Since 2002, the neoliberal policies in Turkey as well as all over the World “Health Transformation Program” or other expressions with “Performance System” has been implemented. The main problem of this study is the “Symbolic Violence”  that health personnel are exposed to while working in this program and the conflict it creates between the workers. In this article, the distribution and control of power in the field of health is discussed in accordance with Bourdieu’s “Theory of Practice”. Health is accepted as a “Field”, the social values and networks that health workers have as “Types of Capital”, the state that implements health policies as “Symbolic Violence”. As one of the researchers worked as a sociologist at the Physical Therapy and Rehabilitation Hospital, in addition to in-depth interviews with 85 health care workers consisting of physicians, physiotherapists and nurses, participant observations were also made. The qualitative research findings, which are descriptive as well as explanatory, have revealed that in daily life in the hospital, employees are exposed to “Symbolic Violence” and “Conflicts” in various degrees. The problems posed by the Performance System have been examined processually in both time and space, rejecting dualism and essentialism. In other words, symbolic violence and conflicts experienced in daily life in the hospital were analyzed in relational sociological way. In particular, uncertainties and differences are presented based on employees’ own statements.
Conflict; Health; Relational Sociology; Symbolic Violence; Turkey
As societies change with modernity, there are changes in sociology and new fields of study emerge. Cultural sociology is one of these areas. In understanding societies, culture is an important concept that cannot be ignored. Bourdieu, as one of the contemporary sociologists, focused on culture, differences and power relations in his relational sociological analyzes to overcome the duality of structure and individual.
According to Bourdieu (1984), the positions of individuals in social space are indicative of their cultural and economic capital and thus their class positions . The lifestyle and tastes of individuals (clothing, food, sports, art, literature, etc.) show their cultural capital. In this context, habitus, practices and dispositions within the health field help us understand the lifestyle and tastes of health workers . In fact, as Bourdieu (1984) exhibits a linear perspective in this analysis , as emphasized by Mohr (2013) and Kasapoglu (2019), he is in fact a relational sociologist [3,4]. Because the most important issue he focuses on is to overcome the structure-individual duality. He does this by including the culture factor in his analysis. However, although he implies that the upper classes determine the tastes or likes of the lower classes, he believes that the lower classes also affect the upper classes and show his relational view.
Taken together with all these levels of analysis, health emerges as a “Field” defined by Bourdieu (1990) . According to Bourdieu (1985), the field (science, art, social, literature, religion, medicine, etc.) is a network or clustering of objective relationships between positions that mediate between social structure and cultural practices . ” Health cannot be considered independent of the social structure and culture. All the economic, political and cultural conditions affect the health level of the society. The relations in the health system develop within the framework of social relations. All changes and developments in the fields of society such as economy, education and politics are reflected in the health field in the process.
In fact, according to Bourdieu’s theory (2012), health is defined as the structure in which a type of capital is distributed in a certain way . The symbolic power, which has the largest capital in the field of health as in other fields in society (law, education, politics, religion, etc.), makes reforms in many subjects in order to maintain its sovereignty and legitimacy and to dominate its own view. Art, much less autonomous areas such as health, according to literature and science, “Health Transformation Program in Turkey” - in accordance with the statement of Bourdieu (1977) - redefined and shaped by the Ministry of Health . State with the capital in a legitimate manner to all health field , using the symbolic power (acceptance-approval on) the Health Transformation Program in Turkey has undertaken since 2003. The state, which has the means of imposing and instilling the principles of “Permanent Opinion” and “Separation” in accordance with its own structure, is the perfect place for the application of symbolic power . The sovereign power, the state, imposes its symbolic capital on its agents through recognition and acceptance for its specific interests.
The Health Transformation Program implemented in Turkey in 2002 and is a health project that continues today. The neoliberal process in Turkey began in the 1970s. In the 1960s, socialization policies were dominant in health services. The way of implementing neoliberal policies in the field of health was achieved through health reforms. One of the important developments in this period was finance management in health services. Studies have been initiated in line with the privatization of hospitals.
According to Kol (2015), privatization in the health sector can cause two main problems : The first is the commercialization of health services, which cannot be considered as a commodity, and the decrease in the quality of service when left to the market economy. The second problem is that the state has failed to protect patient rights as a result of putting the patient in a commercial relationship with the doctor. This directs the government to purchase health services instead of providing health services. The emerging market-based competition concept continues to disrupt the peace among healthcare workers.
“Health Transformation Program in Turkey has carried out many modifications and changes in the health field. With the Health Transformation Program, it is envisaged that public hospitals will become autonomous both in administrative and financial terms and in terms of health service production. In this context, revolving fund and performance system based on this have started to be implemented. The revolving fund performance system, on the other hand, is based on the distribution of the health institution’s income from certain amounts according to the title of the health worker and the health service provided .
According to the “Performans Management in Health Report” prepared by the Ministry of Health (2006), performance measures in health services are patient satisfaction, health outcomes (achieving a better health level), rewarding the service delivery process (process measurement), quality of infrastructure and inputs (input analysis) .
In the field of health, it is necessary to look at politics, economy and cultural processes for all health and disease responses .
According to Bourdieu (2012), “Symbolic Capital” is a category of perception and it cannot be seen by agents . It can only be detected by agents with perception categories that allow them to accept. The symbolic power is based on the acceptance of the principles for which they are applied because of the unknown.
In the field of health, agents in the social sphere have cultural, social and economic capital. The dominant symbolic power, with its capital, develops dominant codes in order to have its world view accepted in the field of health. Health Transformation Program is the program in which the dominant codes are created by using the legitimate power of symbolic power (Ministry Of Health). However, symbolic violence which “describes a type of non-physical violence manifested in the power differential between social groups”  emerges when symbolic power imposes its own world view on agents. Because agents have the same category of perceptions as symbolic power (health reform, social progress, free individuals, health for all, a more egalitarian health service, old health system that has not succeeded, efficiency, effectiveness, quality). However, agents do not fully know the policies of the state, legal texts and institutional agreements. In this system, improvement and improvement of health conditions are presented to the agents as targets. In return, agents accept the Health Transformation Program and appreciate the symbolic power. As Bourdieu (1990) put it, symbolic action responds to socially formed ‘collective expectations and beliefs . In this context, the symbolic power commands and the agents recognize and accept the command. In this system workers feel that they have to obey without even being asked about obedience.
Health Transformation Program in Turkey is an approach consistent with neoliberal policies. In the program, the symbolic power in the provision of health care has only assumed the role of planner and supervisor. In addition, privatization was allowed and the service area of the public sector was narrowed and reduced. The increase in competition with the performance system causes health institutions to act as profit-making enterprises. The restructuring of the public health service in parallel with these neoliberal principles causes the commodification of health . In fact, the Health Transformation Program serves the capitalist system in which commodity production is the highest. In this process, health workers try to maintain or transform their professional positions due to symbolic violence. With the transformation of their capital (cultural, economic) into symbolic capital, they begin to rebuild their practices in the field. The best example of this is the performance system practice for physicians. The physician is charged according to the number of patients examined and treatment methods. This situation causes physicians to examine a large number of patients and to decrease the quality of service and to evaluate the patient with customer logic.
The performance system employs physicians and eliminates their autonomy ; it causes unjust situations for non-physician health personnel . The idea of injustice leads to new areas of struggle among health professionals. In this struggle, the ruling class can use all means such as belief, reputation, perception, knowing, fame, title, dignity, honor, and authority to transform symbolic power (the power to do things with words) into accepted power. Symbolic violence in new areas of struggle and the conflict between health workers caused by this violence constitute the main problem of the study.
Bourdieu (1999) sees the state as an arbitrator in the struggle for or holding the monopoly of legitimate symbolic violence . The capitals owned by the owners of power contribute to what makes it sovereign. This hides the actual position of the owners of power. This creates symbolic violence in favor of the sovereign, as opposed to the sovereign agents. The symbolic power has the legitimacy to use all means of the state while presenting the dominant worldview to social extension. In the process of symbolic violence, the field of law and the media are among the most important tools of symbolic power. Law and the media have an important place in dominating the sovereign view of the state with a monopoly of symbolic violence.
Making use of Bourdieu’s Theory of Practice (1977), the main purpose of the study is to reveal how the process of symbolic violence that health workers are exposed to with the Health Transformation Program . In the empirical part of the study, answers to the following questions were sought:
a) What are the difficulties faced by doctors, physiotherapists and nurses working in the field of health in performing their professions?
b) How is the relationship between the difficulties faced and the construction of the symbolic violence process?
c) What is the relationship between the performance system which is the implementation of the Health Transformation Program and the process of symbolic violence?
Investigation of symbolic violence through applied field research in health is considered that it will guide the investigation of the symbolic violence process in different fields such as economics, education and law and it is thought that it will contribute to the relevant literature with this feature.
On the other hand, due to the fact that the hospital where the research was conducted was a Physical Therapy and Rehabilitation: Training and Research Hospital (PTR: TRH), and there are a limited number of major disciplines of medicine.
This manuscript is part of a PhD thesis (Akbal, 2018) uses interpretive epistemology, the answers to ‘How’ and “What” questions were sought. Therefore, the research type is descriptive and explanatory .
In this study, qualitative research techniques were used in accordance with interpretive epistemology. While presenting the process of symbolic violence, critical discourse analysis (Vodak and Fairclough, 1998) was used to understand and interpret the relations of discourse and power .
In this study, in-depth interviews and observation techniques were used to reveal how the health personel working in Veterans PTR: TRH are affected by the transformation process in health, the process of symbolic violence and conflict. One of the researchers was also a sociologist at the PTR: TRH, which enabled to make participant observations.
The universe of this study is composed of health personnel working in Veterans PTR: TRH. The sample of our study consisted of 85 health workers, including 26 doctors, 22 physiotherapists and 37 nurses. In the study, “Theoretical Sampling” was used in accordance with the purpose of the study .
In the Findings section, all the data obtained for the purposes of the research were analyzed. In the study, it was revealed that performance system and practices are the basis of the difficulties faced by the health profession groups interviewed while performing their occupations.
The most important problem faced by doctors, physiotherapists and nurses in performing their professions is the ‘performance system. The findings in this section are given in order for physicians, physiotherapists and nurses.
Doctors’ Occupational Difficulties and Symbolic Violence
The performance system has been implemented by the Ministry of Health since 2004 in hospitals affiliated to state to encourage health workers to provide efficient and quality service. Different payment methods, such as payment by service, visit, day and case and item-based budgeting and global budgeting, are used to finance health care. Performance-based payment system causes public health institutions to become competitive actors in the system. Employees are rewarded for the achievement of the organization and individual performance goals.
The Health Transformation Program and Performance System, according to the Minister of Health, “is an exemplary application that is far from subjective assessments, based entirely on record, based on objective measurements developed and shaped over time”. It It is prepared and presented to the society by the symbolic power which Bourdieu (1991) defines as the power of establishing and structuring reality . Symbolic power convinces those subject to the system’s legitimacy and creates common perception schemes. According to Bourdieu (1990), “Symbolic power is the power to do things with words” .
Symbolic power uses symbolic violence to maintain its legitimacy. In this context, symbolic violence does not appear to be physical violence. According to Jenkins (1992), symbolic violence is related to the process of the imposition of symbols and meanings that groups and classes accept as legitimate . It is associated with the recognition process of agents. The symbolic power states that the Health Transformation Program will carry out the implementation process in four stages. These four stages of conceptualization, legal enactment, as controlled by selecting the local application and dissemination throughout Turkey is establishing its own symbolic system. Symbolic power reveals symbolic violence by using its concepts, powers, law and public opinion and enables the recognition of the symbolic system.
D1: The performance system, the more money the patient. The performance system enslaves the doctor, returns to trade, and money should not be in this much health. I think that the system in the early 2000s was much more beautiful and more respectful to the doctor. The doctor had more respect for the patient then. It’s officially a cashier, so I don’t like it.
D3: The performance system has made the profession thoroughly worthless. The doctor takes so much money, he doesn’t care about us, he says you’re gonna beat him. Everyone is waiting for your attention, smiling face, they don’t want to wait in line, they say you will get everyone, they encouraged people to emergency. In this system, doctors were like horses running and running to grab a piece of straw taken from the front.
All the doctors interviewed in the study stated that they complained about the performance system. Because it is emphasized that the performance system has turned health institutions and organizations into profit-making businesses, which serve according to market conditions in accordance with neoliberal policies. Charges are made for every procedure performed in the field of health. This situation directs health care workers to take care of health services commercially. Symbolic violence emerges with the recognition and approval of symbolic power and performance system by the health personnel.
D3: Doctors perform unnecessary surgery to score points. Surgeon, general practitioner, everyone is competing in the same category. Here I get 20 thousand points, no revolving funds, another hospital 7000 rubles to the same score being taken. You’ve done the same job, what’s your sin just because the hospital doesn’t distribute returns?
D9: I feel sorry for young people to work like dogs for a thousand, five hundred liras. While the average scores were around 15 thousand, now it is around 35 thousand; I know the doctor didn’t do what he said I did, but the system wants me to confirm it. The score I work and collect like crazy, that doctor gets from the work he didn’t do, could it be such an unfair system? Honestly working doctor who is below average can’t get any money. In this system, good medicine quality service is not important, serial work is important. They do things that should not be done, it seems that everyone in my country has appendicitis.
D18: For example, internal medicine has become an examination medicine. It is easy to ask for an examination instead of an examination, the patient is convinced, we also looked at the ultrasound. You didn’t get anything, but he’s performing, the x-ray is innocent, there’s a terrible mr and tomography spree. There is no beam permit in Europe because they don’t take that much X-ray. The performance system is an event of dismay, I don’t know why they don’t change. This isn’t an issue, you decide about the patient’s life. This is consciously wrong, but it would be wrong to just install it on the physician. In the past, you can not find the doctor went out of the performance system, now this event returned to examination medicine.
The participants emphasized that in order to increase the base salaries of doctors, more examinations are required and surgery is performed to increase the performance score just as they examine patients above normal. It is believed that the legitimate performance system put into practice by symbolic power creates unseen pressure on physicians, that is, by applying symbolic violence, it leads physicians to work more.
As stated by the doctors, patients are hospitalized for performance, discharged as soon as possible and replaced with another patient. One of the most important indicators is thought to be the number of operations.
During the first period when the symbolic power was dominant, the number of operations increased threefold during the last four years of the project. According to the performance system, operation is among the highest performance scores. Yet another issue that was discussed in the interviews is that to require unnecessary tests. When the number of imaging of some devices is examined by years, it is seen that there is a significant increase especially in MR and BT imaging numbers. Also according to the statistics of 2015 among OECD countries in the number of MR imaging per devices in Turkey ranked the first . The increase in the number of MR imaging indicates that more requests are being made due to performance concerns.
Although performance system scores are fixed, performance fees are covered by the revolving fund of health institutions. Therefore, economic capital is unequally distributed. For this reason, great differences are observed between the incomes of doctors. Doctors point to competition and conflict as a natural consequence of this inequality in economic capital.
D2: I absolutely do not approve of the performance system, something that disturbs peace and stresses people. I didn’t have a good doctor relationship where I came from because of performance concerns. Everyone is trying to do more than each other and this quality is very low. People try to look after the patient in two to three minutes, can not question the patient well, treatments can not be given correctly, I saw the doctor’s mistakes because of performance concerns. Because of performance concerns, doctors are competing against each other and trying to dig the other’s well. The performance system has brought down physicians, man says I am a surgeon, how the FTR specialist approaches me. At the end of the month in public hospitals who have what curcuna have.
D9: The transformation system and performance system in health have made us like this and destroyed our peace. No one is concerned about professional solidarity, sacrifice, good service; I am worried about how I can raise this salary, which lowers quality. Turkish Medical Association and Ankara Medical Chamber have a number of activities but these have been bypassed.
Doctors believe that the performance system creates an unfair environment by increasing competition among themselves. This is in fact the most important source of conflict among physicians. The performance system has prevented better provision of health services. For this reason, it is claimed that the biggest concern of the doctors is not the health services, but the performance fee they will receive that month. This situation decreases the quality of health; more importantly, it is stressed that it causes tension between health care personnel and disrupts peace among physicians. In fact, the symbolic power uses the performance system as a legitimate means of coercion, and thus tries to make doctors see more patients by operating them longer. Failure to control this situation is considered to be the most important deficiency of the system. The fact that doctors see a large number of patients and the same branches receive different performance fees put pressure on doctors and cause tensions between the branches. Symbolic power exerts symbolic violence on healthcare workers in order to maintain its sovereignty by using its symbolic capital. As the field of health is a field of struggle like other fields, those with high capital continue their struggles.
D6: Performance system output decay of manhood. There is no such thing as quality, the more you look at it, the better it is, then you assume that it is of good quality, it goes to God. The patient has three or five minutes left. We’re like orange, we’re coming, they’re sucking our water, we’re going to pulp. Performance is not a nice system at all. If everyone makes your voice, they will silence very easily.
D8: The performance system is no different from the paperwork I just said, it’s the one that imprisones the doctor entirely on the computer; perhaps a system that has been forced to show that he has even done things that he did not actually do, a system that is not necessary. I think it would be unfair if two FTR experts in different provinces receive different salaries, and this can be standardized.
D15: Performance is a burden on the physician’s back, a way of beating the physician. Something very handsome is performing; You will look at 70 patients a day, 40 per month will do surgery, we will give you five thousand pounds, he says. He says you’il work like a horse in return. You will not show enough attention to the patient, you will collect points, I will give you six thousand pounds money at the end of the month, this situation is civilized slavery. The state is staking the state, I do not know how to prevent it.
The Transformation of Health Program as a project, which is prepared by the symbolic power by making necessary laws and using legal ground, is presented to healthcare workers. While presenting to healthcare workers, the same perception schemes are created by means of language, press and law to ensure recognition of the project. The project is also supported by intellectuals who control social authority. In fact, a fully encoded symbolic system is presented here. Laws (applicable) are interpreted, implemented and reproduced by specially trained experts. In this context, doctors doubt the imposition of legitimacy in the social order, but they accept the symbolic system offered by the symbolic power, leading to the emergence of symbolic violence. Symbolic power maintains inequalities to maintain sovereignty.
Almost all of the system-related challenges appear to be related to the Health Transformation Program and the performance system. Another problem posed by performance is “İnadequate Economic İncome”.
D7: Your naked salary is too low for your pension. No graduate graduate salary reflected in the retirement salary is not 2800 TL, additional payment, performance, guard money, etc. and retirement is not reflected. When you get retired salary 2000 tl, fear of not being able to retire is one of the troubles. Another problem is that our hospital does not have revolving funds, there is 3-4 thousand differences between us and the hospital with revolving funds.
D22: The salary is low, in small places the revolving fund is good, the physician deserves it, he gets the performance of the salary he earned to the hospital, but this is not reflected in the retirement. In fact, according to the branches need to fix, then there will be no race between doctors, jealousy. I have not experienced it, but it could be jealousy and anger towards the system, not against that physician.
Payments such as performance fees, fixed surcharges and seizure fees that doctors receive while performing their duties are not reflected in their pensions. In addition, if the working health institution does not have revolving fund or collected money is low the performance fee is not paid or reflected in the salaries of doctors. This has started to be implemented with the Health Transformation Program since 2003. Therefore, doctors perform more in order to increase their income, see more patients and their working time increases depending on this situation. It is claimed that many doctors are not retired and have to continue working because their salary will decrease if they retire.
D11: Working conditions are the most significant difficulty, long working hours, continuation after seizures, working hours up to 36 hours in many branches.
D21: It is forgotten that the health worker is the doctor in the first place, I think this is the biggest problem. The patient and his / her relatives ignore this as they have their own needs. If this is remembered, we do not sit in the policlinic between noon, not everyone can come to the door and interrupt. Already there is a functioning examination process, but in the end I keep going in order, but everyone is insensitive patients, relatives, managers. Do you have a job, do you have a plan, that is, you are always forgotten that you are human, there is an inhumane approach in terms of working conditions.
The symbolic force applies symbolic violence through existing laws in relation to overtime hours. The current regulation is implemented through the management of health institutions. The performance scores of doctors increase during long working hours, while the performance score of the institution increases. Doctors state that the personnel who increase the performance score of the health institution are also protected by the management.
D9: Since I could not cope with the administration in my former hospital, they asked me to come to this hospital temporarily for three months. In the hospital where I used to work, the management has removed the “stop button hasta for patient entry, interpret what it means, and the whole problem of the hospital is to make money. I was working on the ethics committee at my old hospital, and we found some corruption there. We have reported that my interlocutor is the administration. Management always says, talk, suggest. Because the corrupt doctor makes money to the hospital, that score seems to be the success of the hospital, it is also written to the administrator’s household. These are always faded because there is such a partnership. Everybody’s doing this on this system.
As Bourdieu (1987) points out, symbolic power contributes to the continuity of the system by supporting inequality . According to the doctors interviewed, another issue that feeds inequality is unfair distribution of work.
D3: There is internal pressure from the system even though it does not appear. We can’t handle it and now we have burnout syndrome. All our enthusiasm for work has been broken, the pleasure of the profession is over. My wife gets up at two in the night, does angiography, sleepless morning in the polyclinic looking at 100 patients, working conditions are not human at all. There, he gives circulating capital, but he cannot spare time for his wife and child, and social life is to rest and relax at home.
D12: We have a heavy workload. It is a serious challenge to have a high number of patients, such as seizures, and to have a large number of patients under our responsibility. The high number of patients is not heterogeneous, it is not so in every hospital, it is concentrated in some areas.
Doctors state that the distribution of tasks in health institutions is not fair, that the workload varies considerably according to branches and hospitals, the workload should decrease with specialization in the task, but on the contrary, it increases even more. It creates a symbolic system by using the concepts of compulsory service, patient continuity and emergency health care. In this process, symbolic violence (such as strategic personnel, compulsory service) emerges as a result of the health workers fulfilling the requirements of the system. Unfair distribution of work and inequalities in performance are often expressed by the doctors interviewed in terms of patient density and continuous service.
According to the “Performance Management in Health and Performance-Based Payment System Report” (2006), the payment of performance-based wages plays an important role in the motivation of employees and the success of organizations . However, the doctors interviewed use a discourse contrary to this opinion. They argue that the performance system creates anxiety and tension in doctors, causes injustice, and prevents them from fully exercising their profession.
D3: Bring performance to motivate, but not so destructive. Give to the Eastern Anatolia, increase the coefficient where you have difficulty, if you give three thousand to the physician who has made 20 thousand points with all the facilities in the city, give five thousand to the doctor who has the same score in Nallihan. I worked in all kinds of hospitals in the Ministry, I worked as a manager, if the employee is not satisfied, the patient is not satisfied. The situation of the health sector is not good for employees. There are many expert advisors in the ministry who receive more salaries than me, just thinking.
D22: A physician should not pass through it because he earns more for me than the other physician. How many patients a day and how many minutes the physician will take care of. should be determined, performance concerns when there is no more efficient care of those patients.
The legal basis of the performance system is the Health Transformation Program and its implementation leads to the emergence of symbolic violence. The performance system creates a competitive environment among doctors; it causes conflicts both between the same branches and between different branches. It may also lead to stigmatization of the physician whose performance score is low and to be excluded because it affects institutional performance. The performance system, which is defined directly through the medical practice of doctors, is indirectly defined for other health professionals, thus causing conflict between doctors and other occupational groups.
Occupational Difficulties of Physiotherapists and Symbolic Violence
One of the most important difficulties of the physiotherapists involved in the study is the performance system that almost all of the physicians stated.
F2: We don’t get performance, I think physiotherapists should get it, after doctors, we serve the most in this hospital. Our physiotherapy technicians and nurses contribute in the same way. In my opinion, as a medical team, circulating capital needs to be allocated in certain proportions, according to the work done or the specific status.
F21: The more patients the current system, the more money, the more performance. The performance system is so nonsense, it doesn’t pass by the physiotherapist. Because of the performance, there is a queue in hospitals, most patients are treated in vain, surgery is in vain. In the meantime, we perish, but the patient is not guilty, no matter how much goes to the hall, money is taken in an area, performance is not this job.
According to the health performance system of the Ministry of Health (2006), performance fees are distributed from the hospital incomes (revolving fund) of the health institution . The share allocated to the personnel is calculated according to the average service points. Personal performance scores are determined by multiplying the coefficients of the health institution managers, laboratory branch physicians and other health personnel based on the titles, duties, working conditions and working periods and working in risky departments that are characterized by characteristics, by the average performance score of the institution. (For example, Chief physician coefficient: 5.00 - Biochemistry: 2.00 - Director: 1.00 - Doctor: 1.00 - Self-employed doctor: 0.30 - Physiotherapist: 0.40 - Nurse: 0.40 - Officer: 0.25).
Only the medical services provided by doctors (5300 medical procedures have been scored, but the procedures performed by assistant health personnel whose devices are under the responsibility of the doctor have not been scored) are made quantifiable. Other health care providers, doctors and managers outside the clinic whose services cannot be scored are rated according to the average score of the institution. Thus, the direct performance of clinical doctors and the indirect performance of managers and other health personnel are measured. Physiotherapists have indirect performance because they are non-physician health personnel and their procedure is not scored because they work under the control of physicians and their coefficients are lower than doctors. It is stated that the performance system is a system that operates entirely on financial gain, which increases the number of patients in hospitals and makes many medical procedures unnecessary. Physiotherapists also state that although they provide medical services like doctors, they never benefit from performance fees.
Physiotherapists make a comparison with physicians who receive performance fees that are very different from themselves due to their training and responsibilites and they find this comparison natural.
F6: The performance system is very painful, I see the patient several times every day, sometimes for months, so the doctor doesn’t have that, so we can’t even reach the doctor when we need to communicate with the patient, but they have the performance. This is due to the fact that he is an FTR doctor in our country.
F18: According to what we do, our salary is low. The doctor takes the most part of the performance cake, leaving us 10-20 tl. There is nothing in the Health Implementation Communiqué that limits the number of patients the doctor receives to a single physiotherapist. I respect physicians, they have studied for six years and five years of expertise on school, they are the ones who made the decision, but this system is unfair, it shouldn’t be that much difference. It’s obviously offensive. I’d be uncomfortable if the doctor took it from me, of course it would get high, but not that much.
Physiotherapists’ medical services are not scored in the performance system, ie their performance coefficients are calculated indirectly. However, since these wages are distributed according to performance coefficient, the share of other health workers (such as physiotherapists, nurses, social workers) is very low compared to doctors and managers.
Physiotherapists emphasize that the performance system increases occupational injustice and causes the motivation of physiotherapists to decrease. Even when they receive performance fees, it is stated that there is a high performance difference between doctors because their coefficients are quite low compared to doctors. In fact, even in the salaries of physiotherapists performing the same profession in two different cities, there are visible differences. Physiotherapists, who state that their salaries are very low compared to doctors in the normal process, think that the performance system deepens this difference further. This may cause conflict between the doctor and the physiotherapist. The symbolic power maintains its dominance by feeding inequalities with the symbolic system it conducts. Physiotherapists recognize the symbolic system even though they have objections to the performance system and fulfill their requirements. In this way, the symbolic power unintentionally applies symbolic violence to health workers - which health workers are also not aware of.
F3: As far as I see the performance system is a system that enriches the doctor, I question the reliability of this system. For example, I take 7 patients in the neurological hall, 20 patients in the hand hall, 50 patients in the group, how does the system adjust this? According to the system, I take fewer patients, but I have the most severe patients and I do the most intensive work. If the group receives the most money, the system is screwed. The system, which forces us to score, to numerical data, is both contrary to the spirit of the profession and disrupts quality. Although the doctor does not need the patient increases the examinations, the state is damaged. Physiotherapist makes the patient do stretching, but when you look at the page furnished, tics thrown, I can not do all of this, time is not enough. It is not true that all of them are overcharged, the system has directed everything to the material.
According to physiotherapists another important difficulty is high number of patients derived from performance sysyem.
F9: The number of patients is still too high, and the newly graduated assistants come to the hall and say why don’t you get more patients, because every patient we receive turns to him as money. The performance system is a huge loss of motivation for us, and it is very devastating for us not to receive money in other places. The performance system should be removed, the doctor writes every incoming patient whether or not he needs treatment for extra money. I think they consider the patient very poor quality, instead of half an hour and five minutes, the patient comes with false diagnoses. Standing patient never ends, you finish the treatment and send it back on Monday, we talked, he says. If we’re teammates, ask if there’s any improvement in the treatment? They never buy us a castle, they don’t get our opinion.
F15: It doesn’t matter whether public or private, hospitals are a business, somehow it should be turning around. The more patients you get in this system, the more billing you will get, so the employer wants to give you more patients. If the law says five patients a day, the problem arises as to how the employer will run the business and how it will cover the cost. Quality decreases, we do not treat patients. If 25-50 patients are taken per day, the patient is not treated. The circulating capital that is never given to us goes to doctors. It’s not a difficult thing for doctors, he says go and do it, he teases.
The performance system is one of the main reasons for increasing the number of patients for physiotherapists as well as doctors. Doctors complain about the short duration of examination, diagnosis and treatment, and the poor quality service caused by the high number of patients; physiotherapists complain about the impossibility of serving more than one patient at the same time. Both occupational groups connect the cause of patient increase to the performance system. However, as stated by physiotherapists, doctors are not satisfied with the performance and want the performance system to be abolished. Because this system, which is carried out by the symbolic power by the law, decreases the quality of service for the groups providing health care and receiving health care services and causes conflicts in the relations between the healthcare workers in the competition environment created.
F7: We work with three patients in each session, finding 15-16 patients a day. Normally, for a productive treatment, you get one patient in each session, because you have a lot of patients, you have to keep up with them. I do whatever the patient needs, but I’m running around, giving it to myself. The doctor sees the patient at the first examination, I deal with the patient for 60 days, the performance goes there. If they see a slight looseness in your face, you will immediately go to complain or punish. Everything is known in the complaint but not in the reward.
Like physicians, physiotherapists state that the most important challenge they face in performing their profession is the performance system. Physiotherapists, however, argue that doctors receive a very high performance fee compared to their occupational groups, which in turn leads to injustice and conflict.
Professional Difficulties of Nurses and Symbolic Violence
Some of the difficulties that arise from the system that nurses face in performing their profession are the same as those seen with doctors and physiotherapists. First of all, the performance system is an undesirable system in the field of health for nurses.
N5: In order to get into the performance system, he has to take criteria to measure my performance. For example, they can’t measure mine, I’m dressing, I’m injecting, I’m wearing serum, I’m entering the name of the doctor, where my work goes, my performance is zero, aside from the financial side of the job, the doctor always seems to do it. If it’s going to be a performance system, my work should be in my name.
N21: There is a lot of difference between me and the doctor, because the Ministry of Health considers the event as the Ministry of Health, in the performance evaluation, even the performance of my work is seen in the doctor and I feel that I do not work. According to the Ministry of Health, my labor is worthless. Because it works in the logic of business, you get that much money if you do this operation. Unfortunately, the doctor’s class, they’re looking at the money to go into their pockets. We are far below this level. Therefore, the economic gap continues to increase. The performance system needs to be lifted for everyone, it is contrary to the principle of the social state of the constitution.
N37: Works are performed to get full salaries. Other medical services, i.e non-performing procedures, are performed less frequently. For example, family visits are not made. The performance is given only to doctors. Not for the nurses. THP is a completely patient and money-oriented system. Of course I do if they have to be done because they are presented on legitimate grounds. We accept things we can’t change.
The performance system, which has been implemented with the Health Transformation Program, is defined as an extremely unfair system for nurses. According to this system, the performance of nurses, like physiotherapists, is measured indirectly. This directs nurses to make a comparison with the doctors whose performance is directly measured. Because according to the nurses, they provide health services like doctors, but every procedure they perform is shown through the responsible doctor. According to the nurses interviewed, because every medical procedure is charged in the performance system, it causes the commercialization of the health field. Accordingly, it is stated that it will lead health care workers to perform transactions corresponding to high wages in the performance system. Although the system is opposed by nurses, the symbolic system of symbolic power is recognized and fulfilled. It is thought that the rulers make recognition of the system through tendencies and symbolic distinctions it creates. Whatever the system requires, nurses continue to provide health care with the tendency not to victimize the patient. The physician-nurse and the physiotherapist-nurse persist in symbolic power by persuading them to exist. However, as with physiotherapists, nurses also cause conflict with doctors because of the performance system.
One of the most important reasons why nurses object to the performance system is that they have an insufficient economic capital as they are indirectly involved in the performance system. At the same time, they state that their economic capital is low as a problem arising from the system.
N6: The money will be less, of course, the doctors will be better, but our work should be rewarded a little more. We are always with the patient, but the nurses are seen as the practitioner in the doctor’s center. I’ve been doing this for 15 years, I thought about resignation for the first time two months ago, my salary goes to child care and car money, I get tired twice as much.
N20: Economically there is a gap between the doctor and the nurse, I think we’re getting one third. I can understand that the doctor’s fee is high, theoretically the patient is more at risk for him, we are the practitioner of the treatment on a diagnosis made by them. We take risks too, so I find their money right, but I think it’s wrong for the nurse to take as much as a third of it. The doctor makes the diagnosis, plans his treatment and leaves. I am the person who is alone with the patient for 24 hours in the clinic, I am the one who follows, I am the one who informs, then I do not think we are equal, I think it is unfair to pay.
According to Bourdieu (1987), symbolic power is a socially approved authority and holds the power of law . It carries out a “naming and law-making action” by announcing the provision that should be related to them in conflicts between individuals or groups, through laws (Health Transformation Program and Performance System). The provision is the most perfect form of public discourse that addresses all agents, and has the power to make itself universally acceptable. These provisions, which Bourdieu describes as “Magical Laws”, bless the appearance of the state’s order. Through these provisions, it gives its agents status, powers and identities. In other words, it assigns a symbolic power by distributing different capitals to actors or institutions through law. While symbolic power continues the symbolic system created by the authority of the laws; one of the factors that reinforce the existence of the ‘doctor and others’ scheme is the lower level of the economic capital of other health workers. According to the nurses, there was a reasonable difference in terms of economic capital between doctors and nurses and physiotherapists in the health institution where the study was conducted; then the economic capital gap increased considerably, and even the nurses’ economic capital decreased further than the current state. With the performance system, when doctors’ current income increases, doctors and others are reinforced, and nurses, like physiotherapists, find themselves in a comparison and conflict in terms of their work. The fact that there is a significant difference between nurses and doctors in terms of economic capital and this reduces the motivation of nurses.
In order to bring innovations to the existing systems in many fields such as education, law, economy and health, by the symbolic power, a number of regulations are made under the title of reform. According to Bourdieu (1990;1998), the dominant discourse imposes sanctions on the underdeveloped countries with the violent policies adopted by the IMF, OECD and the World Bank [5,25]. In Turkey, a number of reforms in the health field to the present day with the effects of neoliberal policies implemented at the beginning of the 90s. In 2002, in accordance with the symbolic power, neoliberal discourse, which was elected by the government in 2002, the Health Transformation Program was initiated in 2003 with the support of the World Bank. In other words, all features of neoliberal discourse (unregulated financial market, individualism, temporality, competition, flexible market conditions) have been defined in the political process and the program has been presented to the society.
Symbolic power has entered a new process of formation by changing rules and regularities in the field of health. The most important reason of this formation process, as stated by Bourdieu, is thought to preserve its position in the field and its network of objective relations, that is to say its sovereignty. While maintaining its sovereignty, it also tends to struggle with individuals and institutions that occupy other positions within the field. In this struggle, an individual adapts to the rules and regularities of the field in which he / she wants to stay within the institution in order to maintain his / her position or to obtain the most appropriate position. In this case, too, it is subjected to symbolic violence by accepting / consenting or obeying the rules of the area determined by the symbolic power.
Symbolic powers which have symbolic capital in the hands Transformation Program in Health in Turkey “Human centrism, sustainability, continuous quality improvement, participation, agreeableness, volunteerism, decentralization, competition in services” as presented in the health field by using its dominant codes and put into practice. In the beginning of the program, media tools, public opinion polls were presented to the society and health problems were explained to individuals, groups and institutions, while it was emphasized that the Health Transformation Program would be a solution to these problems and expectations. However, in this process, no opinions of healthcare workers or health care providers about the program are included. Health care workers and health care providers are subject to symbolic violence by accepting / consenting to the program offered by the dominant codes of the dominant sector.
In order to show how the symbolic violence they are subjected to, the difficulties experienced by the participants were set out. According to the participants, one of the most important steps of the Health Transformation Program is the ‘Performance system. As mentioned before, the performance system is the payment of health workers over their performances, the measurement of the performance of the institution according to the performance of the employee, and the performance of the financial transactions of the health enterprises transferred to the private sector according to these performance measurements.
The performance system is thought to be one of the tools that symbolic power uses to apply the dominant worldview neoliberal discourse in the field of health. Because, as the participants stated, the system increases the competition, decreases the quality of service, creates an environment of insecurity, and mechanizes the health workers and creates the financial market logic determined by the market conditions. The work performed by the health care worker is entered into the system as the corresponding performance score and the employees whose fixed economic capitals are limited are directed to make more transactions in order to increase their economic capital. This leads to an increase in unnecessary health care or missing / incorrect health care. The increase in competition is thought to cause conflict even between two employees having the same occupational status, increasing individualism among health workers and making them lonely and unhappy.
While performance fees are determined by revolving fund commissions, managers and healthcare professionals are paid according to coefficient differences. As the number of patients applying to health care facilities is different, there are huge disparities between the performance fees between two doctors in the same branch. In other words, the performance system reinforces inequality and conflict between physicians, physiotherapists and nurses both among themselves and among other health professionals. It is considered that symbolic power reinforces the distinction between performance system and “doctor and others”. Symbolic power continues its hegemony by creating and reinforcing dualities .
Doctors in healthcare institutions see a large number of patients, perform a large number of procedures, plan treatment, and cannot allocate the time needed for the patient to increase their economic capital. This situation leads to unnecessary medical practices, decreases the trust of the patient to the doctor and other health workers, decreases the respect in parallel with the trust and increases the violence against the health workers. The symbolic power, with its performance system, causes physicians and other healthcare professionals to see more patients and to take them into treatment programs and to expose their working time with the consent of the employees, causing them to be exposed to symbolic violence. However, symbolic power reproduces the performance system and symbolic violence and inequality at every stage of health.
At the same time, it can cause health gaining applications such as commercial enterprises to gain importance. Although the competition environment created by the performance system does not increase the motivation of the employees, it can create a competition environment and cause financial criteria to gain importance instead of health service.
As a result, because health care workers are not satisfied with the system, because the performance system, which is seen as the source of symbolic violence, implements the symbolic power by laws; they perform their duties as requested. The performance system is the basis of the many difficulties that doctors, physiotherapists and nurses define from the system, the profession itself and the patient, and thus the symbolic violence experienced by the health worker, the main problem of the study.
In fact, some dichotomies and one-way determinations inevitably come to the fore in this study. However, the relational sociological importance here is to examine the differences in terms of health personnel (physician, physiotherapist, nurse) based on process in daily life. It should also be noted that, as far as possible, a holistic view is made not to be essentialist. As Mohr (2013) has already pointed out, Bourdieu was forced to accept linear determinations, which he criticized as a relational sociologist, contrary to his theory . In many relational sociological studies, it is once again underlined that there is not a single relational sociology that includes all the principles .
Figure 1: Occupational Difficulties of Health Personnel.
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