Balcioglu, Zeynep (2014). 'Health, Equality and Gender: Do Women Have Equal Access to Health Services in Turkey? – An Analysis through Capabilities Approach and Theory on Durable Inequalities' Paper presented at the annual conference of the HDCA, 2-5 September 2014, Athens, Greece.
The most common and well known definition of health is provided by the World Health Organization says: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (Constitution of WHO, 1948) Nevertheless, even this very broad definition has been criticized for years by both professional and non-professional circles, because it calls for the involvement of the very extensive spectrum of social determinants –like education, income, political empowerment etc.- that are assumed to be effective on one's ability to achieve the state of health.
However, all possible definitions of health inherently endorse that health is a very important value to a person, because it determines her/his overall quality of life by framing her/his abilities to attain achievements. In that sense, the provision of free public healthcare services is necessary as a matter and requirement of 'equality' that is derived from the notion of justice, because it opens up the equal access to the path towards the state of health where people can enjoy their life opportunities. What I mean by equality is not the same treatment of all people regardless of their differences; instead it is the implementation of the principle of equality in equitable sense that is addressing differences. People are diverse in terms of the capabilities and the handicaps they have. Therefore, they have to overcome different barriers to be able to utilize the equal access to achieve the state of health. Hence, provision of universal healthcare service that allows equal access to everyone may not be sufficient to reduce the inequalities in health.
In Turkey, the project called Health Transformation Programme (HTP) was started to be implemented in 2010. The project was developed in cooperation with international institutions like World Bank and World Health Organization in line with the Accession Partnership Document declared by European Union by Turkey's Ministry of Health. One of the major changes that HTP brought about is the neutralization of the conditions for women and men to get access to free healthcare services since women had historically been disproportionately disadvantaged under the previous system. It can be said that such an amendment is good for women's deliberate interests, because finally it gives women an equal status with men by recognizing them as independent agents of the society. However, regarding Turkey's very low performance in realization of the overall gender equality with reference to the Global Gender Gap Report (2012), the gender-neutral stance of the health reformation is very likely to remain insufficient to enable women to attain the state of health.
In this paper; I will particularly focus on and evaluate the impact of HTP on women's welfare –in the form of state of health-, and independence –as the agency role- as the important components of the concept of equality of citizens in democratically governed countries. To do my policy evaluation; I will use the Capabilities Approach by Amartya Sen and the theory on 'Durable Inequalities' by Charles Tilly as a lens through which one can determine the existence of inequalities, and the processes and mechanisms that deepens inequalities. Considering the changes in health law about women's status, I argue that HTP must be evaluated within a broader framework of social and public policies. The reform programme in this sense remains limited to make a transformative change in women's life, because significant amount and content of information have been left behind in making and implementation of the health policy. It does create betterment in women's legal status by removing the clause that stigmatizes them as the dependent/indigent subjects. However, it is possible to say that there is a risk that woman's vulnerability may increase due to the lack of relevant social, public or civil mechanisms, policies and institutions that support women as independent income earners and decision makers.
Focusing on what women are capable to do, instead of what they have; I argue that the diverse personal and social factors of the citizens necessitate disparate treatment and opportunities as guarantees to enable them enjoy their equal legal status. Hence, women's practical and strategic interests become complementary and access to health service by women increase as a matter of equality. Therefore, amending the law without transforming the underlying structure in both culture and economy cannot overcome existing inequalities; rather makes them 'durable' by remaining inactive to substantial differences in societal norms, normalized customs/traditions and social capabilities that continue to deprive women.
There will be three major parts in this paper:
The first part will provide a short background of HTP. I will compare and contrast it with the old system and try to find out what have been changed related to women's access to healthcare services. In the second part, I will do a policy evaluation of HTP through the concept of Basic Capability Equality; and finally in the last section, I will bring out possible critiques of Basic Capability Equality and present the concept of 'accountability of reasonableness' as a decision making mechanism that can provide a ground, where the legitimacy in utilization of Capabilities Approach can be improved.
 Turkey ranks as 124th out of 135 countries in gender equality according to the Global Gender Gap Report that is prepared by World Economic Forum. (Haussman R., Tyson L. D. & Zahidi S., 2012: 11)