Analysis

Healthcare in Turkey: from laggard to leader

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.c7456 (Published 21 January 2011) Cite this as: BMJ 2011;342:c7456
  1. Enis Baris, director1,
  2. Salih Mollahaliloglu, head 2,
  3. Sabahattin Aydin, deputy undersecretary3
  1. 1Division of Country Health Systems, WHO Regional Office for Europe, Copenhagen, Denmark
  2. 2School of Public Health, Ministry of Health, Turkey
  3. 3Ministry of Health, Turkey
  1. Correspondence to: E Baris, The World Bank, Room H9-271, 1818 H Street NW, Washington, DC 20433, USA ebaris{at}worldbank.org

Enis Baris and colleagues observe that a political commitment to universal health coverage together with a significant investment in health has seen Turkey’s health indicators catch up and surpass other middle income countries

Less than a decade ago, the health system in Turkey was considered a laggard, not only relative to the rest of the Organisation for Economic Cooperation and Development (OECD) but to other high middle income countries. A major discrepancy existed between constitutional aspirations of equitable access to healthcare for all citizens and the reality on the ground. Health mattered, yet was seldom addressed on the political agenda. Today, the health system in Turkey is transformed, not quite to the point of favourable comparison with the rest of the OECD and most of the European Union, but fast closing the gap in health outcomes, responsiveness, and fair financing. We describe the Health Transformation Programme (HTP) launched in 2003, analyse the reasons behind its achievements, and share the lessons learnt.

An underachieving health system

Turkey’s health system was highly fragmented: it was governed by two ministries and financed and regulated through three separate statutory health insurance schemes. The system covered all of the employed population and a large proportion of the self employed, though with significant variations in the scope and depth of benefit packages. Direct and copayments at the point of service and subsidies from the state budget were the norm, and included the Green Card scheme, a health insurance plan for the poor, covering inpatient care for about 2.5 million people. Overall, about 65% of the population was covered. In 1998, Turkey spent 3.6% of its gross domestic product on healthcare, or about $295 per capita at purchasing power parity (£191; €220 at current exchange rates). About 40% of total health expenditure was private and out of pocket.1

Service provision was also highly fragmented. Several ministries and health insurance schemes offered or purchased different service packages from public or private providers. Despite a reasonable level of coverage, most people turned to the private sector to receive more responsive and higher quality care. Most physicians remained on the public payroll for job security and benefits, but supplemented their low salaries by taking under the table payments in public facilities or working part time in private. Rampant absenteeism and low productivity and technical quality, especially in primary care, was common, with unnecessary referrals to outpatient specialist services. Further issues were severe inequalities in rural areas, especially in the east and south east of the country, and inequalities in access to services because of shortages of facilities, technology, and skilled health workers. Public health and primary care were given little attention, evidenced by lower life expectancy and higher maternal and child mortality relative to other middle income countries.2 3

Political change spearheaded transformation

Turkey entered the 21st century with a broad based consensus on the need to strengthen its health system governance, introduce universal coverage, and expand and streamline service delivery. But after two decades of ineffectual coalition governments, the country was without the leadership or political commitment to implement these goals. The 2002 elections, in the aftermath of a major financial crisis, propelled a new majority Justice and Development Party (Adalet ve Kalkınma Partisi, or AKP) government into power. The new government understood the urgency of the need to transform the health system. It was quick to realise that the popular mandate would quickly dissipate if the government could not deliver on its promise of putting the state at the service of its citizens—a fundamental shift in Turkish political culture—but also understood the importance of reducing inter-regional inequalities in access to health and other social services in safeguarding social peace and stability in the country. There was also the constant embarrassment of facing international criticism for appallingly high maternal and infant mortality.

Transformation in Health, a white paper issued by the Ministry of Health in December 2003, provided a candid assessment of the shortcomings of the existing system. It also laid out the guiding principles of the Health Transformation Programme: a people focused approach, pluralism, separation of power, decentralisation, and competitiveness. These goals entailed radical restructuring, such as the redefining of the roles and responsibilities of the Ministry of Health towards “more steering and less rowing”; separation of the provision and financing of healthcare to achieve more efficient resource allocation and use; the introduction of universal health insurance; increasing the financial and administrative autonomy of public hospitals to improve technical efficiency and strengthen management; and the introduction of family medicine to integrate and streamline the delivery of primary and inpatient care.4

The effects of health reforms seven years on

Table 1 compares health and health system outcomes before and after the start of the transformation programme, using the WHO health system framework.5 There have been reductions in infant and maternal mortality and substantial increases in access to and use of services and in patient satisfaction, especially in primary care. Table 2 shows an improvement in Turkey’s rankings compared with 16 high middle income countries.

Table 1

 Health system indicators before (2000) and after (2008) the Health Transformation Programme in Turkey1 2 6 7 8 9

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Table 2

 Life expectancy, health expenditures, and overall economic and human development in Turkey compared with highest value in 16 other high middle income countries before (2000) and after Turkey’s transformation programme*10

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There are three reasons for the improvements. First is the political commitment at the highest level. Health has been placed at the top of the policy agenda and reforms implemented without any major setbacks during a period of political stability and sustained economic growth. Concrete examples of this political commitment include the prime minister’s frequent references to health and the health system, and the substantial increase in share of the government budget allocated to health expenditure—from 11.5% in 2000 to 16.5% in 2008—especially in view of the concurrent fast growth in government revenues and expenditures by about 5% a year.10 The rapid growth of the economy after the 2001 financial crisis also helped: while total health expenditures rose from TL44bn (£18bn; €21bn; $28bn) in 2003 to TL61bn in 2008, a 40% increase in real terms, its relative share in gross domestic product only rose from 6.2% to 6.4%. In 2009 it stood at 5.7%.11

Secondly, the Ministry of Health, which had previously been one of the weakest ministries, assumed more assertive leadership in the health sector. Five previous attempts to pass a law on universal health insurance had failed. Other laws that were passed were either overturned by the constitutional court or could not be implemented because of lack of further regulation and enforcement. It was unclear who had the primary responsibility for policy and planning, regulation, and financing because of overlapping political and administrative authority across the Ministries of Health, Finance, and Labour and Social Security, as well as provincial governments and municipalities. Despite ongoing political bickering, turf wars, and legal challenges, the Ministry of Health asserted its position as the steward of the health system in charge of policy making, planning, regulation, and oversight. The National Health Insurance Fund (NHIF), under the political authority of the Ministry of Labour and Social Security, assumed responsibility for revenue collection, pooling, and purchasing, effectively splitting financing and provision, and ending vertical segmentation of statutory entitlements by making all services accessible to all, regardless of affiliation with previous health insurance schemes. The playing field in service provision was levelled as both public and private providers could now be contracted by the NHIF and reimbursed for services rendered to the population.

The third reason for improved indicators was the understanding that performance improvement would require well designed financial and nonfinancial incentive schemes to increase satisfaction of health professionals. The introduction of family medicine and the prorated capitation payment significantly raised the income of general practitioners and nurses working in primary care. Similarly, a performance based supplementary payment system adopted in public hospitals brought about a major reduction in part time private practice and a threefold to fivefold increase in the income of specialists. The new payment system, which incentivises team work and sense of ownership of health facilities, resulted in substantial investment in technology, infrastructure, and amenities, and an increase in productivity. Absenteeism has fallen, and both outpatient and inpatient utilisation rates have more than doubled, mainly as a result of a major increase in the proportion of physicians opting to work full time in the public sector (table 1).

Achievements and lessons

Health for all in Turkey is no longer merely an aspiration. Universal health coverage is ensured as a result of a high level of political commitment.12 Today, catastrophic health expenditure impoverishes only 0.4% of the Turkish population.7

Equally important is the growing international recognition that it is indeed possible to improve health outcomes in such a short span by investing in health systems. Turkey is now frequently cited as a success story, rather than as an underperformer, having improved its health outcomes at a pace and to a level almost unheard of in middle income countries,8 9 and in the case of health related millennium development goals, well before the 2015 deadline (fig 1 and 2 ).13 14 15

Figure1

Fig 1 Change in mortality among children under 5 (millennium development goal four) between 1990 and 200914

Figure2

Fig 2 Change in maternal mortality ratio (millennium development goal five) between 1990 and 200915

The recent Turkish experience provides at least three key lessons for other high middle income countries. One obvious lesson is the need to invest in health systems.16 17 Among the OECD countries, Turkey allocates the largest proportion of its public health budget, about 7.7%, to investment, compared with the OECD average of 4.2%.18 The budget allocated to expanding prevention and primary healthcare to underserved areas has also increased 58% in real terms.6 The 112 emergency telephone line now serves rural areas as well as cities. Seventeen air ambulances routinely serve geographically remote areas, transporting high risk pregnant women and sick children to better equipped urban facilities.6 An additional 111 000 health workers have been recruited. The health workforce is now distributed more equitably in geographical terms6 resulting in reduced inequalities in access to care among the poorest. The urban/rural and rich/poor ratios are now 1:1 for both birth attendance by skilled health staff and measles immunisation coverage (table 1).6

A second and less obvious lesson is the importance of encouraging demand for essential health services by reducing sociocultural barriers and offering financial incentives. Pregnant women who live in remote areas are provided with free accommodation in cities for up to one month before delivery. Since the programme began in October 2008, close to 7000 pregnant women have used free predelivery care. In 2004, Turkey introduced a conditional cash transfer scheme, about TL17 (£7; €8; $12) per month payable to mothers, to encourage pregnant women, mothers, and their children to visit health facilities regularly, with an additional payment of about TL55 if women delivered their babies in public hospitals.6 As a result, the proportion of women who have attended at least four prenatal visits rose from 53.9% in 2003 to 73.7% in 2008 and the proportion of births attended by skilled health staff rose from 83% to 91.3% over the same period.13 Also in 2008, measles immunisation coverage reached 96%, from 82% in 2002. As a result, there were only four measles cases in 2008, down from 30 509 in 2001.6

The third lesson is the importance of vision and leadership to set values and guiding principles, and the determination to follow through policy implementation. A shift of perspective has placed the patient or citizen as the basis of all policy goals and performance evaluation. Reference to, and continuous monitoring and evaluation of, responsiveness to patients’ needs and preferences and patient satisfaction figure prominently in policy papers, reports, and public speeches, and have been introduced as benchmarks into various supplementary payment schemes that are performance based and measured regularly through patient satisfaction surveys.4 6 19 The population’s satisfaction is now, at 67%, at the highest level since regular polling of patients began and service utilisation is at an all time high (table 1).8 19

Finally, considerable investment has been made to improve data availability, quality, and timeliness, complemented by household and user surveys. A nationwide survey on maternal mortality in 2006 put an end to the large disparity that had existed between national and international estimates and set the benchmark against which future progress will be assessed. All maternal deaths are now investigated, at times by the health minister himself, to identify the cause of death and take corrective action. Onsite oversight is routine, with the minister and his field coordinators reportedly having travelled 600 000 km and visited all 81 provinces, often more than once a year.6

Unfinished agenda

Health systems alone can only do so much to improve health without concurrent improvement in human development and increase in equality of opportunity. This is particularly true in Turkey, where income inequality is rising and literacy is yet to be universal (table 2). A large gender gap persists as a result of lower enrolment and participation of girls and women in education and labour.20 Regardless of the socioeconomic differences, non-communicable diseases are rising because of unhealthy lifestyles: Turks still smoke a lot, and as they rapidly urbanise, they also become less physically active and more obese. A rapidly ageing population, especially in the west of the country, is already using health services more often as a result of improved access, demanding higher quality and more user friendly care.

All these factors mean that the much improved health system needs constantly to adapt to changing health and healthcare needs. The emerging challenges are now more programmatic and less structural, such as further embedding health in all policies, especially in relation to environmental and behavioural determinants of health; establishing disease prevention and health promotion services in all family based and community based primary care services; and improving public knowledge about healthy behaviour and healthier living and ageing.8

Conclusion

In just seven years, Turkey’s Health Transformation Programme has been able to ensure universal health coverage for essential care and significantly improve health outcomes. The major challenge now is how to steer a much more complex health system in the right direction and adapt it to the changing needs and preferences of an increasingly assertive citizenry and a democratic and pluralistic governance structure, while improving efficiency and financial sustainability. These are the same challenges that the rest of OECD and EU member states face today.9

Notes

Cite this as: BMJ 2011;342:c7456

Footnotes

  • We thank the minister of health, Recep Akdag, and Nihat Tosun, undersecretary of health, for their encouragement and support. We also thank Francesca Seneca and Mary Stewart Burgher from WHO for help with data compilation and editing.

  • Contributors and sources: This article draws on authors’ extensive involvement in the Health Transformation Programme (HTP) from its early conceptual phase to date. EB’s involvement was through external technical assistance during HTP’s design phase, whereas SM and SA were directly involved in HTP design and implementation. At the time of writing EB was Director, Division of Country Health Systems, WHO Regional Office for Europe; he is currently with the World Bank. At the time of writing SA was deputy undersecretary, Ministry of Health, Turkey; he is now president of Istanbul Medipol University. EB prepared the initial draft of this article. SM and SA contributed to the final draft. EB is guarantor.

  • Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; externally peer reviewed.

References