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Perspective

T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

october 1, 2015

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coverage and notable improve- ments in outcomes and equity.

Health insurance was intro- duced in Turkey in 1945, at first covering blue-collar workers and later other groups. From 1960 on- ward, Turkey’s 5-year development plans included universal health coverage as an objective; a new constitution in 1982 guaranteed rights to health insurance and health services; and a 1987 Basic Law on Health aimed to opera- tionalize these rights. But the law wasn’t implemented, universal cov- erage failed to materialize, and the poor and unemployed remained without effective coverage. Although the “Green Card” scheme was in- troduced in 1992 to cover low- income households, it wasn’t inte- grated with existing insurance schemes and lacked a system for identifying potential beneficiaries;

moreover, it provided limited fi- nancial assistance for inpatient care and none for outpatient consulta- tions, diagnostic tests, or medi- cines; uptake was therefore low.

Battling economic instability, rampant inflation, rising unem- ployment, and a dissatisfied pub- lic, successive coalition govern- ments between 1990 and 2002 did not prioritize health coverage and services. The Turkish health system faced insufficient and in- equitable financing, a shortage and inequitable distribution of physical infrastructure and human resources, disparate health out- comes, and public dissatisfaction.

Then, in 2002, a new political party won a parliamentary major- ity and created a government com- mitted to economic and social reforms. In 2003, it introduced a Health Transformation Program

(HTP) that aimed to improve pub- lic health, provide health insurance for all citizens, expand access to care, and develop a patient-cen- tered system that could address health inequities and improve out- comes, especially for women and children.1 The 2003 Directive on Patient Rights defined citizens’ rights to health insurance and choice of health care providers. It codified providers’ obligations regarding information provision, confidentiality, and patient consent for interventions and established systems for citizens to express their views about health services.2

Health reforms introduced be- tween 2003 and 2010 separated policymaking, regulatory, financ- ing, and service-provision roles: the Ministry of Health would focus on policy and strategy de- velopment, while other agencies oversaw public health and deliv- ery of personal health services. The Social Security Institution was established as a single payer, pooling both risk and funds from contributory health insurance and

IN T E R N AT I O N A L HE A LT H C A R E S Y S T E M S

Transforming Turkey’s Health System — Lessons for Universal Coverage Rifat Atun, M.B., B.S., M.B.A.

In 2003, Turkey embarked on ambitious health sys-tem reform to overcome major inequities in health outcomes and to protect all citizens against financial risk. Within 10 years, it had achieved universal health

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the government-financed Green Card scheme; it was responsible for strategic purchasing from pro- viders, and its mandate was to im- prove service quality and efficiency.

The introduction of the HTP coincided with a period of sus- tained economic growth, which enabled the government to increase health expenditures at an average annual rate of 9.1%. Public-sector funding increased from 63.0% of total health expenditures in 2000 to 75.2% in 2010, the highest in the E7 group of countries with emerging economies — includ- ing Brazil (47.0%), China (53.6%), India (29.2%), Indonesia (49.1%), Mexico (48.9%), and Russia (62.1%) — while health expenditures rose from 4.1% of the gross domestic product in 2002 to 6.1% in 2010.3

In 2004, Green Card benefits were expanded and new mecha- nisms introduced to identify po- tential beneficiaries. In 2006, the Social Insurance and General Health Insurance Law was ratified, though a court challenge by the Turkish Medical Association and medical professionals’ unions re- sulted in amendments and delayed implementation. Between 2008 and 2012, Turkey’s various insur- ance schemes were transferred to the newly established Social Secu- rity Institution and merged to es- tablish general health insurance with a unified risk pool and a har- monized benefits package cover- ing preventive health care and family medicine services (provid- ed free at the point of delivery) plus targeted health promotion and prevention programs.

Between 2003 and 2011, the number of Green Card beneficia- ries increased from 2.4 million to 10.2 million — 13.8% of the population, including more than 60% of those in the lowest in-

Transforming Turkey’s Health System

Selected Characteristics of the Health Care System and Health Outcomes in Turkey.*

Variable Value

Health expenditures

Per capita (U.S.$) 665

Percentage of GDP 6.3

Out-of-pocket (% of private health expenditures) 64.4

Public sources (% of total) 73.9

Health insurance

Rate in population (%) 98

Source of funding Employers (7.5%) and employees (5%), government contributions for Green Card beneficiaries

Annual physician income (U.S.$)

Salaried general practitioners 37,900

Salaried specialists 65,300

Generalist–specialist balance (%)

Generalists 31.9

Specialists 68.1

Access

No. of hospital beds per 10,000 population in 2011 25

No. of physicians per 1000 population in 2011 1.7

Life and death

Life expectancy at birth (yr) 75

Additional life expectancy at 60 yr of age (yr) 21

Annual no. of deaths per 1000 population 6

Annual no. of infant deaths per 1000 live births in 2013 17

Annual no. of deaths of children ≤5 yr of age per 1000 live births in 2013 19

Annual no. of maternal deaths per 100,000 live births in 2013 20

Fertility and childbirth

Average no. of births per woman 2.1

Births attended by skilled health personnel in 2009 (%) 95

Pregnant women receiving any prenatal care in 2009 (%) 95

Preventive care

General availability of colorectal-cancer screening at primary care level Yes

Children 12–23 mo of age receiving measles immunization in 2013 (%) 98

Rates of chronic diseases

Diabetes prevalence (% of 2013 population 20–79 yr of age) 14.9

HIV incidence (cases per 100,000 population) 0.12

Prevalence of risk factors (%)

Obesity in adults ≥18 yr of age in 2014 29.5

Overweight in children <5 yr of age in 2004 9.1

Underweight in children <5 yr of age in 2008 1.7

Smoking in 2011 27

* Data are from the World Bank, the Organization for Economic Cooperation and Development, the World Health Organization, and the Turkish Ministry of Health Statistics Year Book and are for 2012, except as noted. GDP denotes gross domestic product, and HIV human immunodefi- ciency virus.

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come decile (a further 24% of the lowest-decile population was cov-

ered by contributory health insurance). In- surance coverage also improved in all other

income deciles, and 85 to 96% of people in the top deciles were covered by contributory health in- surance by 2011.4

Simultaneously, health services expansion was made possible by increasing the size of the work- force; improving its distribution by means of compulsory service, higher remuneration, and con- tracting; scaling up primary care services; strengthening emergen- cy medical services; and enabling insured people (other than Green Card holders) to choose private- sector providers.

Family medicine–centered pri- mary care was introduced in 2005. By 2011, the Ministry of Health had contracts with 20,000 new family medicine teams at 6250

centers, providing expanded pri- mary care services including pre- vention, women’s and pediatric health care, mobile health care for rural residents, and home care for the homebound (see table and case histories; to compare this country with others, see the interactive graphic). The number of primary care visits increased from 74.8 million in 2002 to 244.3 million in 2011.4

Hospital capacity was expanded from fewer than 2.0 acute care beds per 1000 population in 2000 to 2.6 per 1000 in 2011. By 2010, the Social Security Institution had contracted with 421 private hos- pitals (90% of large hospitals) to provide diagnostic and curative care and complex emergency ser- vices such as burn care, intensive care, cardiovascular surgery, and neonatal care. Hospital visits, in- cluding inpatient admissions, in- creased from 124.3 million in 2002 to 337.8 million in 2011, even as

active purchasing by the Social Security Institution drove efficien- cy gains by establishing tariffs for paying hospitals, reducing the average length of stay from 5.8 days in 2002 to 4.1 in 2010, and improving occupancy from 59.4% in 2002 to 65.6% in 2011.5

Utilization of maternal and child health services and child mortality improved significantly between 2003 and 2008, especial- ly among rural and socioeconom- ically disadvantaged populations. Meanwhile, provision of free health care services for costly interven- tions and reduced cost sharing low- ered out-of-pocket and catastroph- ic expenditures. And satisfaction with health services grew from 39.5% in 2003 to 75.9% in 2011.4

Several factors contributed to this transformation. Turkey’s pop- ulation was receptive to reforms that promised health rights and better, more accessible care, and such popular legitimacy helped to overcome the medical profes- sion’s resistance. Newfound polit- ical stability had invigorated Tur- key after 20 years of ineffective governing coalitions, and the new government’s absolute majority in the Grand National Assembly per- mitted swift development and implementation of legislation and policies. Economic growth and a broadened tax base provided Tur- key’s government with the means to expand its noncontributory insurance scheme, while rising employment levels helped increase coverage through contributory health insurance.

In addition, sustained support from the Council of Ministers helped to overcome opposition from medical professionals and the civil service. And a commit- ted transformation team led by the health minister provided con-

Transforming Turkey’s Health System

myocardial infarction A 55-year-old man with no other serious health conditions has a moderately severe myocardial infarction.

Chest pain and breathlessness develop during the day in Mr. Öztürk, a civil servant who lives in a large city. His family calls an ambulance, which arrives within 10 minutes. He is assessed by the paramedical staff and stabilized with oxygen and painkillers. His electrocardiogram indicates a myocardial infarction. He is taken to the nearest public university hospital, which is able to administer 24/7 primary percutaneous coronary intervention (PCI) within 60 minutes after a patient with a heart attack arrives at the hospital. Mr. Öztürk is assessed in the emergency department and transferred to the cardiology unit for coronary angi- ography and PCI in two coronary arteries and a stent in one.

His recovery is uncomplicated, and the results demonstrated on echocardiog- raphy are not considered worrisome. Mr. Öztürk is discharged from the hospital after 2 days and is referred to a cardiac rehabilitation program at the hospital.

His hospital costs and the three new medications that he receives on dis- charge — an anticoagulant, a beta-blocker, and a statin — are covered fully by the Social Security Institution. He makes an appointment the following week to see his family physician and to receive a repeat prescription for the medicines, for which he pays 20% of the cost. He is seen in the university hospital outpa- tient clinic 6 weeks after his discharge, for which he incurs a small cost.

An interactive graphic is

available at NEJM.org

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tinuity and strategic direction for the HTP, mobilized provincial lead- ership, and addressed implemen- tation challenges as they arose.

Turkey’s experience offers five key lessons. First, universal health coverage may be best achieved through comprehensive improve- ments combining demand-side changes (health insurance) with supply-side changes (increased hu- man resources and strong primary care). Second, reforms should be carefully sequenced, with flexible implementation informed by pub- lic receptivity to change. In Turkey, major policies were implemented when the sociocultural, economic, and political contexts were favor- able, and tactical changes, such as reduced copayments and expand- ed choice of providers, were used to improve users’ experience of the health system, increasing their satisfaction and support.

Third, implementation is facili-

tated when the transformation team works closely with field coor- dinators, who oversee day-to-day operations and gather real-time intelligence to rapidly address im- plementation bottlenecks by refin- ing the scope, speed, and sequence of reforms. Turkey’s transforma- tion team drew on international experience and collaborated with agencies including the World Bank, the World Health Organi- zation, and the Organization for Economic Cooperation and De- velopment.

Fourth, it’s important to focus on improving the system’s respon- siveness to citizens; public support provided legitimacy for Turkey’s reforms and helped to overcome opposition. And fifth, swift policy formulation and decision making and carefully sequenced imple- mentation can fend off organized opposition and bureaucratic resis- tance to reform.

But the sustained success of this new program faces hazards. Expectation of good government helped change the balance of power in Turkey in 2002. The transformations that advanced a right to health have increased ex- pectations for an accountable, transparent, responsive executive. Citizens and opposition groups are better organized to scrutinize Tur- key’s health system, and the elec- torate has become more polarized. Problems in neighboring Iran, Iraq, Syria, Russia, and Ukraine threaten Turkey’s political stabil- ity, and concerns regarding human rights, citizens’ ability to voice grievances, and the growing dem- ocratic deficit exacerbate this fra- gility.

The continued global economic crisis and financial-market vola- tility threaten Turkey’s strong eco- nomic growth, which is critical to sustaining investments in a health system facing increasing burdens of chronic illness and disability. To transition from a middle-income to a high-income country, Turkey needs to create a knowledge economy in which the health system plays a major part, but the life-sciences industry, uni- versities, and the health system are not yet collaborating to gen- erate meaningful research, devel- opment, and innovation.

Moreover, the reforms alienat- ed many health care profession- als. In designing and implement- ing reforms, the health ministry didn’t always accommodate the views of such opponents, who have questioned the integrity of the ministry’s data; more inclu- sive, broad-based reforms could foster a committed workforce and create an environment of shared values based on collaboration.

Turkey’s experience shows that with committed leadership, mid-

Transforming Turkey’s Health System

pregnancy and childbirth A healthy 23-year-old woman is pregnant for the first time.

Ms. Kaya and her family have recently enrolled in the Green Card scheme and registered with the new family medicine center when she discovers that she is pregnant. At the center, Ms. Kaya meets a nurse and the family doctor and re- ceives advice on family planning, healthy nutrition, exercise, and risks associated with tobacco and alcohol use. During this visit, her pregnancy is confirmed.

In her first antenatal consultation, Ms. Kaya has her history taken; a general physical check; measurements of height, weight, and blood pressure; abdominal examination to determine the size of the uterus; and a hand-held Doppler test to assess the fetal heart rate. She has a urine examination for bacteria and protein and blood tests for hemoglobin, ferritin, and hepatitis B. Ms. Kaya also receives tetanus toxoid booster and vitamin D supplements. She is provided with general advice on pregnancy and referred to the new “mother-friendly hospital” for an ultrasound, which proves to be normal. Ms. Kaya has three further antenatal clinic visits and receives iron supplements. Her delivery at the hospital is uneventful.

Ms. Kaya has postnatal checks for herself and the baby before being dis- charged home 24 hours after delivery. During the 6-week postnatal period, she receives four home visits by the family nurse; at the first visit, the baby is given a heel-prick test for phenylketonuria, congenital hypothyroidism, and biotinidase deficiency. Ms. Kaya receives continued support for breast-feeding and checks for postpartum depression. The baby is registered in the family health center and receives, according to schedule, immunizations for 11 conditions.

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Transforming Turkey’s Health System

dle-income countries can achieve universal health coverage and si- multaneously improve population health, financial risk protection, and user satisfaction — health system goals to which all coun- tries should aspire.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

From the Department of Global Health and Population and of Health Policy and Man- agement, Harvard T.H. Chan School of Pub- lic Health, Harvard University, Boston.

1. Republic of Turkey, Ministry of Health. Turkey Health Transformation Program (http://www.saglik.gov.tr/EN/belge/2-125/ turkey-health-transformation-program.html). 2. The Ministry of Health of the Republic of Turkey. The directive on patients rights. 2003 (http://sbu.saglik.gov.tr/hastahaklari/ yeniyonerge.htm).

3. The World Bank. World development in- dicators, 2012 (http://data.worldbank.org/ data-catalog/world-development-indicators/ wdi-2012). 4. Atun R, Aydın S, Chakraborty S, et al. Uni- versal health coverage in Turkey: enhance- ment of equity. Lancet 2013;382:65-99. 5. Atun R, Aydın S, Aran M, Gürol I, Chakraborty S, Akdağ R. Health-care reform in Turkey: far from perfect. Lancet 2014; 383(9911):e1. DOI: 10.1056/NEJMp1410433 Copyright © 2015 Massachusetts Medical Society.

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