Right or Mercy?
Health Services for the Poor and
the Green Card Practice in Turkey*
Z. urdan Atalay-Güneş**
Abstract: It is necessary to start analysis of the understanding of citizenship in Turkey
from 18 century including the Ottoman Era. The historical analysis of the development
of the citizenship represents the expansion of social rights was gradual and this expansion failed to cover all citizens in terms of some rights. Particularly an access to health
services for the poor is to be examined within the scope of ‘right’ and ‘mercy’ contradiction. While ‘right’ refers to social rights of the citizens within the framework of citizenship (T.H. Marshall, 1963), ‘mercy’ refers to the grace of the service providers and
planners of the social policies. The example of the access to health services for the poor
is the Green Card Practice, applied since 1992, is the subject of the interviews done by
planners and providers of this service. The Green Card Practice as the research has
shown will continue to swing around the right-mercy paradox and there are various
problems encountered in application of social policies based on citizenship.
Key Words: Citizenship, poor, right, health, the Green Card.
In order to understand how the understanding of citizenship, which started
to develop with social, civil and modern rights starting from the 18th century on,
took its shape in Turkey ; it is necessary to closely look through the process of
building a social state starting from the late times of the Ottoman Era. During
this period, efforts to become citizens from subjects can be seen and the effort
to cover all citizens with civil, political and social rights gained acceleration after the announcement of the Republic. Comprehensive range of civil and political rights was realized during the early Republican era when compared to social
rights. On the other hand, expansion of social rights was gradual and this expansion failed to cover all citizens in terms of some rights. Especially when access
to health services for the poor is to be questioned, it can be seen that this access
is limited to the extent that the state shows “mercy” and it is not included within
the scope of rights.
In this article, access of the poor to health service rights will be analyzed based on the ‘right-mercy’ paradox starting from the late Ottoman era until the
2000’s. Whereas “right” corresponds to social rights with reference to the desc*
This article is based on the paper presented at the “Human Rights and Citizenship” Conference (14-15 December 2006, Ankara) organized by the Human Rights Research and Documentation Center of TODAĐE
(Public Administration Institute for Middle East and Turkey) and subjected to the peer review of two anonymous referees.
**
PhD student at METU Department of Sociology, Lecturer at Mardin Artuklu University.
Turkish Yearbook of Human Rights, Vol. 26-30, 2004-2008, s. 87-98.
88 Turkish Yearbook of Human Rights
ription of citizenship rights by T. H. Marshall (1963), “mercy” corresponds to
providers of these services and their decisions; in other words to their grace.
When access of the poor to health services is of the primary concern, one needs
to ask to what extent the Green Card Practice which was put into operation in
1992 as a milestone for health rights in Turkey can be conceptualized as a right
based on interviews with planners and providers of this service.
ACCESS OF THE POOR TO HEALTH SERVICES WITHI& THE PARADOX OF
RIGHT A&D MERCY DURI&G THE HISTORICAL PROCESS:
THE LATE OTTOMA& ERA: I&VE&TIO& OF SOCIAL POLICIES
When formation of social state and access of the poor to health services in
Turkey is at the stake; it is not sufficient just to consider the history of Republic
of Turkey but one needs to expand the historical starting point to include the
last two centuries of the Ottoman Empire. This is because it is claimed by many
researchers that the foundation of the modern state –among which, social policies can be listed- was laid during the modernization process of the Ottoman
Empire (Zücher 2000, Ahmad 1995). During the 18th century, which is considered to be the longest century of the Ottoman Empire by Ortaylı (2000), the state
mechanism as well as social structure started to change starting from the military and “modern” state organizations which were formed as a result of rapid
modernization efforts. This was accompanied by strengthening of the central
authority and more control of the reinforced authority on daily life. As a matter
of fact, social policies are acknowledged as instruments of rebuilding the society with the interference of the state just as in Europe. According to Özbek
(2002b), social state corresponds to the change of the relationship between the
society and the state that changes with economy and becomes reshaped and
transformed with social relationships and a way to interfere with the society.
Özbek (2002a) considered two periods when discussing the formation of social
state in the Ottoman Empire (The Abdülhamid and Constitutional Monarchy periods) and underlines another important differentiation. This is that the mercy
and charity associated with the personality of the sultan during the Abdülhamid
period turned into association of the presence of the state during the period of
the Committee of Union and Progress and those charitable organizations stood
out during this period. Whereas a differentiation of being ‘deserving’ and ‘undeserving’ poors was made by the state just like the Poor Law of England,
mercy stands out for the policies made for the ‘deserving’ poor. Deserving poor
people were defined as homeless people, orphans and widows and organizations
like Darülşafaka and Darülaceze were established to help them out. The undeserving poor people, on the other hand, were recognized as threats to the social
structure and they became the object of police measures (Ergut; 2002, 154).
Right Or Mercy? Health Services For The Poor And The Green Card Practice in Turkey
89
Again, during this period, social protectivity manifests itself primarily in
some arrangements for mining workers (Talas, 1992). As the central government develops, civil and military bureaucracy also grows. This forces the state
into considering the needs of the growing group and as a result, the Military Retirement Fund was established in 1866 and the Retirement Fund for Civil Officers was established in 1881. These two groups were presented with pension,
social assistance for family members and health services (Akdur; 1998). The
other section of the population had to pay for private doctors for these services
and there was no regulation on by whom and under which circumstances this
service should be offered (Oral; 2002). The poor, on the other hand, could make
use of these services only if there were foundations founded by the sultan and/or
his relatives. If such foundations did not exist in the region, this people were
granted the right to benefit from military health services as required with the regulation adopted in 1877 (Oral; 2002). Despite all these regulations, health services and social services were not taken into consideration as basic responsibilities of the state (Akdur; 1998). Considering particularly access of the poor to
health services, it is observed that the issue was tried to be solved within the field of charities. Reconsidering this period, the poor can gain access to health
services through the opportunities offered by the army and foundations and considering that health services were offered only in some big cities by the Ottoman Empire, how limited access of the poor to health services is clear.
THE REPUBLICA& ERA
It is possible to state that more visible efforts were spent to cover the whole
population in terms of health services along with the establishment of the Republic. When the Ministry of Health was formed in 1920 prior to the announcement of the Republic, the primary objective was the organization and management of health services as well as providing these services in a more egalitarian way all around the country. This is because; the Ottoman Empire offered
limited health services only to some cities. The newly founded nation state, on
the other hand, aimed to reach everywhere in the country in an egalitarian way.
We can summarize all regulations of this period as rights gathered in the center
within a limited structure and problems that resulted from this structure.
At the end of 1940’s, two important institutions were founded to cover the
employed population. These were the Social Security Organization (SSK) founded in 1945 and the Retirement Fund (ES) founded in 1949. These two institutions offered different amounts of pension salary and health services to people
who were employed within their scope and their families but the offered health
services were highly limited.
90 Turkish Yearbook of Human Rights
Formation of the nation state followed in the footsteps of the western example in many aspects during these early times and it was insufficient in the field of
social policy. Nevertheless:
• The applied regulations were performed in the center without any impact
of the people
• And class differences were ignored during this process (Kongar:
1973,163).
Social policy regulations that were practiced until adoption of the multiparty system ignored class differences and aimed to create social solidarity (Koçak, 1998) and a strong central authority just like in the Bismarck example, like
the model named as corporatist regime of welfare by Esping-Andersen (1990),
Özbek (2002) claims that this characteristic was not limited only to the early
Republican era and corporatist tendencies the ideal of ‘classless society’ determined the domain of social policy in Turkey starting from the late Ottoman Era.
As a matter of fact, Buğra (2006) established that social solidarity and charitability was the common discourse of governments in power since the 1950’s until
the 1980’s for their approach towards poverty instead of the discourse of rights
based on social citizenship.
PLA&&ED YEARS
After the military coup in 1960, the planned period was adopted in Turkey.
According to the Constitution of 1961, the state is responsible for its citizens.
However, it is also stated in Article 53 of the Constitution of 1961 that this responsibility is limited to social-economic resources of the state. During this period, not only economy, but also health services became the subject of rational
planning and the Law of Socialization of Health Service number 224 was adopted in 1961. The main objective of this law can be summarized as ensuring reorganization of health services in order to enhance access to them. The system
of ‘from village clinics to hospitals’ which is also known as the transfer chain,
was also adopted with this law. Healthy life and access to health services were
described as basic rights and the responsibility of ensuring this was encumbered
on the state. This system was going to be financed with premiums from organizations like SSK (Social Security Organization) and ES (Retirement Fund) as
well as state contributions and it was going to be ensured that everyone gained
free access to health services (Oral, 2002). The main goal was to make health
services accessible. For the first time, this goal was on the to-do list of the state.
The meaning of this application for the poor was being included within the scope of access to the health system. However, the objectives of the law could not
be fulfilled.
Right Or Mercy? Health Services For The Poor And The Green Card Practice in Turkey
91
The question about how the portion of the population which was not included within the scope of either SSK or ES was going to be included in social security and health systems was raised in the first development plan which covered the years between 1963 and 1967. A partial answer to this question was presented through establishment of Bağ-Kur (the independent security fund) to cover artisans and craftsmen in 1971. However, the major population which was
not covered with social security and health systems, continued to be the main
problem of following development plans. There were various suggestions on
how the sector of agriculture, which offered employment opportunities to a
great portion of people working in the informal sector or as employed.
Application of the social policy for the poor during the period before is the
Law to Pay Monthly Salaries for Dependent, Poor and Needy People who are
over the age of 60 –which is also publicly known as “elder’s salary”. Buğra
(2006) established that the reference to social state given in the law text was different from other applications. The “dependence” condition of the law suggested that state responsibility was going to be valid only on those people who has
nobody else to take the responsibility. Once again, this situation displays the
describing and/or compensating role of family ties for the lack of a social state
(Buğra, 2001; Kalaycıoğlu, Rittersberger- Tılıç, 2000). In this case, it is clear
that responsibility in social policies in Turkey is shared between the family and
the state, not the state and citizen.
THE 1980’S A&D THE FOLLOWI&G TIMES
In the Constitution formed after the military coup of 1980 and the following
period, the state principle was conserved but the priority was given neither to
social society nor to the individual; but to the state (Talas, 1992). The state of
the Constitution of 1961 which was responsible for social security of its citizens
was replaced with the ‘regulating state’. The fact that the state was responsible
for ensuring social rights to the extent that its fiscal and economic capacity allowed was also repeated in the Constitution of 1982 (Article 65). A similar role
is suggested for the state for overcoming recession of the welfare state in Europe (Money: 1997). Considering plans which were also prepared during this period, it can be seen that more emphasis was placed on the increasing need for
social assistance and the rate of poverty that increased parallel to changing socio-economic conditions. Within this framework, the Fund for Social Assistance
and Encouraging Solidarity was established in the year 1986. The fixations of
Şenses (1999) on the establishment of the fund, its timing, its way of organization and distribution of resources among it overlap with the historical background we have portrayed and consideration of the poverty problem. Şenses (1999)
who assessed the adoption of funds through as the response of the state to increasing rate of poverty and to distribution of income which was disturbed by the
92 Turkish Yearbook of Human Rights
structural harmonization packages applied in 1980’s underlines that the organization completely remained in formal boundaries despite efforts to include ‘civil’ elements to it. What determined distribution of resources to funds and to
foundations under these funds was arbitration. Who the poor and what their needs were as well as to what extent these needs were going to be met was completely subject to subjective decisions made by administrators. Buğra (2006)
shows us the traditional aspect of the social assistance understanding by underlining that it was wished that donations which were included in the law text but
not applied as well as private donations should be given to the poor through the
channel of foundations -in the foundation of which religious and traditional references were present. To summarize, it is hard to conceptualize the contributions to the poor as rights granted to them.
In the year 1983, examples to cover the population by social insurances failed except for including agricultural workers within the scope of social security
at their option. It can be seen that the scope of this insurance, which aimed to
cover the whole agriculture sector, remained highly limited. In this case, the
conditions to benefit from health services and social insurance in Turkey, where
more than half of the population is not included in the formal labour market, are
realized through the family. And this has created a dynamic which partially solves the problem of completely covering the population of the welfare state
and/or ensuring continuity of powerful family bonds (Buğra, 2001; Kalaycıoğlu,
Rittersberger- Tılıç, 2000).
Taking all this process into account in terms of access to health services by
the poor, it can be obviously seen that the poor are completely pushed out of the
health system and they are subject to the mercy of those who offer these services. Hospital managements were granted the right to treat some patients free-ofcharge with the Regulation on Regulating Hospital Management which was
adopted in1973 and regulated in 1983 (DPT; 2001). However, this regulation
did not determine any criteria on how to categorize these so-called ‘some’ patients and this decision was made completely made by hospital managements.
The ways employed by the poor to gain access to health services during this period were receiving treatment if accepted by hospital managements and meeting
other healthcare needs in informal ways within the framework of solidarity
among families or applying to the Social Security Organization through the
mercy shown by the state.
THE GREE& CARD PRACTICE
In 1990’s, discussions on general health insurance continued and Doğru Yol
Partisi DYP (“The True Path Party”) came up with the suggestion of Green
Card, which offered free access to health services for the poor, in its election
propaganda under the presidency of Süleyman Demirel. According to the law,
Right Or Mercy? Health Services For The Poor And The Green Card Practice in Turkey
93
put into operation by the coalition government of DYP and SHP in 1992, everyone, who could prove that their income was lower than one third of the minimum wage, was going to obtain the right to use this card. In case patients with
green cards needed treatment in bed, all their expenses were paid by the Ministry of Health. And if they were treated on foot, their treatment and medication expenses were not paid. This provision was amended with regulations carried out in 2003 and 2004 and it was ensured that expenses for both types of
treatment were paid. Green cards were issued in temporary status until the general health insurance system was introduced. Within the framework of this law, if
needy people can prove their poorness after a long bureaucratic process, they
obtained the right to access limited health services.
With a regulation made in the Village Law in March 2006, temporary village
watchmen working without any affiliation to an insurance organization; other
temporary village watchmen who aborted their duties with indemnification as
well as their families for whom they were responsible also had the right to get
Green Cards regardless of the criteria given in the law. It is predicted that there
are about 57 thousand temporary village watchmen living in the Southeastern
Anatolia. This case shows that the Green Card practice is not limited only to the
poor and its scope is expanding. According to data for the year 2006, as announced on the web site of the Ministry of Health, the Green Card Practice had
created the opportunity to access health services for 12 million 199 thousand
and 750 people until then.
The Green Card practice was going to be merged into the General Health Insurance application which was planned to enter into effect on the 1st of January
2007 but was delayed until the 1st of July 2007 as a result of articles which were
cancelled in the Constitutional Court. Contrary to the claims that the Green
Card practice is going to be abolished, citizens who benefited from this application will continue to benefit from free health services without paying any premiums as they are not included in the labour market within the framework of
the new insurance system.
In this sense, the Green Card, which offers legal rights to the poor for the
purpose of accessing health services is not a “right-based” and therefore a
frequently seen policy of the Republican era as established by Buğra (Buğra,
2006: 35). The general idea about poverty during the period following 1980
was: “fighting poverty is not ‘the state’s business’ and the problem of ‘poverty’
is transferred on the future and economic development”.
RESEARCH A&D FI&DI&GS
It is important to assess how the Green Card practice, which describes access
of the poor to health services as rights, is understood in order to understand how
this policy is implemented. This is because, as stated by Lowe (1999:46), “‘Po-
94 Turkish Yearbook of Human Rights
licy, in this perspective, is not what Cabinets and senior officials plan but what
lower-paid officials do… ”. The findings which were referenced in this article
are based on interviews with 10 people who plan, suggest and prepare social policies in Turkey by taking the Green Card practice as an example while working
in the field of social services with different responsibilities and authorities (Atalay; 2002). The research was carried out between December 2001 and August
2002. The people who were interviewed were people working in the State Planning Organization, Ministry of Health, Social Assistance and Solidarity Foundations and Green Card Bureaus with different responsibilities and authorities in
application and planning of the Green Card practice.
The main concern of these interviews was to observe the conceptualization
of social state in Turkey by people working in these types of positions over the
Green Card example. During the term of the research, the objective was to see
how they consider the 10 years of Green Card practice which is one of the crucial policies in Turkish Welfare State. This is because their conception of social
state in Turkey sufficiently explains access to health services by the poor and
the applications involved in this process.
Before describing the relationship between social state and poverty, it would
be useful to observe descriptions of poverty made during these interviews as
well as their impact on accessing Green Card. Poverty can be described as being
unable to meet basic needs like health, income, food and shelter. Lack of access
to education is explained as both the reason for and an outcome of poverty.
Along with this, during one of these interviews, an employee working in a
Green Card bureau described poverty as “people’s acting as freeloaders”. Description of poverty within amoral framework and discussing criminal tendency of
the poor were also common in other interviews. This shows us that the “deserving” and “undeserving” discussion of the poverty literature still remains valid.
Lowe argues that ‘ …insufficient funds were allocated to the service and that, in
the absence of the criteria by which to rational benefit, local officials fell back
on the traditional-but highly arbitrary and unscientific-distinction between ‘deserving’ and ‘undeserving’ poor (Lowe, 1999;48)’.
Green Card is an important application ensuring the right to access health
services for the poor as considered by planners and appliers. The state offers security for the poor by guaranteeing this right but reaching this security involves
very long bureaucratic process. During these interviews, it was observed through Green Card Bureau applications that these processes were not always applied as stated in the law upon. For example, according to the law, obtaining the
Green Card requires calculations on the person’s income and people who own a
house or car are prevented from obtaining it so long as they do not gain income
from these properties. However, during the research, it was seen that owning a
car and/or house prevented people from obtaining Green Card. Therefore, it can
Right Or Mercy? Health Services For The Poor And The Green Card Practice in Turkey
95
be said that who may and who may not obtain this right is subject to solutions
of people who implement the policy and to their mercy.
Legally guaranteeing access to health services is always accompanied with
considering people benefiting from this right as legitimate. The people who were interviewed said that Green Card holders were treated as second-class people
not in the institutions they worked in but in other institutions like hospitals.
The fact that Green Card did not cover payment of treatment expenses for
on-foot treatment was criticized by the interviewed people but emphasis was
made on the fact that this disadvantage was compensated by Social Assistance
and Solidarity Foundations. Also, Green Card generally ensured priority in benefiting from other opportunities offered by the foundation. But the problems in
distribution of resources of the foundation, which were described as ‘limited’
and the fact that needy people had to prove their poverty in order to receive
their medication expenses were not referenced. During the meeting of the Board
of Trustees of the foundation, which I attended during the research, money was
described as ‘holy’ and it was stated that it was distributed in accordance with
personal decisions of the governor and some people who demanded help were
described as ‘help addicts’. At the date this research was being conducted, the
condition for fully benefiting from health services depended on the state’s
mercy. With the regulations carried out in 2003 and 2004, Green Card holders
also gained the right to get their medicine from pharmacies by presenting their
health books.
We can discuss the presence of two different groups in assessments on social
state in Turkey. People in the first group said that social state should keep equal
distance/close proximity to everyone, offer equal rights and operate in accordance with the principle of contrast and they claimed that there is no social state
in Turkey due to lack of these characteristics.
Keeping equal distance to everyone means that there should not be any active clientelist bonds like fellowship or relationship in access to offered services.
Offering equal rights to everyone completes this principle. At the same time,
this is a criticism to the sectional structure and differences of offered services.
The principle of contrast, on the other hand, corresponds to a citizenship description which is defined with rights and duties. In order to access rights, assigned duties, should be fulfilled or the price should be paid. What is meant here
may not correspond to services but a specific price should be paid. This point of
view describes their conception of the poor. Considering the issue from this point of view, it is not sufficient to be merely a ‘citizen’ to benefit from services
offered by the state but a ‘price’ should be paid as well.
The people in the second group defended that there is a social state in Turkey by referencing to the social state principle in the Constitution despite the
96 Turkish Yearbook of Human Rights
presence of deficiencies or economic limitations. Despite these deficiencies of
economic limitations, the state was doing its best and tried to create health, education and employment opportunities for the people. This point of view, which
legitimizes the situation, was shared particularly among those who performed
planning activities for social policies and it is also meant to legitimize their own
position.
Creating health, education and employment opportunities was stated by all
participations as a must of social state. It was particularly highlighted that creating employment opportunities would be a solution for the currently experienced poverty and it was stated that lack of employment opportunities resulted in
crime rates going higher. The reason for underlining employment was the recession experienced during that year. Particularly the people who were working in
the planning field stated that demand for Green Card had substantially increased
with the recession. In addition to that, taking place under the social insurance
umbrella which forms an important branch of state applications in Turkey was
to be articulated to the formal manpower market. Being included in this manpower market was considered to be the basis for right-oriented formation of the
state-citizen relationship, which was a common discussion of the interviews. As
stated by Buğra (2006), this corresponds to transferring the problem of poverty
to economic development. Among the problems experienced with Green Card
given to those who are not included in the formal manpower market is lack of
harmony between ‘right’ descriptions of those who plan these policies and those
who implement them.
Both groups emphasized that all citizens should benefit from health services
and living healthy was a part of human rights and they also put emphasis on the
principle of contrast. Despite the fact that rights obtained within other institutions have been obtained ‘ in return for a price’ and they are included within the
scope of guarantee, it is hard to conceptualize Green Card as a right because of
the fact that it considers poverty as a temporary situation and a price is paid in
return for offered services. In addition to this, the fact that the law was adopted
in a temporary status enhances the problems encountered in implementation
(Atalay, 2002). Also the fact that Green Card holders benefit from health services without paying any fee resulted in ‘insensitive’ attitudes like ‘abusing’ the
card or losing it as discussed during the interviews.
AS A CO&CLUSIO&
The Green Card practice which was adopted in 1992, a period that corresponds to a turning point in social state applications in Turkey for granting access to health services for the poor, can be thought of as a right-oriented application only with reference to the law text. This ‘right’ can be obtained only after
green card holders prove their poverty. However, when implementation is the
Right Or Mercy? Health Services For The Poor And The Green Card Practice in Turkey
97
case, poor citizens need to overcome not only bureaucratic process but also present ‘prejudices’ in order to obtain this ‘right’. In this case, ‘mercy’ of the implementing person stands out. The conclusion we reached at the end of interviews with planners and implementers of this service is that the Green Card
practice will continue to swing around the right-mercy paradox and there are
various problems encountered in application of social policies based on citizenship.
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