1Turkey: the integrated delivery of long-term care WHO Regional Office for Europe series on integrated delivery of long-term care TURKEY Country case study on the integrated delivery of long-term care Abstract This report describes the main findings of an assessment of the integrated delivery of long-term health and social services in Turkey. The country’s population is young but ageing rapidly. Life expectancy has increased, but older people have high rates of chronic conditions and physical and sensorial limitations. Knowledge of the needs of unpaid caregivers is very limited, and the available services to meet these needs are limited. Long-term care services include residential, home-based and community services. There are no standardized procedures for assessing needs or clearly defined care pathways in long-term care. Service provision, governance and financing are highly fragmented, and coverage is low. Data for assessing long-term care performance are very limited. Keywords LONG-TERM CARE HEALTH SERVICES FOR THE AGED CAREGIVERS INTEGRATED DELIVERY SYSTEMS WOMEN’S HEALTH SERVICES TURKEY Document number: WHO/EURO:2021-4212-43971-61980 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design and layout Erica Barbazza, design Jakob Heichelmann, layout Cover photo: Mr Coskun Gurboga Ministry of Family and Social Affairs TURKEY Country case study on the integrated delivery of long-term care WHO Regional Office for Europe series on integrated delivery of long-term care Turkey: The integrated delivery of long-term care ii Contents List of tables iii List of figures iii Abbreviations iii Acknowledgements iv Introduction 1 Background 3 Methods 5 Health and social needs of older people 9 Performance 15 Delivery of services 18 System enablers 26 Policy pointers 30 References 33 Turkey: The integrated delivery of long-term careiii List of tables Page Table 1. Overview of the components of the assessment framework 6 Table 2. Main demographic indicators 9 Table 3. Causes of death and disability, 2017 11 Table 4. Selected measures of lifestyle risk factors and determinants of health 11 Table 5. Self-rated measures of perceived health among older people 13 Table 6. Self-reported unmet needs for specific health care–related services for financial reasons among people 65 years or older, 2014 16 Table 7. Screening and vaccination rates among older people, 2014 20 Table 8. Residential care provision by type of providers and capacity, 2016 26 Table 9. Home health-care personnel by type of care professionals, 2017 31 List of figures Fig. 1. Framework for assessing integrated delivery of health and social services for long-term care 5 Fig. 2. Field evidence components and informants 8 Abbreviations EU European Union GDP gross domestic product IHME Institute for Health Metrics and Evaluation OECD Organisation for Economic and Co-operation and Development Turkey: The integrated delivery of long-term care iv Acknowledgements This report is part of a series developed by the WHO Regional Office for Europe to assess the integrated delivery of services for long-term care across health and social sectors. The series is developed as part of an interprogrammatic initiative to accelerate progress towards integrating services to deliver long-term care services with a perspective of equity, gender and human rights. The collaboration includes the Health Service Delivery programme of the Division of Health Systems and Public Health, the Ageing and Health programme of the Division of Noncommunicable Diseases and Promoting Health through the Life-course and the Gender and Human Rights programme of the Division of Policy and Governance for Health, all at the WHO Regional Office for Europe. Access to facilities and securing expertise and input was provided by the following institutions and agencies provided valuable contributions to the content of this report (in alphabetical order): Ankara University, Geriatrics Nurses Association, Geriatric Physiotherapists Society, Geriatrics Society, Hacettepe University, the Konya Province, the Ministry of Health, the Ministry of Family, Labour and Social Services, Academic, the Municipality of Ankara, SADEFE/EVSAD – Residential Health and Social Services Association, the Social Security Institute, Necmettin Erbakan, University, Turkish Alzheimer Association, Turkish Retirees Association, as well as numerous service providers, including a public care home, a private hospital and a rehabilitation centre in the Municipality of Ankara and an Alzheimer day care centre in the Konya Province. The following experts provided substantial intellectual contributions through interviews to the publication of this report (in alphabetical order): Seçil Akay, Kürşat Aldemir, Zübeyde Özkan Altunay, Okan Aydin, Şerife Aydındağ, Salim Birdir, Ömer Faruk Bilgin, Seyhun Çakmak, Filiz Can, Mümine Nurdan Doğukan, Banu Ekinci, Aylin Koyun Er, Elçin Er, Esma Firuze, Coşgun Gürboğa, İncili Sevgisun Kapucu, Ersin Karabulut, Bülent Karakuş, M. Ziya Kelat, Işın Baral Kulaksizoğlu, Gül Menet, Münevver Özcan, Emine Özmete, Sıla Toker, Tuğba Mançu Tülek, Mine Tunçel, Sonnur Ünal, Cafer Tufan Yazicioğlu, İnci Yanikoğlu, Nadide Yiğiteli, Ertan Yiğman, and Hulusi Armağan Yildirim. Editors Erica Barbazza, WHO Regional Office for Europe Toker Ergüder, WHO Country Office in Turkey Margrieta Langins, WHO Regional Office for Europe Tufan Nayır, WHO Country Office in Turkey Hector Pardo-Hernandez, WHO Regional Office for Europe Juan Tello, WHO Regional Office for Europe Contributors The following individuals contributed to this document with their expert editorial input and review, in alphabetical order: Stefania Ilinca, European Centre for Social Welfare Policy and Research, Vienna, Austria Kai Leichsenring, European Centre for Social Welfare Policy and Research, Vienna, Austria Ricardo Rodrigues, European Centre for Social Welfare Policy and Research, Vienna, Austria Turkey: The integrated delivery of long-term carev Series editors Juan Tello, WHO Regional Office for Europe Manfred Huber, WHO Regional Office for Europe Isabel Yordi, WHO Regional Office for Europe The work has been made possible by the financial support of Government of Germany and the Government of Kazakhstan through the WHO European Centre for Primary Health Care in Almaty, Kazakhstan. Turkey: the integrated delivery of long-term care 1 Introduction The European population is ageing rapidly (1). Low fertility rates and higher life expectancy are the leading causes fostering this shift (1). In the WHO European Region, births per woman have remained at around 1.7 between 2000 and 2019, below replacement level fertility (2). Average life expectancy increased from 73.0 years at birth in 2000 to 77.1 years in 2015 (2). In the same period, life expectancy at age 65 years increased from 16.4 to 18.4 years (2), and the percentage of the population 65 years or older increased from 13.3% to 15.5%. In European Union (EU) countries, the proportion of the population older than 80 years is 5.6%, which is expected to increase to 14.6% by 2100 (3). As the proportion and total number of older people increases, their needs and care should be considered. In 2017, cardiovascular diseases, cancer and nervous system disorders were the leading causes of death and disability-adjusted life- years among people 70 years or older, whereas musculoskeletal disorders, sense organ diseases and cardiovascular diseases were the leading causes of years lived with disability (4). The re-emergence and persistence of communicable diseases is an added challenge. In the WHO European Region alone, an estimated 72 000 people die every year from seasonal influenza (2). In EU counties in 2014, almost 50% of people 65 years or older reported long-term restrictions in daily activities, whereas more than two thirds reported physical or sensory functional limitations (3). As a result of these changing scenarios, health systems have been compelled to adapt to meet the needs of older people (5). Meeting these needs is not limited to addressing the symptoms or disability associated with disease. It encompasses promoting the development and maintenance of the functional ability that allows well-being in older age, a process known as healthy ageing, and that enables people to live a fulfilling life in accordance with their values (6). As part of the response to addressing the needs of older people, the 2016 Global Strategy and Action Plan on Ageing and Health calls for every country to implement a sustainable and equitable system of long-term care (1). Long-term care refers to “the activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity” (1). Long-term care covers a wide range of health and social services that can be delivered in various settings, including the beneficiary’s home, hospice and day-care facilities (7). Fragmentation of services is not limited to the delivery of services; it also can be seen during needs assessment, when accessing benefits and packages, in data collection and in the diversity of quality improvement efforts (8). Fragmentation of services has been linked to dual administrative procedures, hindrances in access to care and longer waiting times (8) and has been identified as a barrier to reducing hospitalization for ambulatory care sensitive conditions (9). Turkey: the integrated delivery of long-term care 2 In the European Region, the Strategy and Action Plan for Healthy Ageing in Europe 2012–2020 provides policy directions for ensuring healthy ageing (10). The WHO European Framework for Action on Integrated Health Services Delivery aims to streamline efforts for strengthening people-centred health systems and to promote integrated care models of primary, hospital and social services that are effectively managed and delivered by a coordinated array of providers (11). These efforts are in accordance with the recommendations of WHO’s 13th General Programme of Work for integrated services delivery based on a primary health care approach (12). Addressing the needs of older people is underpinned by a strong gender component that goes beyond biological factors and their differential effect on ageing (13). The multiple facets of gender, understood as the social norms, roles and relationships of and between women and men, influence the provision of long- term care services (13). Older women report lower self-perceived health status and higher rates of unmet health needs (3) and are traditionally responsible for providing unpaid, informal care to older relatives at home (14). Men are affected by higher rates of risky behaviour and lower overall and healthy life expectancy (3). The Regional Office’s strategies on health and well-being for women (15) and men (16) highlight the importance of incorporating gender as determinant of men’s and women’s health to design policies that are responsive to their specific needs and contribute to achieving gender equality. Promoting the availability and quality of long-term care services that are integrated, people-centred and properly managed is an appropriate step for ensuring healthy lives and well-being in old age, in accordance with the Sustainable Development Goals (17). Turkey: the integrated delivery of long-term care3 Background Following a wave of sweeping reforms starting with the 2003 Health Transformation Plan, Turkey restructured its health-care system with the explicit goal of providing comprehensive health-care services for the entire population. The programme was followed by decisive actions to improve the quality, affordability and accessibility of health-care services; a general health insurance scheme was established in 2008 and extended in 2012 to the entire population. The new system replaced an underperforming occupation-based insurance system, with the aim of ensuring equal access to standardized care for all. In 2013, only 1% of the population was not covered by any health insurance, a considerable decrease from 6.5% in 2012 and 11% in 2011 (18). Between 2003 and 2013, public health expenditure as a share of GDP increased from 2.6% to 5.1%, and the level of satisfaction with health-care services increased from 48% to 78%. These data, together with a reduction in out-of-pocket payments and catastrophic health expenditure, testify to the success of the implemented reforms (19). Despite these improvements, health insecurity and income-based inequalities in access to care persist. Progress has been geographically unequal, with marked differences in health status and access to care between regions and between urban and rural settings (19). In 2010, the family physician scheme was extended to the entire country and increases in health-care personnel have been registered despite a persistent shortage of qualified human resources. Improving the health-care workforce, both qualitatively and quantitatively, was identified as a key priority in the 10th Development Plan covering the period 2014 to 2018. In 2011, a restructuring of the Ministry of Health led to the creation of the Public Health Institute of Turkey in an attempt to plan and manage resources in the health system more effectively and efficiently. On the backdrop of sustained health system reforms, there have been significant steps in establishing a long-term care system. Law 633/2011 led to the creation of the Ministry of Family, Labour and Social Services and, within its structure, of the Directorate-General for Disabled and Elderly Care Services with responsibilities for organizing and implementing long-term care services. The new structure integrates formerly independent units with competencies to organize and provide care services for people with disabilities and older people and has the mission “to coordinate national policies and strategies for the social participation of disabled and older people” (20). Shortly after the Ministry of Family, Labour and Social Services was created, a National Plan for Action was adopted, which highlighted the importance of improving the social integration of older people, developing long-term services and improving access to health care. A further reform in 2014 extended the Turkey: the integrated delivery of long-term care 4 Ministry’s ability to purchase care services through public procurement and to stimulate service provision by local governments with financing from general budget revenue (18). This report set out to assess the health and social services for older people and the level of integration in the delivery of services, using a human rights and gender perspective. The health status of older people, their needs and the main causes of death and disability are summarized. Concomitantly, these data are contrasted against the available health-care and long-term care services, including entitlements, the organization of providers, pathways to access to care and management and quality assurance. The overall performance of the system is evaluated from several perspectives, including coverage, amenable mortality, preventable hospitalizations and beneficiaries’ satisfaction, among others. Lastly, and based on the collected data, actionable policy pointers are presented. Turkey: the integrated delivery of long-term care5 Methods This assessment was completed following the principles of systems thinking (21), people-centredness and integrated care (11,22), life-course approach (23), healthy ageing (6), human rights (24) and gender perspective (25). The conceptual framework underpinning this assessment is the European Framework for Action on Integrated Health Service Delivery (11). This policy framework calls for designing models of care based on the health and social needs and the alignment of the system enablers accordingly. Based on this, the assessment is developed along four domains: health and social needs, performance, services delivery and system enablers (11,26). These domains and their respective features are illustrated in Fig. 1 and listed in Table 1. The assessment was structured in the following four domains. • Health and social needs. This domain explores the main demographic and epidemiological trends at the country level, with an emphasis on people 65 years or older. The main determinants of health and lifestyle risk factors affecting people’s health are listed, together with the underlying health needs of older people. The latter includes self-assessed outcomes and measures of disability and daily life limitations. The specific profile and needs of caregivers are investigated, together with measures to ensure older people’s rights, dignity protection and support from the community. • Performance. This domain encompasses an appraisal of long-term care services coverage. It also compiles information on the quality of long- Fig. 1. Framework for assessing integrated delivery of health and social services for long-term care Demographics Determinants and risk factors Health and well-being Socialization and behaviour Rights Coverage System outcomes Type of services Patient engagement Design of care Organization of providers and settings Management Cross-sectoral governance Incentives and financing Competent workforce Medicines and devices Information and communication technology HEALTH AND SOCIAL NEEDS PERFORMANCE SERVICES DELIVERY SYSTEM ENABLERS Source: Country assessment framework for the integrated delivery of long-term care (26). Turkey: the integrated delivery of long-term care 6 Table 1. Overview of the components of the assessment framework Domain Demographics Coverage Types of services Patient engagement Design of long-term care Organization of providers and settings for long-term care Management System outcomes Rights Determinants and risk factors Health and well-being Socialization and behaviour Population structure and dynamics Socioeconomic status of older people Lifestyle and risk factors Health and social needs of older people Disability and well-being of older people Social inclusions and networks Gender behaviour when seeking care Rights of older people Rights and needs of carergivers Long-term care services coverage Health services for older people Self-management support for older people Needs assessment Quality of care for older people Social services for older people Shared decision-making with older people Pathways and integrated services delivery Long-term care settings (public and private) Management of transitions Out-of-hours services Services for caregivers Peer-to-peer support and social inclusion Disease management Long-term care providers Care and case coordination or management Cultural, social and gender patterns of caring Autonomy and decision making Facility management Quality management including quality improvement mechanisms Health and social needsa Performance Services delivery FeatureSubdomain Cross-sectoral governance Incentives and financing Medicines and devices for older adults Information and communica- tion technology Competent workforce System enablers Integrated long-term care priorities Planning, recruitment and staffing Shared planning Continuous professional development Governance and accountability arrangements Workforce compositiona Allocation of resources Professionalization of long-term care roles Provider payments Access to medical devices by older people Data capture in health and social sectors Information exchange Financial coverage Mechanisms for the responsible use and management of medicines Application of new technology and online platforms a Disaggregated for women and men to ensure gender-responsive assessment and policy recommendations. Source: Country assessment framework for the integrated delivery of long-term care (26). Domain FeatureSubdomain Turkey: the integrated delivery of long-term care7 term care using waiting times, hospital length of stay, hospitalization rates for ambulatory care sensitive conditions, preventing and reporting safety incidents and other performance measures. • Services delivery. This domain exhaustively explores the existing services available to older people and their caregivers and the procedures in place for completing needs assessment, for diseases and transition management and the available care pathways. Policies for fostering patient engagement are also covered. The profile of service providers, whether they are public, private for- profit or not-for-profit, and the various settings in which services are provided, is also compiled. The quality assurance efforts within settings and the initiatives to ensure information exchange among providers are considered. • System enablers. This domain includes the health system facilitators that intersect with health services delivery, including governance, financing of and allocation of resources for long-term care, the planning, production and update of a dedicated workforce and the availability of information technology. Data sources This report was constructed applying mixed methods, relying on qualitative data, literature searches, observational facility visits, semi structured interviews and round-table discussions with key informants. This design was adopted to consolidate a comprehensive view of long-term care in Turkey. The specific sources and process for data collection are described below. Database data Initial desk research was completed for existing, standardized indicators. Data were extracted from international databases: Eurostat (3), the Institute for Health Metrics and Evaluation (4) and the Organisation for Economic and Co-operation and Development (OECD) (27) as well as the Turkish Statistical Institute (28). These data primarily informed an analysis of the current health context in the scope of depicting the health and well-being of older people in Turkey. Scientific and grey literature The literature search targeted scientific and grey literature on Turkey’s long-term care services using the topics listed in Table 1 as keywords. Searches for grey literature included the WHO database WHOLIS for Turkey-specific reporting such as the Health Systems in Transition series (29). Other grey literature included reporting from such organizations as the European Commission and the OECD. Searches for scientific literature were conducted using MEDLINE (PubMed) and Google Scholar on the topic of health and social services. Literature was reviewed in English. Field evidence A five-day country visit took place in 2018 covering Ankara and the Konya Province. There were unstructured expert interviews and group discussions with more than 50 experts representing the Ministry of Health, the Ministry of Family, Labour and Social Services, the Social Security Institute, the Municipality of Ankara, the Konya Province, Hacettepe University, Ankara University and Necmettin Erbakan University as well as numerous non-profit service providers (Fig. 2). Turkey: the integrated delivery of long-term care 8 In addition, four site visits were organized: a public care home, a private hospital and a rehabilitation centre in the Municipality of Ankara as well as an Alzheimer day care centre in the Konya Province. Each visit included a guided tour of the facilities and extensive discussion with representatives of the management team and staff. Fig. 2. Field evidence components and informants Stakeholders including: · Ministry of Health · Ministry of Family and Social Protection · Social Security Institute · Municipality of Ankara · Konya Province · Hacettepe University · Ankara University · Necmettin Erbakan University Site visits WorkshopSemi-structured interviews Four site visits to institutions delivering long-term care: · Public care home, Ankara · Private Hospital, Ankara · Rehabilitation Center, Ankara · Alzheimer Day Care Center, Konya Province Forums and open discussions with representatives from: · Ministry of Health · Ministry of Family and Social Protection · Social Security Institute · Academics · Non-profit providers of care · Nongovernmental organizations Turkey: the integrated delivery of long-term care9 Health and social needs of older people About this section The demographic and epidemiological data presented in this section provide a snapshot of the main characteristics of the older population and their needs. Data are disaggregated by sex when available. Data were mostly obtained through initial desk research; country experts filled in information gaps and validated the findings. The proportion of older people in the population is low but growing fast Turkey’s total population was 81.9 million in 2018, about the same as the population of Germany, the most populous country in the EU (28) (Table 2). Population has increased by about 10 million during the past decade (28) (Table 2). The population is expected to grow to 93 million by 2030 and to 104 million by 2050 (27). Table 2. Main demographic indicators Demographic measure Total Year Total populationa 81 867 223 2018Women (%) 40 808 147 (49.8%) Men (%) 41 059 075 (50.2%) Population 65 years or oldera (% of total population) 7 163 354 (8.8%) 2018Women (% of population 65 years or older) 4 004 710 (55.9%) Men (% of population 65 years or older) 3 158 645 (44.1%) Population 85 years or oldera (% of total population) 659 657 (0.8%) 2018Women (% of population 85 years or older) 430 567 (65.3%) Men (% of population 85 years or older) 229 090 (34.7%) Net migrationb 370 616 2017 Fertility rateb (births per woman) 2.07 2017 Median age (years)b 29.9 2015 Life expectancy at birth (years)b 78.5 2017Women 81.3 Men 75.7 Life expectancy at age 65 yearsd 18.4 2018Women 20.0 Men 16.6 Sources: aTurkish Statistical Institute [online database] (28); bPopulation statistics at regional level, 2019 (3); cProfiles of ageing 2019 (30); dEuropean core health indicators (31). Turkey: the integrated delivery of long-term care 10 Unlike most European countries, the population is relatively young, since less than 9% of the total population is 65 years of age or older. As life expectancy increases and fertility rates decline, population ageing is expected to accelerate (32). Between 2012 and 2016, the number of older people increased from 5.7 million to 6.6 million – an increase of 17% (33). Life expectancy has increased in recent decades, especially among women Life expectancy at birth was 81.3 years for women and 75.7 for men in 2017 (3) (Table 2). In 2018, 7.1 million people (8.8% of the total population) were 65 years of age or older (3), of which 55.9% were women (Table 2). The proportion of people 65 years or older is expected to increase to 12% by 2030 and to 21% by 2050 (30). The total population 85 years of age or older is about 650 000, about 0.8% of the total population (Table 2). This population segment is expected to grow to about 918 000 by 2030 and 2 678 000 by 2050 (30). The median age was 29.9 years in 2015 and expected to increase to 35.0 years by 2030 and 41.7 years by 2050 (30). Household size is declining and older women are more likely to live alone Data on household living arrangements are limited. The once-prevalent extended families with more than two generations living in the same household (more than 30% in 1978) currently account for 12% of families. According to 2004 data, 41% of older people live with extended family, 32% live with a partner and 12% live alone. Women are more likely to live alone: 17% of older women live in a single-person household versus 5% of older men (30). The average household size in 2019 was 3.3, much higher than the EU average of 2.3 but lower than the 3.7 average for the country in 2008 (3). The old-age dependency ratio, defined as people 65 and over who are economically inactive divided by the number of people 15–64 years old times 100, was 12.9 in 2019 (31) versus 10.2 in 2005 and 10.5 in 2010. Noncommunicable conditions are the leading causes of mortality and morbidity Among people 70 years of age or older, the leading causes of mortality and of disability-adjusted life-years are cardiovascular conditions, Alzheimer’s disease and chronic obstructive pulmonary disease. The leading determinants of years lived with disability are low back pain, diabetes and age-related hearing loss, whereas the top risk factors associated with disability are smoking, high fasting plasma glucose and high systolic blood pressure, both for women and men (4). Table 3 shows data disaggregated by sex. Turkey: the integrated delivery of long-term care11 Table 3. Causes of death and disability, 2017 Measure of death or disability Women Men Top causes of death among people 70 years of age or older Alzheimer’s disease Ischaemic heart disease Stroke Chronic obstructive pulmonary disease Lung cancer Ischaemic heart disease Chronic obstructive pulmonary disease Stroke Lung cancer Alzheimer’s disease Top determinants of disability- adjusted life years among people 70 years of age or older Alzheimer’s disease Chronic obstructive pulmonary disease Ischaemic heart disease Stroke Lung cancer Ischemic heart disease Chronic obstructive pulmonary disease Stroke Lung cancer Diabetes Top determinants of years lived with disability among people 70 years or older Low back pain Diabetes Age-related hearing loss Falls Chronic obstructive pulmonary disease Diabetes Low back pain Age-related hearing loss Chronic obstructive pulmonary disease Stroke Top risk factors associated with disability among people 70 years or older Smoking High fasting plasma glucose High systolic blood pressure High body-mass index High LDL cholesterol Smoking High fasting plasma glucose High systolic blood pressure High body-mass index Alcohol use Source: Institute for Health Metrics and Evaluation [website] (4). Among older people, alcohol consumption is much lower than in the EU as is smoking among women. Men, however, report higher rates of smoking. More older women than men have obesity. Table 4 presents further information on lifestyle- related risk factors. Among people 70 years of age or older, 85% of women and 51% of men reported low physical activity in 2017 (34). Poverty rates are higher among women The rate of poverty or social exclusion for the entire population is 36%. Among older people, this rate was 23%, women being disproportionately more affected than men (Table 4) (3). Income inequality (ratio of the total income received by the 20% of the country’s population with the highest income and the total income received by the 20% of the country’s population with the lowest income) for the overall population in 2019 was 8.4 versus 5.1 for the EU (31). Among older people, income inequality was 6.9 versus 4.3 for the rest of the EU (31). Older people report high rates of longstanding health problems For women reaching the age of 65 years, life expectancy is 20 years versus 16 for men, both similar to EU averages (Table 2). In 2017, 63% of older people reported long-term restrictions in daily activities versus 49% in the EU (Table 5) (31). The percentage of people living with dementia in 2012 was 0.44%, much lower than the 1.55% average for the WHO European Region. This translates into 331 000 people, of which 59% are women (35). Among people 60 years and older, the prevalence of dementia in 2018 was about 4%, also lower than the 7% EU average (36). The percentages of people 65 years of age or older with depression were 14% for women and 10% for men (3). Turkey: the integrated delivery of long-term care 12 A total of 2% of people all ages in 2014 reported unmet needs for dental care services because of financial barriers, waiting times or travelling distances, lower than the 3% EU average (31). Perceived poor social support was reported by 23% of both older women and men, higher than the 18% EU averages among women and men in 2014 (3). No strategies to identify the needs of unpaid caregivers Long-term care is generally understood to be the responsibility of the family (37). A 2011 survey of people 40 years of age and older found that 83% of individuals consider caring for older relatives a responsibility of the family, and 11% place that responsibility on the government. Both the Penal and the Civil Code in Turkey specify the obligation of relatives to care for dependent individuals within the family (18). When asked about their expectations for old age, 62% of adults express the expectation to live with their spouse, 21% to co-reside with adult children and 5% to live in a nursing home (38). Overall, women overwhelmingly bear the responsibility for caring for older people (39). The 2011 Turkish Family Structure Survey found that 32% of older people received care from a daughter-in-law, 27% from a spouse, 22% from a son and 20% Table 4. Selected measures of lifestyle-related risk factors and determinants of health Risk factor or determinant Turkey (%) EU 28 (%) Year People 65 years or older reporting hazardous alcohol consumptiona 0.4 3.6 2014 People 65 years or older reporting high blood pressure in the past 12 monthsa 54.6 49.2 Obese population 65 years or older, measured (%)b Women 32.8 20.7 2014 Men 17.7 18.8 Daily smokers by age – 65–69 yearsc Women 7.1 11.0d 2015 Men 20.0 16.0d Daily smokers by age – 70–74 yearsc Women 5.1 7.8d 2015 Men 16.0 11.0d Daily smokers by age – 75–79 yearsc Women 3.6 5.5d 2015 Men 11.0 8.4d Daily smokers by age – 80 years or olderc Women 2.2 3.3d 2015 Men 7.2 5.6d Risk of poverty or social exclusion for people 65 years or olderb Women 25.6 17.3 2015 Men 20.8 12.8 Sources: aEuropean core health indicators (31); bPopulation statistics at regional level (3); cInstitute for Health Metrics and Evaluation [website] (4). dWestern Europe only. Turkey: the integrated delivery of long-term care13 Table 5. Self-rated measures of perceived health among older peoplea Measure Turkey EU 28 Year People 65 years or older who assess their health as being very good or good (%)b 20.9 41.7 2019 People 65 years or older reporting any longstanding health problem (%)c Women 86.4 63.2 2017 Men 73.4 60.3 People 65 years or older reporting severe or very severe body pain (%)c Women 40.4 19.0 2014 Men 21.1 10.2 People aged 65 or over reporting severe physical and sensory functional limitations (%)c Vision, women 25.0 6.8 2014 Vision, men 18.0 4.0 Hearing, women 22.6 12.0 Hearing, men 23.4 12.4 Walking, women 52.0 25.3 Walking, men 30.2 15.7 Overall, women 62.3 32.1 Overall, men 45.4 24.3 aThe comparability of self-reported data across populations should be interpreted with caution. Sources: bEuropean core health indicators (31); cPopulation statistics at regional level (3). from a daughter. Other studies have found similar findings and report that taking care of older people is a significant barrier for full-time employment (39). The Directorate-General for Disabled and Elderly Services acknowledges that lack of support for unpaid caregivers is especially worrisome, since there is heavy reliance on the informal care provided by families, and especially women. There are plans to reorient services towards a more comprehensive needs assessment to better respond to the needs of households. Legislation addressing issues of abuse and violence against older people The Healthy Aging Action Plan and Implementation Program for 2015–2020 is a programmatic document setting up the main intervention strategies for promoting well-being in old age (40). The Plan subscribes to a holistic understanding of long- term care that not only responds to needs arising from loss of capacity but also strengthens and preserves the functional capacity of older adults. This action plan identifies abuse, violence against older people and the rising prevalence and significant burden of dementia as intervention areas that need to be addressed. Limited data on community involvement and health literacy The Healthy Aging Action Plan and Implementation Program for 2015–2020 has dedicated measures to raise awareness in the community, specifically about older people’s care needs and measured via social awareness surveys. There are no data yet on the results of these initiatives (40). Health literacy is low in Turkey’s Turkey: the integrated delivery of long-term care 14 population compared with the EU (41): 65% are considered to have inadequate or problematic health literacy versus 48% for the EU (41). In Turkey, low literacy is correlated with worse health outcomes and understanding of medical conditions, overwhelmingly affecting people of lower socioeconomic status. Highlights Turkey’s population is relatively young, although rising life expectancy and lower fertility rates will result in rapid population ageing during the upcoming decades. Cardiovascular conditions and Alzheimer’s disease are the leading causes of death and disability. Smoking rates among older men are high, whereas women are more disproportionately affected by obesity. A very high proportion of older people report longstanding health problems or sensory and functional limitations, especially women. Women are disproportionally affected by poverty. Families are legally and traditionally expected to care for older relatives. There is no structured strategy to understand the needs of unpaid caregivers. Turkey: the integrated delivery of long-term care15 Performance About this section Coverage of long-term care services and system outcomes such as amenable hospitalizations, falls and ulcers and other preventable adverse events, waiting times and barriers to access indicate the per- formance of the long-term care system. The data presented in this section were obtained from international databases and registries that allow Turkey’s system to be compared with those of other European countries. Low coverage of long-term care services The Healthcare Access and Quality Index, a measure of health access and quality, was 74 in the year 2016 (4). Public satisfaction and perception of accessibility to health care have increased during the past decade. Universal coverage has not been achieved, since unemployed, self-employed and informal workers and low- income households are more likely to be uninsured, and out-of-pocket expenditure, especially informal payments, pose a barrier to care (42). There are also large regional disparities in the provision of care. Southeast Anatolia has fewer beds per 1000 people than the rest of Turkey. The number of magnetic resonance imaging scanners, computed tomography and other devices is lower in East Marmara, Central Anatolia, Central East Anatolia, Southeast Anatolia and West Black Sea. South-eastern, mid-eastern and north-eastern regions have health-care workforce shortages compared with the rest of the country (42). The delivery of long-term care services is undersized with respect to population needs. In 2013, 930 000 people needed services and 446 000 received any type of support. Of these, 427 000 received only financial support while family members and other informal caregivers provided all necessary care. In 2016, residential care coverage was estimated at 23 500 residents, less than 0.4% of the total population of older people (43). Occupancy rates in public care homes are higher, with about 1500 empty places within a total capacity of 18 000 places and 8332 older people on waiting lists. Beneficiaries in public care homes are subject to lower co-payments, and almost one third receive services free of charge. Private for- profit care homes, with considerably higher out-of-pocket costs, report an occupancy rate of 70%. Regarding home health care, 304 000 people were registered as active service recipients in 2016. More than 70% of the users are older than 65 years, and 22% are older than 85 years. Most home health-care recipients receive treatment for nervous system (38%) or cardiovascular conditions (23%), and the most common reason for terminating home health treatment is death (59%). A total of 16% of users completely recover after treatment and 10% recuperate sufficiently so that they do not need professional interventions in the home. Turkey: the integrated delivery of long-term care 16 Limited data to assess the performance of long-term care provision A total of 6% of hospitalizations for common chronic conditions (diabetes, hypertension, heart failure, chronic obstructive pulmonary disease and asthma) and about 1100 discharges per 100 000 people could have been avoided in 2015, both higher than the EU averages of 5.5% avoidable hospitalizations and 1000 discharges per 100 000 people (36). The average inpatient length of stay was 3.7 days for women and 4.4 for men (3). Eligible high-volume surgical procedures conducted as day surgery included 53% of cataract surgeries, 9% of inguinal hernia repairs and 18% of tonsillectomies, all very low compared with other European countries (36). According to a 2015 assessment, the Social Security Institute paid for 942 059 hospitalizations for ambulatory care sensitive conditions, including hypertension, angina, congestive heart failure, diabetes, emphysema, chronic obstructive pulmonary disease and bronchial asthma (44). Of these, an estimated 60–80% could have been avoided, or well over half a million hospitalizations. Although the estimated preventability of these conditions is similar to that of other countries in which similar assessments have been conducted (45,46), evidence indicates that people with the assessed conditions underuse primary care services (44). Five-year age-standardized net survival between 2010 and 2014 for breast, colon and rectal cancer were 82%, 55% and 53%, respectively, all lower than the respective 83%, 61% and 60% averages for the EU (36). In primary care, 0.3 per 1000 older people received long-term benzodiazepines or related drugs and 1.2 per 1000 older people received long-acting benzodiazepines. Both are lower than in other European countries (27). Financial barriers disproportionately affect women Older people report higher rates of unmet health care and access to prescribed medicines compared with the EU. Women are particularly affected. Table 6 presents data disaggregated by sex. Table 6. Self-reported unmet needs for specific health care–related services for financial reasons among people 65 years of age or older, 2014 Type of care Turkey (%) EU 28 (%) Health care, women 12.0 6.1 Health care, men 11.6 4.7 Dental care, women 11.8 10.1 Dental care, men 10.6 8.3 Mental health care, women 4.0 2.0 Mental health care, men 3.5 1.2 Prescribed medicines, women 10.1 5.6 Prescribed medicines, men 8.1 4.5 Total women 15.2 13.4 Total men 15.0 10.8 Source: Population statistics at regional level (3). Turkey: the integrated delivery of long-term care17 Highlights Data to assess how the health and long-term care system perform are very limited. Long-term care service delivery is undersized with respect to population needs, especially regarding residential services. Older people report higher rates of unmet health care and prescribed medicines compared with the EU. Data disaggregated by sex are missing for most measures. Of the 7 million pensioners in 2016, 18% were women and 82% were men. This marked gender divide raises concerns about the financial independence of older women and their ability to maintain a decent standard of living (20). Issues of affordability are also salient, since means testing is applied for access to benefits, and many older people who need care are not able to afford the necessary co- payment. As a result, most municipalities provide home-based support only to low-income older individuals. Turkey: the integrated delivery of long-term care 18 Delivery of services About this section An important requirement to assess the integrated delivery of long- term care is understanding the services available to older people, the organization of providers and settings, the needs assessment process and the care pathways. Obtaining this information exclusively via desk research may not provide the entire picture. In this section, data obtained from the published literature were complemented with information from semistructured interviews and discussion with key informants, including government representatives, managers, health practitioners and unpaid caregivers. Health services available to older people are comprehensive The basket of health services available to beneficiaries is quite comprehensive, as described below (29). Vaccination. Vaccinations are covered under the public system. The rates of influenza vaccination coverage are very low, less than 10% for men and women (Table 7). Preventive and public health services. Currently, eight prevention programmes address the determinants of functional decline and preventing noncommuni-cable diseases. They focus on healthy nutrition and physical activity, smoking cessation, reducing salt intake and preventing chronic respiratory disease, cardiovascular disease, kidney disease , cancer and diabetes. The coverage of these programmes is limited, especially among women in rural areas. Dental care. The public system covers inpatient and outpatient dental care, including examinations, diagnostic tests and procedures, conservative dental treatment, endodontic treatment, prostheses and orthodontic treatment for children younger than 18 years of age (29). Diagnostic services. The health system covers diagnostic services, medical examinations and imaging services (29). There are national screening programs for breast, colorectal and cervical cancer as well as tuberculosis. Breast and colorectal cancer screening levels among older people are very low compared with the EU (Table 7). Regarding the entire population, the 2012 Health Interview Survey revealed that, among women 15 years or older, 20% had mammography and 22% smear tests in urban settings versus 15% and 14%, respectively, in rural areas. More recent data from 2016 suggest that 24% of women 15 years or older countrywide had mammography within the previous five years (34). Turkey: the integrated delivery of long-term care19 Mental health. Mental health services are provided in mental hospitals and mental health wards in general and teaching hospitals. Services are covered under the public system, but capacity is insufficient to meet the needs of the population (29). Outpatient mental health care services are subject to co-payments. Medications. There are co-payments for pharmaceuticals; beneficiaries with chronic conditions, such as diabetes or cancer, are exempt. Restrictions apply, such as the number of days and number of items reimbursed, except for people with chronic conditions, who can receive supplies for longer periods with a doctor’s note (29). Medical devices. The public system covers prostheses, medical goods and medical equipment. As of 2018, Turkey had 15.1 computed tomography devices and 11.2 magnetic resonance imaging scanners per million people (34). There is wide regional variation: the Mediterranean, West Anatolia, Northeast Anatolia, Istanbul and West Marmara regions are above the country average for computed tomography devices per million people, and all other regions are below average. Similarly, the Mediterranean, West Anatolia and Istanbul regions are above the country average for magnetic resonance imaging scanners per million people while all other regions are below (34). Rehabilitation. Rehabilitative care services are provided in physiotherapy and rehabilitation hospitals and in specialized wards in general hospitals. Older people can also receive rehabilitative care in specialized centres and rest homes. Rehabilitative services are covered under the public system, but co-payments apply. Palliative care. Palliative care is traditionally provided within hospitals, while private hospices have only recently emerged in the long-term care system. According to data for 2016, 177 hospitals had dedicated palliative care units, with a total capacity of 2000 beds serving 27 000 patients throughout the year. Data for 2017 show a considerable increase in capacity, with 237 hospitals operating more than 2700 palliative care beds (20). Social services are available mostly in large metropolitan areas Local governments are responsible for providing social services. Municipalities can allocate mobile units to provide health and social services to residents, regardless of age. These services include support with daily activities, grooming and care, Table 7. Screening and vaccination rates among older people, 2014 Screening and vaccination measure Turkey (%) EU 28 (%) Women 50–69 years old reporting a mammography in the past two years 24.7 68.7 People 50–74 years old reporting colorectal cancer screening in the past two years 21.7 31.3 Women 23.5 31.4 Men 19.9 31.3 People 65 years or older reporting influenza vaccination in the past 12 months 8.9 45.9 Women 8.3 44.5 Men 9.6 47.7 Source: European core health indicators (31). Turkey: the integrated delivery of long-term care 20 cooking, home repairs and providing informational material on older people’s rights and basic nursing services (such as measuring blood pressure). These services are available mostly in large metropolitan areas (such as Ankara); many municipalities provide few or no home-based support services. Services available to unpaid caregivers are limited to cash benefits Cash benefits for low-income households, provided by the Ministry of Family, Labour and Social Services, are currently the only form of support for unpaid caregivers. Similar to other currently existing support mechanisms, cash benefits are limited in scope and restricted to selected target groups. Eligibility for care allowances for households providing care to dependent older individuals is limited to households below the poverty line, in which the net income of each family member is lower than two thirds of the minimum income. Eligible beneficiaries must demonstrate a 50% or higher degree of disability as assessed by the Disability Health Committee (20). As of 2017, beneficiaries received 847.16 Turkish lira per month. In 2016, care allowances were granted to 478 000 beneficiaries, a clear majority of which were middle-aged women (20). The beneficiaries of care allowances are considered employees in national employment data. Home-based care services do not include respite care, and caregiver support services are only emerging. The Ministry of Family, Labour and Social Services runs a scheme for temporary and guest care services for people with disabilities. For up to 30 days per year, eligible beneficiaries can be placed and provided all necessary care in a Ministry-operated facility if the informal caregivers cannot provide needed care. At the current capacity (300 users), this service is severely underdeveloped compared with population needs. Immigrant care workers are becoming increasingly relevant in providing long-term care services. Although no official data exist on their numbers or profile, they are generally believed to becoming more important. Immigrant caregivers are mostly women from such countries as Azerbaijan, Georgia, the Republic of Moldova, Turkmenistan and Uzbekistan (43). The increased reliance of middle- and higher- income households on migrant caregivers reveals a significant gap in the supply of affordable long-term care services. Not qualifying for public benefits (exclusively targeting low-income individuals and households) and either unwilling or unable to afford private residential care services, middle- and higher-income families rely on migrant live-in caregivers as substitutes or in conjunction with family-provided informal care (43). The lack of statistical information and of a legislative framework in the field renders this workforce invisible and impossible to monitor in terms of quantity, quality and type of care provided. Entitlements are based on means testing Long-term care services are mostly provided based on a social assistance rationale. This means that they can be accessed, if available, based on means testing, primarily considering the material conditions and the socioeconomic position of the care user or the household in establishing eligibility for support. Currently, there are no coordinated, nationwide efforts to stratify the older population in need groups. Where practised, needs assessment is used to define care plans rather than to assess eligibility for care. Turkey: the integrated delivery of long-term care21 All residents are required to register with a general practitioner regardless of insurance status (42). Primary health care is free even when health insurance premiums have not been paid. Secondary and tertiary care often requires out- of-pocket payments, although no fees are required for emergency care, cancer treatment, intensive care, neonatal services, dialysis and other services (42). No standardized needs assessment or care pathways No standardized needs assessment instruments have been developed. Each service provider is free to develop and apply its own assessment strategy (47). The Ministry of Health and other stakeholders are currently developing standardized geriatric assessment instruments and guidelines for screening programmes for older people (such as osteoporosis, cancer, an information campaign on fall prevention and dementia). Because such instruments are bound to emphasize a medicalized approach to care and needs assessment, they should be supplemented by modules or tools that focus on assessing the social and affective needs of vulnerable and frail older people. Nevertheless, these tools can contribute to reducing the burden of disability and future care needs in the population. Residential care access is based on medical certification of the general functional and physical and mental health status of beneficiaries. The application process is centralized at the provincial level for public care homes. Beneficiaries or their families must initiate the process themselves. Subsequently, a service specialist or social worker assesses the level of emergency for admission. Despite such assessments, the process is generally slow due to considerable waiting lists, especially for publicly operated residential facilities. If economically deprived older individuals who need residential care are forced to wait for admission, the provincial directorates for older people care provide financial support during the waiting period (20). Access to home-based services is simpler, since applications are processed through the operation of local call centres where older people themselves, family members or care professionals (often general practitioners) can signal the need for support of a dependent person and register their basic identification details. The call automatically triggers an eligibility and assessment procedure (follow-up calls by specialized home-care professionals and visit to the user’s home) that informs future service provision (48). Currently, entry points and referral systems for home- based health and social care services are fragmented, with different procedures, call centres and application-processing procedures. Similarly, private and public care providers operate independent and not coordinated entry points. Long-term care services are highly fragmented The allocation of responsibilities for different types of home-based care services to diverse providers leads to service fragmentation and difficulties in coordinating different types of care. Besides the lack of coordination in service planning and provision between the two main ministries with responsibilities in the area (the Ministry of Health and the Ministry of Family, Labour and Social Services), vertical integration is weak. Representatives of care providers affiliated with municipalities, nongovernmental organizations and private provider representatives reported ongoing challenges cooperating and coordinating efforts with and the Ministry of Family, Labour and Social Services. The same actors reported that the collaboration and communication at the service level among care professionals was much better than the coordination at higher governance levels. Turkey: the integrated delivery of long-term care 22 A study of physicians’ attitudes towards home health care found that many are discontent with the discordant organization of hospitals and primary care centres, which renders coordination much more difficult. Further, physicians reported that existing regulation limits their responsiveness capacity in practice and that more collaboration and coordination between departments is necessary to improve the quality of care (49). The importance of integrating health and social care is acknowledged at the service level and also at the highest decision-making levels within key ministries. The Ministry of Health and the Ministry of Family, Labour and Social Services readily acknowledge current shortcomings and are working on initiatives to address these issues (Box 1). The integration of financing and the supplementation of local resources for long-term care provision are very positive signs that there is a growing understanding of the need to promote integration across the fields of health and social care and between central and local governance. In parallel, bottom-up initiatives complement the efforts of public decision- makers. Numerous innovative projects of nongovernmental organizations and of professional associations respond to gaps in public service provision and are likely to have strong demonstrator effects and push the pace of change (Box 2). Multidisciplinary teams are present in public and private providers Needs assessment and home-based services teams consist of social workers, psychologists and cleaning and home maintenance personnel. Home health professionals include physicians, nurses, medical technicians, physiotherapists, dietitians and psychologists (48). The inclusion of social workers attests to the efforts for integrating social care professionals in providing long-term care. Palliative care units also rely on multidisciplinary teams, including physicians, nurses, physiotherapists, psychologists, social workers and other relevant professionals. Most residential care providers employ or collaborate with medical specialists, psychologists, occupational therapists and kinesiotherapists. The use of multidisciplinary teams in providing care helps to ensure that service providers can respond appropriately to complex and diverse care needs with a wide range of support services. Numerous communication and coordination protocols have been proposed or implemented across the health and social care sectors and across governance levels to address fragmentation in services delivery. Noteworthy is the 2013 Ministry of Health Programme for Promoting Multisectoral Health Responsibility. This Programme aims to “mobilize parties through a multisectoral health responsibility approach and enhance and improve the level of public health in the spirit of cooperation”. Further, in recognition of the fragmentation issues affecting the system, a protocol on care integration among home health-care and social support services has been prepared (20). The promotion of a whole- of-society approach to health and well-being and of cross-sectoral governance is encouraging trends towards further integration in the future, although a large gap remains between the goals of such initiatives and their implementation. Box 1. Coordination protocols between key stakeholders Sources: expert opinion; Rostgaard (50); Aspinal et al. (51). Turkey: the integrated delivery of long-term care23 A good-practice example for multistakeholder cooperation is the Alzheimer day-care centre in the Municipality of Karatay, Konya Province. In this agency, operations are underpinned by a protocol between the university, the Municipality of Karatay and the Turkish Alzheimer Association. Further, the centre was established with generous private support, demonstrating how stakeholders in a local community can contribute to building support programmes for older people. These grassroots efforts, with communities mobilizing varied local resources around a shared goal, could be promoted as best-practice examples for integrating the delivery of long-term care services. The aims of the Alzheimer day- care centre reflect the principles of person-centred service provision, including user involvement, emphasis on enhancing the quality of life and evidence-informed development of staff and daily activities. Box 2. Alzheimer day-care centre in the Municipality of Karatay (Konya) Activities performed in this centre include: · seminars to raise public awareness on Alzheimer disease; · support programmes for patient families who need psychological support; · psychomotor activity practices; · music and other leisure activities; and · the Aged Sycamores and Tiny Saplings Are Together project. Research carried out in this centre includes projects on: · how physical activity affects cognitive functioning in Alzheimer’s disease; · assessment of physical functioning related to sarcopenia in Alzheimer’s disease; · assessment of swallowing disorders in moderate and severe phases of Alzheimer’s disease; and · assessment of hand functioning in Alzheimer’s diseases with computer analysis. Long-term care includes residential care, home care and community services Primary health care services are provided in family and population health centres and in private physician offices and clinics. These services are free of charge. There is no gatekeeping system, and beneficiaries can access secondary or tertiary hospital levels without a referral. Co-payments apply in these instances, introduced to discourage the misuse of hospital services (29). The main responsibilities for formal long-term care provision lie with and the Ministry of Family, Labour and Social Services, the Ministry of Health and local governments (municipalities). In addition, other public, nongovernmental and private sector organizations offer a range of care and support services for dependent older individuals (43). Long-term care includes residential care, home care and community services. Residential care. Care in residential institutions is the most common type of in-kind formal care provision (20). Services include joint provision of care and accommodation. The Ministry of Family, Labour and Social Services provides residential care in the form of nursing homes, care homes and rehabilitation centres. Beneficiaries 60 years of age or older without any physical or mental limitations can access nursing homes. Care homes and rehabilitation centres target beneficiaries 60 years of age or older with mental or physical decline. Private providers and nongovernmental organizations may apply Turkey: the integrated delivery of long-term care 24 other admission criteria (for example, private nursing homes generally admit individuals as young as 55 years). Hospitals also play an important role in residential long-term care provision, since older people who need support and rehabilitation have numerous inpatient care spells. Alternative residential options include older people living homes and life home units. Older people living homes are small, protected care units organized in remodelled flats in apartment buildings located in larger cities. Each unit accommodates up to four older people who can maintain a higher degree of independence. Similarly, life home units are arrangements affiliated with nursing homes but not situated within their premises. Life home units allow older individuals with higher functional status to maintain social participation and community integration. Home-based care services. Home-based care services can be broadly separated into home health care and home-based social services. General practitioners and hospital personnel provide home health care, under the oversight of either the Ministry of Health or a private institution. Home health- care services include rehabilitation, physiotherapy, follow-up treatment and psychological therapy in accordance with the recommendations of a physician (49). Home health-care teams provide both psychosocial and physiological care and administer medical and nursing interventions to prevent unnecessary hospitalizations (20,43). Home-based social services fall under the responsibility of municipalities and entail mostly support with daily activities. Because each municipality can decide how many resources to allocate to home-based social support for older individuals, important geographical disparities have emerged. Community-based care. Community-based care is very limited in capacity. As of 2016, and the Ministry of Family, Labour and Social Services operated five service centres for older people who need social support and social inclusion (50). Private providers, notably the Alzheimer Association, also operate a few other similar centres in large urban areas (Istanbul, Eskisehir, Mersin and the Konya province). Nongovernmental organizations offer programmes such as Neighbour from the Heart and My Patient is Safe, which are devoted to providing unpaid caregivers support services. Private initiatives are nevertheless isolated and small in scale (37). Capacity is low compared with the demand for services The Ministry of Family, Labour and Social Services acknowledges the need for expanding the capacity of residential care. A plan for building an additional 40 residential care homes and rehabilitation centres in the next few years has been approved; construction has started in five locations. Table 8 summarizes residential care provision by type of provider. Home-based care services are highly concentrated around densely populated urban areas. This is in part because local governments are largely responsible for home-based care provision. Services are largely determined by the availability of local financial resources. Private providers also tend to concentrate in urban areas, where demand for services and ability to pay are higher. In the absence of top- down initiatives that could ensure a minimum standard and availability of care, rural populations are especially underserved by public and private providers, even Turkey: the integrated delivery of long-term care25 Table 8. Residential care provision by type of providers and capacity, 2016 Type of provider Number of facilities Number of beneficiaries Unoccupied places Total capacity Public facilities operated by and the Ministry of Family, Labour and Social Services 141 13 248 716 14 412 Public facilities operated by other ministries 2 566 4 570 Public facilities operated by municipalities 21 2 083 894 2 977 Private non-profit facilities operated by nongovernmental organizations 30 1 761 755 2 516 Private facilities operated by minority groups 5 355 153 508 Public facilities operated by private for-profit providers 172 6 659 2 855 9 615 Older people homes 41 154 6 160 Total 412 24 826 5 383 30 758 Source: Özmete (20) – based on data published by and the Ministry of Family, Labour and Social Services. though poor health status and dependence levels may be even more common in these areas. Quality standards and assurance are not fully developed The Ministry of Family, Labour and Social Services is responsible for performance monitoring and quality assurance in long-term care. Minimal standards are theoretically ensured through accreditation processes and yearly municipal audits. However, there is no official monitoring system in place, published accreditation procedures for institutional care or data on audits and other quality assurance activities (42). Dedicated units within and the Ministry of Family, Labour and Social Services are currently working to develop quality standards and monitoring systems for all types of long-term care services. As part of this initiative, the Ministry has started inspecting institutions providing long-term care using a new care services quality standard. The results of these inspections are not publicly available (39). Highlights The basket of health services available to beneficiaries is quite comprehensive. Local governments are responsible for providing social services, but service provision is mostly limited to urban areas. No standardized needs assessment instruments or care pathways for long-term care have been developed. Long-term care services include residential care, home care and community services. Service provision is highly fragmented, and the capacity of providers is low. There is no information on the utilization of long-term care services disaggregated by sex. Turkey: the integrated delivery of long-term care 26 System enablers About this section Integrated services delivery is fostered by implementing measures that enhance governance, funding, adequate staffing and information technology platforms. This section describes these system enablers. The data were collected from published evidence, databases and consultation with stakeholders. Governance is highly fragmented The Ministry of Health is chiefly responsible for governance of the health system. Provincial health directorates of the Ministry of Health and municipal governments implement policies at the operational level and oversee administrative decision- making, including public health measures, health-care regulations in rural areas and budgetary allocations (29). The Ministry of Family, Labour and Social Services is responsible for coordinating, regulating and overseeing long-term care services provided by public or private providers and for overseeing the cash benefit schemes. It is also involved in direct service provision, operating numerous homes for residential care, rehabilitation centres and day-care centres (47). Most of these responsibilities are concentrated under the Directorate-General for Disabled and Elderly Services, coordinated at the national level through dedicated units. The main legislative acts relevant for the operation of long-term care services are: Regulation of Nursing Homes, Care Homes and Rehabilitation Centres. Establishes eligibility criteria for care and nursing homes, the mix of services provided and the responsibilities of the different personnel that comprise the workforce rendering services. Regulation Determining the Foundation and Operation Principles of Public Nursing Homes. Establishes operation and monitoring standards for publicly operated nursing homes. Regulation of Private Nursing Homes and Care Home Centres. Establishes procedures, services standards, pricing and conditions of operation for privately operated residential care facilities. Regulation on the Payment of Allowance to Elderly Residing in Social Service Institutions. Establishes entitlements of daily allowances for low-income older people who benefit from free-of-charge nursing home care (20). Home health care falls under the provisions of the Regulation to Provide Home Health Care Services by the Ministry of Health and subsidiary institutions. The Turkey: the integrated delivery of long-term care27 home health-care services are targeted to the entire population but, in practice, the vast majority of users are older people. Home and social services fall under the responsibility of local governments. The Ministry of Labour and Social Security, through the Social Security Institute, also plays a role in the long-term care, albeit limited to managing and operating various social security schemes. Particularly relevant is managing insurance funds for old-age pensions and for social support for low-income individuals and families. Public expenditure in long-term care is low Health expenditure per capita was €824, and health expenditure represented 4.2% of the country’s GDP in 2017 (36). Both increased to €906 and 4.2% of the country’s GDP in 2019 (36). Public expenditure on health was 3.2% of GDP in 2018 (34). Health-care services are financed primarily from social health insurance and from government sources. According to 2018 data, less than 18% of costs correspond to out-of-pocket expenses (29,34). Out-of-pocket expenses are required for prescriptions, medical devices and outpatient care without a referral (29). Additional costs are informal payments to health-care workers; the 2008 survey on corruption found that bribery in health care had decreased in the previous decade but remained a widespread problem. It is estimated that up to 70% of families made a payment for health care in 2013 (42). An amendment of the Law on Full-day Working Hours for University and Health Staff entered into force on 30 January 2010. Providers are allowed to work at only one workplace, and unofficial payments are subject to disciplinary action. There is no long-term care insurance. Instead, a tax-based scheme providing financial support for low-income individuals who need long-term care with or without social security coverage is in place. The Ministry of Family, Labour and Social Services provides a social assistance scheme (care allowance) to unpaid caregivers in households below the poverty line and direct payments to care homes or day-care centres for low-income individuals who require such services (43). These schemes are financed from the central budget allocated through the Ministry of Family, Labour and Social Services and therefore sustained by general taxation. Care services operated by local governments and metropolitan municipalities are funded entirely by local budgets. In 2016, and the Ministry of Family, Labour and Social Services created the Elderly Support Programme to address both the limited supply and highly concentrated geographical distribution of home-based care services. Through the Programme, direct financial transfers from and the Ministry of Family, Labour and Social Services are allocated to municipalities to develop home care and home support services and to reduce the institutionalization of older people (50). Households directly fund a considerable proportion of long-term care through out-of-pocket payments. In the absence of a long-term care insurance scheme, all individuals who do not qualify for social assistance (falling under a certain income and/or wealth threshold) must pay for the services rendered. From this perspective, middle-income and higher-income groups do not have access to long-term care. Turkey: the integrated delivery of long-term care 28 There are workforce shortages in long-term care General practitioners are paid per capita adjusted by coefficients for the different population groups. Physicians in public hospitals are paid a salary based on performance. Physicians in private hospitals are also paid a salary. Nurses and midwives are paid a salary reflecting their experience and not their specialty. Other health practitioners are salaried and receive additional funds from their institutions (29). There is a shortage of human resources in health and social services (20,43). This problem is exacerbated by the unequal distribution of health-care personnel among provinces, leaving certain population groups severely underserved. According to Eurostat data, there were 188 physicians, 60 general practitioners and 220 nurses per 100 000 population in 2015 (3). According to more recent data (34), as of 2018 there were 187 physicians, 54 general practitioners and 301 nurses per 100 000 people. The regions of western Anatolia, Istanbul and Aegean ranked above the national average for total physicians per 100 000 people. East Black Sea, Northeast Anatolia and West Black Sea ranked above the national average for general practitioners, and East Black Sea, West Black Sea and West Anatolia ranked above the national average for nurses (34). Statistics from the Ministry of Health highlight a reduced workforce for the operation of health services at home. Of the 4600 professionals employed, more than half were nurses and more than 1000 general practitioners (Table 9). The low level of professionalization in the long-term care workforce and the general lack of competencies in geriatrics limits the quality of the system (20,43). The Tenth Development Plan in Turkey set clear targets for quantitative and qualitative improvements in the health-care workforce. The 2014 Yearly Development Plan included a Health Care Personnel Strategic Plan focusing on the distribution of practitioners across the country. In addition, the Ministry of Health’s Institute for Public Health has given priority to increasing the quality of the care workforce by organizing specialized trainings for workers and providers. These and other measures are included in the Healthy Aging Action Plan and Implementation Program for 2015–2020. Table 9. Home health-care personnel by type of care professionals, 2017 Measure 2017 Total health-care professionals 6251 Specialist physicians 284 General practitioners 1098 Dentists 286 Medical secretaries 249 Nurses and medical assistants 2744 Emergency medical technicians 62 Social workers 66 Drivers 1227 Physiotherapists 84 Dietitians 71 Psychologists 80 Source: WHO and Turkey’s Ministry of Health, 2017. Turkey: the integrated delivery of long-term care29 Continued education programmes for professions in long-term care Between 2010 and 2014, the Turkish Employment Agency organized almost 500 vocational training courses for long-term care workers, reaching more than 11 000 participants. In addition, diploma programmes, about 80 on older people care in 2013, reached an estimated 3000 students. Information technology platforms are interoperable among providers The Integrated Social Assistance System (ISAS – Butunlesi) is a virtual social registry that integrates data collection from 19 public institutions. This system enables eligibility for support services to be determined and access to beneficiaries’ history of service use across all social assistance programmes. The system is fully integrated with the national identification database and partly integrated with social insurance and education databases and is instrumental in registering beneficiaries for social assistance programmes. The system is used to cross-check reported data and verify its accuracy across several government databases and to integrate data collected through household visits in the user’s virtual poverty profile. The system includes 17 separate data modules for each user (such as social assistance, general health insurance, disability and older people salaries module and home care) with data from more than 34 million individuals. Electronic medical records are available in primary, secondary and tertiary care facilities. Coverage exceeds 75% of facilities, and interoperability with other databases and information technology databases is adequate (51). Highlights Governance of long-term care is highly fragmented. Health expenditure and long-term care expenditure are low, and much of long-term care is funded directly by private households through out- of-pocket payments. There is a shortage of human resources in health and social services, and there are national strategies to quantitatively and qualitatively improve the health-care workforce. The Integrated Social Assistance System (ISAS – Butunlesi) is a state-of-the-art database that facilitates communication among providers and consolidates the collection of data on the utilization of health and social services. Turkey: the integrated delivery of long-term care 30 Policy pointers The following conclusions are pointers to address needs, coordinate providers and align system components towards more integrated delivery of health and social services. Intensifying efforts for eliciting and addressing the health and social needs of older people Older people report high rates of longstanding health problems and of physical and sensorial limitations. Measures to prevent, slow down and reverse loss in intrinsic capacity could include developing multisectoral interventions for preventing poverty and dependence in vulnerable groups (such as women, residents of rural areas, disadvantaged occupational classes, migrants and refugees). There is also a need for giving priority to interventions and programmes for reducing income- based inequalities in health and functional status and to address geographical disparities in the availability of services, especially between urban and rural areas. Strengthening mechanisms for addressing the specific gender needs Women report higher rates of physical and sensory functional limitations. They are also disproportionately affected by poverty and are less likely to receive a pension in old age, thus compromising their ability to maintain financial independence. Men have lower life expectancy and are more likely to engage in lifestyle-related high- risk behaviour. Besides these data, knowledge is limited on the specific needs of beneficiaries and unpaid caregivers or of long-term care utilization and satisfaction with care disaggregated by sex. Turkey should intensify efforts for collecting data on the utilization of health and long-term care services disaggregated by sex and using this information to adapt interventions for meeting the specific needs of women and men. Increasing support for families and unpaid caregivers Strong family ethics and related values can lead to an idealized interpretation of the desirability and merits of care provided in the family. Instead, a more balanced conceptualization of family care needs to be considered, acknowledging the heavy toll it takes on families and primary caregivers and the limitations of untrained informal caregivers in providing appropriate and high-quality care. The limits of providing care in the family are becoming ever more apparent as the prevalence of dementia increases and a growing number of older people live with functional impairments and multimorbid conditions and require specialized and formalized care provision. Informal care is essential for the sustainability and future development of a long-term care system but cannot substitute for the development of accessible and high-quality formal long-term care. Meanwhile, since the system heavily relies on the care provided by families, respite care and work flexibility Turkey: the integrated delivery of long-term care31 could be strengthened. There is also a need for understanding the profile, needs and roles of immigrant caregivers and ensuring the legal protection of their rights. Integrating needs assessment and defining patient pathways Currently, beneficiaries and their families are responsible for initiating and following up the process of requesting long-term care services, which includes different agencies and processing procedures. Entry points and referrals to health and social services are fragmented, public and private operators do not cooperate and there is no standard needs assessment protocol or procedure. This, together with the limited capacity of providers, results in long waiting times, especially in public facilities. There is a pressing need for standardizing needs assessment, entry points and patient pathways. Such measures would simplify the application process for long-term care and would foster the integration of service delivery. Implementing regular quality assurance procedures Policies and accreditation procedures are in place for monitoring the quality of service provision in long-term care, but these are not published or regularly implemented. The Ministry of Family, Labour and Social Services has also started inspecting agencies providing long-term care, but there are no data on the results of these inspections. Accreditation procedures and quality assurance protocols should be standardized and regularly implemented. Analysing and disseminating the results of these measures would also be of key importance. Increasing long-term care supply The severe capacity limitations and the unbalanced distribution of care services (in both the health and social sectors) act as barriers to deeper care integration. Providers markedly overstretch their resources to address needs, especially in rural areas. In recognition of this limitation, the Healthy Aging Action Plan and Implementation Program for 2015–2020 prepared by the Directorate-General for Public Health recognizes the development of home-based care services as the second most important intervention for promoting active ageing and well-being in old age (20). Similarly, and the Ministry of Family, Labour and Social Services has adopted plans to increase the number and capacity of publicly operated nursing homes. The community-based approach to long-term care falls under the responsibility of municipalities, but this responsibility has not been sufficiently aligned with the allocation of funds. Smaller municipalities might be unable to develop a network of day-care centres. Aligning long-term care governance, funding and delivery Long-term care is fragmented in its governance, funding and delivery. Numerous public and private actors share responsibilities for regulation, service coordination and provision. The creation of and the Ministry of Family, Labour and Social Services in 2011 was an important step towards integrating initiatives in the social sector, but more remains to be done, especially regarding the organization of care services at home. This includes primarily addressing the following challenges: a more comprehensive definition of long-term care needs (including assessment procedures) and needs-based support mechanisms, the need to re-centre services Turkey: the integrated delivery of long-term care 32 around population and community needs (focus on prevention and support for caregivers), the inadequate provision and unbalanced distribution of formal services, the insufficient quantity and quality of the workforce and the fragmented and insufficient funding of long-term care. Because they are coordinated and operated by different institutions following distinct approaches to health and well-being, home health services and home- based care services remain very fragmented, with likely repercussions for the quality of care (47). At the same time, within the current legislative framework the mandates of institutional stakeholders are not properly aligned (52). There are overlaps between the mandate given to the Ministry of Health for providing home-based health service and the responsibility of municipalities to organize and operate mobile health teams and offer access to basic health services. Existing gaps in service provision could also be linked with a problematic division of responsibilities among actors. Care professionals also highlight the need to better align responsibilities and incentives within the legislative framework for long-term care. They refer particularly to the underdeveloped legislation and its mismatch with the practice of home- based health care (49). Vertical integration of activities among municipalities and the Ministry of Family, Labour and Social Services is also lacking. The provincial protocol on the cooperative implementation of home health care, care and social support services, signed in March 2015, aims to foster electronic data sharing among agencies providing long-term care services and better coordination among ministries and municipalities in the provision of long-term care (6). To date, the Ministry of Family, Labour and Social Services has not released any measures on the uptake or results of this initiative in its annual reports or monthly bulletins (39). There is evidence from interviews with officials from the Ministry of Health at the local, regional and national levels that lack of coordination and consensus among stakeholders remains a major roadblock for the success of new initiatives and strategic plans such as this one (41). Increasing public long-term care funding There is a need to move from means testing to needs testing of benefits by restructuring the long-term care funding, either by establishing a new long-term care insurance fund or by covering long-term care needs within the scope of the general health insurance. This shift is essential to address salient issues related to fairness and equity in access and to reduce out-of-pocket spending. Proposals to develop a long-term care insurance scheme have been discussed for years; the slow pace of progress is likely due both to the immense complexity of the task and to the cultural underpinnings of the long-term care system. 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Turkey: the integrated delivery of long-term care 38 Turkey: the integrated delivery of long-term care39 World Health Organization Regional Office for Europe UN City, Marmorvej 51 DK-2100, Copenhagen Ø, Denmark Tel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int WHO/EURO:2021-4212-43971-61980 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. 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Country case study on the integrated delivery of long-term care: Turkey
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