from 1.4 billion TL to 2.7 billion TL in the last four years. So much so that companies do not participate in tenders any longer because of the unpaid debts and the necessary materials for the continuation of medical service cannot be supplied. The reasons of this complication can be examined in five parts: 1. Internal Dynamics, 2. Restrictive Effects of Laws, 3. The Problem of Financing, Equipment and Material, 4. Status of the Buildings, and 5. The Competition of Private Hospitals and Foundation University Hospitals.

II. Internal Dynamics 

1. Democratic Mechanisms 

Universities were attached to the Ministry of Education from 1933 until 1960. A law dated 1961 made universities autonomous institutions. Rectors and deans were elected directly through the votes of academics. Important decisions were taken through discussions in committees at the university and faculty levels. The coup d’état of 12th September, 1980, fundamentally terminated democratic process. The whole authority of the committees was granted to the rector. In the remaining committees, problems of the university are not discussed from various perspectives, mechanisms of shared wisdom are not implemented, suggestions and creative ideas of the academics and staff are not taken into account. Nonetheless, it is crucial to add that in the autonomous period before 1980, the university was not also very successful at making self-assessment and solving problems.

2. Strategic Planning, Objective Evaluation and Feedback

Despite the introduction of strategic planning in 2006 with a regulation,[6] the executives have not been put forward precise initiative and determination. Studies have not been executed and could not reach out all the employees. The spirit of total quality and transparent accountable management style in which tasks and process are clearly determined, valid rules are followed, results are constantly reviewed, were not adopted. In addition, the Yüksek Öğretim Kurumu (Council of Higher Education) (YÖK) did not lead and audit the universities in this regard.

The quality of health services in the faculties have not been identified according to patient and employee satisfaction with clear and measurable targets, even when partially identified, these subjects have not been discussed and handled nor precautions taken by the executives. Hospital management is usually carried out by a member of the medical school, who carried out other duties, rather than by the people who have been especially trained in this area.[7] Objective criteria and transparency have not been mostly present in assignment, promotion and tasking. Especially top-down political assignments and favouritism have reduced the motivation to work.

III. The Negative Effects of Restrictive Laws

1. Human Resources Management 

The working of the staff is governed by the Civil Servants Act (Law No. 657) or the Higher Education Act (Law No. 2547).[8] [9] According to these laws, the number and quality of staff are determined by the Ministry of Finance or the Council of Higher Education, and without the control of university.  The quantity and quality of the planning of human resources and permanent staff is not proportionate to the required work to be carried out in the hospital. For example, operations halt due to the lack of anesthetists, and services are shut down because of the insufficient number of nurses. Very expensive and delicate devices are handed over an employee who has never been trained for it. Over again, many expensive devices cannot be used for 24 hours, even though there is need for it, due to the shortage of staff. Laws No. 657 and 2547 determine and fix the wages of the staff. Accordingly, the wage of staff working less cannot be cut and those with extraordinary success cannot be further remunerated. Once again, due to the same laws, the executive has no sanction on staff who do not work, follow the discipline and the rule of ethics. The penalties given are mostly overruled by the administrative court, and nobody gets fired. In such instances, the working place of the staff can be changed and at times this is even for the benefit of the staff concerned. The employee shortage has been further increased with the ‘Health Transformation Programme.’ The number of employees in permanent positions from the state payroll reduced gradually. Retired employees have not been replaced with new ones. Those in personnel cadres such as 4B, have been in a disadvantaged position compared to others. Labour peace and the sentiment of justice have been damaged because the principle of ‘equal pay for equal work’ has not been implemented. Nurses have started to prefer public and private hospitals.[10]

The service procurement from subcontractor companies has caused big problems. In addition, these companies employed workers with very low wages, under very severe conditions, even uninsured, due to excessive greed for profit. They have changed personnel frequently. Management remained largely insensitive to these problems.

2. Part-Time Working Scheme

Part-time working of academics at the faculty has created an obstacle to the development since its establishment. These multi-talented academics, certainly, made great contributions to the faculty. However, working in a private institution, which is the rival of the university hospital, and at the same time at the university hospital, has inevitably created a conflict of interest. It was necessary get into full day working scheme with a long-term planning, it was required to pay a net monthly income, −which is acceptable and equivalent of their labour−, to these people who prefer this working order. However, the government has enacted the law in a rushed way without taking any precautions and without compromise with physician organisations. Due to the ever-changing legal situation, the academics were pushed into a great uncertainty, where it is unclear what would happen tomorrow. On average, 50% of the academics, 80% in some branches, have gone to the private sector. The university was unable to get rid of this difficult situation because no physician possessing experience to maintain the same quality of service remained.

3. Quantity-Based Performance System

University hospitals started to implement a system that has been implemented in the hospitals that belong to Ministry of Health. Regardless of the quality of the healthcare, doctors are directed to examine more patients and to perform more surgeries. By highlighting the hospitals’ profit goals, instead of the quality, the quantity of the service provided is emphasised. Since the referral chain does not function, the trivial medical cases that can be solved in their initial stage occupy the university polyclinics where more complicated medical cases are supposed to be solved. This situation prevents the patients with serious health problems from getting the service on time.

IV. The Problem of Financing, Equipment and Material  

With the Health Transformation Programme, the state has suspended the hospital allowances significantly and has inflicted the health costs (on the SGK) and the university’s circulating capital. Together with the balance compensation paid by the state in other faculties, education and research costs are also inflicted on the circulating capital. Cost of the service production is 30% more expensive in the university hospitals. Besides, new diagnosis and therapy methods that can only be implemented in the universities are not in the list of Sağlıkta Uygulama Tebliği (Implementation in Health Declaration) (SUT) and therefore cannot be refunded. Price increase in the materials is 56% in the last five years but the SUT prices have not changed in the last six years. In order to inform authorities about these issues, “The Association of University Hospitals” has been founded.[11] This association has offered to make a joint tender in order to decrease the prices.[12] Moreover it has brought forward other proposals. Hospitals’ debts are sometimes waived due to the public pressure. Moreover, a protocol setting out that the materials will be paid by the Ministry of Health, recently has been signed with the YÖK.[13] However, these precautions are temporary and superficial. No radical and permanent step was taken to solve the essential problem.

Faculties, which are the tertiary hospitals, need to be equipped with advanced devices so that they provide services to all patients equally regardless of additional payments made by the patients and without making them wait for months. There is no master plan at the faculty level and there is no long-term central planning regarding the devices needed. Usually devices are purchased spontaneously with the individual efforts of the academics and sometimes research funds are used to purchase devices. Within the framework of the current public tender act,[14] the cheapest devices are purchased regardless of the quality, durability of the material and the device. The biomedical engineering unit that periodically calibrates, maintains and repairs the purchased devices is insufficient. Since the payments to the companies have been delayed recently, many companies are unwilling to bid.

V. Status of the Buildings

Most of the existing buildings were not constructed according to the hospital architecture. Floors were added when needed and attachments were made to the buildings. Some buildings were damaged due to the 1999 earthquake but no damage survey was made. Many years later, a building research was performed by a foreign company but neither the employees nor the public were informed about the results. The number of engineers and architects working in the building operations of the universities is insufficient. Therefore, the buildings are neglected. An on-site reconstruction project was prepared.[15] However, the administration does not inform the employees and the public in detail and in sufficient frequency.

VI. The Competition of Private Hospitals and Foundation University Hospitals

Between 2002 and 2011, the government suspended the hospital allowances; however, the government gave incentives for private hospitals and foundation universities to develop and increase in number. During that period, while the increase in the number of public hospitals was 10%, the increase in the number of private hospitals was 90%.[16] The share of private hospitals in the number of days spent in hospital increased from 5.3% to 17% and in surgeries it increased from 13.7% to 33.2%. In our country, some hospitals provide services with high fees they determine, and private hospitals and foundation universities that have contracts with the SGK can bill extra charges up to 200%. Since these hospitals are not within the framework of Laws No. 657 and 2547, they can choose their employees and can determine the salaries of their employees at will. Since they do not have to buy the cheapest devices due to the bidding law, they can buy high quality materials and devices. Unfair competitive practices come into question here.

The right to receive extra payments had not been granted to university hospitals for many years. Although the academics started to get extra payments with the SUT announcement dated 18 March 2014, the payments made are too low and the amount that the academics receive after deductions is far from satisfactory.

VII. Recommendations and Conclusion

The university hospitals must be transparent, controllable, autonomous and independent from the YÖK and the Ministry of Health with a new legal regulation.

Planning and supervision must be implemented by a new, independent and national institution that includes some ministries in our country, insurance companies and doctor and patient representatives.

The referral chain must begin and only the medical cases that cannot be solved in primary and secondary care should be forwarded to these hospitals.

Hospitals should not aim at making profit; the state should appropriate sufficient funds. High quality and accessible medical services must be provided on time to those who need them, using the most advanced devices and materials. The cost-efficiency principle must be minded.

The academics and doctors must have a satisfactory salary and in the long-run, academics and doctors must proceed to the full time working schedule.

The administrators must have adequate information and experience regarding hospital management. The assessments of the hospital administrators must be made by taking annual measurable results and the satisfaction of the employees and the patients into consideration.

Professor Feyza Erkan, İstanbul Faculty of Medicine, İstanbul University

Please cite this publication as follows:

Erkan, F. (September, 2015), “The Problems of Public University Hospitals: The Case of Çapa and Cerrahpaşa,” Vol. IV, Issue 9, pp.64-73, Centre for Policy and Research on Turkey (Research Turkey), London, Research Turkey (http://researchturkey.org/9784)

VIII. Endnotes

[1]N. Yıldırım. İstanbul’un Sağlık Tarihi (Istanbul’s Health History) İstanbul 2010.

[2]Malche Raporu (Malche Report), [Accessed on 2nd September 2015], Available at:

https://www.tbmm.gov.tr/eyayin/GAZETELER/WEB/KUTUPHANEDE%20BULUNAN%20DIJITAL%20KAYNAKLAR/KITAPLAR/DIGER%20YAYINLAR/197000578%20ISTANBUL%20UNIVERSITESI%20HAKKINDA%20RAPOR/0000_0000ISTANBUL%20UNIVERSITESI%20HAKKINDA%20RAPOR.pdf

[3]Sağlıkta Dönüşüm Programı (Health Transformation Programme), [Accessed on 2nd September 2015], Available at:

http://www.saglik.gov.tr/TR/belge/1-2906/saglikta-donusum-programi.html

[4]Türk Tıbbının iki devi iflasın eşiğinde (Turkish Medicine’s Two Giants on the Verge of Bankruptcy) [Accessed on 2nd September 2015], Available at:

http://www.cumhuriyet.com.tr/haber/saglik/335852/Turk_tibbinin_iki_devi_iflasin_esiginde.html

[5]Müezzinoğlu üniversite hastanelerinin toplam borcunu açıkladı. (Müezzinoğlu discloses the total debt of university hospitals), [Accessed on 2nd September 2015], Available at:

http://www.medimagazin.com.tr/hekim/universiteler/tr-muezzinoglu-universite-hastanelerinin-toplam-borcunu-acikladi-2-15-66685.html

[6]Kamu idarelerinde stratejik planlamaya ilişkin usul ve esaslar hakkında yönetmelik. Resmi Gazete Tarihi: 26.05.2006.  Resmi Gazete Sayısı: 26179 (Regulation on the principles and procedures for strategic planning in public administration. Official Gazette Date: 26.05.2006. Official Gazette No: 26179). [Accessed on 2nd September 2015], Available at:

http://mevzuat.basbakanlik.gov.tr/metin.Aspx?

[7]Can A, İbicioğlu H.: Yönetim ve yöneticilik yönünden üniversite hastanelerinin değerlendirilmesi. Süleyman Demirel Üniversitesi İktisadi ve İdari Bilimler Dergisi 2008; 13 (3): 253-275. (Can A, İbicioğlu H.: Evaluation of the university hospitals in terms of administration and management. Süleyman Demirel University Journal of Economics and Administrative Sciences 2008; 13 (3): 253-275).

[8]Devlet Memurları Kanunu. Kanun Numarası: 657. Kabul Tarihi. 14/7/1965. Yayımlandığı Resmi Gazete: 23/7/1965. Sayı: 12056. (Civil Servants Act Law Number: 657. Enactment date. 14/7/1965. Official Gazette: 23/7/1965. No: 12056. [Accessed on 2nd September 2015], Available at:

www.mevzuat.gov.tr/metin1.Aspx?Mevzuat-Kod

[9]Yükseköğretim Kanunu. Kanun Numarası: 2547. Kabul Tarihi: 4/11/1981. Yayımlandığı Resmi Gazete: Tarih: 6/11/1981. Sayı: 17506 (Higher Education ActLaw No: 2547. Enactment date: 4/11/1981. Official Gazette: 6/11/1981. No: 17506). [Accessed on 2nd September 2015], Available at:

www.yok.gov.tr/web/denklikbirimi/2547-sayili-kanun

[10]Kocaman G., Seren Ş., Kurt S. ve ark. Üç üniversite hastanesinde hemşire devir hızı. Hemşirelikte Eğitim ve Araştırma Dergisi 2010; 7 (1): 34-38. (Kocaman G., Seren Ş., Kurt S. et al. Nurse cycle rate in three university hospitals. Journal of Education and Research in Nursing 2010; 7 (1): 34-38).

[11]Üniversite Hastaneleri Birliği (The Association of  University Hospitals), [Accessed on 2nd September 2015], Available at:

http://universitehastaneleribirligi.com/

[12]Üniversite Hastaneleri Birliği (The Association of  University Hospitals), [Accessed on 2nd September 2015], Available at:

http://www.universitehastaneleribirligi.com/Genel%20Toplantılar/tip-fakultelerinin-ilaci-bu-recetede-h113.htm

[13]Müezzinoğlu, Üniversite Hastanelerinin “Tıbbi Malzeme ve Sarf” İhtiyaçlarının Teminine İlişkin Protokole İmza Attı. (Müezzinoğlu has signed the Protocol Relating to Provision of Needs “Medical Supplies and Consumables” of University Hospitals), [Accessed on 2nd September 2015], Available at:

http://www.saglik.gov.tr/TR/belge/1-42623/muezzinoglu-universite-hastanelerinin-tibbi-malzeme-ve-.html

[14]Kamu İhale Kanunu.Kanun Numarası: 4734. Kabul Tarihi: 4/1/2002. Yayımlandığı Yer Resmi Gazete. Tarih: 22/1/2002. Sayı: 24648. Üniversite Hastaneleri Birliği. (Public Procurement Law. Law Number: 4734. Acceptance Date: 4/1/2002. The Publication in the Official Gazette. Date: 22/1/2002. Number: 24648. The Association of University Hospitals). [Accessed on 2nd September 2015], Available at:

www.ihale.gov.tr/mevzuat.aspx

[15]Yeni Çapa Cerrahpaşa. Üniversite Hastaneleri Birliği (New Çapa Cerrahpaşa. The Association of University Hospitals), [Accessed on 2nd September 2015], Available at:

http://yenicapacerrahpasa.org

[16]OECD (2014), OECD Reviews of Health Care Quality: Turkey 2014: Raising Standards, OECD Publishing. Üniversite Hastaneleri Birliği (The Association of University Hospitals), [Accessed on 2nd September 2015], Available at:

http://dx.doi.org/10.1787/9789264202054-en

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