ANALYSIS
HO NEW/REUTERS
Healthcare in Turkey: from laggard to leader •bmj.com/podcasts Turkey’s health minister, Recep Akdag˘ (above), talks about the strides his country has made in providing healthcare 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
Enis Barişs 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 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 interregional 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
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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. 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 579