It is not realistic to allege that health policies are not influenced by global trends. The Turkish healthcare system is in transition towards a more European model. The engine of this transition is doubtless the Government’s Health Transformation Programme. The programme aims to raise the effectiveness of the health services in terms of governance, efficiency and fiscal sustainability.
The Health System
Before illustrating the reform programme it is useful to examine the state of the healthcare system in Turkey, the number of hospitals, physicians, the health insurance system and also government spending on health.
In comparison with population, there is a significant lack of health human resources. Physician density was half of OECD average in 2006. Also nurse density is only one-fifth of the OECD average. Besides the lack of human resources, human resources are inadequately distributed among provinces (this is especially true before 2003.) The graphs included provide us with some statistics about the Turkish healthcare system.
There are also important issues concerning social insurance funds. Historically, there were three different social insurance funds:
(i) emekli sandıgı – government employees and retirement fund,
(ii) sosyal sigortalar kurumu (SSK) - blue and white collar workers in public and private sector and
(iii) bag-kur - social security organisation for artisans and self-employed.
There has also been a programme called Green Card, its objective being to provide health services for poor citizens.
There are, however serious contradictions concerning the coverage of health insurance; according to the Turkey Statistical Institute, 64% of the population is covered by health insurance where the ratio is 85% according to National Planning Organisation. These discrepancies are especially noticeable in the information concerning coverage of SSK and Bagkur. Their total coverage is 46,2% according to Turkey Statistical Institute and 68,6% according to the National Planning Organisation.
Public health expenditures were 4% of the GDP. According to the 1999-2000 National Health Accounts (NHA) private expenditures on health in Turkey constituted approximately 37% of total health expenditures. Half of health expenditures were on the curative care.
Access to healthcare was not equal among the regions of the country, delivery of healthcare services was strongly influenced by the fragmentation of the insurance institutions and also the quality of healthcare services was poor at the beginning of 2003. Also health indicators were significantly lower compared to the other OECD countries.
To summarise, the fragmented structure of health financing, with the majority of the health expenditures on curative service rather than primary healthcare services, the regional inequalities in access to healthcare services and governance were the main imperfections of the Turkish healthcare system. These long standing problems need to be addressed by a comprehensive reform programme. The Health Transformation Programme is designed to address these problems.
Health Transformation Programme
The basic principles of the Health Transformation Programme are:
(i) Human orientation, which refers to individual needs and expectations as a basis of planning the health services, and also the “family health” concept are the keystones of the health services;
(ii) Sustainability, which refers to fact that the restructuring of the health services should be compatible with the domestic conditions as well, especially for the sustainability of the fiscal policies;
(iii) Continuous quality improvement;
(iv) Participation of all stakeholders;
(v) Conciliation of health service providers and other civil institutions;
(vii) Separation of authorities such as financing, planning, supervising;
(viii) Decentralisation, and
(ix) Competitiveness in service.
The Health Transformation programme is offering to enhance the role of the Ministry of Health in terms of planning, controlling, monitoring and evaluating rather than service providing. The responsibility of a state department involves policy making, priority setting, data collection, and analysis, financing and overseeing the local public health activities. Also in the re-organisation process, enhancing the autonomy of hospitals is the key factor. Social security reform is designed to avoid inefficiencies of insurance and duplications of health insurance. Also family medicine practice is designed to mediate improvement in primary healthcare services. E-health was one of the other key factors to monitor the effects of the regulations and the outcomes to the policy makers.
The Health Transformation Programme (HTP) has a framework of eight themes;
1. Rearranging the Ministry of Health as a planning and supervising authority;
2. Unifying all citizens under a single social security institute;
3. Increasing the accessibility of healthcare services;
4. Improving the motivation of health personnel and increasing knowledge and skills;
5. Supporting the system through education and scientific institutions;
6. Advancing the qualification and efficiency of the healthcare services by means of quality management and accreditation;
7. Institutional restructuring in rational management of medicine and supplies, and
8. Providing access to effective information for decision making, through the establishment of an effective Health Information System.
For Turkey, a new operating system for primary healthcare services, family medicine, was first implemented in Düzce in 2005. Today, in 23 provinces, meaning about nine million citizens, are benefiting from the practice. Approximately 20% of Turkish citizens are enrolled with family doctors. Family medicine practices put primary care services at the top of the public agenda, make primary care attractive and thus facilitate easy and widespread provision of these services. Success of the system will reduce the number of patients visiting hospitals and alleviate excessive workload at hospitals.
The biggest barrier to the effectiveness of the implementation of family medicine is the shortage in numbers of practitioners. In provinces where family medicine is under implementation, community health centres are being established. These centres provide integrated, preventive, diagnostic, curative and rehabilitation services and are responsible for overseeing preventive health services such as vaccination campaigns, and reproductive and child health services.
In a survey conducted under family medicine studies in Düzce, people were asked to what extent they were contented with family medicine services given so far and answers revealed their level of satisfaction (Family Medicine Survey).
Expenditures on primary healthcare have also increased. In 2002, total budget allocated to preventive and the primary healthcare services was 578 million dollars and in 2007 total budget allocated to preventive and the primary healthcare services increased to 1,720 million dollars.
As part of the programme all public hospitals except university hospitals and the hospitals belonging to Ministry of Defence were integrated under control of Ministry of Health. Thanks to this regulation obstacles concerning patient accessibility to the healthcare services were eliminated, as was discrimination among different social insurance coverage. Also unbalanced workloads among hospitals were regulated. Today all hospitals deliver service to all people homogenously. Hospitals have also become more autonomous and their procurement methods more flexible.
To fulfil its aim of improving the management of healthcare institutions, the Turkey Health Institute arranges an education programme for public hospital managers called the Hospital Management Certification Programme. The programme consists of lectures such as finance management in health institutions, human resource management, information systems management, total quality management in hospitals, financial accounting health institutions, marketing strategy for hospitals, supply chain management in hospitals and health law.
Law 5502 was adopted by the Turkish Grand National Assembly in 2006. This law, which was meant to accompany Law 5510 (Law on Social Security and Universal Health Insurance), aimed at unifying the three different social security and health insurance schemes (SSK, Bag-Kur and Emekli-Sandigi) into one unified social security institute. Implementation of this law had been underway since 2006. As a result, there currently exists within the SSI, a Universal Health Insurance Fund (UHI Fund).
As a short-term plan, the Ministry of Health developed a strategic plan for the period 2009-2013 which consists of nine main pillars and strategic objectives:
1. Decreasing the risks of illness and protecting public health by improving preventive and primary healthcare;
2. Delivering effective, efficient, accessible and equal curative services;
3. Performance management and quality improvement in healthcare services;
4. Re-organising and capacity improvements of both public and private health institutions;
5. Improving medicine and medical device services;
6. Establishing, processing and developing e-health and decision support system;
7. National and international collaboration to improve the health services;
8. Encouraging health tourism, and
9. To complete covering all citizens under the social security insurance.
The effects of the Health Reform Programme cannot be seen in the base health indicators such as infant mortality rate, life expectancy at birth. However it is obvious that overall satisfaction concerning health services has risen dramatically. The rise in overall satisfaction indicates health reform has revealed positive short-term effects. It is however, vital that not only policy makers but also other stakeholders such as investors keep monitoring the system to ensure long-term improvements.
Private Hospitals and Healthcare Organisations Association The Private Hospitals and Healthcare Organisations Association is a service-provider with the strongest voice of the private healthcare sector. Although our association was established in 1991, it became a legal establishment in 2004, using its previous knowledge, experience and know-how. Our association has been going under the umbrella of OHSAD since 30.12.2004 as a result of four associations in the healthcare sector merging together to create one stronger organisation. These four associations are The Private Hospital’s Association, Healthcare Organisations Association, Tourist Regions Health care Institutions and Organisations Association and The South-East Anatolian Private Healthcare Institutions Association. After this conglomeration was established, 80% of the private hospitals and 850 healthcare organisations joined the same association.
In recent years, the importance of non-governmental organisations (NGO) and their participation has increased in reaction to existing laws and regulations. This increased participation led to some difficulties regarding organisation but they were rapidly solved during the the period of re-organisation of NGOs. But there are still some problems including financial sources, education, culture, lack of communication and confusion which are the factors that affect the development of NGOs.
We have established our association’s centre office in Elmadag, Taksim Istanbul in May 2005. This is a central place for our meetings that will serve our “strong association-strong sector” principle to deal with the outstanding problems. Professionals were hired to carry out these projects.
Our main aim is to use the country’s limited healthcare resources in the best way possible and to develop the healthcare sector to improve the health level of society by providing effective and qualified healthcare service representation. The way in which our aim can be achieved is through providing a strong base for changes to occur in the healthcare sector with the support of members. Our achievements are based on our institutional structure and professional staff. Our guidance is provided by our distinguished members, suggestions and ideas, like Mr.Yasar Yıldırım and Mrs.Banu Küçükel who represent us in EAHM. OHSAD has been a member of EAHM since 2003 and the 82nd Executive Committee Meeting was organised succesfully in April 2006 by OHSAD in Istanbul, with the leadership of Mr.Yasar Yıldırım.
All our achievements are for a healthier community and a continuously improving health sector in Turkey.
Full references available