Turkey - Health sector review

Report No. 6089-TU Turkey Health Sector Review September 1%!, 1986 Population, Health and Nutrition Department FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Tm~ (Annual Averages) Value of UST Turkish Lira 1980 76.0 1981 111.2 1982 162.6 1983 225.5 1984 366.7 1985 542e0 FISCA4 TEAR January 1 - December 31 NMI ACRORME USED IEN TEN REP=R BAG-KJR - Social Insurance Agency of Merchants, Artisans and Self Employed Professionals GmS - Compulsory Medical Service GERF - Government Employees Retirement Fund GDPHC - General Directorate for Primary Health Care GDMCHFP - General Directorate for Maternal and Child Health and Family Planning IHSS - Integrated Healths Services Scheme ILO - International Labor Organization MCH - Maternal and Child Health MOHSA - Ministry of Health and Social Assistance MWRA - Married Women of Reproductive Age PHC - Primary Health Care SIO - Social Insurance Organization SIS - State Institute of Statistics SPO ' State Planning Organization UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Children Organization WHO - World Health Organization YOK - Higher Education Council  FOR OFFICIUL USE ONLY T 9 R K x I REALTR SECTOR RR11EV TABIZ OF CoIIED Page EXECUTIVE SUNNARY ..... ............................... 5 I. HEALTH, NUTRITION AND FERTILITY STATUS A. Sector Background ........................ ........ 10 B . Health . . . . . . . . .% * a. * ll *0*0.00s C. Nutrition ......... 15 D. Fertility ........ .. , 17 E. Environmental Factors .............. ##.* ...... 19 II. SECTORAL POLICIES AND OBJECTIVES A. Health ......** ....**, O#*** *******.....****, 21 B. Nutrition ............ .......................... 23 C. Population ** *** ***C** 9904 *9#940.......0**.00*...9 24 III. SECTORAL ORGANIZATION A. The Ministry of Health and Social Assistance ..... 26 B. The Medical Schools *,****************........... 29 C. The Social Security System ....................... 30 D. The Private Sector .............................. 36 E. Management Systems and Issues ................... 39 IV. SECTORAL RESOURCES A. Health Personnel ....... .............***. 44 B. Health Facilities .** ............................ 49 C. Health Costs and Financing ...................... 51 D. Pharmaceuticals ..... 55 V. LAYING THE FOUNDATIONS OF A DEVELOPMENT STRATEGY 59 A. Improving Coordination of Sectoral Activities ... 61 B. Strengthening Investment Planning ............... 61 C. Focussing on Priority Areas in Primary Health Care 66 D. Increasing Hospital Utilization ................. 67 E. Adiusting Users Charges .......................... 73 F. Strengthening Social Security's Financial Basis *. 76 G. Outlining a Program of Applied Research ......... 80 This report vas prepared by Messrs. Louis G. Vassiliou, dt4)1 De Geyndt, Dr. Jean Pillet (PHN), Dr. Jean Lecomte and Prof. Kamil Turan (Consultants), following a mission to Turkey in October 1985. This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  -4- LIST OF TABLES 1: Basic PHN Indicators for Turkey and Selected Countries 2: Demographic Characteristics 3: Evolution of Food Consumntion 4: Consumption Levels by Regions, and Urban and Rural Areas 5: New FP Acceptors by Method and Year in MDHSA Facilities 6: New FP Acceptors by Method and Region in MORSA Facilities 7: Distribution of Married Women Practicing Contraception by Exposure Status 8: Distribution of Female Contraceptive Users, by Method 9: Health Pereonnel (Public and Private Sectors) 10: Distribution of General Practitioners and Specialists 11: Distribution of MORSA Personnel by Categories 12: Evolution and Regional Distribution of Physicians 13: Health Infrastructure (Public and Private Sectors) 14: Hospitals and Beds by Type 15: Hospitals and Beds, by Ownership 16: Hospitals Under-Construction in October 1985 17: MOHSA and General Budget (1976-1984) 18: Budget of Ministry of Health and Social Assistance 19: Distribution of MOHSA Expenditure in 1984 and 1985 20: Public Investments in the Health Sector (1980-1986) 21: Health Sector Investment Program 22: Investment Program of MOHSA 23: Fee Echedule for Selected MORSA Medical Services in 1985 and Real Increase or Decrease Since 1981 24: Universal Old-Age and Disability Pension Scheme - Number of Beneficiaries and Benefits Paid 25: Social Insurance Organization: Contributors and Beneficiaries 26: SIO: Total, Health and Maternity Contributions ZI: SIO: Annual Operating Expenditure on Health Facilities 28: GERP: Beneficiaries and Benefits 29: BAG-KUR - Contributors, Beneficiaries and Benefits 30: Hospital Utilization Indicators by Provider 31: Hospital Utilization Indicators by Type of Facility 32: Hospital Infrastructure and Utilization by Province 33: University Hospital Infrastructure and Utilization 34: Expense per Patient Day and Per Bed for a Sample of Hospitals GRAPHS 1: Contributions & Beneficiaries - Social Insurance Organization 2: User Charges Funds ORGANIZATIONAL CHARTS 1: Ministry of Realth and Social Assistance 2: Provincial Health Services  -5- T U RK I T RBAL?T SECTOR RBVIlV xRCUTIVI SUsmARY Substantial improvements have been achieved in the health sector over the past two decades and most Turkish indicators now compare favorably with similar data for other middle-income countries. Nevertheless, striking inequalities in health status, fertility levels, and access to basic health care still exist between Western and Eastern provinces, and between urban and rural areas. Large segments of the population still suffer from surprisingly high infant and child mortality rates, persistent prevalence of infectious diseases, malnutrition, and relatively high levels of fertility. These are partially caused ane compounded by environmental problems of pollution, sanitation and inadequate water supply, especially in periurban areas. Future efforts should concentrate on measures to improve the health status of lower income groups and residents of remote areas, to check the spread of infectious diseases, control common childhood diseases, and reduce fertility among high risk women. ii. Turkey's total population of 49 million is growing at an average rate of 2.2X p.a. expected to fall to 1.9S for the 1980-2000 period. Improvements in the health status of the population are evidenced by a sharp increase in life expectancy, now estimated at 63 years. Birth and death rates declined substantially during the past two decades, to 31 and 9 per thousand, respectively. However, the infant mortality rate is still very high, at 82 per thousand live births, and hides wide regional variations. Leading causes of infant mortality are perinatal complications, pneumonia, and diarrheal diseases; for child mortality, they are pneumonia, and infectious diseases. Public health authorities recognize high priority to three issues: the follow-up of the 1985 immunization campaign, the control of tuberculosis, and the resurgence of malaria. iii. The nation's food supplies provide a generous average of 3077 calories per person/day. Between 1974 and 1982, daily per capita calorie intake increased from 2260 to 2400; but protein intake decreased from 85 to 75 gr, while animal protein intake declined from 22.5 to 17.3 gr. Malnutrition remains the major contributing factor to child mortality; it also affects 35Z of pregnant women. But malnutrition does not appear in easily identifiable pockets, groups or geographic regions. It appears to be correlated with educational and cultural factors, and family and cooking habits, rathet than income, food availability or distribution factors; there is no evidence so far that recent declines in income levels have affected the nutritional status of the population. Nevertheless, malnutrition of  -6- specific segments of the population and recent trends in consumption patterns call for close monitoring in coming years. iv. Progress in contraception, rise in age of marriage, modernizing influences of education, urbanization and high levels of external migration, have led to a steady decline in the total fertility rate which now stands around four. However, striking regional disparities persist; low fertility rates and high levels of contraceptive prevalence in metropolitan areas coexist with high fertility rates in the rest of the country. The national contraceptive prevalence rate is 34.1% for currently married women, and 45.1% for women at risk. Yet, tFere is a large unmet need for family planning services, estimated at 2.2 million married women of reprodt.tive age; it is illustrated by continuing high levels of induced abortions. Moreover, substantial gains in fertility reduction could be achieved through a shift to more effective methods. v. In 1961, the Government introduced an Integrated Health Service Scheme designed to unify under the same delivery system the services formerly provided by separate agencies. The ambitious goals set at that time have not been met fully but the current Five Year Development Plan reaffirmed Government's commitment to this policy; at the same time, it stated that access to family planning services should be improved; it supported the expansion of the private sector, and encouraged the development of health insurance. However, except for some targets related to infrastructure, there are no quantified objectives in the Plan document. vi. The health sector is notable for its complexity and lack of coordination between largely autonomous public and private organizations. There are more than thirty providers of health services in the public sector: the Ministry of Health and Social Assistance, twenty one independent university hospitals, the Social Insurance Organizatior, the Army, and other ministries and public organizations. Moreover, there is a very active private sector which includes many foundations, religious groups and foreign communities which still operate their own facilities. Although tte Ministry of Health and Social Assistance is formally responsible for the design and implementation of the country's health policy, its authority over these service providers remains rather limited. vii. The country spends about 3.5% of its GNP on health, or some US$40 per capita; this is less than most other middle income countries. Fifty eight percent of these expenses are direct household outlays; most of public expenditures are channelled through the three major providers, i.e. the Ministry of Health (17%), the Social Insurance Organization (less than 12%) and university hospitals (about 8%). Annual investments in the public health sector as a whole decreased by almost 40% between 1982 and 1985 although total public investments increased by 8% (in real terms). The Ministry's budget alone declined by 13% in real terms Juring the 1976-84 period, while total government expenditures were cut by 4%; it now represents 3.1% of the general budget compared to 4.2% in 1978.  -7- viii. Costs of outpatient and inpatient services are relatively low by international standards. Preventive care is provided free, but curative care must be paid for, except by individuals recognized as indigents. Fees are higher in university hospitals than in public facilities; they are also adjusted regularly to keep pace with inflation. This is not the case for the Ministry of Health where the last two adjustments were made in April 1981 and January 1985. ix. The Government is pursuing a determined poli.y to restructure and liberalize its economy and promote the privatization of activities which the private sector can handle more efficiently. However, while privatization in the health field may be appropriate in some instances, this would not permit the Government to extricate itself from the provision of health services or to reduce public health expenditures dramatically. We consider that the State should retain its fundamental responsibility in matters of preventive care, containment of communicable diseases, provision of emergency services and ensuring access to basic health services by the poor. It is also in the national interest to support programs to improve health and nutrition standards, and to achieve fertility rates compatible with the country's resources and development prospects. Finally, sustained public expenditures are needed to lay the foundations for a more efficient and equitable health system. X. The fundamental Government objective in the sector should be to strengthen the effectiveness of the health care delivery system, with a view to redressing existing inequalities in health status, fertility levels and access to basic health services, and further improving the overall status of the population. This can be achieved in spite of current stringent ecouomic and monetary policies. The strategy proposed to reach this objective is articulated around six themes. xi. First, the creation of a sectoral coordination mechanism should be a high priority. This could take the form of an interministerial Higher Health Council, headed by the Prime Minister, with a permanent Secretasiat provided by the Ministry of Health and Social Assistance. Its role would be to provide an appropriate forurt for in-depth discussion of available options, advise the Government, and ensure coordination of sectoral interventions. xii. Second, the investment planning process must be improved. Basic information required by planners and policy makers is not readily available. No objective assessment can presently be made of the hospital construction program. At the sectoral as well as the sub6ectoral level, insufficient attention is being paid to the justification of major projects and the monitoring of their implementation. There are presently 32 hospitals under construction; spreading limited funds over too many projects leads to major delays before any of them can be completed. Furthermore, as civil works absorb the bulk of investments, there are few resources left to equip new facilities, replace obsolete equipment, and purchase much needed vehicles. A crucial responsibility of the proposed Higher Health Council would be to  - 8 - develop a consensus on sectoral investment priorities and on an optimal allocation of financial resources. xiii. Pending the outcome of a critical evaluation of on-going and planned projects. an immediate action program would include: (i) a moratorium on new hospital projects; (ii) an assessment of completion coats, operating expenses and manpower requirements of all on-going projects; (iii) the creation of an ad hoc technical group to scrutinize all on-going hospital construction projects and, whenever appropriate. recommend scaling down or abandoning altogether any project; (iv) delaying implementation of projects where sunk costs have not reached an agreed level; and (v) identify areas for transferring funds freed by the above measures. paying particular attention to first level care in priority areas and target groups. xiv. Third. better integration of services must be achieved, especially for family planning and immunization. Effectiveness of primary health care services at the outreach level is hampered by acute shortages of qualified manpower, lack of vehicles and equipment. and insufficient supplies of drugs. Although implementation of the proposed program would require additional funds, the introduction of a cost recovery mechanism is not recommended at this level. xv. Fourth. increasing the utilization of existing hospital capacity is highly cost-effective and should receive highest priority. Conservative estimates show that at least 20% more admissions could result from a reduction in the average length of stay and a parallel increase in occupancy rates. This would necessitate a profound change in the philosophy of hospital management, doctor's behavior. and structural reforms. But the proposed steps are realistic and include measures to improve: (i) the referral system; (ii) the admission policy; (iii) hospital performance; (iv) bed utilization; and (v) to reorganize urban care. Such measures could significantly reduce the need for new hospital construction.1 xvi. Fifth. the level and structure of the fee schedule applied in public facilities, for persons not recognized as indigents, must be adjusted to ensure proper and steady financing of health services. In a context of high inflation. delaying adjustments of user charges results in a substantial loss of revenue and wide fluctuations in hospital cash flow, which affects the quality of services and threatens the viability of the system. But frequent adjustments do not imply the setting up of an indexing mechanism. On the other hand, the whole structure of the fee schedule applied in public hospitals needs to be reexamined. The five year interval between the last two adjustments has led to aberrations in charges levied for public services. On equity as well as social and economic grounds, it is fully justified to proceed with a gradual correction of existing distortions. 1 The Government has already incorporated this recommendation among the policies of its current five year development plan.  -9- xvii. Finally. strengthening the financial basis of the social security system is a sine qua non to its survival. It still has considerable assets estimated at US$1.5 billion although real rates of return on investments of the three major institutions were largely negative during the past decade; but its current deficit was estimated at US$1.8 billion in 1983. This situation resulted from a combination of factors which include legal constraints. liberal lending policies to the members, generous benefits, conservative management and very high inflation rates. A major reform is under consideration, which would extend health benefits to members of the Social Insurance Agency for the Self-Employed and their dependents; at the same time. an extended health insurance system is being proposed. In view of the complexity and sensitivity of issues under discussion, only a widely open debate, based on an objective consideration of alternatives can lead to a national consensus on the future of the social security system, the nature and extent of its coverage, and tfe monetary implications of possible options. xviii. At a time when critical issues are being addressed and new avenues explored. and when decisions are called for which will radically affect the future of the sector, technical studies are needed to assist the Government in evaluating policy alternatives and their implications. - Priority areas for research include disparities ia health and fertility indicators; hospital utilization; financing of health services; reform of the social security system; and national health insurance. Considerable expertise. which has so far not been tapped, already exists in the country. But outside consultants would also be useful to widen the perspective and take advantage of other countries' experience. xix. Priority investment requirements for the sector are for: (i) design and implementation of primary health care interventions targeted to specific areas and priority population groups; (ii) completion of highest priority on-going projects. while deferring lower priority hospital construction projects; (iii) equipping new facilities; (iv) launching a program for the gradual replacement of obsolete equipment; and (v) upgrading and expanding the Minist Irs fleet of vehicles. giving priority to outreach services and supervision. 2 The Government has already incorporated this recommendation among the policies of its current five year development plan.  - 10 - I. - =ALTR, NDTRTION AND )FUILITY STASMUS A. Sector BEackgroimd 1. Turkey's total population of about 49 million, or 62 persons per square kilometer, ranks it seventh in size among the middle-income countries, and first in the Bank's EMENA region. About 45% of this pokulation is urban (living in places of 20.000 persons or over). a proportion below the region's average; more than half the rural population still lives in communities of less than 1.000 inhabitants. The extensive internal migration of the last two decades. which originated largely from the northern and eastern provinces. has resulted in much higher densities and urbanization rates in the western part of the country. The rural-urban inflow involved close to 3 million persons and contributed to the deterioration of living conditions in "gecekondu" housing3 : by 1980. about 65% of the population of Ankara lived in squatter settlements; this proportion was 45% in Istanbul, 35% in Izmir. and between 20 and 40% in the other major cities. External migration, largely to West Germany. peaked in the early 1970s at about 1.8 million. In 1977. more than 1 million Turks lived in West Germany, of which 40% were women and 36% children below fifteen years of age; by the end of 1983, there were still more than 1 million workers abroad; during that same year, more than 52.000 new migrant workers left the country. mainly to Libya (23.000) and Saudi Arabia (20.000). The government continues to encourage emigration of its labor surplus as these workers' remittances reached US$1.9 billion in 1984. 2. The first enumeration of the Turki h population took place in 1927 and since 1935 censuses have been conducted regularly at five-year intervals. Reliable vital statistics are maintained at the Hacettepe Institute of Population Studies in Ankara. In the 1960s. the natural rate of growth of Turkey's population averaged 2.5% p.a.; this rate declined to 2.3% in the 1970s; emigration further reduced the overall rate of population growth to 2.1% p.a. With the slowing down of external migration, the rate of growth of the resident population is now 2.22 p.a ; it is projected by the World Bank at 1.9% p.a. for the 1980-2000 period ; this would yield a 3 Literally, "built in one night". These are housing built in violation of the city plani without license. Housing standards are generally reasonable but these areas, at least initially. lack adequate infrastructure and urban services. 4 The State Planning Organization's projections are based on a natural rate of increase of 1.6% p.a. by the year 2000, derived from a crude birth rate of 22 and a crude death rate of 6 per thousand; this results in a total population of 66.9 million for that year (see "Country Report on Policy Objectives and Measures Relevant to Population Trends of Turkey", State Planning Organization. June 1982).  - 11 - total population of 65 millions by the end of the centory. The aging process of the population is illustrated by the proportion of children below fifteen, which declined from 40.8% to 37.5% between 1973 and 1983. 3. Turkey compares favorably with Egypt and Iran, the other two most populous countries of the region, on the selected indicators shown in Table 1 (Tunisia, at the same level of per capita income, is also included in the table). Life expectancy at birth is 61 years for males and 66 for females (compared to 49 and 52 years respectively in 1960); this is however below Syrian and Jordanian levels. Mortality and fertility declined substantially during the past two decades (40% and 262 respectively), although progress was much slower for infant mortality. The crude death rate, which was 16 per thousand in- 1960, now stands at 9 per thousand. The crude birth rate fell from 43 to 31 per thousand between 1960 and 1983, i.e. below the average for middle-income countries; however, it is still twice as high as current rates in industrialized countries (14 per thousand on the average). The total fertility rate of 4.1 is again below the average for middle-income countries, but substantially higher than in industrialized economies (1.7 in western countries and 2.3 in eastern European countries). 4. In recent years, improved productivity in agriculture, rural migration, and high rates of inflation which eroded real urban incomes, have somewhat reduced income inequa'ities between rural and urban areas. Nevertheless, disparities between and within regions, and between the cities and rural and periurban areas remain considerable and are apparent in all indicators. A good illustration is provided by literacy rates: national averages were 75% for males and 48% for females in 1975, but 87% and 69% respectively in Istanbul province, and 35% and 8% in Hakkari province in the extreme southeast. In the early 1980s, per capita incomes were twice the national average in the West, but less than haif the national average in the East. These high disparities in terms of per capita incomes and educational levels, as well as religious attitudes have direct bearing on health status and demographic behavior. 3. Health 5. Improvements in the health status of the Turkish population are evidenced by the sharp increase in life expectancy. However, at 82 per thousand (184 in 1960), the infant mortality rate is substantially higher than the rate recorded in industrialized countries (10-20 per thousand). In 1975 for instance, 29% of all deaths reported at the provincial and district level were of children under 1 year of age. Perinatal complications account for half of the reported cases of infant mortality; the second cause of infant deaths is pneumonia (181), followed by diarrheal diseases (8%), and other infectious diseases (5%), Regional variations are striking. In 1977 for instance, while the overall infant mortality rate stood at 134 per thousand, it was 119 in urban areas, 146 in rural areas, 108 in the West, 109 in the South, 151 in the Center, 141 in the North and 177 in the East of  - 12 - the country. High infant mortality reflects, among other things, high fertility, low levels of brenatal care, improper delivery and feeding practices, and environmental factors; they are also the consequ"nce of unequal access to health services, often linked with the reluctance to use them. 6. The child mortality rate (9 per thousand, compared to 47 in 1960) is just below the average for middle-income countries, but again much higher than in industrialized countries (less than 1 per thousand). The major causes of child mortality are pneumonia, infectious diseases, accidents, diarrhea and malformations. These regiotered diagnoses point at the underlying causes: incomplete immunizations, crowded housing, adverse environment, poor water supply and malnutrition. The high mortality by pneumonia and acute respiratory infections among infants and children calls for increased attention, in health education programs, to the effects of passive smoking. 7. The causes of adult mortality are not well known as data refer mainly to recorded cases in urban areas. Major causes of adult death are pneumonia, bronchitis, emphysema, asthma and malignant neoplasm. For the population aged 45 and above, coronary diseases account for 40X of deaths; they are followed by malignant tumors (12%) and cerebrovascular diseases (8%); as many as 20X of cases are recordt.d as ill-defined, while the number of coronary diseases is overestimated. At any rate, mortality by cardiovascular diseases, and the high incidence of lung cancer among adult males are direct consequences of very high levels of tobacco consumption. Maternal mortality reflects inadequate obstetrical care, short intervals between births, and high incidence of induced abortion. 8. Identified leading causes of infant morbidity are measles, diarrhea, intestinal infections and pneumonia, with malnutrition as a contributing factor. As regards adult morbidity, highest incidence refers to acute respiratory problems, diseases of genito-urinary system, gastroenteritis and diarrheal diseases. Some infectious and parasitic diseases, such as plague, rabies, leprosy, trachoma and syphilis, have been largely controlled. Others, like hepatitis, typhoid, hydatidosis, are increasing in spite of active control programs. 9. Public health authorities are presently concentrating their efforts on three major problems: the follow-up of the immunization program; the control of tuberculosis; and the resurgence of malaria. 10. Until the end of 1985, is unixation coverage was extremely low. The only two compulsory vaccinations - against smallpox and typhoid - were discontinued in 1981. No systematic immunization program was conducted by MOESA; the decision about vaccination was left entirely to the parents and only the urban better educated who could bear the cost, had their children immunized. In rural areas, the service was rarely available. In 1979 a sample study showed that only 30% of the age group I to 5 w4s fully immunized against whooping cough, diphtheria, tetanus, measles, poliomyelitis and tuberculosis. More recent estimates by MOHSA on specific  - 13 - disease coverage shoved 65% for tuberculosis, but 35% only for measles and 32% for poliomyelitis, diphtheria, tetanus and whooping cougb. In fact, peripberal services lacked cold chain equipment, vehicles, trained supervisors end intersectoral support. 11. To face this critical situation, the government launcbed in 1985 a nationwide "Expanded and Accelerated Immunization Program", witb the support of the ministries of education, agriculture, industry, the private sector and the ariy. The three-round campaign was also supported by UNICEF, WHO, bilateral donors and NGOs which, altogether, contributed over US$20 million. Four tillion doses of vaccine were produced by MOHSA and 16 million doses were purchased or procured by donors. The campaign ended in December 1985; five million children were reached and full immunization could be as high as 80%. Final costing of the operation and evaluation of immunity by both serology and epidemiological data will permit a full assessment of this "expanded and accelerated" approach which has raised much interest in the international community. At any rate, MOHSA must now organize the follow-up of this operation; other campaigns at three or four year intervals are unlikely to succeed as popular support, intersectoral collaboration and foreign assistance would be difficult to mobilize. The solution lies in the integration of immunizations into regular health services activities, especially now that the PHC system has benefited from the campaign in terms of know-how, vehicles, cold chain, and small equipment. 12. The second problem area is the control of tuberculosis. Incidence of TB fell from 265 per 10,000 population in 1967 to 50 per 10,000 in 1978, but increased again slightly to 65 per 10,000 in 1983. Overcrowding, poor sanitation, and malnutrition linked to low incomes in periurban areas are major contributing factors; moreover, the high cost of treatment remains inaccessible to large numbers of unemployed urban dwellers; these factors are obviously beyond the control of the public health system. Although the apparent rapid decline as well as the resurgence are largely due to changes in the intensity of screening and case finding operations, the disease still poses a serious threat: there were 130,000 registered cases in 1984 and probably as many as 500,000 undetected cases. In spite of progress in ambulatory treatments, 7,500 beds in general or chest hospitals are still occupied by TB patients. As at least 50% of births in rural areas are not attended by health personnel, increased BCG coverage could only be obtained by strengthening the PHC system (i.e. the village midwife and health centers) and by intensifying screening and active case finding operations. The TB control program, with its 249 TB centers throughout the country, has already benefited from integration into PHC, but should be further strengthened by additional facilities for massive bacterioscopy, for selective radiological control as well as provision of free drugs for treatment of indigents. 13. Finally, a third concern of MOHSA is the resurgence of malaria during the 1970s. Although Turkey was declared free of this disease in 1970, large irrigation projects, particularly in Cukrova plain of Adana province, and progressive reinfestation from the Syrian and Iraqi borders swamplands, have reintroduced malaria in the country. Incidence rose  - 14 - rapidly: 9,000 cases in 1975, 32,000 in 1976, and an epidemic of 115,500 cases in 1977 led to a declaration of emergency and a call to WHO for technical assistance. Since then epidemics have been controlled but endemicity remains stable at 30,000 new cases per year. The complex mechanisms of the resurgence have been well analyzed: the impact of agricultural and industrial development on the ecology; the movement of some 600,000 seasonal and permanent migrant workers; and the resistance of mosquitoes to usual insecticides. Malaria in South Eastern Turkey could also become a threat to tourism. It has caused international embarrassment, since infected migrant workers or truck drivers (about 40,000 trucks cross the border every year) can spread the disease to Bulgaria, Yugoalavia, and even Western Europe. 14. The Government has taken active steps to control the disease, earmarking 3X of MOHSA's budget for malaria control in 1985 (US$7.4 million). The malaria program has been integrated with PHC, intensive spraying and screening are going on, amidst increasing resistance from the population. For its part, the State Water Affairs Department (DSI) is actively pursuing drainage activities, including the costly maintenance of extensive irrigation networks. To stop malaria transmission by 1989, four interventions have been designed: - strengthen PEC programs, which cover control or surveillance in all infested or receptive areas, i.e. 37% of the country's population; - develop the mid-level management of malaria services, upgrading and strengthening the Adana Institute of Malariology to train staff at undergraduate and postgraduate levels, and perform as a coordinating center for malaria control and schistosomiasis surveillance; - intensify drainage and spraying in the Cukrova region, in coordination with private industries and agricultural authorities; and finally - complete, in 1986, the construction of nine pumping stations, to lower the ground water level of the Cukrova plain. In addition, the Government is undertaking, with World Bank support, a project for nation-wide improvement of drainage in irrigated areas. 15. MOHSA also fears infestation by schistosoma hematobium in existing and proposed large irrigation areas near the south-eastern borders. Nalacological surveillance has started and will have to increase as irrigation progresses.  - 15- C. Nutrition 16. Turkey has always been a country of agricultural wealth, therefore nutrition was not considered a problem until demographic growth threatened the food balance. The nation's food supplies provide a generous 3077 calories per person/day, the second highest among lower middle income countries. On the average, the population continues to be well fed, although actual consumption may have declined slightly in recent years. However, malnutrition of specific segments of population is a cause of concern. 17. The assessment of the nutritional status of the population is essentially based on the 1974 national survey carried out by Hacettepe University5. After 1976. small studies and surveys were carried out by the University which also sponsored community programs, in Estimesgut. Cubuk and Eswir for example, centered on mother and child malnutrition. In 1982. a Survey on Food Consumption and Nutrition focussed on food availability (see Table 3). New findings tend to confirm that malnutrition is correlated with educational and cultural factors. and family and cooking habits, rather than income, food availability or distribution factors. All indicators are still well above minimum requirements, and the basic assumption is that recent declines in income levels have not. so far, affected the nutritional status of the population; nevertheless, close monitoring of consumption will be required over the coming years. 18. Between 1974 and 1982. daily per capita calorie intake increased slightly from 2260 to 2400; but protein intake decreased from 85 to 75.3 gr. while animal protein intake declined from 22.5 to 17.3 gr. However, in spite of favorable national averages, malnutrition persist in some segments of the population. Malnutrition remains the major contributing factor to child mortality: it is estimated that 20% of preschool children have inadequate growth; 14% of school children are below expected weight for age, and 4% are under expected height for age. Other indicators of malnutrition among children are riboflavin deficiency (6%). rickets (2%). and defective teeth (8%). Prevalence of weight deficiency is only 3% during the first 6 months of life, but reaches 20% at 12 months (to remain at that level until 2 years. and diminish slowly to 10% on the 5th year). The major causes of infant and child malnutrition are: insufficient breast feeding, as the caloric and mineral content of milk becomes insufficient after the first three months of lactation; early weaning, combined with inadequate supplementation, late introduction of solid supplements. inappropriate use of commercial formulas and limited use of the soy bean flour SEKMAMA 5 "Nutrition in Turkey" by T. 0. Koksal, Hacettepe University, Ankara, 1977. 6 "Food Consumption and Ntarition in Turkey" by H. Gencaga, Turkish Development Research Foundation, Ankara. 1985.  - 16 - distributed by MORSA; and frequency of communicable diseases combined with diarrhea episodes. 19. Pregnant and lactating women are the second group affected by malnutrition and in particular by anemia, which occurs among 35% of pregnant women. The usual causes - short birth spacing, high parity, diminishing consumption of proteins - are aggravated by adverse cultural habits that give priority to the feeding of adult males over women and children. Female obesity is a growing problem - 38% suffer from moderate obesity, and 26% from severe obesity - due to over consumption of carbohydrates and fats and a sedentary life style. 20. Malriutrition does tot appear in easily identifiable pockets, groups or geographic regions. It is associated with several closely related factors which include education, size of the family and family income. The newly urbanized population is probably the one that suffers most from malnutrition as it is most affected by unemployment, low earnings, and new eating habits. As can be expected, severe calorie malnutrition is concentrated in lower income groups and affects 252 of the families in the bottom 20% of households, against 8% in the top income bracket. In 40% of the families in the lowest income bracket, per capita daily consumption of animal proteins is less than 10 gr, against 3% for the highest income group. It is estimated that the proportion of income spent on food is 40% for low income urban households, and as high as 65% for low income rural households. So far, lower income groups have adapted to inflation by replacing high priced foods by low cost ones of equal nutritional value. However, the lower consumption of animal proteins signals a possible deterioration of consumption patterns. Table 4 shows the major variations in consumption patterns in various parts of the country. 21. More detailed data would be needed to identify high risk groups in operational terms, and design effective interventions. The Government supports several educational programs in nutrition. Most public or private enterprises operate free or subsidized cafeterias; this satisfies the needs of the family head, but tends to detract his attention from the family food basket. MOHSA conducts programs in five areas: breast feeding; weaning food and supplementation; growth monitoring and clinical follow-up; subsidization and distribution of iron supplemented cereal derivates to prevent anemia and iodized salt to prevent goiter; and nutrition education through MCH and Health Centers as well as schools in association with the Ministry of Education. 22. The Government has no coiordinated policy on food and nutrition. The Ministry of Agriculture monitors food consumption through its Department of Food Affairs that was transferred from MOHSA. No agency is responsible for overseeing the development of food technology, industrial food production, or marketing policies. The creation of an intersectoral advisory body, between MORSA and the ministries responsible for agriculture and education seems appropriate.  - 17 - D. Fertility 23. Progress in contraception, rise in age of marriage, modernizing influences of education, urbanization and high levels of external migration have led to steady declines in fertility. Overall indicators are comparable to those of other middle income countries. but hide striking regional disparities. Low fertility rates and high levels of contraceptive prevalence in metropolitan areas coexist with high fertility rates in the rest of the country. Cultural and religious factors are often an obstacle to rapid response to family planning programs. In rural and eastern areas, entrenched attitudes towards women mean that the majority are still regarded as second-class citizens, despite 50 years of universal suffrage; there are twice as many illiterate women as illiterate men. In remote Anatolian villages, girls are still frequently kept away from school; contraception is considered sinful; polygyny. although illegal, is still practiced in the countryside; men whose wives are unable to produce a son marry again at religious ceremonies not sanctioned by law; marriage still occurs at very early ages in rural areas; and a large number of children is viewed as a blessing to farming families. Turkey is a secular state and a Muslim country and, as such, has not remained indifferent to events which are presently shaking the Islamic world. It is, of all Muslim countries, the one which has achieved the highest levels of female literacy and participation in economic activity. These are both essential determinants for continuing fertility reduction. 24. As early as 1963, MOHSA carried out a "Knowledge. Attitudes, and Practices" survey. with the assistance of the Population Council. which demonstrated that about 75% of I4WRA were in favor of family planning. In 1983. MOHSA conducted a nation-wide fertility survey. but data processing was delayed for financial reasons and the results will not be available before mid-1986. The 1978 Fertility Survey revealed however many characteristics which have probably persisted; it showed that 50% of women of reproductive age were using contraception; this result had been challenged and a prevalence rate of 38%. calculated in conventional terms, was found more realistic; this still placed Turkey in the second position in the Region, after Tunisia. Formal education of women appears to be the strongest determinant of fertility in Turkey. Universal marriage is also a significant factor: in 1978. only 1% of women aged 35 had never been married and an equal proportion were divorced or separated. The estimated completed fertility of 6.3 was much higher than the average desired family size of 3; it also varied widely, from 8.8 in the East. to 5.7 in the West; urban fertility was 5.0. compared to 7.3 in rural areas. Similarly, the total 7 Defined as the average number of live children ever born to ever married women by the end of their reproductive years. or age 49.  - 18 - fertility rate8 was 4.3 at the national level, but only 3.7 in urban areas. compared to 5.1 in rural areas; the difference was even greater between the Western (2.9) and Eastern (6.3) parts of the country. 2 . Contraceptive prevalence rates cannot be derived from service statistics as there are no nationwide comprehensive data on contraceptive use, in MOHSA facilities, or in university hospitals. the SIO, private practitioners or pharmacies. In 1978. only 12% of users relied on modern methods (IUD. pill, condom), while 44% favored inefficient natural methods; IUD was used in only 3% of cases. A more recent estimate of FP users in 1984. made by MOHSA, showed a national prevalence rate of 32.6% for ever married women, 34.1% for currently married women. and 45.1% for exposed women9 (see Table 7). During the same year, new female acceptors represented 7.4% of the total 15-49 age group; this ratio was only 3.6% in the East and 4.7% in the Southeast; on the other hand. the Southwest showed twice as many new acceptors as the national average (see Table 6). 26. A large unmet need for family planning services persists. The 1978 survey already showed that smaller families were generally desired. an important indicator of future fertility trends. The average desired family size of 3 children was half the completed size of 6.3. Overalls 57% of MWRA wanted no more children. This was also the case for 50% of MWRA with two living children (59% in the cities. against 40% in rural areas; 64% in the West, against 31% in the East; 72% with secondary education or more, against 39% for illiterates). Estimates made by MOHSA in 1984 indicate that, to reach the desired norm of 3 children per family, the number of protected women should increase from 2.8 to 5.1 million; for the desirable norm of 2 children per family to be achieved, the number of protected women should be 6.5 million. If this unmet need were satisfied, the crude birth rate would drop to 14-21 per thousand, instead of the current 31 per thousand. 27. But the inadequacy of services and shortfalls in contraceptives supply is best illustrated by continuing high levels of induced abortions. According to the 1978 Fertility Survey, the annual percentage of women of child bearing age who had an abortion increased from 14% to 17% between 1975 and that year. Of the 1.3 million women who had induced abortions, 66% had it after their last delivery. and abortion seemed to be aimed at preventing birth of more children and terminating reproductive life rather than for birth spacing. The proportion of induced abortions increased rapidly with age. i.e. from 6% of women aged 15-19. to 47% of women in the 40-44 age group. Because of early marriage and rapid attainment of reproductive ideals. induced abortions start rather early in reproductive life. In 1984 8 Defined as the average number of children that would be born alive to a woman during her lifetime. if she were to pass through all her childbearing years conforming to prevailing age-specific fertility rates. 9 Exposed status was defined as women living with husband, not in post-partum amenorrhea. not pregnant and not sterile.  - 19 - however, only 20.590 abortions were officially performed nationwide in MOHSA. social security and university hospitals. 28. Ignorance of modern contraceptive methods in rural areas. and widely used inefficient contraceptive methods provide another explanation for the high rates of induced abortions. In 1978, 88% of ever married women were aware of contraceptive method(s); 81% of them knew of the pill and 68% of the IUD; however, 15% of all rural women knew of no method at all. About 63% of the women in the 25-34 age group had used some contraceptive method: 75% in the cities, but only 48% in rural areas; 78% in the West. but only 40% in the East; 93% of those at the secondary school level, but only 47% of those illiterate. As for present use of contraception among women of reproductive age, it is strongly correlated with the number of living children, indicating the desire to space later births rather than delaying the first ones. Tables 5. 6 and 8 provide evidence of the considerable gains in prevalence rates that can be expected through a shift from natural methods and condoms to more effective contraceptive methods. e. Environmental Factors 29. Deteriorating environmental conditions have increased morbidity associated with water and air borne diseases. In rural areas, most communities do not have piped water and rely on wells, public fountains or springs; during the summer dry season, streams and rivers often have to be used for human and animal cons.. ption as well as washing. Sewers rarely exist, and liquid and solid waste disposal systems are primitive. 30. In urban areas, sewage collection and disposal constitute the most severe urban problem in terms of unmet needs, followed by garbage collection and disposal, particularly in the peripheral areas10. Sewer systems exist only in the major cities and serve an estimated 4.4 million people, or 18% of the total urban population; entire sections of most urban areas have unsanitary conditions which contribute to the spread of water borne diseases. In 1980, 69% of the urban population had house connections. 25% used public standpipes, but only 6% had serious difficulty in obtaining water. However, of the 990 municipalities with more than 3,000 inhabitants, only 42% have a fully modernized water supply and distribution system. Although housing conditions have improved markedly. overcrowding still affects most urban areas; between 1970 and 1980. the average urban house increased from 2.3 to 2.86 rooms; at the same time, the average size of urban households declined from 5.7 to 5.2 persons. 10 See "Turkey : Urban Sector Review", World Bank, October 1983 (P,vort No 4631-TU)>  - 20 - 31. Rapid urbanization has further lowered the quality of environment in large cities, as municipal resources are insufficient to cope with growing problems of vater shortages, sewage, garbage disposal, etc. This is compounded by lack of zoning regulations regarding the creation of new industries which also affects health conditions through air and water pollution. Finally, high levels of occupational diseases and accidents are generated by rapid industrialization; these are even higher in smaller enterprises and family shops where unsafe and unhealthy working conditions prevail. In 1982 for example, SI0 statistics show that, among the 2.2 million insured workers who represent at best 15S of the employed labor force, there were 146,000 cases of serious work-related accidents or occupational diseases, resulting in 2,760 cases of permanent disability and more than 1300 deaths. 32. Municipalities carry the entire burden for enforcement of food quality control, with limited success because of scarce technical and financial resources. Moreover, as responsibility for design and supervision of this activity is diluted under six different ministries, regulations in this area are not seriously enforced.  - 21 - I1. - SECTONAJ POLICIES AND OBJECIrUES A. Wealth 33. As early as 1961, the Government established health goals emphasizing integration of public health services (referred to as "socialization"), and increasing coverage in rural areas, including community health and MCH/family planning. The Iategrated Health Service Sebeh (IHSS), was designed to unify under the same health care delivery -system the services formerly provided by separate agencies, and to change health financing laws in order to allow access to public services to all those without bealth insurance. It provides basic medical care, integrated NC8/FP services, prevention and treatment of communicable diseases, environmental health care, school health services, health education, and community development. Improved nutrition is expected from increased production and better distribution of basic food items, but the IHSS is to implement specific programs within MCH, especially for poor pre-school children in both urban and rural areas. 34. The IHSS operates at four levels, the first two providing primary care services. At the first level, health posts serve an average of 2,000-2,500 population. They are staffed with a village midwife who works generally alone. She provides PHC and FP care, dispenses basic drugs and contraceptives, and attends deliveries either at home or at her small station; in addition, the midwife is supposed to visit each household monthly, but lack of transportation makes this task impossible in sparsely populated areas. There are only 14,000 village midwives for some 36,000 villages. Each health post is visited at least once a week by a mobile team based in the health center. 35. At the second level, the health center (RC) is the cornerstone of the system; it serves 10-20,000 persons in scattered areas, while large (urban) centers serve 20-50,000 persons; moreover, each health center supervises at least 3 health posts through its mobile teams. Realt'. centers are modestly equipped, and have a staff of 7 to 10: one MD (generally a new graduate serving his compulsory medical service), one public health nurse, several midwives, a secretary and a driver. HCs are responsible for ambulatory medical care and preventive programs, i.e. inmmunizations, MCH, family planning, health education, control of communicable diseases, epidemiological surveillance, case finding for TB, malaria and cancer. They are also responsible for outreach visits to health houses, homes, schools, work sites, etc. However, the shortage of vehicles limits considerably outreach activities. 36. The third level consists of a local hospital with 50-100 beds, staffed with four specialists (surgeon, gynecologist, internist and pediatrician), one laboratory technician and one dentist; each local hospital serves 5-6 health centers. Finally, at the fourth level, the  - 22- general regional hospital serves a population of 200-400,000 persons, as a referral facility for 20-40 health centers. 37. The ambitious goal set in 1963 was to extend the new system to the whole country in fifteen years, in order to redress inequalities in coverage of basic services and in health status. However, the IHSS failed to achieve these objectives, for lack of thorough preparation and planning at the conceptual stage, insufficient financing, and lukewarm, political and popular support. The only formal basis for the system is still the 1961 Law creating it; but no technical foundation was ever designed to seL up realistic objectives, determine a timetable, evaluate costs and identify sources of financing. Since 1978, UNICEF is assisting MOHSA in the implementation of a Primary Health Care Project which includes components in immunization, oral rehydration, nutrition, MCH/FP, water/sanitation, essential drugs, health management and research. 38. Health education is largely neglected in Turkey and no specific program is implemented in this area. However, MCH clinics cover some aspects of health education in their pre-natal, maternal and child care activities, and primary school programs include some elementary health education topics. Low levels of education among women constitute a major constraint to improving the health status of the population, in rural as well as in newly settled periurban areas, a 1980 survey confirmed the relationship between higher levels of infant mortality and mothers' low educational levels. 39. The Fifth Developmeut Plan (1985-1989) contained general statements reaffirming Government's commitment to "equal access to health services by all citizens", and to "health services for all, everywhere and equally", under a single authority. As regards family planning, it stated that the national policy should be to provide families with "effective measures responsive to the family sizes they desire, in accordance with their socio-economic levels". The Plan introduced two major policy orientations which are bound to affect future sector development: first, private establishments and hospitals received official support through deregulation of fees charged in these facilities, and through contracts to be passed between the public health sector and physicians in private practice; second, the transition to health insurance is to be made during this period; it is not clear however what this entails in practice. 40. But the Plan's objectives focus on institutional issues. There are no quantified targets, and no specific measures are recommended to improve the health status of the population. Objectives include improved accessibility and efficiency of services; emphasis on preventive medicine; better utilization of existing capacity; improved cooperation between state, university and Social Security owned hospitals; the strengthening of regional hospitals, to stem the flow of patients in major cities; the expansion and improvement of maintenance services; and manpower development. A national target of 2.6 beds for 1,000 population has been set, but the Plan explicitly excludes the construction of new hospitals in provinces with under-utilized capacity. Finally, the Plan excludes the  - 23 - construction Qf large teaching hospitals, not cost-effective and difficult to manage, B. Nutrition 41. For more than tuenty years, as evidenced by four Development Plans, self-sufficiency in food and improvement of the nutritional status of the population have been priority objectives; agricultural projects have been largely justified on these grounds, although target groups or food items whose increased availability would improve the nutritional status of the population were rarely identified. Nevertheless, for large segments of the population, food availability in terms of calories and proteins is below nutritional requirements. A small nutrition inte-vention program consisting of the distribution of high protein weaning food (SEKMAN&) is implemented jointly by MOHSA and the Turkish Dairy Corporation with UNICEF assistance. However, it is not replicable in a wider scale. 42. Until the early 1980s, wheat and flour were subsidized. However, provision of wheat at subsidized prices tended to create a dual flour market rather than stabilize prices. As government subsidies were exclusively channelled through bakeries, they were largely confined to the three major metropolitan areas. Rural households and poor urban dwellers who make ttaeir own bread were not reached; moreover, the system hardly benefited smaller cities, especially in the Eastern Anatolia and Mediterranean regions where calorie malnutrition is most prevalent. A more effective mechanism is being introduced for stabilizing prices and aleviating shortages during off-season periods, namely spot sales on the free market, particularly in Eastern Anatolia and the Mediterranean regions. 43. In a longer-tern perspective, the Government has taken measures to encourage consumption of key commodities such as pulses, potatoes, vegetable oils and margarine. Pulse production hae been encouraged througb an intensive research/extension effort known as the Fallow Reduction Program. In addition, the Government has completely liberalized the importation of vegetable oil seeds to reduce domestic prices of oil and promote their consumption. Efforts should also be made to reduce the price of sugar, as the Turkish sugar beet industry is not competitive and local wholesale price of sugar is about 70% above international price. As for the low per capita consumption of potatoes, it is only partly due to consumption habits: a policy has been designed to reduce production costs through seed improvement, extension work, increased output and promotional support. Finally, increased efforts should be made to assist livestock development on the farm, and to increase productivity of village herds as an essential means of improving rural diets. With UNICEF assistance, the Ministry of Agriculture is implementing a Food and Nutrition Planning and Policy Project, now in its third phase, in order to support government's efforts in improving commodity planning and food marketing.  - 24 - C. Population 44. After World War I. Turkey followed an active pronatalist policy, justified by high mortality rates and acute manpower shortages. The First Five Year Development Plan, published in 1963. was the first legal document to recognize that tjr rate of population growth was affecting adversely economic developmentl The 1965 Law on Population Planving reversed the previously ?ronatalist official position and legalized contraceptive use with a view to slowing down labor force growth and increasing savings and investment. For the first time. free or low cost contraceptive services and information were made available to the population; abortion for medical reasons was legalized, but sterilization was banned. However. the Government never supported incentives to encourage fertility reduction. and never questioned existing tax allowances for families of up to five children. Implementation of the 1965 law was rather slow, at least until 1978. Nevertheless. "population planning" programs12 were established in MOHSA and in military and volunteer organizations. 45. The September 1980 Constitution, endorsed by referendum in November 1982. mentions for the first time in a legal document the term "family planning" which, following the ambiguous formulation of Article 41. is to be implemented "through education". The Fourth Plan's (1979-1983) ambitious goal13 was to lower the country's total fertility rate to the level of the most developed provinces, by the year 2000. This implied a reduction of the total fertility rate to 2,7, of the crude birth rate to 22 per thousand, and of the crude death rate to 6 per thousand; the corresponding rate of natural increase would be 1.6Z p.a. 46. The May 1983 Law on Population Planning set forth the principles of population planning, defined the terms termination of pregnancy, sterilization and emergency situation requiring medical intervention, and regulated matters concerning the procurement, manufacture and official recognition of contraceptive drugs and devices. Abortion under 10 weeks of pregnancy was authorized for social or economic reasons; over 10 weeks abortion was authorized for medical reasons only; sterilization was no longer subject to medical justification, and paramedical personnel were authorized to provide FP services, including IUD insertion. MOHSA was given the responsibility to coordinate all FP services delivered by the various proaviders. 11 See "Population Policy of Turkey" (Environmental Problems Foundation of Turkey. Ankara, July 1983) for a presentation of the population issue in a historical perspective. 12 "Population planning" is the official term used in the country to designate family planning activities. 13 See "Country Report on Policy Cbjectives and Measures Relevant to Population Trends in Turkey". State Planning Organization. June 1982.  - 25 - 47. Family planning services are part of the program implemented by the General Directorate for Maternal and Child Health and Family Planning, which operates 600 clinics, 95 dispensaries and 20 independent facilities in periurban areas. These activities complement FP services provided by the primary health care program. IUD, pills and condoms are available, but user or post-partum follow-up is not organized, therefore no current data are available on contraceptive prevalence. SIO and university hospitals provide the full range of services. The Turkish Family Planning Association created in 1963 has 19 branches providing supplies and education materials. The military, the Turkish Development Foundation, labor unions, the Railways Corporation, the Post Office, and insurance schemes also implement their own programs. The private sector remains the main provider of services in urban areas, but no information is available on its real coverage. In rural areas, where full health coverage has not yet been achieved, absence of services, supplies and promotional activity is clearly reflected in higher parity levels, infant mortality and abortions. 48. In the field, responsibility for health education rests primarily on the midwives who conduct individual and group sessions at the health center, the health post or during home visits; a specialized team is in charge of specific target groups such as teachers or religious leaders. UNFPA currently supports a five year project to strengthen and integrate NCH/FP services in 17 Eastern provinces. It executes an education and services project targeted at 150,000 workers in more than one hunured industrial plants; it also assists the Ministries of Education, of Information and of Interior in the training of educators, the production of materials for adult education centers, the production of TV films, and the processing of the 1985 census. Over the last 10 years, UNFPA's assistance amounted to about US$10 million. Other agencies supporting Turkey's family planning programs include the Pathfinder Fund (training of midwives, advisory services to labor unions, and direct support to several FP programs for industrial workers); Family Planning International Assistance, JHPIEGO, INTRAR, the Turkish Family Planning Association and other non government organizations. Substantial assistance in the population field contrasts with the limited support provided by the international community in other areas, and social sectors in particular.  - 26 - III. SICTORAL ORGANIZATION 49, The Turkish health sector is charecterized by an extreme complexity. A large numtler of public, semi-public and private institutions are engaged in the financint, and deIivery of health services. The public sector, for instance, is not limited to the Ministry of Health and Social Assistance (MOHSA). Medical schools. through their university hospitals, cover a substantial part of demand for health services. The Social Insurance Organizatioa (SIO) not only operates its own hospitals: it also purchases services for its members from public and private facilities. The Army has a large network of facilities and covers the health needs of its active members, retirees and their dependents; very little is known about its operations. beyond the number of hospitals and related beds. Other ministries (Education. Youth and Sports). public organizations (Post and Telecommunications. Railways). and state economic enterprises still operate their hospitals. In addition to the very active private for-profit sector. there are many foundations and hospitals for religious groups and foreign communities. Most of health services are however supplied under three largely autonomous systems: (i) the Ministry of Health and Social Assistance. (ii) the Medical Schools and (iii) the Social Security System. While MOHSA is formally responsible for the design and implementation of the country's health policies, its authority over other health services providers remains rather limited. A. The Ministry of Health and Social Assistance (NoESA) 50. Historical evolution. The Ministry14 was created in 1920 to train health personnel, establish and operate model hospitals and maternity clinics. control infectious diseases, and prepare policy proposals for the development of health care. Its major responsibility was seen as the prevention of epidemics and infectious diseases. Curative care was left to the private sector and in this area. MORSA's responsibility was limited to issuing permits for the establishment of private clinics or hospitals. controlling the production and prices of medical supplies and drugs. and supervising the activities of the pharmacies; the model hospitals were only built by the government to encourage private investment in medical care. In the field, MO0SA's departments conducted their own programs independently. with their own resources. The infectious diseases program was quite successful in controlling malaria and tuberculosis and also to a large extent trachoma and syphilis. In the big cities, an immunization program was implemented, with the support -of the Red Crescent and the Child Welfare Society. However, MOHSA was much less successful in promoting the 14 It is also frequently referred to as Ministry of Health and Social Welfare.  - 27 - development of the private sector as health personnel remained in short supply and concentrated in the three major cities; on the other hand, the creation of model hospitals did not stimulate private investments, even in major cities, because of lack of know how and low demand. 51. Improving economic and social conditions, higher levels of education, and rapid urbanization generated increasing demand for personal medical services which could not be met by the private sector or by local governments. This led MOHSA to expand its provision of curative services. Considerable investments were made, but without a coherent plan or specific objectives. This increased the gap in the quality of services and general health status between urban and rural areas and between provinces. The persistent low quality standards and inefficiency of the system was also largely due to the shortage of qualified health personnel. In 1960, a small group of doctors and members of Parliament designed a national system for the "socialization" of health care, without any cooperation or support from MOHSA. This Integrated Health Service Scheme was endorsed by the military government and ratified in 1961 by the Parliament. 52. Present organization. MOHSA assumes a regulatory and policy function and, through a national network of hospitals, clinics, health centers and dispensaries, provides preventive services as well as inpatient and outpatient curative care. MORSA also operates schools for the training of nurses, technicians and midwives. However, it has limited control over the activities of the SIO which provides medical care for its members and their families, in its own hospitals. Similarly, MOHSA has practically no authority over the medical schools which, in addition to providing graduate and post graduate training, operate large teaching hospitals which cover an increasing share of the country's medical care. In the past, many ministries, local governments and state enterprises had their own hospitals and dispensaries to serve their staff and their families. Most of these facilities have now been transferred to MORSA, with the exception of the ones belonging to the Ministry of Defense; in 1983, this Ministry actually created its own medical school. The Child Welfare Society, an old charitable organization helping needy children, was transformed in 1984 into a state economic enterprise. Outside the public sector, the Red Crescent provides emergency assistance and operates blood transfusion centers in the major cities. 53. At the central level, the Minister is assisted- by an Under- Secretary and three Deputy Under-Secretaries (see Organizational Chart I). The Ministry includes six General Directorates and eight central units. General Directorates or units are subdivided into a large number of services. For instance, the General 'Directorate for Maternal and Child Health and FAmily Planning (DGMCHFP) has three Deputy General Directors, five departments, and 14 sections with a total staff of 98 persons. In spite of the IRSS, vertical programs such as malaria eradication and TB control have survived the creation of the General Directorate for Primary Health Care (GlPHC). Moreover, two units still share responsibilities in matters of MCH/FP: the GDMCHEFP, which oversees service delivery; and the GDPHC which carries out the program of integrated health services. The  - 28 - General Directorate for Pharmaceuticals plays a very important role, described below in Section IV. Finally, the General Directorate of Frontiers and Coasts is responsible for the implementation of all international health regulations and for the control of communicable and epidemic diseases at the borders. 54. At the provincial level (Organizational Chart II), the Health Director is the senior health official, formally responsible for the delivery and coordination of all public health services. However, all funds come from the capital city where all decisions relating to health personuel, their job descriptions and specific tasks are also made; only clerical and unskilled workers are hired locally but political and social pressure is such that they enjoy nearly total job security. In reality, as budget allocations for each entity are separate, each General Directorate in Ankara operates its own program t ough its provincial structure. 55. In the populatiou area, the GDMCHFP has three major responsibilities: design and implementation of education and training programs for health personnel and the general public; coordination and distribution of contraceptives to public health facilities; and research and evaluation of family planning activities. The Ministry of the Interior, is in charge of civil registration. The collection and analysis of basic data, including censuses, is the responsibility of the State Institute of Statistics attached to the Office of the Prime Minister. The Scientific Commission of Population Planning, created in 1966 under the responsibility of MOHSA, is in charge of controlling the" quality of the drugs and devices to be used in family planning". Finally, the Inter-Ministerial Permanent Special Commission on Population Activities created in 1980 under the State Planning Organization advises the Government on population issues and monitors and evaluates family planning programs. 56. Three major agencies supply MOHSA with contraceptives. Family Planning International Assistance (FPIA) provides pills (2 millions cycles in 1984-85), IUDs (200,000 in 1984), and condoms (10 millions to be delivered in 1985-1986). UNFPA provides all the contraceptives (pill, IUD, condom) for the 17 Eastern provinces. Finally, the Pathfinder Fund supplies contraceptives through several projects. The public sector never experienced shortages of contraceptives at the national level. However, storage and distribution problems sometimes result in temporary shortages at the provincial level. As far as the private sector is concerned, five companies import raw material, and produce locally eight brands of pills. Altogether, in 1984, 3,300,000 cycles of pills were produced locally, an amount sufficient to protect only 254,000 women during a year, i.e. 3% of MA. 57. For matters related to information and education major responsibility rests with the General Directorate for Health Education. Nevertheless, in the population area, the GDMCHFP has retained control of IEC interventions and operates a Communication Support Center created with UNFPA assistance. The Ministry of Education supports IEC activities in many areas of direct interest to the PHN sector through its National Education  - 29 - Board, the Institute of Nonformal Education, and the Popular Education Centers. The Ministry of Agriculture, Forestry and Rural Affairs has some 1,000 home economists extension workers in rural areas who could participate in health and population education programs. S. The Nddical Schools 58. Medical Schools assume three functions in the public sector, as research institutions, training facilities for high level health personnel, and as direct providers of health services. As the country bas no formal manpower planning or policy, the Universities and their Medical Schools make independent decisions regarding the number of students to be trained, duration and standards of education, curricula, etc. Overall policy and coordination takes place through the Higher Education Council (YOK). For years, the three Medical Schools in Ankara and Istanbul practiced restrictive policies and, in spite of government's pressure, limited the number of students in order to safeguard quality standards and physicians iucomes; they also resisted the establishment of new medical schools in newly created provincial universities. 59. In the 1970s, acute shortages of medical personnel and increasing social demand for all types and levels of education eventually overcame the resistance of the medical establishment, and a very rapid expansion of medical schools took place. The training capacity increased from 4 medical schools with a total enrolment of 900 students in 1964, to 8 schools with 1600 students in 1974; by 1984, there were 22 medical schools with a total enrolment of 5500 students. As was feared, this rapid expansion has been accompanied by a decline in academic standards, as most new schools do not have sufficient teaching staff; moreover, many lack adequate teaching hospitals and two of them have no teaching hospital and use MORSA facilities. In the past, medical schools had been criticized for their restrictive policies and their use of inappropriate curricula and standards, derived from industrialized countries; while there was some value in this criticism, the very rapid increase in enrollments, which will eventually result in an oversupply of less qualified physicians, is obviously not the solution to Turkey's health problems. 60. As services providers, university hospitals, especially the oldest ones, play a very important role in supplying curative care; many of them actually serve more as medical than teaching facilities. Demand for their services is very high as it is believed that these are of higher quality, and this is largely true since they are more receptive to new knowledge and technology, and have more resources to invest in equipment and materials. However, like most Turkish hospitals, they are affected by inefficient management, as they are directed by prestigious physicians, appointed for four years, with limited training or interest in administrative matters.  - 30 - C. The Social Security System 61. The origin of the social security system in Turkey -can be traced to the XIIth century when foundations, with government support, already provided some coverage of health risks. Under the Ottoman Empire. as early as in the XIIIth century. a sort of crop-insurance scheme existed in the agricultural sector, while most trade guilds operated social and economic protection funds; in Istanbul alone, in the XVIIth century. 1109 trade guilds were registered, with about 126.000 membersl5. Foundations and social welfare institutions evolved into at least twelve large organizations such as the Military Pension Fund (established in 1866), the Civil Servants Pension Fund (1881). or the Sailors Pension Fund (1890). The first social insurance institution in compliance with international conventions was created in 1921 for the benefit of coal miners, and Turkey is now signatory to most ILO Conventions regarding labor standards and social security. The various funds and schemes were merged in 1945 (for industrial workers) and 1950 (for civil servants); the system was subsequently expanded to cover self-employed and agricultural workers. 62. There is a perceptible trend within the system towards general coverage and standardization of benefits. Although they vary with the institution, benefits tend to be generous; moreover, built-in safeguards have been relatively successful in protecting beneficiaries during these times of high inflation. The present situation is characterized by the juxtaposition of universal and occupational schemes, which include short-term as well as long-term insurance programs. These are: - National Health service: free preventive care for the whole population; paying curative services, but fees waived for indigents. - Universal Old Age and Disability Pension scheme: financial support to some 700,000 needy individuals. - Active civil servants: free medical care for 1.4 million government employees and their dependents. - Government Employees Retirement Fund: pensions; free curative care for more than 660.000 pensioners and their dependents. - Social Insurance Organization: pensions; pre-paid curative care for 12.8 million beneficiaries. - Social Insurance Agency of Merchants. Artisans and Self- Employed Professionals: pensions; health benefits under consideration for some 10 million persons. - Private Funds: pensions; pre-paid curative care for about 300,000 persons. with limited benefits for dependents. 15 Social Security Council: "Extending and Improving the Effectiveness of the Social Security System, and the Unification of Social Security Institutions". Ankara, March 1983 (report in Turkish).  - 31 - 63. The-nationsl health service is a universal scheme which, under the 1961 Act concerning the IRSS, guarantees each citizen free preventive care and family planning services. Curative services must be paid for, except by individuals recognized as indigents. 64. The Universal 014-Age and Disability Pension Scheme, introduced in 1976, provides a flat-rate old-age or invalidity pension to needy individuals fulfilling given criteria. The scheme, administered by the Government Employees Retirement Fund, is fully financed by the state. At the end of 1984, it covered more than 713,000 pensioners, i.e. 565.000 old persons, 44,000 invalids, and 104,000 disabled individuals (see Table 24). Total financial outlays for that year amounted to TL23.6 billion (US$64.4 million). The number of pensioners peaked in 1981 but is now back at the 1979 level. Pensions have been substantially eroded by inflation and, on a per capita basis, decreased by 63% in real terms between 1979 and 1984. 65. Cash benefits are also awarded to families of draftees during their National Military Service. The cost of this program is born by the municipalities, and actual levels of benefits may vary. 66. As regards occupational schemes, a distinction has to be made between civil servants and other categories of workers. Among the former, the Turkish law recognizes active and passive civil servants, i.e. those still working and those who retired; as will be seen, both groups are covered under a generous system which extends its long and short-term benefits to relatives and survivors alike. Active Civil Servants 67. Active civil servants, their spouses, dependant children and parents are fully covered in case of illness or maternity. These are benefits "in kind" provided directly by the employer, i.e. the State, at no cost to the worker. No institution collects contributions or manages a specidl fund as all related expenses are borne directly by the Department of the civil servant concerned. Health benefits include medical and laboratory examinations, admission to health facilities, drugs and medical supplies during treatment, transportation of the patient, dental treatment, prosthetic devices, eye glasses and hearing aids. During sick or maternity leave, civil servants continue to enjoy full pay. There are no statutory requirements or time limit to these benefits. 68. Since September 1983, minor restrictions have been introduced into the system, such as a 10% charge for drugs for out-patient services; these will not affect the overall level of expenditures. Medical expenses are identified in the budget of each public organization (Article 180); they fluctuate, as shall be seen later in this report, with the level of fees decided by the Government. In current prices, they represented US$33.6 million in 1984, compared to US$53.6 million in 1981.  - 32 - 69. Finally, although there are no specific family benefits, a heating allowance called social assistance benefit was introduced in 1977 for some civil servants, then extended to the pensioners; this flat-rate cash benefit is now equivalent to 25% of the salary of a civil servant within the middle-income biacket. Other benefits of lesser importance include a nursing allowance, coverage of funeral expenses, and a marriage allowance corresponding to two years of pension. The Government lupioyees Retirement Fund 70. The Government Employees Retirement Fund (GERF) covers old-age, death, invalidity, employment injuries and occupational diseases for white collar workers in central government, local governments and state economic enterprises. In addition to these long-term insurance benefits, GERF also provides short-term health and maternity benefits for its pensioners, their dependents and their survivors. Medical care is obtained by contracting out services to MOHSA facilities or university hospitals. The fund was created in 1950, by merging all public institutions' pension schemes, with a view to standardizing benefits and statutory requirements for all govt:nment workers. Financed by contributions from civil servants and the State as employer, it is attached to the Ministry of Finance and Customs. In 1981, contributions were raised to 10% of basic salaries for employees and 18% for the State. 71. Pensionable age for civil servants is generally 65 for males and 60 for females; irrespective of age, a proportional pension can be claimed after 25 years of contributions for males and 20 for females. Invalidity and survivors pensions are subject to some statutory requirements. Between 1981 and 1984, the number of active members (i.e. civil servants and public sector employees) declined slightly from 1,415,000 to 1,375,000; but the overall number of passive members (i.e. various types of pensioners and their dependents) increased from 573,000 to almost 662,000. The Social Insurance Organization 72. Under the Social Insurance Act of 1964, the Social Insurance Organization (STO) is a state economic enterprise providing short-term medical and maternity benefits, employment related accident and occupational disease benefits, and long-term benefits in terms of old-age, disability and survivors pensions. These cover all employed persons, with the exception of civil servants (manual labor in the public sector is covered), the military, and domestic servants. Under the 1973 Social Insurance Law Relative to Agricultural Workers, the pernmanently employed in agriculture, with a work contract, have become contributors, and beneficiaries, of SIO. The SIO, attached to the Ministry of Labor and Social Security, is a tripartite organization, i.e. its General Assembly is made up of representatives of workers, employers, and the government. Its Governing Body, with members selected from the General Assembly, retains its tripartite nature. A  - 33 - General Director, designated by the Government, is responsible for its management and the implementation of government policy. 73. The SIO covers all insurance programs except family and unemployment benefits. Pensions are paid to all insured persons who contributed at least 5,000 days and are at least 55 years of age for males and 50 for females, or have been insured for at least 25 years, or are disabled and aged at least 50. The old-age pension is equal to 70% of average annual earnings; reduced pensions are also payable at 55-50 years for persons who have been insured for at least 15 years; those who retire at age 55-50 without being entitled to old-age pension receive lump-sum payments equal to the total contributions paid by them or on their behalf. Disability pensions can be awarded to workers who contributed for at least 1800 days; moreover, disability pensions as well as survivor's benefits are also payable to spouses or dependents. 74. Medical coverage includes free diagnosis, therapy and drugs to the insured person and pensioner and the direct members of their families. Sickness benefits cover the cost of treatment for six months, and can be extended for eighteen months. Dependents contribute 20% to the cost of medicines. When the contributor or the pensioner dies, the dependents remain eligible for health benefIts. The SIO operates its own health facilities. Their number has increased with the number of contributors, especially after 1965 under the pressure of labor unions; 8IO now has at least one general hospital in 44 of the 67 provinces. Since the 1982 extension of coverage to agricultural workers, the SIO is confronted with the problem of providing health care to rural areas. 75. The SIO also maintains contracts with private or public institutions, generally for outpatient care, or for inpatient care in areas where it does not operate its own hospital. In the case of MOUSA facilities, this constitutes an indirect subsidy, as current fees in public facilities are well below real operating costs of SIO hospitals. As the marginal cost to the recipient of health care is nil or negligible, one would expect an over consumption of health services by SIO's 13 million beneficiaries. Yet, the number of physician contacts per insured per year is only 1.4, compared with 3 to 4 in other middle income countries with comparable systems; one reason could be that SI members frequently use public health services. Also surprising is the low rate of hospital admissions (48 per thousand beneficiaries against 70-80 in other middle income countries). As no ready explanation is available for these low utilization rates, the finding requires further investigation. 76. The SI0 covered more than 2.4 million insured workers in 1984, with a very large majority of males, and a substantial number of public sector employees (see Table 25). If non-contributing members and dependents qualifying for health benefits are added, the total number of persons covered by the SIO in 1984 was 12.8 million, or one fourth of the Turkish population. While self-employed are covered under a separate system (see below), there is still a substantial proportion of the labor force unaccounted for, especially in family businesees and cottage industries  - 34 - which employ large numbers of unreported children and apprentices (the 1980 census showed a 42% participation rate for children aged 12-14 and of 60% for children aged 14-16). Recent years show a disturbing trend: between 1979 and 1984, the number of contributors increased by only 13%, but the total number of beneficiaries increased by 78%;- during the same period, total contributions declined by 6% in real terms (Tables 25 and 26). Health related benefits paid by SI0 in 1984 (i.e. direct expenses for health services, plus salaries compensation for temporary disability) amounted to TL98.6 billion (US$21 per beneficiary); this represented an increase of 5% in real terms, over 1983 disbursements. 77. The SI0 is financed by a set of premiums, covering each individual risk, paid by the employee and the employer. Overall contributions are very high and vary between 33.5 and 39% of total labor costs; for health alone, they correspond to 11% of salaries, 5% paid by the employee and 6% by the employer. Contributions, over a minimum and up to a maximum wage, are adjusted periodically. There is no state contribution,. In 1981, they were slightly increased to the following levels: RATM OF COITEIBUTIOUS TO SO AS PEILCETAGE OF TOTAL WAGES Workers Employers Total - Illness 5 6 11 - Maternity - 1 1 - Accid. & Occup. dis. - 1.5-7 1.5-7 - Retirement 9 11 20 - Total 14 19.5-25 33.5-39 78. All SIO resources are allocated to a Special Fund which operated with a net positive cash flow until 1980. Since that year, however, the SIO had to borrow increasing amounts from the Central Bank to cover its deficit. This deficit has three main causes, two of which call for overdue structural adjustments. First, high rates of internal inflation have obviously had a negative impact on SIO's financial situation as cost of health services, and corresponding reimbursements, increased more rapidly than premiums linked to salary levels. A second, more serious reason is employers' lengthening delays in transferring accrued premiums to SIO: about TL73 billion in 1983 (US$324 million); a quarter of these overdue payments are employees contributions collected at the source. The economic recession and the difficulties experienced by most enterprises explain to some extent this situation, but these enterprises take advantage of inadequate collection procedures to build their liquidities. The third cause of SIO's financial problems is the rising proportion of beneficiaries compared to contributing members: between 1973 and 1984, this ratio increased from 1/7 to 1/2.5.  - 35 - The Social Insurance Agency of Nerchants, Artisans and Self Employed Professionals 79. The Social Insurance Agency of Merchants, Artisans and Self Employed (BAG-KUR) was created in 1972 to provide coverage for the above categories, on a compulsory and contributory basis. The 1973 Social Insurance Law Relative to Self-Employed Persons Active in Agriculture extended the same benefits to these workers. Moreover, any citizen not covered by a social security institution, including housewives, can apply for membership. The General Assembly and Governing Body make up the higher administration of BAG-KUR, also attached to the Ministry of Labor and Social Security; it is managed by a DULector General designated by the government. 80. The institution provides only long-term benefits; for health coverage, its members have to rely on private insurance or the universal scheme. It is financed only by individual contributions set at 20% of the income level stated by the insured person; this rate, increased in 1981, is substantially higher than in the past (13% in 1972 at the creation of BAG-KUR, and 15% in 1979). Overdue payments were estimated at TL6 billion in 1982 (US$37 million). Benefits are comparable to the ones provided by 5IO. The number of contributors is increasing regularly, from 1.2 million in 1979, to 1.4 million in 1981 and 2.1 million in 1985 (see Table 29). The total number of persons receiving monthly benefits increased more rapidly, from 136,000 in 1981, to 239,000 in 1985; more than 60% of beneficiaries are pensioners. 81. The Government has decided to include health benefits in the BAG-KUR package, and a bill to this effect is under consideration by the Parliament. The new scheme would be compulsory but introduced gradually, starting with the major cities; its adoption would practically result in a universal health insurance scheme. BAG-KUR would not set-up its own network, but purchase services from public facilities. Health benefits would be comparable to those provided by SIO. As no employer contribution can be expected, members would have to bear the full cost of the insurance; the proposed level of premiums, and their adequacy, are discussed below. The Private Funds 82. When the various schemes were regrouped under the Social Insurance Organization, in 1964, some private funds retained their independence, for actuarial or political reasons. The law provides however that they must ensure minimum benefits to their members, comparable to the ones described for SIO. 83. There are about 26 funds for employees of banks, insurance companies, chambers of commerce and industry, and stock exchanges. They all cover old-age, invalidity and survivors risks; with the exception of four funds (where those risks are directly covered by the employer), they also provide illness and maternity benefits. Beneficiaries include about 78,000 contributors and their 152,000 depe nts, 13,000 pensioners and their  - 36 - 26.000 dependents, and about 4.000 survivors. Each fund is administered by an elected Governing Body. subject to financial supervision of the Ministry of Labor and Social Security. 84. Although they have the status of civil servants. primary school teachers have retained their Mutual Assistance Fund. For a small monthly fee, the fund provides them with additional benefits. in terms of lump-sum payments in cases of birth. retirement or death. Attached to the Ministry of Education, the fund is supervised by the Ministries of Finance and Labor. 85. Finally, the Coal Mine Workers Afssistance Fund, established in 1921, still operates and provides additional benefits in kind and cash in cases of illness. industrial accidents, and occupational diseases; the fund also awards grants and scholarships. It is supervised by the Ministry of Labor and Social Security. D. The Private Sector 86. With 40S of its pbysicians working in private practice, Turkey appears to have an important private sector. However, for most physiciang. this is a part time activity: since 1981. medical doctors working in the public sector have been authorized to maintain a private practice after regular work hours. Some of them take advantage of this privilege in the cities, but all of them do in rural areas. The number of physicians working exclusively in private practice is not known but is said to be small. Private physicians provide a substantial share of primary care (as much as 40% of first contacts in rural areas); they also provide some ambulatory chronic care, but they rely almost entirely on public hospitals for inpatient services. In this set up. physicians must keep a hospital appointment that ensures them hospitalization privileges, a sine qua non for successful private practice. Overall, there are advantages to this dual system: the Government is spared part of the burden of outpatient care. while patients retain the right to choose their physician; quality of care can be preserved as long as control mechanisms operate effectively. Basically, the Turkish medical practice resembles those in Europe or in the United States; the major difference lies in the fact that third party payors - insurance or social security - play a much smaller role in Turkeyl6. 87. About 90% of private physicians practice alone. while 7% work in partnership of legs than four physicians, and less than 3% work in large groups offering a wide scope of specialties. Less than 1% of nurses are self employed, but almost 4% of midwives have their own practice: 32% of 16 The SI0, the Army, the Government and some other public entities provide health services in their own facilities and do not reimburse visits to private practitioners.  - 37 - technicians - especially physical therapists, opticians, dental and lab technicians - prefer self-employment or have some partnership with physicians or dentists. 88. Private hospitals represent only 4% of total beds in the country (see Table 15). The larger ones are in fact non profit institutions: 8 hospitals. with 680 beds belong to foreign communities; 4 hospitals (320 beds) are owned by philanthropic associations or foundations; and 5 hospitals (930 beds) are owned by ethnic or religious minorities; most are located in the Istanbul metropolitan area and are gradually being absorbed by the public system. The other 93 private hospitals, totalling 2,770 beds, are owned by investors and operate for profit; of these, only 4 (560 beds altogether), located in the three largest cities, are modern facilities; the 89 others are small, often underequipped, and run by the owner physician; they are located in capital cities of western provinces and sea side resorts. Private hospitals serve two profitable markets, namely the rich and the tourist population; they concentrate on short stay, low risk, and highly lucrative types of care, mostly abdominal surgery and obstetrics, and have little impact on the bulk of the population. 89. The Government intends to extend the role of the private sector, and the State Planning Organization is exploring various alternatives. Technically, the role of private physicians, as providers of ambulatory care, in solo or group practice, could be easily expanded. It would require nevertheless that SIO and other health insurance schemes agree to reimburse a fixed amount for visits to private physicians; this is the way most European Social Security Systems operate. This could increase substantially access to care; quality of services could also be improved; finally, the patient's free choice of physician, an issue of great concern to the Medical Association, would be respected. 90. Expanding the role of private hospitals, would raise at least three technical and financial issues: - First, small inpatient facilities, with limited resources, cannot apply standards of modern medicine which requires costly equipment and an array of expertise. Larger group operated facilities would be more acceptable on technical grounds and certainly more cost effective. - Second, private hospitals can be profitable only if they skim inpatient care and concentrate on short stay low risk admissions (simple or intermediate surgery and obstetrics), and leaving long stay, high risk, high cost admissions to public hospitals. Therefore, investments in private hospitals in provincial capitals would not be made unless substantial incentives were offered. - Third, at the overall sectoral policy level it is argued that, for the time being, global bed capacity should not be increased. In this context, the expansion of the private sector implies a transfer of public or SIO facilities, i.e. a "privatization" of  - 38 - some public hospitals. In terms of size, type, condition and location existing facilities would rarely be attractive to private investors. 91. The proposal also raises a more fundamental issue, as the lot of a substantial segment of the population could be worsened in the process. The bulk of the population would still not be able to pay for private hospital care, unless third party payors foot part of the bill. The State, GERF, group insurance schemes, large companies, etc., could be made to reimburse part of private hospitalization costs. The SIO itself already finds it advantageous to use private facilities in areas where it does not operate its own hospital; and it could divest itself of all its facilities to purchase services in the open market, as advocated in some circles. Basically, however, the success of any attempt to expand the private sector would be contingent upon the existence of a third party payor. Conceivably, this could take the form, either of a universal health insurance program, or of a catastrophic insurance targeted to a segment of the population. 92. The foundations of a universal health insurance schRee, ensuring comprehensive benefits to all individuals, already exist in Turkey, with the 1961 law on IHSS, and the 1976 law creating the Universal Old-Age and Disability Pension Scheme. What would be needed is a mechanism to collect, in addition to government's financing under the overall budget (indigents or unemployed would be unable to contribute), mandatory mea-s-tested contributions from potential beneficiaries, not already covered by the social security system. This seems to be the current line of thinking, as illustrated by the proposal to extend health benefits to BAG-KUR membe-s. 93. Alternatively, a more limited option would consist in the creation of a catastrophic health insurance program designed to put a ceiling on individual financial exposure arising from occasional or prolonged disease. Ideally, annual health related expenses of each individual or household would be limited to a proportion of their income, which could vary with its level. In a long term perspective, such a system could curtail excessive utilization of public services. However, its effective operation would call for close monitoring of both incomes and health expenditures. 94. The choice is not an easy one as it would have direct implications for taxpayers, and raise the risk of confrontation with strongly vested interests. Any decision in this area is bound to affect wage earners of the modern sector, i.e. the organized - and unionized - part of the labor force. To diffuse politically sensitive issues, and enlist the support of institutionalized leadership and the population at large, it would be indispensable to set-up an effective consultative mechanism. Only then could it be expected to overcome the resistance of ocganized labor, and contributors of the Social Insurance Organization, when :hey will be called to subsidize at least part of the health benefits for agricultural workers, the self-employed or the cohorts of unemployed.  - 39 - B. Msaagement Systems and Issues 95. MOHSA's present organizational structure is the outcome of a long historical evolution and pragmatic compromise. Formal lines of authority are unclear and the department's operations are further disrupted by each change of government. The weaknesses of the civil service in the health sector have long been identified by national and external expertsl7, but reforms have been hampered by passive resistance or open opposition from officials concerned or special interest groups. For instance. high level managerial positions are almost exclusively held by male physicians, while middle level management positions are filled by other health personnel such as dentists, women physicians, veterinarians. or experienced paramedicals; practically none received formal training in management or administration; they show more interest, and concern, for professional and technical issues than for managerial or organizational problems. The same report noted in 1980 that "The government medical establishment is isolated from the larger concerns of health care in Turkey and unchallenged in its thinking.. Few health care experts exist outside the narrowly medical disciplines.. The medically trained official is the sole and unquestioned decision maker in the MOHSA.. The managerial model and the style of command within the Ministry would seem to be based on the clinical model.. Subordinates and the public are to be administered to, and doctors are to deal with one another as independent. professionally ethical colleagues". 96. The sector's effectiveness is also affected by personnel mamnaement issues. many of which are beyond MOHSA's control. As most public agencies, MOHSA suffers from overstaffing at the central level and in administrative positions. Government's past lenient recruitment policy. designed to absorb labor surplus. resulted in plethoric and often unproductive personnel. Some senior professionals and technicians are paid above the civil service scale, and many health personnel receive special hardship allowances; however, as government salaries cannot keep pace with inflation and with the private sector. private practice or second jobs tend to expand for medical and paramedical staff alike. Frequent changes of senior staff constitute a major disrupting factor; these are generally political appointees, replaced by each new government, even when no change in policy is involved. The lengthy replacement process generates considerable stress on the individuals concerned and their subordinates; a different ideological emphasis may be introduced; on-going programs may loose momentum or be canceled altogether; new teams have to be set-up and go through the normal learning process, while disillusioned civil servants wait for the next government. As officials relieved of office must stay on the ministry's payroll with the same salary. they load the civil service with posts of advisers or consultants. expecting to be one day reinstated. 17 See "The Management of Primary Health Care in Turkey' by Dr. Iris Kapil, UNICEF, Ankara. March 1980.  - 40 - 97. Another factor affecting MOHSA, as most government departments, is the lack of promotion opportunities. The rating system reaults in more than 100,000 fotms filled every year and stored by the Personnel Office but the system is not geared to rewarding, or sanctioning, actual performance. Senior positions are frequently filled through outside recruitment rather than internal promotion. Finally, the coexistence of traditional and modern values in orgauizational thinking and management styles creates frequent frictions highly detrimental to the smooth operation of government institutions. 98. A striking fact is the weakxiess of MOHSA's informatio, system, due to the absence, in the organizational structure, of a general directorate for statistics responsible for centralization, processing, analysis and feed-back of epidemiological and health related data. As this function cannot be performed by the existing Research, Planning and Coordination Council - a relatively small unit whose limited staff is largely absorbed by the preparation and follow-up on the ministry's budget - each directorate produces its own set of statistics. This results in more limited coverage and lower quality of current statistics (generally processed by hand), duplication of efforts and, in the final analysis, a weaker statistical basis for planning, management, monitoring and evaluation. 99. Health services umaagement. The country's historical evolution has created a highly centralized public administration, with minimal delegation of authority to lower levels of operations. This hierarchical approach also applies to the health sector. Hospital managers, program managers and all university trained health staff are appointed by the Minister. MORSA and SIO regulations stipulate that the hospital manager must be a physician, and the Minister makes his selection among the hospital specialists. In larger hospitals, this individual tends to be one of the most prestigious specialists. Management experience or ability to manage is not a consideration in the selection of managers. Intdeed, management is often viewed as that part of the organization which deals with laundry, kitchen, power supply, housekeeping, bookkeeping, transportation, etc. In fact, this practicing clinical specialist who is the highest authority in the hospital is called "head of the hospital". The term "hospital director" is used for the person in charge of logistics, called a business manager in other countries; hospital directors are graduates from the School of Health Administration. Another key management position is the director of nursing to which one accedes after ten years of nursing experience, but again without a requirement for management skills and experience. At any rate, the hospital or the health center only controls a small part of the budget since salaries are paid centrally and do not enter the hospital accounting system. The part of the budget under control of the hospital's business manager deals with current expenses, some medical equipment and furniture, and repairs. The 'head of the hospit-l" is rarely involved in budgetary matters. Cost accounting is absent a.d cost per unit of service is not available.  - 41 - 100. Primary health care shares most of the difficulties of other health services. These are compounded by acute manpower shortages in outreach services. For instance, about two thirds of health posts are not properly staffed. Although 85% of health centers are manned by an MD, this is often an inexperienced, unmotivated, not properly supervised MD performitg his or her compulsory medical service; many are actively involved in private practice after bours and therefore neglect outreach activities. Incomplete integration of activities raises another set of problems. TB and malaria services were only integrated in 1980, under the PEC Directorate, but the 126 1CR centers and 370 MNC stations are still under the authority of the Directorate of MCH and continue to operate under separate management, technical supervision and recording systems. Without the MCR and FP components, the activities of the 3,000 health centers are incomplete, while some 500 NCH facilities remain isolated from the main stream of health care and are underutilized. 101. Lack of vehicles affects dramatically the efficiency of outreach services: most village midwives have to rely on occasional transportation (mopeds have been tried successfully in some regions); half of the health centers have no vehicles; two thirds of vehicles in use are over 15 years of age. Medical equipment, especially in health centers, is insufficient or needs modernization. Public facilities provide only very basic or emergency drugs and deliver prescriptions for the rest; however, as there are no pharmacies in rural areas, people tend to bypass the first or second levels. Finally, as PRC services do not charge fees, they cannot supplement their recurrent budget allocations and frequent shortages of fuel, drugs or supplies paralyze their activities. 102. Maintenance of buildings, equipment and vehicles is remarkable by any standard. Hospitals as well as smaller facilities are well maintained, by numerous and well qualified personnel; yet, many old facilities, often over 80 years old, need extensive repair and remodeling that are well beyond the limited regular maintenance budgets. Cleaning is scrupulously carried out by in-house staff; some large hospitals have started contracting for cleaning with private companies, but it is too early to evaluate their services. Maintenance of equipment and vehicles is highly efficient. Some X-ray equipment is over 20 years old, and still operating; 83% of the vehicles in services are over 15 years. Hospitals' mechanical and electrical engineers are backed up by seven well equipped and well staffed Regional Maintenance Centers that carry out, with more ingenuity than resources, impressive repairs that would not be undertaken in less cost- conscious countries. Sophisticated equipment is sometimes maintained with the assistance of universities, in particular the Middle East Technological University. In spite of a very rational management of physical resources, the decline in real terms of maintenance budgets generates an increasing back-log of overdue operations. As at least 202 of facilities and equipment are already totally obsolete, investment budgets must weigh carefully expansion of the system versus its modernization.  - 42 - 103. COustruCtion uanagemt follows rigid procedures. All project proposals are subject to SPO approval before any funds can be appropriated by the Ministry of Finance; the law applies to all public institutions, including the SIO. Responsibility for construction then passes to the Ministry of Public Works (ZIPW) which follows standard bidding regulations to award the contracts to private contractors; this ministry will retain full supervision responsibility. Upon completion of construction, the health facility will be handed over to its owner, for commissioning and operation. These procedures have two weaknesses. First, the modest salaries for PPW staff do not permit recruitment and retention of highly qualified architects and engineers; this staff has limited expertise in design and in construction supervision of health facilities which partially explains inefficient design of oversized and dysfunctional buildings; this will eventually result in higher operating costs. Second, management practices result in excessive delays, with hospitals taking 10 years or more to be completed. The delays, which often work to the benefit of contractors, may have one or more of the following causes: the contractor underbids to win the contract award and subsequently negotiates for additional funds after construction has started; appropriated funds are not necessarily allocated and construction programs are based on appropriated moneys; and higher than anticipated inflation rates result in the renegotiation of the contracts with frequent work stoppages. 104. Design parameters also have a crucial importance. It is customary in Turkey to provide housing for staff, usually nurses, on the grounds of health facilities. This practice greatly increases the surface requirements for all constructions of health posts and health centers. All health centers include 476 m2 for housing; this results in an extraordinarily high total gross building space of 813, 791, and 646 m2 respectively, for a city area, a district or a village. Similarly, a health post requires 120 m2 which is at least 50% above usual standards. This is only partially offset by relatively low construction costs (US$120 to 130 per m2 in October 1985 for health centers and health posts, excluding equipment). 105. In the case of hospitals, the space required for staff bousing is relatively smaller (less than 5% of the total gross space). But design parameters are not uniform and show remarkably wide variations. The standard 50 bed district hospital is sized at 5,027 gross m2, or 100 m2 per bed which is double internationally accepted standards; for a 100 bed hospital, this decreases to 80 m2, which is still too high. A 475 bed hospital (400 general care and 75 maternity beds) requires 22,386 gross m2 or an acceptable 47 m2 per bed, even including 682 m2 for nurse quarters. The 1,000 bed MOHSA hospital in Izmir opened in 1982 has 117,000 m2 of gross space or 117 m2 per bed which is extremely high even for a teaching hospital. Hospital construction cost was about US$ 150 per m2 in October 1985. The practice of building hospitals of over 1,000 beds should be reconsidered as such large facilities have been proven to be less efficient to operate.  - 43 - 106. Design parameters for future university hospitals have been set by the Higher Education Council at a quite modest level. Gross space for a 600 bed university hospital will be 40,000 m2 and double this amount for a 1,200 bed facility. This translates into 67 m2 per bed, a relatively low average for a university hospital which requires classrooms, conference halls, more circulation space, and more space between beds to accommodate students and professors; space standards for university hospitals are usually between 80 and 100 m2 per bed.  - 44 - IV. - SUCTODAL DUSOUR A. Realth Personnel 107. In 1983, Turkey had more than 32,000 physicien, of which almost 19,000 were specialists (see Table 9); there were in addition, about 6,800 dentists and 11,400 pharmacists, all heavily concentrated in urban areas. The national average of one physician for 1,400 persons compared favorably with other countries at the same income levels; however, this ratio concealed wide variations, ranging from 1/602 to 1/6334 (see Table 12). On the other hand, the oversupply of specialists explains the high rate of vacancies in generalists positions in public hospitals, as well as the difficulty faced by MOSA in extending health coverage in the provinces. The system's effectiveness is also affected by the imbalance between the numbers of higher level and paramedical personnel, as the number of nurses is in the same range as the number of doctors. 108. The uneven distribution of high level health personnel is documented by some 1980 statistics. For example, 67% of the doctors were working in the cities of Ankara, Istanbul or Izair, an average of one doctor per 495, 585, and 733 persons respectively; in other provinces and in rural areas, the ratio varied between 1/2500 and 1/14000. The distribution between public and private sectors is uncertain as physicians employed by the public sector are authorized since 1981 to work part-time as private practitioners. In 1980 about 55% of the specialists were in the private sector; 16% were on HORSA's payroll; 12% worked for the SIO; 11% for the medical schools; and the rest for other ministries and local authorities. As regards general practitioners, only 19% were included in the private sector; 34% were working for MOHSA, 31% for the medical schools, 10% for the SIO and the rest for other ministries and local authorities. 109. The country has about 59,000 paramedical., or about one per 826 population. Nurses and nurse aides are largely concentrated in hospitals, while most of the 14,000 trained midwives are assigned to rural areas. There are also some 12,000 health officers and technicians responsible for health education and environmental bealth; they are often involved in delivery of health services in the absence of physicians or nurses. Although there are enough nurses in hospitals, the quality of care, especially in smaller public facilities, remains low. The slow rate of recruitment for midwives and technicians has been a limiting factor in rural areas. The future supply of midwives, who are the traditional basis for rural health care, has beeu further affected by the decision to close the vocational junior high schools for village midwives. 110. Nurses and midwives are employed almost exclusively by the public sector; only 4% of the midwives but 34% of the technicians work for the private sector. Nurses seem more evenly distributed between regions and sectors, and reflect the existing infrastructure; in 1980, 74% were on  - 45 - MOHSA's payroll, 12% worked for the SIO, 11% for the medical schools, and the rest for other ministries of local authorities. The rapid increase in the number of graduates at all levels was not aceompanied by parallel progress in the quality of training; as regards nurses, this is aggravated by, and further contributes to, deteriorating morale, insufficient motivation, low salaries, and generally negative attitude of nurses towards their profession. Ill. figher education and training of health personnel is provided by universities and specialized institutions. Until 1984, when nominal fees were introduced at the higher level, public education in Turkey was free. Medical education lasts six years; post-graduate specialization requires four additional years in a teaching hospital or one of the large general hospitals. SiDce 1981, medical graduates must serve two years in public health facilities. The country has 22 medical schools, 8 schools of dentistry, 7 schools of pharmacy and five nursing schools attached to the universities. These universities also operate schools of higher education where they train health personnel in specialized fields, such as physiotherapy, rehabilitation, health administration, health technology, and nutrition. Finally, MORSA operates two schools of higher education for more specialized personnel: the School of Social Work, and the Institute of Health Education. 112. The "hospital director" or business manager is a graduate of the School of Health Administration, transferred by MOHSA in 1982 to Hacettepe University in Ankara. The School is a four year post-secondary education program; it has currently about 500 students in the regular license program, 15 students at the master's level and 5 doctoral students. It accepts about 100 students per year which is the number fixed by the Higher Education Council. There is clearly an oversupply of graduates as many must find jobs in other sectors; a maximum enrollmeut of about 50 students per year would satisfy the needs of the sector. A graduate will typically start a career in the logistical services of a hospital and after ten years experience may become the "hospital director". The profession of health administration has little prestige as does public administration in general. 113. Paramedical training lasts four years after completion of the first cycle of secondary education; it is provided in MOHSA's vocational schools for nurses, midwives and health technicians. Moreover, nurses aides are trained in practical courses given in hospitals, vhile health technicians (X-rays, laboratories, anesthesia) receive on-the-job training. The midwife is the backbone of the rural health care system since she is often the only resource at the village level; but there are less than 14,000 midwives for the 36,000 villages. The replacement of vocational schools for lower level village-midwives by training institutions for higher level nurse-midwives has worsened the staffing problems of peripheral services. The Vth Plan has set a target of 10,500 additional nurse-midwives by 1990, but this type of personnel may find it difficult to adapt to a life long career in rural areas.  - 46- 114. As regards manpower development, four areas call for priority attention, namely: the implications of a growing supply of health personnel, especially at the higher level; the compulsory medical service; the concept of family physician; and training in public health and health management. The grovinag supply of health personnel has influenced the 1985-1990 Manpower Development Plan prepared by the Higher Education Council: it projects a dramatic increase in higher education graduates, from 348,000 to 526,000 per year. The REC also identified current shortages and set targets for some categories of personnel, in the heaith sector in particular. These are presented below. BIGER EDUCATION CO CIocS PROJCTIONS OF MNNPORE I IN E T EALTh SSCOBR 1984 1990 Exist in Needed Target Nurses & midwives 62,000 75,500 112,000 Technicians 15,000 15,900 26,600 Dentist 7,800 8,700 12,900 Pharmacists 12,000 12,000 12,000 Physicians 33,600 37,800 56,200 TOTAL: 130,400 149,900 219,700 115. The method used, which adds up estimated vacancies with projected norms, tends to overestimate actual requirements. Except for pharmacists, all categories of personnel would be substantially increased, by 68% for the sector as a whole; this "demand' for bealth personnel is expected to level off after five years. In quantitative terms, the existing system could train the "needed" personnel. However, this increase in staff would be difficult to absorb in such a short period. Moreover, it would be hard to justify as long as the real issues related to the quality of training have not been addressed. In more specific terms, even if only half the additional supply were to be oriented towards the public sector (a rather conservative estimate under current conditions), absorption of so many high level staff would require substantial increases in recurrent budgets. The implications of a rapidly growing supply of health personnel on the public sector's development prospect warrant a more in-depth analysis than the one prepared for the current five-year plan. 116. Issues related to the training of physicians preseutly dominate the manpower debate. Medical education in Turkey has been for many years an example of innovative development. Modern Turkey had adopted the Western model of medicine and, for decades, a few medical schools turned out limited numbers of graduates with solid scientific qualifications. In the early 1960s, to balance the expansion of clinical services and hospital-based teaching, and strengthen social and preventive medicine, the innovative Hacettepe medical school established Community-based teaching programs which  - 47 - were to become blueprints of the future health system. However, during the 1970's, demographic growth, increased health consciousness, extension of coverage to rural areas, and the development of higher technology increased the demand for physicians. As a result, the number of medical schools was gradually raised to 22. Since 1981, in compliance with Government objectives, these schools have substantially increased their intake and 2,500 graduates are expected annually to meet YOK's objective of 56,200 physicians in 1989. 117. This trend raises serious concerns among many medical educators who fear a further deterioration in education standards, as medical schools have neither the necessary faculty nor adequate operating budgets. First, training in basic sciences is likely to suffer most from the rapid increase in enrollments combined with budget restrictions affecting labs and eletronic equipment; this could result in a cohort of second rate doctors, as experience in many countries has shown that physicians never recuperate deficiencies in basic science training. Second, clinical training would also be affected by the deterioration of the student-instructor or student- bed ratios; however, this problem could be somewhat alleviated by increasing the use of MORSA facilities as teaching hospitals. Finally, as regards public health training, rapidly increasing enrollments make it all the more difficult to strengthen and expand training in such areas as epidemiology, sociology and demography, health administration, and community practice. 118. Since 1981, new graduates have to serve two years of Coupulsory Medical Service (CMS) in public facilities; this does not exempt male physicians from the sixteen-months compulsory military service. This measure was introduced as a compensation, as medical education is still practically free (only nominal fees are levied since 1983). The experience has been so far very positive, but the foundations of the system must now be consolidated. In general, young doctors have shown dedication and have established good rapport with the population; the CMS is proving vital to the health system in rural areas as primary health care consultations have doubled in four years. The second batch of 3,000 doctors completed their service at the end of 1985, and the program is now being evaluated. Some of its drawbacks have been identified already: lack of supervision and medical guidance, absence of career opportunities, isolation, lack of vehicles for outreach activities and limited contact with peripheral facilities and staff. To improve training opportunities for these young graduates, MORSA envisages splitting the CMS in two parts: one year of supervised service in hospitals (as an additional year of rotating internship) and one year in peripheral health centers. The evaluation will also include an estimation of needs for additional equipment and vehicles; it is also expected to deal with the issue of improved incentives and working conditions. 119. The trend towards specialization (over 60% of Turkish physicians are specialists) has created a shortage in general practitioners in front- line services; this is exacerbated by the inappropriate clinical training of general practitioners. To fill this gap the concept of Family Pbysician has been put forward and has found strong supporters within MOHSA. A new specialty in Family Practice, close to the US model, would be opened in the  - 48 - universities, to train clinicians with a community orientation, to serve mainly in the public sector. Post graduate training would last three years, i.e. one year of practice followed by two years of formal education. They would serve in intermediate and small facilities, as well as in urban polyclinics. Acting as team leaders for ambulatory care, they would refer to, and coordinate as needed the activities of other specialists. To facilitate the transition and encourage students to enter the new system, incentives would be adopted; these could include the validation of one year of CMS as the year of practice, an adequate salary upon certification and improved career opportunities in the public sector. 120. The introduction of the Family Physician would influence the pattern of future outpatient services, and create a constituency of strong supporters of "medicalization" of public health services. Therefore, it is essential to carefully assess the implications and potential drawbacks of the proposed reform, especially as the impact of this experience introduced in the USA less than ten years ago has not yet been fully analyzed. The Family Physician could rapidly supersede the general practitioner with the immediate result of an extension of all medical studies by two or three years. This would have obvious implications on the cost of medical training. Moreover, as shown by the US and Latin American experience, this could raise average costs of medical care, not only for the basic consultation, but also by generating additional demand for more sophisticated and expensive services. In this context, it should be recalled that most European countries, because of the resistance of tIedical Associations, responded to the same issue by advocatirg improved training of general practitioners who have retained control of the first level of medical care. 121. Until 1965, training in public health was carried out at post graduate level at a central School of Public Health; it was later on introduced in the undergraduate curriculum of Medical Schools together with conmunity practice. The change has proved very positive as all physicians now receive basic training in preventive medicine. However, in the move, the country lost a valuable tool for training epidemiologists, public health and tropical diseases specialists, general and hospital administrators; this gap was only partly filled with the opening in 1982 of a special program for hospital directors in Hacettepe University. At the lower level, the Refik Saydan Institute of Hygiene, in Ankara, carries out inservice training for paramedical personnel, through periodic ad hoc courses for TB, malaria, or pharmacy technicians. 122. Post graduate training in public health is presently obtained through overseas scholarships. Considering current needs, the organization of a national program would be fully justified. An interestitng specialization in public health is under consideration: a three year post graduate training with a core of internal medicine, obstetrics. gynecology, pediatrics and infectology, and majors in epidemiology, primary health care, occupational or military medicine. As for the Family Physician the training objective is a combination of clinical and public health skills, in this case with emphasis in public health.  - 49 - B. Healtb Facilities 123. The number of facilities providing outpatient care is not vell known as private practitioners cover a considerable, albeit not well documented, share of outpatient services, and all bospitals also provide outpatient care. For its part, MOHSA operates an extensive network of about 10,400 facilities consisting of 300 government physician's offices, 2400 dispensaries and health units, 7100 health posts, and 500 MCH centers and stations. In addition, there are more than 8600 privately owned pharmacies. The Fifth Plan's objective was to build 720 additional health centers, and 4215 smaller facilities by 1989. Hospital lufrastructure 124. In 1984, the country had 730 health facilities for inpatient care, with a total of 115,600 beds (see Tables 13 through 16 and 30 through 34). Most of these beds belong to the three major care providers, namely MOHSA (52%), the SlO (15%) and the Universities (12%); the remaining is distributed among the Ministry of Defense (13%), State Economic Enterprises, other ministries, large municipalities, minority and religious groups, and the private for-profit sector (2.4% only). Special purpose hospitals and institutions are gradually disappearing through merger with larger facilities, while smaller inpatient facilities are being closed altogether. Overall, Turkey has 2.4 beds per 1,000 population, a relatively favorable ratio compared with other middle-income countries (Jordan, 1.9; Tunisia, 2.1; Colombia and Ecuador, 1.8). But this capacity is not fully used as "staffed" beds represent only 87.5% of the total ("approved" beds). This drops to 2.1 the real bed/population ratio. The unused capacity is caused by lack of staff and/or equipment, but also by the use of the space for nurse residences; it is normal for nurses to live on hospital grounds, but a number of facilities did not include nurse quarters in their building plans. There are wide geographical differences in the bed/population ratio (4.4 in Istanbul, against 0.3 in Agri and Hakkari provinces). 125. There are 451 WOES hospitals in the country, with 60,500 beds, including more than 100 health centers; this total also includes 35 long term facilities with some 13,600 beds. Most of MOUSA constructions were built in the 1950s; some date from the first years of the Republic. Old as well as more recent hospitals are always spacious, solidly built and remarkably maintained. In keeping with the concepts of the 1950s, direct service areas such as halls, corridors, waiting rooms, wards and nursing stations, are generally sized liberally, allowing for additional capacity when needed. Conversely, support areas such as X-rays, labs, offices, laundry, kitchen, etc., are barely sufficient. There is a marked deficit in internal communications space, as well as elevators for materials, staff or public. Finally, most emergency and outpatient departments have become insufficient to meet the needs of growing urban populations.  - 50 - 126. Equipment of public hospitals is modest and generally aging. Hostelry equipment such as beds and other furniture is sturdy. Diagnostic medical equipment such as radiography. scintigraphy. echography. laboratory may be adequate for routine secondary care testing, but is often insufficient or outdated for tertiary care; shortage of high performance equipment, such as fast X-ray processors and multianalyzers. slows down bed turnover. Therapeutic equipment in operating rooms and intensive or intermediate care units is generally sufficient but specialized equipment is lacking or is of lov quality in radiotherapy. rehabilitation therapy and prosthetics units. Finally. equipment for kitchen. laundry. sterilization, power and water systems is. as a rule, contemporary to the construction of the hospital and has been kept operational through exceptionally good maintenance. in spite of its diversity due to age and lack of standardization. A carefully planned re-equipment and modernization of services would be a highly cost-effective investment by improving the quality of care and increasing the overall productivity of the system. 127. Staffing is adequate but sometimes excessive in smaller hospitals with low utilization rates. Managerial and administrative staff are rarely properly trained, but medical personnel are competent and recruited among the best. Nursing staff is efficient and highly disciplined. Ancillary personnel is abundant. Overall. staffing does not raise any constraints in hospitals operations, although low salaries scales affect morale and performance, especially at the middle and lower levels. 128. The SIO operates 77 short-stay hospitals with more than 17.700 bedsl8. SIO hospitals are generally more recent and better equipped; their staff are better paid than civil servants, with a marked difference at the mid-level. All but three of these hospitals have more than 100 beds. Overall, 302 of admissions are in obstetrics; few complex and high technology procedures are performed, as these cases are referred to MOHSA or university hospitals. SIO's clients are mostly urban-based and the five cities with the highest number of hospital discharges are: Istanbul (131.600). Izmir (63,700). Ankara (38.100), Zonguldak (31,600). and Bursa (28,900). These five cities account for half of SIO's hospitalizations. 129. The 20 universities operate 21 university hospitals (two in Istanbul University). with 13,800 beds; there is also one military medical school. Table 33 lists the university hospitals attached to these medical schools together with utilization statistics derived from the MOHSA data source book for 1984. No information is available on the military medical school hospital, and Edirne University is not listed with a university hospital. Sixty percent of the beds are located in four university hospitals: two in Istanbul, one in Ankara and one in Izmir, and they account for 50% of all admissions. University hospitals in Turkey do not only treat 18 The 1984 SIO activities report lists a total of 18,314 beds; this is 3% higher than the MOHSA data source, and may be due to the inclusion of beds in some dispensaries.  - 51 - the more severe cases. as is often the case in developed countries, but receive a mix of patients. Hospital Utilization 130. For the sector as a whole, the average of 48 ad&isiaon per thousand population is relatively low by international standards19. For middle income countries this ratio is in the 70-90 range. One fourth of inpatients are treated in SIO facilities. and about 10% of hospital admissions for SIO beneficiaries are contracted out to other providers in the public or private sector. Overall, the admission rate for this insured population is. coincidentally, also 48 per thousand. This is a surprisingly low rate for a population with full medical insurance coverage. as uninsured patients treated by MORSA have similar utilization rates. 131. Occupancy rates vary widely. but are gonerally low. In 1984, for the three major providers, they were 54% (MOHSA and Universities), and 67% (SIO)20. Larger, older and well established facilities tend to have higher occupancy rates. In the case of MOHSA average low occupancy can be partially explained by the existence of 103 health centers with beds (15% average occupancy), and by the fact that more than half of its hospitals have 100 or less beds; smaller facilities tend to have lower occupancy rates. typically around 50-60%. University hospitals show large variations ranging from a low of 37% to a high of 75%, 132. Average lengtbs of stay (ALOS) are generally high, and variations are quite marked for all providers. MOHSA and SIO hospitals. which account for 85% of all hospitalizations, have an ALOS of 7.1 and 7.7 respectively. In University hospitals, ALOS are in the 6.7-13.8 range, with an average of 10.2 days. The national average is 7.6 for all hospital stays but drops to 6.4 if only acute care short-stay hospitals. which account for 97% of all admissions. are considered. C. Health Cooto Sn Financing 133. Scanty data are a major obstacle to a comprehensive analysis of cost and financing of services in the sector. Only rough estimates can be made of households expenditures on health and there is no direct access to costs of services provided by privately owned facilities. No data are readily available on medical expenditures of large private companies who 19 Hospital statistics used in this analysis exclude the 44 military facilities with their 15.100 beds for wbich no utilization information could be obtained. 20 The SIO reported a 71% occupancy rate in 1984.  - 52 - often provide additional health benefits to their employees. Information on the cost of services in SIO facilities is not collected systematically. and the real level of health expenditures by the social security system is not well known. The situation is only slightly better in the public sector, at least as regards expenditures. which nevertheless tend to be equated with costs of service delivery. Only the major university hospitals gather relevant data but these are not published and no systematic analysis is conducted. even at the individual facility level. 134. No attention seems to be paid to the cost of outpatient core. In public health facilities. this cost is extremely low and could easily be calculated for dispensaries and health centers where expenditures consist almost exclusively of salaries (only emergency drugs and supplies are available in limited quantities). Estimates would be more difficult to make for hospitals where outpatient services are manned by the same personnel and use the same equipment and laboratories. These daily clinics attract a considerable number of patients: the ratio of visits to admissions in public hospitals is almost 14 to 1 (see Tables 32 and 33). This excessive burden on hospitals affects their effectiveness. as discussed below, but also generates higher operating costs by encouraging use of sophisticated and expensive services, not always justified for simple out patient care. 135. In SO hospitals, consultations are prepaid by beneficiaries. In University hospitals. fees vary with the institution and the type of service. and are substantially higher than in public hospitals. As for MOESA facilities, the charge for outpatient visits was set at TL100 from 1981 through the end of 198421; physical examination charges were set at TL1000. These fees were raised to TL500 and TL2500 respectively in the beginning of 1985; in real terms. this represented a 46% increase in charges for outpatient visits. but a 27% decrease in charges for physical examinations (see Table 23). 136. Neither the SIO. nor any University or MOHSA hospital provide data on their costs of inpatient care. An analysis of expenses per patient day. and per bed, was conducted by the mission for a sample of MOHSA hospitals (see Table 34). It confirmed the wide spread between daily expenses per bed. and per patient, a direct reflection of the nature of the institution and variations in occupancy rates. It showed that in 1984 the average cost per patient day was in the range of TL3-11,000 in general hospitals (US$8- 29). about TL6,000 in teaching hospitals, and twice as much in the most specialized facilities. These very low costs for a middle income country were confirmed by spot checks in other public facilities. The study also revealed that personnel expenditures represent more than 70% of expenses in general hospitals, against 40-50% in teaching hospitals and around 40% in specialized institutions. User fees cover only 5-12% of total expenses in general hospitals. 13-19Z in teaching hospitals, and as much as 30-35% iv specialized surgery facilities. 21 This corresponded to US$0.90 and US$0.27 at the 1981 and 1984 exchange rates.  - 53 - 137. Cost recovery in the public sector is only partial and adjustments hardly keep pace with inflation. Table 23 presents the fee schedule applied in NOH&A facilities for inpatient and outpatient care; it is of special interest as it compares fees applied since January 1985 (under a current inflation rate of more than 40% p.a.). with the ones which prevailed from April 1981 through December 1984. The very structure of the schedule is questionable as it does not reflect the relative cost of each service or the real level of expenses incurred. More disquieting is the fact that. in real terms, fees were raised for most outpatient services (to TL500 or almost US$1 for a simple visit). but reduced (often substantially) for inpatient care. Although it may be justifiable, on social grounds, to cut by 56% the charge for use of intensive care units. it seems more difficult to explain a 42% ..eduction in charges for "deluxe" accommodation in public hospitals (51% in the case of private rooms). 138. Overall. cost recovery in the 206 MOHSA hospitals authorized to levy user fees amounted to TL6.3 billion in 1984 (US$17 million), i.e. less than 8% of the ministry's recurrent budget. In real terms. this represented more than twice the amount collected in 1980. but a reduction of 10% compared to 1981, after the previous fee adjustment. Chart I illustrates the erosion of annual resources, and the swing generated by the 1981 adjustment in selected hospitals. It is not possible at this stage to assess the impact of the 1985 revision of the fee schedule. 139. Total health expenditures represent about 3.5% of the country's GNP; this ratio is below the 42 or more found in other middle income counti-ies or in Latin America. Total health expenditures exceeded TL407 billion in 198322; this corresponded to almost TL8.600 per capita (US$38). Private expenditures amount to 58% of the total; this estimate is derived from the last household expenditures survey which showed that, in 1978/79, 2.8% of private income was spent on health related services. Another source indicates that in 1974. household expenditures on health absorbed 4.8% of available incomes in rural areas, against 3.3% in urban areas; the lower ratio for the cities was explained by easier access to free public services. Since 1982. total public investments have been declining in real terms (see Table 20). They also declined in relative terms. i.e. as a proportion of total public investments. Between 1982 and 1985. annual investments in the public health sector were reduced by almost 40%, although total public investments increased by 8%. As a consequence, the share of health in total public investments has fallen from 2% in 1982. to 1.1% in 1985. 22 This figure does not include outlays from the Miaistry of Defence. or private investments, which may amount to 5% of public investments.  - 54 - TOTAL U8ALTU KPEEDITURES IN 198323 Source Billion TL Distribution - Household expenditures 235,9 58.0 - Ministry of Public Health 69.9 17.2 - Social Insurance Organization 46.8 11.5 - Gvt Employees Retirement Fund 4.6 1.1 - University Hospitals 33.9 8.3 - Gvt direct payments (Art.180) 11.6 2.8 - Public enterprises 4.5 1.1 - Total 407.2 100.0 - Health expenditures as % of GNP 3.5% - - Per capita health expenditures TL; 8.578 - US$: 38.04 140. Total NORSA expenditures in 1984 exceeded TL100.1 billion (US$273 million); this includes more than 83% of operating expenditures (see Tables 17. 18 and 19). For that year, the ministry's outlays represented 3.1% of total government expenditures; the year 1984 saw a reversal in a deteriorating trend. which started in 1978 when health expenditures peaked at 4.2% of total public outlays. In real terms, however, total MOHSA's expenditures declined by 13% during the 1976-1984 period. while total government expenditures declined by only 4%. The allocated budget for 1985 shows a nominal increase of 34%; even if implemented at this level, this would represent a decline in real terms. as this year's inflation rate was higher than 40%. The decline of current expenditures in real terms has affected the sector's effectiveness: personnel expenditures absorb an increasing share of MOHSA's operational resources and further reduce allocations for drugs, materials, supplies. etc.; fees collected in hospitals can only partly fill the gap, but do not apply in small hlealth facilities. Capital ezpenditures absorbed 17% of the Ministry's resources in 1984 and are expected to decrease to 14% in 1985. Overall. hospitals absorb half of the ministry's resources ("curative services" in the budget presentation). The General Directorate for PHC is allocated about 25% of the budget. This leaves about 25% to cover central administration expenses, and finance the three vertical programs not integrated within PHC (TB, malaria and MCH/FP). 141. Health related expenditures by the Social Insurance Organization amounted to TL70.2 billion in 1984 (US$191 million); in addition. SIO paid TL31.9 billion for salary compensation. About 83% of direct health expenses are incurred in SIO facilities (see Table 27). However. the organization also purchases services from MOHSA or university hospitals, for specialized 23 Statistics provided by lzacettepe UniNtersity, and mission estimates.  - 55 - treatment or in areas where it does not operate its own facility: these represented 12% of total expenses in 1984. Finally. investments absorbed about 5% of annual expenses. The health branch of the SIO still shows a positive balance as contributions for health and maternity represented 184% of outlays in 1984 and 195% in 1983. However, the deteriorating trend is evidenced by the decline in real terms of health and maternity contributions (see Table 26). 142. Annual health benefits paid by the Government Employees RetiremeAnt Fund have more than doubled in real terms since 1979 although the number of beneficiaries increased by only 30% (see Table 28). They amounted to TL7.? billion in 1984 (US$19.6 million) and consisted mainly of drugs (59%), hospital expenses (22%), and dental treatments (17%). The budget of each ministry and public institution includes an earmarked provision for reimbursement of medical expenses incurred by active civil servants; this appears in Article 180. In 1984, these public expenditures for health amounted to TL12.3 billion (US$33.5 million), compared to TL11.6 billion in 1983. 143. Health expenditures of University Hospitals are significant and represent more than 8% of the total. or about half tMOHSA's expenditures. The estimate for 1983 was TL33.9 billion (US$150 million). including TL8.3 billion for investments24. But the real level of these expenditures is not well know as the budget of each university hospital is part of the budget of the medical school which, in turn, is included in the larger budget of the university. Moreover, fees play a very important role in university hospitals which are free to determine their level and adjust them regularly to keep pace with inflation; in addition. donations from individuals and contributions from charitable institutions are not negligible. Fees and donations amount to substantial resources but information on their amounts is not readily accessible; in the case of the two facilities operated by the University of Istanbul, they are said to be of the same magnitude as the budget appropriations. In more general terms, it seems that in university hospitals, fees account for at least as much as regular salaries in physicians incomes. This practice is not authorized in MOHSA hospitals. D. Pharwaceuticals 144. The foundations of a modern pharmaceutical industry were laid in 1928 with the first law that regulated imports and sales of drugs. and encouraged local and foreign investment in this sector. Large investments were made in the mid-1950s. including by some multinational corporations. The itdustry now includes 86 establishments, five of which belong to the 24 Prof. M. Tokat, Hacettepe University.  - 56 - public sector25. Of the 81 private companies. 7 are foreign-owned; 16 of the private plants produce raw materials as well as drugs. This is a relatively modern and capital-intensive industry representing almost 25,000 jobs; it exports drugs to industrialized countries and technology to developing countries. The 10 largest producers, which include 5 of the foreign companies, account for more than 66X of output. Although MOHSA produces a substantial share of its vaccines needs. it does not operate a drugs production unit. 145. Total production. by manufacturers prices. peaked in 1982 at US$427 million but fell to US$317 million in 1984. It is largely based on imported raw materials (US$121 million in 1984). which reduce substantially imports of drugs (less than US$3 million). The local industry produces 1810 different drugs, under more than 3500 dosage forms; this includes 3.3 million cycles of contraceptive pills. marketed under 8 names. and produced by five companies. Most large public hospitals have a laboratory for galenic standard preparations. The local industry also produces an increasing line of medical and surgical supplies and small appliances. Overall. about 9.000 drugs are registered in Turkey, but only 2.500 are in the market as many are outdated, or have been replaced by new lines of products. 146. The Refik Saydan Institute of Public Health produces vaccines, serum and biological reagents. Vaccine production includes BOG. DPT, measles, polio and rabies, but covers only part of the needs of the country. For the immunization campaign, it supplied 25% of requirements. Some of the bacteriological techniques must be modernized and the virological ones must be expanded. Considering the country's population and potential savings in hard currencies. MOHSA envisages completing the vaccine production to become self-sufficient. The Institute of Public Health, under the Department of Pharmacy and Pharmaceutical Products, is responsible for quality control of drugs (registration and off-the-shelf testing), cosmetics, and narcotics. 147. Pharmaceuticals c _,ption is still relatively low. at US$7.60 per capita in 1984. The Manufacturer's Association has calculated that, in 1984, the ratio of drug consumption to GNP was 0.7% in Turkey, compared to 1X in Switzerland and the United Kingdom, 1.2% in W. Germany and France. and 1.9% in Japan. Consumption remains at minimal levels in public hospitals and shortages are frequent in smallest facilities; as for out-patient facilities, they only carry a minimum stock of emergency drugs, and patients are expected to purchase their own drugs. This situation is in strong contrast with conditions prevailing in university hospitals and SIO facilities. This explains why drugs and medical supplies amounted to only TL6.8 billion in 1984 (US$18.5 million), or 8g of MOHSA's operating budget. In large MORSA hospitals. drugs and medical supplies represent 9-15S of total costs, being higher in specialized than in general hospitals; in 50-bed district hospitals, they rarely exceed 5% of expenses. Information 25 Data in this section were provided by MOHSA's General Directorate for Pharmaceuticals and the Pharmaceutical and Chemical Manufacturers Association  - 57 - on drugs expenditures in university or SIO hospitals is not readily available but it will be recalled that, overall, these represent 25% of health expenditures of the SIO and 59% of GERF's. 148. The retail distribution of drugs to consumers goes either through institutions as SIO, GERF and their consumers' cooperatives, or more generally through the large network of 8,000 retail pharmacies. However, since MORSA facilities do not provide medicines and small retail outlets are not authorized to dispense drugs iu the absence of a pharmacist, rural populations have limited access to basic drugs. 149. Turkey runs a large foreign trade deficit iu pharmaceuticals, which exceeded US$114 million in 1984, and US$75 million during the first semester of 1985. This is because, although it imports less than 1% of its drugs, it still imports two-thirds of the raw materials needed for its industry; in 1984, the country purchased abroad US$2.7 million of drugs against US$120.9 million of raw materials. Total exports cover only 13-16% of imports; they amounted to US$16.1 million in 1984, and US$12.6 million during the first semester of 1985. The tripling of exports of raw materials since 1980 illustrates improving quality standards of the local industry which is now selling for instance acetylsalicilic acid and tetracycline to Europe and the USA. Pharmaceuticals are now sold to 19 foreign countries, including 7 industrialized eastern and western countries. 150. Strict quality controls are imposed on the pharmaceutical industry. Moreover, sales prices must be approved by NOHSA, while markups are limited to 9% for wholesalers and 25% for retailers. Profits of the drug manufacturer may not exceed 15% of the corporation's yearly revenues or, for individual drugs, 20% of the product's yearly sales. Moreover, MOESA exerts leverage on local manufacturers through import licencing which may affect their production or pricing policies. It also oversees the activities of the 8,600 private pharmacies scattered around the country. Updated regulations were introduced in January 1985 and, in anticipation, large investments were made during the last two years. 151. Turkey has not yet adopted a clear policy towards essential drugs or generics. The interpretation of "essential drugs", deviates from the WHO list of precisely defined chemicals, to include drugs that are considered useful. MORSA has not adopted standard drug lists nor standardized treatment protocols for hospitals or health centers, much less incentives to utilize essential drugs. Because of the pressure of advertising and marketing, generics are almost unknown in the private sector, either to the prescriber or to the pharmacist. Similarly, only a few generics are utilized in MORSA, SIO or University Hospitals, where no Drug Utilization Review committees have been set up to improve scientific quality of treatment and reduce the costs of medicines. The Government should encourage changes in that direction.  - 58 - 152. Access to basic drugs26 is another area of concern f or MOHSA. Aside from a small supply of emergency or TB drugs, health centers and village midwives do not have medicines in stock; they write prescriptions. However, because the commercial drug outlets are very few in rural areas, actual access to drugs is often limited. The cost of drugs creates another constraint. SIO and GERF secure co-payment for prescribed drugs (80% for active affiliates and 90% for retirees and pensioners). However, indigents cannot afford to pay for prescriptions. The problem is more acute for chronic treatments such as diabetes. hypertension or arthritis, or in the case of cancer chemotherapy; the latter, either as adjuvant or curative therapy, costs an average of US$300 per treatment (excluding adriamycine and other expensive drugs) or 3 times the minimum monthly salary. 153. MOHSA has the overall responsibility to design and enforce regulations on manufacturing pra.tices and ensure high quality standardo; it collaborates closely with WHO in this area. Its staff at the central level includes more than 80 professional pharmacists and there are 67 provincial units of varying importance; MOHSA also operates the Central Control Laboratory, staffed with 70 pharmacists. Quality control is an area of growing concern for MOHSA. Until recently, industry had not felt the need to upgrade their production methods. Government's inability to control quality, and therefore to enforce strict regulations especially on small manufacturers, left the door open to leniency. In 1984 however. to comply with internationally accepted standards and preserve the prestige of local products. Government and industry agreed to adhere to the Good Manufacturing Practices Code tGMP)D by November 1986. As a result, many companies are investing heavily to ccmply with GMPs, to avoid being absorbed by larger manufacturers or going out of business. To carry out its extended mission, MOHSA's Control Laboratory must be expanded. Its different units presently perform 3500 tests each year. This performance could be stretched to 4.000 tests within acceptable safety margins, but the estimated 14.000 tests that will be needed by 1987 will require the expansion of laboratories, additional equipment, computerization of administrative procedures and records. and training of specialized staff. The total cost of this operation is estimated at US$750.000 and the Government is exploring alternatives for financing this expansion. 26 The deliberately loose denomination of "basic drugs" regroups some 20 to 40 drugs that are either of domestic use and available without prescription (aspirin, vitamins, cold medicines. etc.). or drugs that are needed for primary health care programs (oral rehydration salts. chloroquine. iron preparations. etc.).  - 59 - V. lAYING 7 FOUNDMIONS OF L DEVELOlIiF T STIATEGY 154. Substantial improvements have been achieved in the health sector over the past two decades and most Turkish indicators now compare favorably with similar data for other middle-income countries. Nevertheless, striking inequalities in health status, fertility levels and access to basic health services still exist between Western and Eastern provinces, and between urban and rural areas. Large segments of the population still suffer from surprisingly high infant and child mortality rates, persistent prevalence of infectious diseases, malnutrition, and relatively high levels of fertility. These are compounded by environmental factors, reflecting a low, and often deteriorating, quality of life, especially in periurban areas, brought about by nearly two decades of accelerated internal migration. 155. Efforts te improve the health status of lower income groups, to check the spread of infectious diseases such as tuberculosis and malaria, and to control the most frequent childhood diseases, have not achieved the expected results. The IHSS has not yet succeeded in reducing inequalities in health status and access to basic health care. The integration of services has been retarded by vested interests, bureaucratic and political resistance, and the lack of financial support. This is best illustrated by the low levels of immunization and contraceptive prevalence in rural areas. No routine program for childhood 4wmunization is implemented by the public sector and, until the end of 1985, responsibility for vaccination seemed to have been left to parental initiative, or at least to those parents who recognize the need, have access to the service and can pay for it. There is still a large unmet demand for family planning services, but the absence of an explicit nationwide population program remains an obstacle to speedy progress in coverage. 156. The present health status of the Turkish population has been strongly affected by extensive internal migration fueled by the rapid industrialization of the 1970s, then by economic stagnation, declining incomes and high levels of unemployment. However, this low health status is also the outcome of organizational and managerial constraints, exacerbated by declining financial resources, at a time when a very strong social demand for improved public health services generates a continuing pressure for higher levels of expenditures. 157. Under its current policy, the Government is determined to restructure and liberalize the economy and promote the privatization of activities which the private sector can handle more efficiently. Hovever, while privatization in the health field may be appropriate in some instaries, this would not permit the Government to extricate itself from the provision of health services, or to reduce dramatically public health expenditures. It is advocated in the following pages that even in the context of the legitimate objectives pursued by the Government, there are compelling reasons for sustained high levels of public expenditures in the health sector. General arguments in favor of a public health sector are  - 60 - well known: the State must retain its fundamental responsibility in matters of preventive care, containment of communicable diseases, and emergency services; moreover, it must ensure access to basic health services to the poor; finally it is in the national interest to maintain adequate health and nutrition standards, and to encourage the reduction of fertility rates to levels compatible witb the country's resources and development prospects. 158. In the case of Turkey, more arguments militate in favor of a continuing public presence in the health sector. First, on-going economic and fiscal constraints limit what the Government can do at present to improve the incomes of the most vulnerable and disadvantaged groups; these groups therefore require particular attention to ensure adequate access to health services, at least until structural adjustments have started bearing fruit. Second, sustained public expenditures are needed to lay the foundations of a more efficient, financially sound, public health sector, capable of providing quality services to all segments of the population, at a cost acceptable to the individual and the community at large. 159. Most Turkish data are within the range of international indicators for middle income countries; indeed, many of these countries display much worse indicators for mortality, life expectancy, calorie intake or fertility. Yet, one can be more demanding in the case of Turkey, because of its long history, solidly entrenched traditions, abundant and qualified labor force, and vast infrastructure. First, as mentioned repeatedly in this report, national averages hide unacceptable disparities, most notably regarding infant mortality and fertility rates, and access to basic health services. Second, Turkey has most of the resources needed to address its health problems successfully, provided the right steps are taken to overcome well recognized obstacles, and agreement can be reached on an appropriate development strategy. 160. Consequently, the fundamental objective of the sector should be to strengthen the effectiveness of the health care delivery system, with a view to redressing existing inequalities in terms of health and nutritional status, fertility, and access to basic health services, and further improving the overall status of the population. Under current tight monetary policy, the challenge confronting the Government would be to achieve this objective without major investments and/or substantial increases in operating budgets; secondarily, it would appear feasible to mobilize additional resources by levying higher fees from users able, and willing, to pay. The development strategy proposed to achieve this objective would revolve around seven themes, namely: (i) the creation of an appropriate coordination mechanism; (ii) the critical evaluation of the on- going and prospective sectoral investment program; (iii) the design and implementation of a priority primary health care program targeted to specific population groups; (iv) the improved utilization of existing facilities; (v) the improved financing of bealth services through an adjustment of the user charges system, and (vi} the strengthening of social security's financial basis; this action program would be backed up by (vii) an applied research program, designed to pave the may for more fundamental and long lasting interventions.  - 61 - A. Improving Coordinotion of Sectoral Activities 161. The preceding pages have given ample evidence of the lack of coordination of sectoral policies and interventions between the main providers of health services. At a time when a restructuring of the economy is taking place, when crucial issues are being debated in the country and major reforms contemplated, the absence of a8 appropriate mechanism to discuss the sector's development prospects and identify coherent proposals, is a dramatic gap which must be corrected without delay. The State Planning Organization, absorbed by many other tasks of a more general uature, cannot fulfill this technical and policy role. On the other band, the strongly centralized system, which requires SPO's participation in most phases of the planning process, is detrimental to the flexibility needed to adapt to rapidly changing conditions. SPO's major functions are hampered by involvement in details at the project level. Only a coordinating body could set the stage for an in-depth discussion of available options and provide a much needed technical basis for future governmental decisions. Because of the multiplicity of agencies involved, such a coordinating body would need to take the form of an Interministerial Higber Health Council headed by the Prime Minister. Its Secretariat would be assured by the Ministry of Health and Social Assistance, mandated by law to regulate and control all public health activities. 162. The Higher Health Council would be responsible for developing standards, establishing priorities, and designing and coordinating the implementation of a sectoral development strategy outlined below. It would also commission a series of much needed studies on such topics as the improvement of the utilization of existing facilities; the design of new curricula for training of public health specialists and hospital administrators; the cost of inpatient and outpatient services in the various types of facilities; effective ways of reducing regional disparities in terms of coverage and quality of services; alternative ways of financing health service delivery; monitoring of sectoral recurrent and capital expenditures; etc. This program provides strong justification for strengthening and upgrading the Research, Planning and Coordination Unit to the General Directorate level. B. Strengthening Investmet Planing 163. Improving the iuVestment planning process in the sector is long overdue. The updated list of projects included in the Fifth Plan provides three sets of financial information for each project: (i) its total cost, including in some cases the foreign exchange component; (ii) the cumulated capital expenditures through the end of the year; and (iii) the allocation of the Ministry of Finance for the current year, or rather the allocation recommended by SPO. As far as the health sector is concerned, these data are meaningless for three reasons:  - 62 - - in the context of the high inflation characteristic of recent years, sight has been lost of base costs of on-going projects; although these have been increasing regularly and often substantially in real prices, the amounts mentioned in Plan documents are not updated periodically; for example, the current cost of the 1,110 bed hospital planned by the SIO in Izmir certainly exceeds TL7 billion, but is shown as TL4 billion in most recent SP0 documents; - the cumulated investments for each on-going project aggregate rapidly depreciating moretary units of succeeding years over five to ten years periods; chey are actually provided only for book keeping purposes; - the current year allocation for each project is also only indicative as it is not expected that the amount agreed upon with SP0 will actually be available; red tape and administrative delays in releasing funds are general causes for, or means of, reducing public expenditures; moreover, each allocation is decreased by the 1OZ value added tax; finally, the nominal allocation is substantially eroded by the current 40Z inflation rate. 164. Moreover, the implications of these projects in terms of additional operating costs and manpower requirements are generally overlooked. 165. The SI0 Izmir hospital illustrates the uncertainty surrounding many projects in the health sector, and more generally the planning process itself. In the 1986 update of the Plan document, it is presented as a 1100-bed project launched in 1978; its total base cost is given as TL4 billion; it is further mentioned that TL233 million have already been spent under this project; finally the 1986 allocation to continue implementation is put at TLIOO million (less than US$200,000 at going rates). The reality seems to be quite different: first, local SI0 authorities refer to it as a 600-bed facility; second, the actual cost of the construction alone will undoubtedly exceed TL7 billion (1985 prices); moreover, implementation is at the very early stages and sunk costs are minimal; finally, in view of the total cost of the project, its priority status, and the rather limited amounts spent so far, one may wonder what progress could be achieved with a TL100 million allocation expected to be eroded by some 30-40% by inflation and late appropriation. 166. Under prevailing conditions, it is understandable that technical units in charge of project monitoring would concentrate on current year investments. But this has led to an implicit change in concepts. Sectoral documents updated by SPO have come to represent a list of annual capital expenditure proposals, ratber than projects to be implemented during a given period to achieve the Plan's objectives. There is some merit to this approach when inflation runs at very high rates; however, crucial data have been lost iu the process as there is no readily available information on current commitments at the project, sub-sector, or sector levels. It has  - 63 - become urgent to f ill this gap and each organization Ohould, at the very least. regularly update its eatimtes of additional fincing required to complete every on-going project. The Public Iavestmt Program 167. Table 20 presents the evolution and breakdown of public investments in the health sector since 1980. In relative terms the sector's share in total public investments fell to 1.1%. from a maximum of 2% in 1980. The decline in sectoral investments is largely due to the reduction in outlays from the consolidated budget which covers MORSA. all university hospitals and the small capital expenses for health by other ministries; a parallel evolution can be noted in investments of state economic enterprises. which include the SI0. This decline was only partially offset by increased capital expenditures by local administrations and, since 1984. by the financing of new equipment through publlc hospitals' revolving funds. The consolidated budget financed more than 95% of public investments in 1980, but only 75.5% in 1985; during the same period, the share of municipalities increased from 4.3% to 11.9%. 168. The Fifth Development Plan includes a list of 385 projects for the health sector27. As of the end of 1984. their total cost is indicated as TL133.2 billion and it is also mentioned that TL36.4 billion were spent through the end of 1984 for their implementation (see Table 21). The 1985 allocation of TL36.2 billion of the Ministry of Finance (about US$72 million) was distributed as follows: 1% for feasibility studies, 46% for on-going projects, and 53% for new projects. As mentioned above. the vaJue of these data is rather limited and the 1985 allocation will reach, at best, TL34.9 billion. Table 21 also presents the break-down of the program between MOHSA, university hospitals, the SIO, and the other institutions which constitute the health sector. Thes,e are reviewed in the following paragraphs. 169. The 1985 investment prog-am of the Niaistry of Health and Social Assistance, to which were allocated TL15.2 billion, is presented in Table 22. For constructions, the priority given to completion of on-going projects is evident (TL7.1 billion, against TLO.9 billion for new projects). The program also includes equipment. major upgrading and repairs of existing facilities, and replazement of about 10% of the ministry's vehicles. Another salient feature of MO}ISA's investment program is the large share of primary health care projects. which include 36 health centers and 109 health posts to be completed in 1985. and another 130 small facilities to be completed after 1985. This yearts allocation for primary health care (TL4.1 billion) will absorb 52% of investments planned in civil workC; this represents more than the 272 apparent ratio to total investments as PHC will receive part of funds earmarked for equipment, vehicles or repairs. The investment program for curative services is centered on the 27 The 1986 update extended the list to 454 projects  - 64 - completion of 8 hospitals (see Table 16); these add up to 1900 beds, i.e. a 3% increase in MOHSA's present capacity. 170. The Higher Education Council (EEC) which oversees investments in University 8ospitals also gives priority to completion of on-going projects and has rejected all new project proposals since 1984. It has al6o scaled down the size of many hospitals under construction and, with a view to rationalizing future investments, has introduced new design standards for hospitals. The HEC does not keep updated records of base costs, or of amounts needed to complete on-going projects; every year, it allocates to each university its share of the funds obtained from the Ministry of Finance, earmarking specific amounts for each project, including Uts. In 1985, for instance, investment proposals from all universities amounted to some TL70 billion; this was brought down to TL27 billion by the EEC, but the allocation from the Ministry of Finance was limited to TL25 billion, out of which TL10.5 billion were earmarked for UHs. There are 109 health-related projects for 20 universities but most resources are absorbed by the on-going construction and equipment of 15 Uts, with a total of 10,850 beds. As some medical schools now operate in MOHSA facilities which will be eventually returned to the Ministry, the completion of this program Sill not result in a net addition of 10,850 beds to the present capacity of the medical schools. 171. The Social Iasuramce Organisation received an allocation of TL3.7 billion in 1985. It has revised its investment program which now consists of two groups of projects. The first group represents 20 on-going projects which would require more than TL9.9 billion to be completed (in 1984 prices); it includes 9 hospitals with a total of 3,700 beds, or an additional capacity of 17%. The second group includes 15 new projects (mainly small health facilities) with an aggregate cost of TL5.5 billion (1984 prices). An Immediate Action Program 172. In the 1970s and early 1980s, under strong pressure from their constituencies, MORSA, SIO, the Universities, as well as many other organizations started building large hospitals; some are already operational, but the on-going construction program includes 32 more hospitals, representing some 16,500 additional beds, with a very modest share for MOHSA (see Table 16). Consequently, hospitals under construction still absorb the bulk of investments. On the other hand, low health standards, unequal coverage, and a very strong social demand for improved public health services, fuels a continuing pressure for more hospitals. Moreover, because the number of admissions is relatively low and is certain to increase in coming years, it is argued in some circles that the national network of hospitals must be rapidly expanded to accommodate future demand. Indeed, if all facilities under construction became fully operational by 1990, the overall 14% increase in hospital capacity over five years would hardly affect the present bed to population ratio which would remain at 2.4 per tbousand. As for the sector, it would be in a position to absorb  -65- perhaps twice as much capital, assuming that financing is the only obstacle to a swift completion and that procurement and disbursement procedures are improved. Nevertheless, there is significant underutilization of current capacity and opportunities exist to improve efficiency, which could free resources from hospital construction for higher priority needs. 173. In spite of the considerable amounts involved, and the critical cost implications of operating these new facilities, insufficient attention is being paid to the justification of these projects, and the monitoring of their implementation. In the absence of an appropriate forum and coordination mechanism, the SPO is not equipped to cope with the technical nature of the issues involved, and the social and political pressures generated by strongly vested interests. At present, no governmental agency has a clear view of the overall investment program, the adjustments which could be needed, and the longer term desirable orientations. The division of the decision making, financing and execution processes between a large number of independent institutions makes it all but impossible to safeguard the higher interests of the sector. It would be the priority task of the proposed Higher Health Council to confront these issues and generate a consensus on an optimal allocation of financial resources; this would likely imply a redistribution between public organizations, between construction and equipment, and between capital and recurrent expenditures. 174. An important reserve capacity already exists in most hospitals and the following section will show that there is considerable room for improving utilization of the existing infrastructure. In a shorter-term perspective and, pending the outcome of a more systematic approach to sectoral issues, the following measures would seem appropriate: - enforce the moratorium on new hospital projects: this measure, introduced in 1984, is not followed with enough rigor; there are obviously cases when new projects may be justified, but the interpretation of the concept of 'on-going project" seems too liberal and extends to projects where sunk cost are marginal. - conduct an objective evaluation of completion costs and additional operating expenses and mampover requiremuts of every on-going project; - set-up a high level ad-hoc technical group, with the mandate to scrutinize the technical justification and architectural designs of all on-going hospital construction projects, taking into account existing as well as planned facilities of all institutions, the geographical distribution of the population, and current utilization patterns; this would include, when appropriate, recommendations for scaling down or abandoning altogether any project. - unless specifically approved by the ad hoc group, delay implenentation of all projects where sunk costs have not reached  - 66 - an agreed level (25X would seem an acceptable ratio considering the slow pace of construction programs). - identify priority -areas for transferring funds freed by the above measures, such as accelerated completion of priority hospitals, equipment, first level care in priority areas and target groups, operating expenditure, etc. C. Focussing on Priority Areas in Primary Health Care 175. Incomplete integratiou of activities hampers the effectiveness of outreach services. While TB and malaria services were integrated in the General Directorate for PRC (but not until 1980), the 600 MCH centers and stations are still under the authority of the General Directorate for MCH/FP and contin:-..; to operate under separate management, technical supervision and recording systems. Some 9,000 health units are not providing enough coverage in MCH and FP, while most MCH facilities, isolated from the main stream of health care, are underutilized. 176. High fertility rates in Eastern and Southern provinces, and in rural areas in general, have a direct bearing on the health status of these populations; they are also incompatible with the country's development objectives. Substantial gains can be expected in maternal, infant and child mortality rates from improved birth spacing and timing, and a reduction in the total number of births. Therefore, in pursuing the objective of better integration of services, care should be exercised not to jeopardize the effectiveness of on-going family plunuing activities; experience in many countries has shown that, at least during the initial stages, integration can affect family planning services which require specific resources and more specialized personnel. The considerable unmet need for family planning services calls for an extension of population activities; it also calls for an improved mix in contraceptive methods. 177. Immunization should obviously rank high in MOHSA's priorities. The objective will be to capitalize on the success of the 1985 campaign to set up an effective system of continuing routine vaccinations; this would prevent the resurgence of the situation that had to be resolved through a massive, and costly, national immunization campaign. 178. As malontrition has been identified as a major contributing factor to child mortality, it too deserves special attention. Much of malnutrition appears to be the result of inappropriate practices that may be smenable to change through education efforts. New social marketing techniques have been effectively used elsewhere to bring about change in behavior regarding distribution of foods within the family, weaning foods, breastfeeding and food hygiene. As public sector work in the field to date has not had the desired impact, it may be worth exploring the possibility of involving commercial communications or marketing agencies in the nutrition education  - 67 - efforts. Part of the nutrition problem is related to income levels, particularly in newly urbanized areas. Although the solution to this problem falls outside healtb services delivery, it is still a health issue for wbich health authorities have an advocacy responsibility, and MOhSA should encourage the formation of an intersectoral nutrition advisory body with the ministries responsible for agriculture and education. 179. While primary health care shares most of the problems of other health services, these are compounded by acute shortages of qualified manpower. For instance, about two thirds of health posts are not properly staffed. Although 85% of health centers are headed by an MD, this is often an inexperienced, unmotivated, not properly supervised MD performing his or her compulsory medical service; many are actively involved in private practice after hours and therefore neglect outreach activities. Lack of vehicles affects dramatically the efficiency of outreach ser-4ices: most village midwives have to rely on occasional transportation (mopeds have been tried successfully in some regions); half of the health centers have no vehicles; two thirds of vehicles in use are over 15 years of age. Medical equipment, especially in health centers, is insufficient or obsolete. Public facilities provide only very basic or emergency drugs and deliver prescriptions for the rest; however, as there are no pharmacies in rural areas, people tend to bypass the first or second levels. Because PHC services do not charge fees, they cannot supplement their recurrent budget allocations and frequent shortages of fuel, drugs or supplies paralyze their activities. 180. Implementation of the proposed program would obviously require additional funding to finance vehicles, equipment, drugs and other supplies, as well as the recruitment, training and higher mobility of health personnel. The introduction of a cost recovery mechanism at this level is not recommended, as it would raise very limited amounts, at an unacceptable social, political and administrative cost. In the present context of stringent monetary policy, additional resources should preferably come from a shift of capital or recurrent funds within MORSA as well as other public health providers. The proposed Higher Health Council would have the authority to present specific recommendations to the Government. D. Increasing Hospital Utilization 181. A substantial rise in admissions (perhaps as much as 202) could be absorbed by a reduction in the average length of stay and a parallel increase in occupancy rates. This would necessitate a profound change in the philosophy of hospital management, doctors' behavior, as well as structural reforms; both raise real challenges in a sector characterized by longstanding traditions and solidly vested economic, political, professional and personal interests. This militates against the construction of new facilities: for the immediate future, improviog the utilization of the ezisting uetwork of public hospitals is bighly cost-effective and should be  68 - the overriding priority for the sector. Most of the basic corrective measures to be taken have already been identified, and their introduction is overdue. The following comments concern M.ORSA, because it operates 60% of inpatieat facilities for which more detailed data are available; by and large they are also applicable to other services providers. 182. Admissions and occupancy rates are too lov, and average lengths of stay are too high by international standards. Activating this unutilized capacity is an obvious, and highly cost-effective, objective which should receive highest priority. MOHSA's thirty largest hospitals have a total theoretical capacity of 20,400 beds, only 80% of which (16,500) are active. Sote beds have been decommissioned for legitimate reasons (unsuitable premises, use as nurse quarters, etc.), but in the majority of cases beds are not activated because, over time, diagnostic and complementary services could not support the theoretical uumber of beds. Strengthening these services could increase by at least 10% the number of active beds, at a relatively low cost. Similarly, leaving aside small district hospitals for which bed occupancy is of secondary concern, large hospitals' bed occupancy rates, whicb are at best in the 60-70% range, could be brought at the 80-85% level with appropriate measures discussed below. laproving the referral systen 183. Public hospitals managed by NORSA are the cornerstone and the most visible part of the health delivery system; they are the largest providers of health services all over the country and the facilities any citizen can turn to for regular or emergency care; they admit patients referred by other providers, including the S10 and university hospitals; ani -onsidering their limited financial resources and often obsolete equipment, they perform at acceptable quality standards, frequently higher than otber providers. Yet, they do not function as a network of facilities. Except for specialized institutions - chest, orthopedic, psychiatric and oncology hospitals - that receive selected patients, other facilities admit and treat any patient, from any origin. In theory, patients should seek primary care or first- contact care in health centers, dispensaries or, as it happens 50% of the time, at a physician's private office; if the case requires further treatment or testing, it is referred to a District or State General Hospital (second level of care), and then only if necessary to a Specialized Hospital. In practice, patients seek care at the facility of their choice, regardless of geographic location or appropriateness; referrals are based on doctors personal acquaintance or university affiliation. The result is an enormous flow of patients and relatives across the country. For example, 38% of the patients of the Numune General Hospital in Ankara come from other provinces, including 10% from Istanbul; at the same time, 10% of the patients in Istanbul's general hospitals come from Ankara. Patients from the East may travel to the West for simple treatments that could be performed in the provinces. Patients affiliated to SIO, who normally should enter S10 facilities, frequently seek admission at MOUSA hospitals.  - 69 - 184. As normal geographic. technical or administrative rules are ignored. workloads of the nervices cannot be forecast and activities cannot be properly programmed. MOHSA has done little to remedy this situation: the classifieetion of hospitale by levels of care is not implemented in practice and abnormal referrals and bypasses are not detected and therefore sanctioned; hospitals are virtually independent on medical and administrative matters; chiefs of medical departments have no formal relationship with their counterparts at the same or higher echelons; similarly. they do not supervise practices in their discipline at lower echelons. Administratively, hospitals are often too dependent on local authorities to respond to other lines of command. Except for the chest hospitals which are linked to the central TB control unit. programmatic responsibilities of hospitals - for instance in orthopedics. oncology. cardiology, etc. - are not clearly defined. The fact that hospitals have neither outreach activities nor inputs into primary care keeps them further away from the perception that they should operate in a system. Finally. within the hospital, the medical director is. as a rule, a clinician who concentrates on clinical activities and seldom sees the role of his hospital in a wider perspective. 185. Referral procedures are not well codified and no guidelines seem to exist. The modest fee designed to deter non-referred patients is not enforced. Advance notice of referrals from one hospital to another, by cable or by phone, is exceptional. This occasionally places a strain on hospital operations and undermines primary care programs. Although implementation of referral systems is a difficult undertaking in any country, initial steps enforced in Turkey would be sufficient to enhance dramatically the efficiency of the entire system. mproving the admission policy 186. One major obstacle to improving hospital efficieicy is the current admission policy, resulting from the poor referral system as well as inadequate out-patient services. Major general hospitals aresdeliberately utilized. on a large scale, as outpatients clinics. This policy has the advantage of facilitating access of the population to secondary and tertiary care and bringing specialists in closer contact with primary care. However, it is a very inefficient instrument for outpatient consultation as well as hospitals admissions as it results in overcrowding at the tertiary level and in a considerable wastage of specialistst time and hospital resources. 187. An analysis of ten major hospitals28 showed. for example, that 28 The ten hospitals analyzed by the mission were: Numune and General Hospital (Ankara); Sisli Etfal, Haydarpa;a Numune, and Haseki (Istanbul); Ptaturk Derlet, and Cosuk (Izmir); Cukurova Numune. and Devlet (Adana); and Numune (Erzurum). They represented about 6,400 active beds. The overall admissions to visits ratio was 5.0% ranging from 2.8% to 14.3%. The overall  - 70 - Numune Hospital in Ankara receives an average of 2.400 outpatients per working day. and more than 3,000 on Mondays; Haydarpaca hospital in Istanbul, with half the bed and staff capacity, receives about the same number of outpatients. Under such conditions of physical crowding and workload pressure, quality of care is affected, regardless of the qualification of physicians and nursing staff. On the other hand, the ratio of admissions to outpatient visits is extremely low. varying from 2.81 to 14.21 and shows that outpatient departments act as general consultation facilities. This misuse of specialist time and hospital resources (X-rays and laboratory notably) could only be justified if hospitals had idle capacity; this is not the case. as evidenced by delays in pre-admission testing and subsequent inpatient testing. Under current conditions. outpatient departments are clearly diverted from their primary function. as demonstrated by low bed occupancy rates. in spite of longer than optimal lengths of stay. The "potential loss" in admissions - if bed occupancy were to be raised to a conservative 85% - runs as high as 402 for the 10 hospitals analyzed. - 188. One related aspect - the Pre-Admission Test (PAT) - is a relatively simple practice that saves bed capacity. At one major hospital. the average time for completing diagnostic testing of alreadv admitted patient was estimated at 3 days (out of an average length of stay of 11 days). Rapid PAT would require supplementing X-ray and lab equipment with rapid processing technology either in polyclinics (see below) or in the hospitals. Improving Hospital Performance 189. Scheduling. Establishing weekly schedules of work for elective treatments in the different services would ailow for better use of existing bed capacity. Weekly/monthly scheduling by clinical and surgical departments would. in turn, lead to the scheduling of support activities. operating rooms, intensive care beds, special X-ray. physiotherapy, laboratory examinations. etc. Weekly/monthly scheduling generally meets the interests of department chiefs, physicians and staff after an induction period and appropriate training and guidance by medical directors. 190. The reallocation of excess capacity and removal of bottlenecks is another cost-effective way of improving hospital performance. Ideally. all hospital services should optimize the use of their capacity so that the flow of patients, from admission to discharge, is not hampered by internal delays and waiting lists. As a consequence of technological advances. the balance between services changes constantly but has not been reviewed lately in many public hospitals. Important bottlenecks exist in administrative sections. radiography, radiotherapy, laboratories, intensive care and coronary care units, neonatal care, physical therapy; in all these services, new equipment is needed. not only to improve quality of care. but also to increase the occupancy rate was 60.5% (45-70% range).  - 71 - increase the level of output. At the same time, some adjustments would be made in areas with an excess capacity of beds, staff or equipment. 191. Quality control is minimal in MORSA hospitals. In other settings, instruments of quality control (peer review, medical audit, tissue committees, records audit, anatomopathology, etc.) bh.ve been developed primarily to improve the quality of medical services. They have, moreover, contributed extensively to improving hospital organization, load and output and have consistently worked to the physician's as well as the patient's advantage. In the case of Turkey, they would greatly improve utilization of hospital capacity. In addition, joint medical/administrative staff meetings would allow generalization of many innovative practices that individual physicians have elready implemented in their immediate environment. Increasing Bed Utilization 192. It should be stressed that improving bed "occupancy" is not a goal in itself: increased bed "utilization" is the real objective, if more services are to be provided with the existing infrastructure. It is not possible to quantify, at this stage, the cumulative impact of improved referral, admissions and prograing, removal of bottlenecks, adoption of more flexible mechanisms, and introduction of quality controls and better management. A conservative estimate would bowever show at least a 20% increase in capacity within the existing premises. 193. Inefficient design and poor management practices are major contributing factors to low occupancy rates. Large rooms reduce flexibility in assigning patients. Room assignments must consider male/female patients, infectious and non-infectious cases, and case severity. Repairs and disinfection of large rooms put out of service a larger number of beds than the same activities performed in private or semi-private rooms. However, the most important weakness is poor management of patient turnover ("census management"). Bed management is under the control of clinical chiefs and not of the hospital director. Thus clinical fiefdoms are created and excess demand in one clinical subspecialty area cannot be compensated by empty beds in another subspecialty. This practice creates about 20 small hospitals within a larger hospital and depresses the occupancy rates for lack of flexibility in room assignments. It should be a policy that hospital beds are the property of the hospital and not of the chiefs of clinical services, and that all medical and surgical beds should be grouped under their general label without distinctions in subspecialties. 194. Average lengths of stay in MORSA as well as SIO hospitals (7.1 and 7.7 days respectively) are too higb, because one out of eight admissions is in obstetrics which has an ALOS of less than three days. University hospitals have a ALOS of 10.2 days which in principle could be explained by a more complex case mix; detailed information on UHs is not available but field visits and interviews tend to confirm that their case mix is similar to that of larger MOHSA hospitals. The major reason for long stays is inefficiency in management systems, i.e., admission and discharge planning,  - 72 - logistics of clinical support systems, underutilization of facilities and equipment. Patients may be in the hospital for three to five days befor- treatment is begun, waiting for the results of laboratory tests or radiological examinations. Test results may be delayed for lack of supplies or for shortage of technicians or for malfunctioning equipment. Operating rooms are used primarily in the morning, and the use of specialized equipment is restricted by the availability of hours of technician time and of special supplies. For all three providers, ALOS could be reduced by about two days with the introduction of more efficient procedures, and this would increase bed turnover rates. Reorganizing Urban Care 195. A major issue confronting the government is the reorganization of urban care for some 22 million persons, in order to achieve a viable mix of all primary care providers, i.e. private doctors, MORSA, 8I0 and university facilities. In this context, MORSA started addressing the most pressing problem, namely, the reduction of overcrowding of outpatient departments in large hospitals. To this effect, it is considering the creation of Urban Polyclinics which would combine the resources, and missions, of Urban Health Centers and Ambulatory Care Centers. As urban centers staffed with general practitioners, nurses and technicians, they would provide first contact care, including integrated MCH/FP services, and cover at the same time preventive activities, environmental health, school health and health education. As ambulatory care centers, they would be organized as a polyclinic, with 12 to 15 specialties, serving between 300,000 and 400,000 persons. The facility would provide secondary care to referred cases; it would screen, check and orient patients referred for hospitalization and possibly act as an admission office to hospitals. It would have enough equipment to perform simple pre-admission tests. 196. Such polyclinics would.certainly relieve hospitals from the pressure of first contact visits, triage, pre-admission testing and treatment. They would also free hospital X-ray and lab capacity for better and faster in-patient care, and therefore contribute substantially to the improvement of hospital productivity. However, their success would to a great extent depend on good working relationships between specialists and hospital staff. Polyclinics could actually be staffed by hospital specialists taking turns, as is presently the case in outpatient departments, or by polyclinic specialists, associated or not with hospitals. 197. Urban polyclinics constitute an attractive alternative to hospital outpatient services which could improve health care delivery in urban areas and at the same time increase hospital productivity. However, the concept is still at an early stage of development and some points would have to be clarified before a decision is made on their creation. First and foremost, it would be necessary to estimate the costs involved in urban land acquisition, construction, equipment, and operation. An analysis would also be required of the implications of the introduction of biomedical equipment at this level of service,in terms of staffing, training, maintenance, etc.  - 73 - 198. Coordination with hospitals would be essential for polyclinics to fulfill their role; if not they would only constitute a new layer of urban facilities, and no progress would be achieved in regulating admissions and alleviating pressure on hospitals. At any rate, the smallest urban health centers presently in operation would still be needed and-their public health functions would not be taken over by polyclinics; they would continue to provide primary care to the poorest segments of the population. Indeed, their public health functions would have to be expanded rather than curtailed; otherwise the present overcrowding of outpatient departments would simply be passed on to the polyclinics. 1. Adjusting User Charges 199. Patients are charged for services received in MOHSA facilities and University hospitals. Medical schools are free to fix the level of their charges, which must be approved by the Higher Education Council. Social security beneficiaries are not charged as health services are prepaid through their contributions and their employers'. An official fee schedule exists for MOHSA and is updated periodically; In MOHSA facilities, these user charges supplement the funds received from the national budget. Revenues collected through user charges are pooled in a fund administered in each hospital by independent bookkeeping staff who report only to the Ministry of Finance; 5X of funds received are transferred to the Treasury, another 10% is centralized for the benefit of other facilities which do not levy fees. In university hospitals up to 50% of fees collected are distributed among physicians as salary supplements; the balance is used for the purchase of equipment, supplies and other small expenses. MOWSA may not use this fund for salary supplements and the fund is only used for equipment purchases and operation or maintenance expenses approved by the Read of the hospital. 200. The share of revenues collected through direct billings in a hospital's total expenditures varies over time (see below) and between hospitals. MOHSA' teaching hospitals cover from 15 to 20% of their expenditures with user fees; specialized acute care hospitals about 30 to 35%; and general hospitals less than 10%. One university hospital collects as much as 50% of its budget from patients, either directly from individuals or th ough third party payors; others collect a lesser percentage, though usually more than large 14OFSA facilities. 201. Although some patients are exempt because recognized as indigents, most of them pay for services received in outpatient facilities as well as hospitals. In order to be considered medically indigent, the patient must bring a certificate from the municipal administration certifying that he is poor; the Read of the hospital (the medical director) then decides on the paying status of the patient. No firm data are available about the number of indigents served by the hospitals and health centers. One prestigious University hospital in Ankara is said to serve a maximum of 2% indigents.  - 74 - The number of indigents receiving free care in MORSA facilities is probably less than 10%. 202. There is some controversy in the country about the impact of fees on the accessibility of care to lover income groups, and the low rate of hospital admissions is at least partly ascribed to user charges and the administrative difficulties and dehumanizing practice of being declared indigent. It is sometimes stated that fees often lead to postponement of care, which results at a later date in more expensive and more high risk treatment. Finally, those who advocate lower fees, or their elimination altogether, point to the income redistribution achieved through this mechanism. Yet, the practice has always been there and is accepted by the vast majority of the population. This is a considerable advantage compared with so many other countries where the absence of a cost recovery mechanism, and the procrastination at introducing user charges, makes it all but impossible to redress the sector's finances and set the stage for viable long term solutions. Nevertheless, what is urgently needed, is an evaluation of real outpatient and inpatient costs, by type of facility and nature of service. The introduction of cost accounting in public facilities, starting with the large hospitals, should receive high priority. 203. In the short run, two issues call for immediate decisions: first, the periodicity of the tariff updating and second, the restructuring of the tariff itself, to bring it more in line with the real cost of services. In a longer term perspective, the Higher Health Council would be exiected to initiate consultations on whether it is desirable - and feasible - to scale charges according to recipients' ability to pay. Adjusting the Fee Xevel 204. University hospitals apply higher fees than MHOSA, and also adjust them frequently; no information on total receipts or their evolution over time is directly accessible but neither does it seem to be an issue calling for special attention. This is not the case for MORSA which is under constant social and political pressure not to increase its fees; at current levels, the revenue generating potential of these fees is negligible. As mentioned earlier and illustrated in Chart 1, delayed adjustments result in wide fluctuations in hospital cash flow, impossible to forecast. The evolution of the past five years, presented below, shows the dramatic impact of the 1981 adjustment (+125X) and the erosion that followed (-101); it is still too early to assess the outcome of the January 1985 adjustment, but the depreciation of the local currency has been at least 40% during the year.  - 75 - Y38B COLLCT=D IN TMe W 2064ES BPITAZB (TL million) Current 198 Prices Prices lndes 1980 917 43 100 1981 2 927 96 225 1982 3 514 90 212 1983 4 794 97 227 1984 6 257 86 203 205. Without regard to the general issue of public financing of health services, frequent and regular adjustments of MORSA's fee schedule are inescapable. This does not imply the setting up of an indexing mechanism which would trigger automatic adjustments linked to inflation. What is needed is the official recognition that, as long as inflation will remain at high levels, the Government will be expected to adjust fees in order to safeguard the quality of services and the longer term viability of the system. Adjusting the Fees Structure 206. The whole structure of the fee schedule applied in MOESA hospitals needs to be reexamined. Irregular updating (five years between the last two adjustments in a context of very high inflation rates) makes it all the more difficult to confront unpopular decisions, and has led to the aberrations discussed above. It will be recalled (see Table 23) that the January 1985 adjustment resulted in a reduction in real terms of 42% (compared to April 1981) of the daily rate for a "deluxe room" in public hospitals; at that date's exchange rate, this corresponded to US$9.23. At the same time, the charge for a small dressing in outpatient facilities was increased by 193X, to US$1.85. Under present circumstances which entail increased hardship for large segments of the population, it would not be advisable to increase dramatically the tariff to reflect the real cost of all services; however, on social as well as economic grounds it would be fully justified to proceed to a gradual restructuring of this tariff. Revising pricing policy to reduce existing distortions, would at the same time improve equity. As regards social security beneficiaries receiving services in MORSA facilities, fees should be adjusted at least to the level of operating costs in SIO hospitals, in order to eliminate the indirect, and substantial, subsidy to SIO.  - 76 - F. Strenagtheixg Social Security-s Fianciel Basis 207. The SIO, as vell as BAG-KUR and the GERF operate under capitalization financing systems. Their resources are generated by individual contributions and payroll deductions which have consistently increased in recent years, to reacb the rate of 34.5Z for the SIO, 201 for BAG-KUR and 28S for GERP. Hovever, because of escalating costs and an 801 level of collection of premiums, the system is confronted with a groving deficit estimated at TL400 billion in 1983 (US$1.8 billion), while legal reserves are not maintained at the required actuarial level. 208. The Plan states that welfare and social security services must be expanded to larger segments of the population. At the same time these institutions are expected to meet their commitments from their own resources, while government subsidies would be terminated. To achieve these seemingly contradictory objectives, it is proposed to strengthen the system's management, improve premium collection, eliminate expenditures which correspond to public transfers, and change the provisions governing early retirement. However, the Plan only suggests that eligibility for retirement, for all agencies, be postponed to 55 years for men and 50 years for women. It would certainly be preferable to extend to both sexes the same limit of 60 years or, at least, generalize the 60-55 age limits existing in BAG-KUR. 209. The most important proposal put forward in the Plan is that all health care institutions of the Social Insurance Organization be turned over to KOUSA: 8IO would then purchase health services for its beneficiaries, in return for their financial contribution to the system. The outcome of this proposal is not yet clear as it is likely to generate the resistance of strongly vested interests. At any rate, it emphasizes the need to strengthen the financial foundations of the system. Assets of Social Security Institutioua 210. The assets of the three major social security institutions exceeded US$1.4 billion in 1984. A major proportion is kept in local banks. Another substantial proportion of their assets is composed of house mortgages and personal loans to individual members: more than 202 for GERF and about the same ratio for 810 (in the "bonds and securities" category). As for outstanding contributions, they represent 16.5X of SIO's assets, and more than 24S of BAG-KUR's.  - 77 - ASS1WTS OF IWOR SOCIAL 5RCURI INSTITUTIONS A UDI DISTRIBUTION IN 1984 CZ) GUI BiD BAG-KUR EIID8 TOTAL - Bank deposits 59.4 30.0 66.7 - 40.0 - Bonds & securities 15.6 26.0 2.4 32.2 21.1 - Land & buildings 1.2 23.0 - 67.8 16.9 - Outstanding contrib. - 16.5 24.1 - 12.8 - Loans to members 20.7 - - - 5.0 - Others 3.1 4.5 6.8 - 4.2 Total 100.0 100.0 100.0 100.0 100.0 TL Billion 131.2 334.0 60.1 20.0 545.3 US $ Million 357.8 910.7 163.9 54.4 1,486.8 Utilization of Assets 211. The resources of social insurance institutions. and their utilization. are determined by law and controlled by the Ministry of Finance and Customs; only the private funds can freely manage their resources. Over the years. and as in many other countries. the three major institutions have not only been geared to the benefits of their members; they have also largely been used to the advantage of the State. Legal constraints, liberal lending policies, generous benefits. conservative management and rapid inflation have limited the profitability of the system and endangered its long term viability. In the early 1960s. with the introduction of development planning, the operating surplus of social security institutions was mobilized to finance public investments. In 1965 for example. it is estimated29 that investible funds of the SIO represented 27