Prof. Mustafa Özmen
Professor of Radiology
deputy General director
Since the formation of the modern Republic of turkey in 1923, successive governments have looked towards the West in the development of the country’s economic models. this is reflected in turkey’s current candidature for EU membership. In the same period, turkey has seen a relatively rapid population growth and a high rate of urbanisation. In spite of this, the turkish community’s central cultural value of collective social responsibility for health and welfare has remained strong.
Driven by these influences, Turkey’s health and social reform agendas have been ambitious in the past few decades. The growth in the healthcare sector has been substantial. Key recent gains have been built on a strong tertiary health sector, a gradual move towards corporate provider accountability and workforce development. These gains have been underpinned by relatively strong economic growth in the last few years.
According to the Annual Plan of the State Planning Organisation of Turkey, the country’s population had grown to 72.9 million in 2006. This makes Turkey one of the twenty most populous countries in the world, between Germany and France. The same plan shows that the annual population growth rate is 1.24 %, or 1.41% in the year 2000. In 2006, 68 % of the population lived in urban areas.
The latest reports of the Ministry of Health show life expectancy in Turkey is increasing. In 2006 it was 74.0 years for women and 69.1 years for men: lower than the USA and higher than China. A current objective of the health service reforms is to increase life expectancy to international benchmarks. Turkey has a young population structure; 29 percent of the population is under age fifteen. The part of the population of age 65 and over accounts for seven percent of the total population in Turkey.
A Centralised Yet Complex Structure
Turkey’s health system has a centralised structure. However, in many aspects it suffers from fragmentation and complexity in the responsibilities and relationship of its component parts. Healthcare is provided by public, semi-public and private organisations, but there is limited coordination amongst them. Healthcare is financed by the government by tax and by premium and out-ofpocket payments. Last year, a new Social Security Institution was established by a law that combined four major different social insurance organisations and reassigned structural responsibilities for health and social insurance in Turkey.
The Ministry of Health (MoH) is the main government body responsible for health sector policy-making and implementation of national health strategies. This is progressed through a combination of funded programmes and direct provision of health services. The MoH is also the major provider of primary/secondary/ tertiary healthcare, maternal health services, children’s and family planning services. It is essentially the only provider of preventive health services through an extensive network of health facilities (health centres and health posts) providing primary, secondary, and specialised in-patient and out-patient services. According to MoH data, in 2006, the MoH had 795 public hospitals and 6,203 health centres. There were 56 university hospitals and a rapidly increasing count of 332 private hospitals.
Programme Establishes Independent Practices
In recent years a programme has been operating, which has established independent family medicine practices in a number of regions. A goal of this programme is to strengthen primary healthcare and the referral chain to improve access to and equity of distribution arrangements for diagnostic, specialist and secondary care services.
Hospital Industry Privatisation Trends
According to the Ministry of Health statistics, Turkey had 332 private hospitals in 2006, a substantial increase from the count of 237 in 2002. A major factor associated with this increase has been governmental actions such as the social security institution’s policy of purchasing increasing proportions of healthcare services from the private sector. These trends have been paralleled by a growth in private health insurance marketing and uptake. The Association of the Insurance and Reinsurance Companies of Turkey has reported that the premium income of private health insurance companies has increased from 12 million dollars in 1991 to 717 million dollars in 2006. According to the same data, almost 1.2 million people in Turkey have private health insurance and 36 private insurance companies were providing this cover in 2006.
The private hospital sector in Turkey has embarked on a vigorous export programme for elective surgery services as has been happening in other countries in the region with few regulatory constraints on the private hospital sector. This has further fuelled the growth of the private hospital sector relative to public hospitals.
Healthcare Expenditure Growth
The results of National Health Account Study in 2006 shows that Turkey’s total health expenditure was 31.4 billion dollars (see table 1, below). It has four main sources of healthcare financing:
• Public expenditure - 22.8 billion dollars (72.4%)
• Private expenditure - 8.6 billion dollars (27.6%)
• Out of pocket expenditure - 6.1 billion dollars (19.3%)
• Other private expenditure - 2.7 billion dollars (8.3%)
Generally, out-of-pocket payments consist of direct payments to private doctors and institutions, premiums for voluntary health insurance and co-payments. In 1992, Turkey’s total health expenditure was 6.02 billion dollars, public expenditure was 4.04 billion dollars (67.1%), and private expenditure was 1.98 billion dollars (32.9%). According to the National Health Account Study in 2006, healthcare expenditure has generally exceeded 7.7% of the gross domestic product (GDP). The proportion of GDP spent on healthcare increased from 1992 (3.7%) to 2000 (6.6%). Healthcare expenditure per person in Turkey in 2006 was calculated at 411 dollars, this compares with 103 dollars in 1992.
Radiology in Turkey
Radiological services in Turkey represent a substantial and growing proportion, approximately 6%, of the operating budget and approximately 20% of the capital assets of the health system. Diagnostic imaging services are distributed through hospitals, free-standing specialist diagnostic imaging centres and centres associated with other specialties. For years in order to overcome the waiting list problem, public institutions were allowed to refer the patient to private imaging centres. This resulted in a major growth over the past ten years in the utilisation of diagnostic imaging. However, this also resulted in the overuse of diagnostic imaging, creating a reflex on the payer side to lower the prices of diagnostic exams.
In common with other countries, some concern has been expressed in recent years about these arrangements. By next year, healthcare institutions will be prevented from referring their patients to imaging centres. However as an alternative, they will be able to cooperate with them as partners in service provision. Discussions are also underway on the need for a review of referral requirements and the process of accreditation of diagnostic imaging facilities. Major success factors in the growth of diagnostic imaging have included:
• Improved access to CT, MRI and PET facilities;
• Development of capacity in teleradiology and PACS facilities, and
• A commencement of reviews of funding and payment arrangements for diagnostic imaging services.
Turkey’s healthcare system has been a major focus of its social and economic reforms over the past two decades. The pressure for reform has been escalated by Turkey’s EU candidate processes. In addition to the gradual growth in Turkey’s GDP there has been a substantial growth in the proportion of GDP allocated to healthcare. Structural reforms in the social security and health insurance arrangements are now providing potentially powerful tools for making Turkey’s healthcare services more accountable and better equipped to lobby for the right resources in the right places.