Since the announcement of the Health Transformation Program (HTP; Sağlıkta Dönüşüm Programı) in 2003, Turkey’s healthcare system has undergone a major reorganization whereby the boundaries between the private and public sectors have been redrawn and responsibilities for financing, delivery, and regulation reshuffled. The reform package—combining elements of the New Public Management (Yeni Kamu İşletmeciliği) paradigm with an emphasis on universal access—and its expeditious implementation have provided rich and challenging material for students of social policy reform. In his book The Politics of Healthcare Reform in Turkey, Volkan Yılmaz takes on this challenge and provides a comprehensive analysis of the political dynamics of the HTP.

The theoretical framework adopted in the book combines historical institutionalist approaches with recent ideational scholarship, and as a result is able to discern actors’ subjective interpretations of the reform, as well as their motivations, values, ideas, and ideologies. This approach allows Yılmaz to explore the alliances and struggles among major policy actors, how they interact with their peculiar institutional context, and the consequences of these interactions.

The book makes three important contributions to the literature. First, it achieves one of its stated goals of going beyond stakeholder analyses to explain how this specific health reform package fit in with the governing Justice and Development Party’s (Adalet ve Kalkınma Partisi, AKP) political program, crafted ideology, and short- to mid-term political strategies (p. 149). Combined with a detailed account of the content of the reforms, this approach is also able to skillfully demonstrate how the reforms are changing the health care system and to pinpoint critical trends, such as a strong private sector in healthcare delivery, income-based inequalities in access to services, financial pressures to sustain a comprehensive benefits package and quality of care, difficulties in managing the flow of patients without a gatekeeping system, increasing tensions in doctor-patient relations, and so on. Academic researchers and policy experts would certainly benefit from this analysis in that it firmly situates current and future trends within the context of Turkey’s political and economic history.

Second, students of comparative health policy will find in the book many occasions to compare and contrast developments in Turkey’s health system with those in other systems, especially in the context of emerging market economies. Chapter 4, for instance, briefly examines reform initiatives undertaken in Latin America, Eastern Europe, and Central Asia since the late 1980s. This analysis recognizes different stages of public policy—agenda setting, formulation, implementation, and evaluation—and highlights the interplay between domestic and international actors and between ideas and strategies. Chapter 5 develops this approach by focusing on the role of the World Bank (WB) in Turkey’s health reform. Here, Yılmaz describes the relationship between the AKP government and the World Bank as mutually beneficial: the AKP shared the pro-market global policy paradigm promoted by the bank and “took advantage of WB know-how and expertise on healthcare reforms,” while the bank “appreciated the Turkish reform experience” and promoted it as a success story (p. 142). Yılmaz’s analysis offers a valuable opportunity to examine the interplay among global, national, local, and regional actors and thereby expand the social policy literature. There are, however, some shortcomings in this regard. For example, although Chapters 4 and 5 mention some of the relevant theoretical approaches, (e.g., global social policy) and concepts (e.g., policy diffusion, epistemic communities), Yılmaz does not systematically develop any one of the approaches, nor does he explain how ideational perspectives shape this part of his analysis. Additionally, the book falls rather short of its promise of fully integrating the global perspective into policy analysis. The discussion on global reform dynamics begins with the 1990s, and there is even a subsection entitled “The Global Healthcare Reform Agenda Arrives in Turkey” (pp. 67–71). Does this imply that interactions with international institutions or learning from other healthcare systems did not matter before the 1990s? Can we expand this analysis in order to see how some of the ideas already discussed in the book—such as corporatism, healthcare as a right, or the primary healthcare promoted by the 1978 Declaration of Alma-Ata—diffused across boundaries and influenced health reform initiatives? I think one way to do this would be to look beyond the World Bank and examine how Turkey’s policy actors were connected to global policy circles, like the networks of the World Health Organization (WHO), or whether or not the Turkish Medical Association (Türk Tabipleri Birliği, TTB) closely followed the policy developments taking place in other countries. A discussion on regional policy dynamics in the context of the European Union (EU) or certain initiatives in the Middle East could also have added to this analysis of how different levels or scales of policy—global, regional, national, local—interact in specific policy contexts.

Third, the chapter on the TTB offers a rare glimpse into the dynamics of the conflict between the AKP government and the largest organization representing doctors in Turkey. The comparative health policy literature offers many examples of medical associations opposing health reform initiatives for a variety of reasons, as well as governments’ efforts to moderate the power of physicians. In Turkey, however, the nature of this conflict and the ways in which it has exhibited itself are quite striking. Yılmaz summarizes the TTB’s main criticisms of the HTP and explains this conflict partly in terms of vast ideological and political differences. Given its peculiar characteristics—it is defined as “a secularist organization that support[s] the rights of the Kurdish minority and has been part of a pro-labor rights alliance” (179)—the TTB was naturally at the forefront of criticizing the AKP’s neoliberal policies. At the same time, reforms in the healthcare system challenged the TTB to strike a balance between its critical stance on the one hand and protecting the rights of its members on the other.

This chapter (Chapter 7) provides a much needed closer look at the TTB within the framework of policy studies and draws our attention to its transformation from a corporatist professional body to a dissenting civil society organization during the 1970s. While the emergence of a new cadre of leadership with socialist leanings is identified as a major factor driving this transformation, one wonders whether there have been other factors peculiar to the association or the wider political context that contributed to this transformation? In addition, how do we make sense of this transformation: is it a complete transformation from top to bottom, or does the TTB still have certain attributes of a corporatist organization with a responsibility to represent the interests of its members and serve as a mediator between the government and citizens? The details of some of the conflicts over the proposed amendments to the legislation governing the establishment and functioning of the TTB (pp. 179–182) might suggest that the organization has been trying to retain some of those corporatist characteristics (p. 180).

On the other side of the conflict, the AKP governments have often excluded the TTB from the planning and implementation of its reform program. Yılmaz’s account of this subject goes beyond the typical stakeholder analyses by demonstrating that this divide was not simply a matter of lack of communication or collaboration due to ideological differences. Indeed, the government actively tried to undermine the TTB’s legitimacy and power when, for example, it claimed that “serving the public interest should not be a TTB mandate” (p. 180). Despite the richness of Yılmaz’s account of this subject, there are three possible issues. First, this side of his analysis falls short of fulfilling one of the main goals of this study; namely, situating these developments within their specific historical and political context. While reference is indeed made to some developments in this regard—such as the “shrinking democratic space in Turkish politics” (p. 175), a limited “willingness of the mainstream media” to report on the TTB’s views (p. 189), and the AKP’s “transformation from a single-party government with a shaky legitimacy to a cartel party” (p. 180)—these connections are nevertheless not systematically explored. For instance, could the government’s full-time work requirement or its attempt to change the legislation governing the TTB be analyzed in the light of the AKP’s “synthesis of neoliberalism and populism” (p. 155) that was discussed in earlier chapters? Is this all part of an attempt to undermine corporatism in the governance of the healthcare system, especially in the light of references to “greedy” doctors who defend the status quo against the “greater representative power of the government” and who “trample the national will” (p. 174)? Second, although Yılmaz’s analysis brings up many good examples of how and why ideas matter, it does not go so far in exploring the actual interplay between ideas and power. Are we, for instance, witnessing a populist attack on the ideas of autonomy or on the roles of the medical profession, which were defined within the context of the relations between the state and the medical profession in the 1950s? The third gap concerns the consequences for the medical profession of these developments; namely, the growing influence of populist discourse, marketization, and managerialism. Despite Yılmaz’s impressive account of the contradictions experienced by the TTB and a few references to proletarianization or marginalization, in general such consequences are not systematically explored.

Overall, The Politics of Healthcare Reform in Turkey takes its rightful place on the comparative health policy shelf as the first book to offer a comprehensive analysis of Turkey’s recent health reforms. Yılmaz identifies the tensions and conflicting components within the health reform program, and explores how key actors—such as the AKP governments, the TTB, and private healthcare organizations—have tried to shape the reforms’ content and implementation. By focusing on actors’ subjective perceptions of the reforms, Yılmaz helps us to understand why the reform contains universalist elements right alongside market-based reforms; why the AKP governments pushed for swift implementation of the reform program (briefly, the HTP served as an important factor in the consolidation of the party’s rule by rendering it legitimate); why the TTB staunchly opposed the HTP (briefly, because of the association’s key characteristics, contrasting ideas about how to reform the healthcare system, and the TTB’s fight against attempts to undermine its legitimacy); and in what ways private providers will continue to influence the direction of health reforms in the near future. While the book would benefit from more clearly laying out its theoretical contribution in terms of “expand[ing] the literature, which has been skewed towards Western European and North American countries” (p. 5), it concludes strongly with a very clear warning to the social policy literature, which has failed to respond to significant challenges to democratic politics in many countries. As Yılmaz warns, merely identifying the specific positions of relevant stakeholders and presenting medical associations or civil society organizations that oppose reforms as “obstacles” to successful reform could blind us to the ongoing erosion of democratic institutions and of the legitimacy of alternative views on healthcare policies. Given the widespread rise of populist and authoritarian discourses in many countries, policy scholars should be careful to not to celebrate “political will” without questioning it, but should instead carefully study the relationship between market reforms, democratic institutions and values, and populism.