President Barack Obama is determined to reform the American healthcare system this year. The direction of this reform remains unclear, and supporters of various approaches (such as emphasizing public or private solutions) often point to the experiences of other countries as an example for good or ill. Tired of hearing about the Canadian or British health services? Consider the case of Turkey.
The Ottoman Empire was established by Turks who had roamed from central Asia before establishing themselves in the Middle East and southeastern Europe. The Ottomans ruled over a huge territory for more than 500 years. Medical education followed the Islamic tradition of the Middle Ages. Neurosurgical history notes the contributions of Serefeddin Sabuncuoglu, who published his work “Imperial Surgery” (in Turkish) in 1465. The author described and illustrated surgical treatment of such conditions as trauma to the head and spine, seizures and hydrocephalus. In the late 18th century, after English envoys witnessed vaccination for smallpox in Istanbul, the technique was introduced in Great Britain (leading to the safer method of cowpox vaccination invented soon after by Jenner).
Like other nation-states, the Ottoman Empire underwent dynamic shifts throughout its history. Change had been afoot in the Ottoman Empire in the 19th century, hinting at the revolutionary reforms to be completed by Mustafa Kemal Ataturk. A complete break with the past occurred after World War I, in which the Ottomans were allied with Germany. In the war’s wake Ataturk created the Republic of Turkey, a modern, democratic state. The scale of the reforms he led is hard to imagine in both magnitude and speed of adoption. They included change from the Arabic to the Roman alphabet, universal education, and complete separation of mosque and state. As in Western Europe, Ottoman medicine began to evolve from a decentralized system to one where the state played an increasingly important role in organizing medical education, licensing and public health.
With the creation of the modern republic, a centralized state healthcare system was established. To encourage competition and improve access to hospital-based care, government reforms in 2003 allowed for an expansion of private hospitals. These facilities contract with government and private health plans, as well as receive direct patient payments, which supply a majority of their income. This system has fostered the growth of modern subspecialized medicine; today there are some 500 Turkish neurosurgeons with access to the latest methods of neuroimaging and operative technology
On a recent trip to Istanbul I visited two hospitals built and run by the private Acibadem Healthcare Group, which owns hospitals and clinics throughout Turkey. These are sparkling facilities, clean and completely up-to-date not just in their medical technology (such as 3-Tesla intraoperative MRI), but in such aspects as throughput, patient-centered service and quality assurance. And they have emergency rooms via which they take all comers.
What will the American healthcare system look like after reform? We all want to eliminate waste and ensure access to all, and eliminate the fear that illness will lead to economic ruin. Perhaps an expanded governmental role will help us achieve these goals. But if we are to learn at all from the experience of others, we should consider that in countries such as Turkey, the private sector plays an increasingly important role in the delivery of patient care.
Michael Schulder, MD, is co-associate editor of the AANS Neurosurgeon. He is vice chair of the Department of Neurosurgery and director of the Harvey Cushing Brain Tumor Institute at the North Shore Long Island Jewish Health System, Manhassett, N.Y. The author reported no conflicts for disclosure.