The Ministry of Health now has a company!

Dr. Nilüfer Ustael*

In 1991, when I started practicing medicine in Sungurlu, the word " company " entered our language. We had a man named Muzaffer, a hospital staff member. He had worked in the emergency room for years. He was our right-hand man, teaching us novice doctors the local language and guiding us. Our tailor would sew our scrubs and sheets. First came Muzaffer, followed by company personnel; inexperienced, whose names we didn't even learn because they were frequently replaced to avoid increasing severance pay. Our relationships with companies grew as we expanded from catering companies to security services: car rental companies, laboratory services, imaging services, software companies, and nuclear medicine services. As if that weren't enough, hospitals were closed, and hospital operations were transferred to corporations (COI city hospitals). Everything but the doctors, nurses, and patients became corporations.

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Public administrators loved this company. They asked, "Why don't we establish it?" Health tourism was a significant source of profit. The Ministry of Health stepped in to regulate the field, and USHAŞ (International Health Services Inc.) was established by Statutory Decree No. 663 on Certain Regulations in the Field of Health. It began operations on February 4, 2019. USHAŞ is a joint-stock company governed by private law, but its shares are entirely owned by the Treasury and it began operating under the Ministry of Health. Through USHAŞ, the Ministry began acting as a market actor, exercising public authority .

Defined duties: Promotion, coordination, and guidance in the field of international health tourism; intermediary activities in international health services; entering into international agreements and supporting processes in the public and private sectors; issuing authorization documents; responding to applications, resolving disputes, identifying problems, and taking preventive measures; conducting consultancy and project implementation on healthcare systems, financing, PPP models, and consulting. Opening and operating healthcare institutions abroad, and establishing partnerships; constructing buildings and supplying medical supplies; recruiting international students for healthcare professional training, establishing education abroad, developing incentives, and supporting international students and educational institutions; participating in congresses, seminars, research, and publications; collaborating and providing recommendations on standards, accreditation, pricing, and legislation; and advising the Ministry on policies, strategies, service standards, and legal regulations.

USHAŞ is not legally subject to the Law on Public Procurement Contracts or the Decree Law on State-Owned Enterprises. However, those serving on its board of directors are paid the same amount as the chairpersons and members of the boards of state-owned enterprises. What now, state-owned enterprise or not? Unraveling the company, a vast entity that extends beyond health tourism activities, appears to require in-depth investigation.

For now, let's examine some of its activities related to health tourism. According to the Regulation on International Health Tourism and Tourist Health dated April 26, 2025, those who come to our country for treatment, those who come as tourists but need healthcare, and even Turkish citizens residing abroad are required to receive all non-emergency healthcare services from an institution accredited by USHAŞ. USHAŞ is tasked with providing intermediary certificates and referring foreign patients, essentially acting as brokers .

According to the Turkish Code of Obligations, a broker is a person who acts as an intermediary in the establishment of a contract between two parties and has a commercial counterpart. In the healthcare field, Law No. 1219 on the Practice of Medicine and Branches of Medicine, Law No. 6023 on the Turkish Medical Association (TTB), and the Code of Professional Ethics for Physicians prohibit patient referral, mediation, and commercial gain, i.e., brokerage. The Ministry of Health's Advertising and Promotion Regulation prohibits "mediation" and "patient recruitment" activities. The special powers granted to USHAŞ violate all these prohibitions and undermine physician autonomy. They create the risk of patients being guided by commercial criteria in their choices.

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There's also "HealthTürkiye." USHAŞ, a joint venture between the Ministry of Health and the Ministry of Culture and Tourism , has an official health tourism brand and a web portal (www.healthturkiye.com). Patients traveling to Turkey must use this portal as their sole entry point. Similarly, public and private healthcare institutions, intermediary institutions, and individuals and legal entities offering consultancy and guidance services engaged in health tourism are required to register with the HealthTürkiye system. Registration and document processing are handled by USHAŞ.

Patient satisfaction surveys evaluate patient treatment processes, and service providers are subject to sanctions when necessary. Patients can only receive services from institutions registered in the system. This is pure brokerage. Registered institutions, with advertising and promotional authorization, gain visibility under the HealthTürkiye brand in international promotion. The revenue stream from health tourism is recorded. Foreign patients' identity, contact information, travel, and accommodation information, satisfaction and complaint records, diagnosis, treatments and procedures administered, medications and medical devices used, treatment duration and outcome information, and the patient's entire history of transactions at the healthcare facility must be recorded on the HealthTürkiye portal. What they say: Patients can learn about treatment options, compare them, calculate costs, and make travel plans on the portal. Isn't that a great convenience?

However, health data is considered "special personal data" under the Personal Data Protection Law (KVKK) and can be processed with explicit consent. Because USHAŞ acts on behalf of a public entity, it relies on the "duty assigned by law" exception. Thus, the uncontrolled processing of data for commercial benefit and its collection in a centralized system ignores the risks of data being used for commercialization of healthcare services, the potential for sharing with international institutions to conflict with the KVKK and international data security principles, and the violation of physician-patient confidentiality and professional ethics.

So where does USHAŞ's revenue come from? The authorization fee, the system usage fee for its portal, brokerage/coordination fees, promotion/organization participation fees, etc. There's a "brokerage service revenue" item in its activity reports. What else? We don't know. Because it's not transparent.

What's the situation in public hospitals? Payments for incoming international patients are recorded through revolving fund revenues and paid directly by the international patient. Incredibly, it's known that in some university hospitals, this service is contracted out to an intermediary institution, the invoice is collected by the intermediary institution, and the patient makes the payment. The fee schedule charged by the intermediary institution to the patient is a mystery. Does USHAŞ also receive a share of the "referral, promotion, and intermediary services" here? We don't know.

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Why would the public establish a company? Public interest? USHAŞ, a closed-door company, lacks transparency in its use of revenues and is not open to independent auditing. Its revenues are not transferred directly to the public budget but are instead invested within the company's own budget. Therefore, the claim that revenues will be used for the "public good" is not based on any legally mandated guarantee. It should be understood that public interest should be measured not only by economic profit but also by equality of access to care, physician autonomy, and patient rights .

USHAŞ's activities in this respect seem to be highly debatable.

*Member of the Central Council of the Turkish Medical Association