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Health care systems in transition: Turkey

1 января 2002 г. Всемирная организация здравоохранения

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1HiT summary: Turkey, 2004 HiT summary Turkey Fig. 1. Total health care expenditure as % of GDP, comparing Turkey, selected countries and EU average Source: WHO Regional Office for Europe health for all database. Health Care Systems in Transition European Observatory on Health Systems and Policies WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Denmark Telephone: +45 39 17 17 17 Fax: +45 39 17 18 70 E-mail: observatory@who.dk www.observatory.dk European Observatory on Health Systems and Policies Bulgaria (1994) Greece (2001) Italy (2002) Romania (2002) Turkey (1998) EU average (2000) Introduction Government and recent political history The Republic of Turkey is a secular and democratic state headed by a President. Legislative power resides with the Grand National Assembly, which consists of 550 elected representatives, including the Prime Minister and the Council of Ministers. Turkey is a candidate country for accession to the European Union (EU), although it does not yet have a date for the start of accession negotiations. Population Turkey’s population of about 66 million people is relatively young. In recent years it has experienced rapid urbanisation due to migration from the eastern to the western part of the country. Health status Infant and maternal mortality rates in Turkey are much higher than in any other country in Europe, while estimates of life expectancy are lower. These indicators also vary between different parts of the country, suggesting a degree of health inequality within Turkey. In 1999 infant mortality in Turkey was 40 deaths per 1000 live births, compared to an EU average of 4.9, a Central and Eastern European (CEE) average of 11.3 and an newly independent states (NIS) average of 17.8. The trend for maternal mortality is worse. WHO calculated a rate of 130 maternal deaths per 100 000 live births in 1998, although other sources quote a higher rate of 180. This compares to a European average (of the countries in WHO’s European Region) of 20.3 and a Central Asian Republics (CAR) average of 42.6. Poor health status in Turkey – both in absolute and relative terms – is associated with an unequal distribution of income, rapid urbanisation and health care system failures. Leading causes of death Infectious diseases are the main cause of death in infants up to the age of five. The main causes of death among adults are heart disease and accidents (for those aged 25 to 44) and heart disease and smoking-related respiratory disorders (for those aged 45 to 64). 0 2 4 6 8 10 2HiT summary: Turkey, 2004 Recent history of the health care system The 1961 Law on the Nationalization of Health Care Delivery established the concept of integrated primary care delivered by health centres and health posts across the country, but its vision has yet to be fully realized. Subsequent attempts to introduce a universal statutory health insurance scheme have also failed. The 1990s saw a rapid increase in the number of private facilities for health care and the development of a market for private health insurance, although demand for the latter has fallen more recently. Reform trends Establishing a universal statutory health insurance scheme has been a key objective since the 1960s, but universal coverage remains an elusive goal. In addition to universal coverage, reform proposals of the 1990s have focused on decentralisation, training of family doctors and health care managers, introducing a gate-keeping family doctor model for primary health care in urban areas and improving management information systems. Health care expenditure and GDP Official statistics suggest that total expenditure on health care as a proportion of GDP is low in Turkey, relative to EU member states and CEE countries, although the actual volume of private expenditure is not known. Total expenditure currently stands at 4.3% (in 2000). Overview Turkey has the seventh largest economy of all European OECD countries measured in terms of total levels of gross domestic product (GDP). However, GDP per capita is the lowest among these countries. This low level of GDP per capita is reflected in the poor health status of the population and the questionable performance of the health care system. In spite of several reform attempts that have taken place over recent decades, the Turkish health care system continues to face problems of low population coverage, heavy reliance on out- of-pocket payments and an uneven distribution of facilities and personnel, all of which lead to inadequate and unequal access to health services. Organizational structure The complex structure of the Turkish health care system reflects historical developments rather than rational planning processes. Health care is provided by public, quasi-public, private and philanthropic organizations, but relations among them are not well structured or regulated. The Ministry of Health is the largest provider of health care in Turkey and the only provider of preventive services. At the central level, the Ministry of Health is responsible for Turkey’s health policy and health services. At the provincial level, health services provided by the Ministry of Health are administered by provincial health directorates accountable to provincial governors. Lack of coordination between different directorates within the Ministry of Health and between the centre and the provinces is a key issue. Health services provided by the Ministry of Health are funded by the Ministry of Finance. The Ministry of Defence has its own health care infrastructure exclusively for the use of military personnel and their dependants. The Council of Higher education is responsible for university hospitals. The Ministry of Labour and Social Security has jurisdiction over the SSK, the insurance scheme for private sector employees and blue-collar public sector employees, which is the second largest provider of health care in Turkey. The two other social security institutions are Bag-Kur, the insurance scheme for self- employed people, and the GERF, which insures retired civil servants and is managed by the Ministry of Finance. 3HiT summary: Turkey, 2004 Many private hospitals, polyclinics, laboratories and diagnostic centres were established in the larger cities during the economic liberalisation of the 1980s, mainly as a result of substantial incentives provided by the government (see below). The Turkish Medical Association and other professional organizations are neither well organized nor distinguished by clearly defined responsibilities. Planning, regulation and management Overall responsibility for planning, coordinating, financially supporting and developing health institutions is divided among the Ministry of Health, the military, parliamentary commissions and others. The State Planning Organization is responsible for strategic planning and investment appraisal and planning. Decentralization of the health care system The Ministry of Health is strongly centralized and, until recently, local (provincial) decision- making has not been encouraged. Dealing with local health problems at a local level has been problematic due to excessive bureaucracy. The government’s current reform proposals aim to increase the decentralization of some responsibilities to provincial level (see below). Health care financing and expenditure Health care financing Turkey has three main sources of health care financing: • the general government budget funded by tax revenue and allocated mainly to the Ministry of Health, the Ministry of Defence, university hospitals, other public agencies and the health care expenditure of active civil servants • social security contributions obtained from members of the three social security schemes: SSK, Bag-Kur and the GERF • out-of-pocket payments in the form of direct payments to private doctors and institutions, premiums paid for private health insurance and cost sharing. Coverage Estimating the proportion of the population covered by the social security system is difficult and controversial. While official statistics show that it covers over 95% of the population, this figure is likely to be inflated by double counting. In theory, Turkish citizens have access to primary care that is largely free at the point of use. In practice, this is not the case. The Green Card scheme established in 1992 is directly funded by the government for people earning less than a minimum level of income (11.3 million people). Complementary sources of financing According to official statistics, taxes accounted for 40.4% of health care funding in 1998, social security contributions for 31.5% and out-of- pocket payments for 28.1%. However, the proportion of out-of-pocket payments is likely to be much higher, largely because national statistics are based on data collected from private providers, who may under-report revenue, but also due to the boom in private sector enterprise and activity and the rapid expansion of private health insurance during the 1990s. About 650 000 people are estimated to have some form of cover from about 30 private health insurers, although numbers have declined in recent years. Informal payments are also an issue. Recent surveys suggest that many people regard corruption in the health sector to be a major problem. It seems clear that there are significant financial barriers to access in Turkey, although the precise distribution of private expenditure is not known. 4HiT summary: Turkey, 2004 Fig. 2. Hospital beds in acute hospitals per 1000 population, Turkey, selected countries and EU average, 1990–2001 Source: WHO Regional Office for Europe health for all database. Health care expenditure Official statistics suggest that total expenditure on health care as a proportion of GDP is low in Turkey, relative to EU Member States and CEE countries, although the actual volume of private expenditure is not known. Total expenditure has generally exceeded 3.0% of GDP and currently stands at 4.3% (in 2000). Under-spending is most marked in the public sector; the size of the government’s budget allocation for health care resembles that of low income countries, despite Turkey’s middle income status. Public spending on preventive services is particularly low. Between 1992 and 1998, the proportion of the Ministry of Health’s budget allocated to preventive services declined from 7 to 3%. Health care delivery Primary care At the provincial level, the Ministry of Health provides primary care through health centres and posts, mother and child health and family planning centres and tuberculosis dispensaries. The national network of health centres and health posts that was envisaged through the 1961 Law on the Nationalization of Health Care Delivery has yet to be achieved. While infrastructure has been successfully developed in rural areas, infrastructure in urban areas is relatively weak, partly due to rapid urbanization. At the same time, doctors have been trained to become specialists rather than general practitioners, and there have been serious shortcomings in the number and quality of nurses and midwives (see below). As a result, private practitioners seem to be an important point of initial contact with the health 0 1 2 3 4 5 6 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Greece Italy Turkey EU average 5HiT summary: Turkey, 2004 Fig. 3. Physicians per 1000 population, Turkey, selected countries and EU average, 1990–2001 Source: WHO Regional Office for Europe health for all database. care system, both for urban and rural populations, although people living in rural areas make less use of private doctors and are more likely to use health centres. The choice of initial contact also varies according to income, education and geography, with wealthier and university-educated people and those living in western Turkey making more use of private practitioners. Health indicators demonstrate the severe constraints primary health care has been facing in Turkey. Attempts during the 1990s to provide coordinated and integrated primary care in eight pilot provinces were unsuccessful, and coordination and collaboration among primary care providers is still almost non-existent. Reasons for this failure include the limited leadership of the Ministry of Health, the lack of properly trained staff (particularly general practitioners and family doctors), insufficient managerial capacity and ineffective legislation. Turkey does not have a functional referral system, mainly due to the importance accorded to free choice, which has restricted the development of general practitioners as gate-keepers, and the inability of hospitals to refuse to treat self- referred patients. Public health services The Ministry of Health takes the lead in environmental services through environmental health officers located across the country. Municipalities also provide sanitary services. The Ministry of Labour and Social Security is responsible for occupational health services, but the services it provides are inadequate. School health services are provided by the Ministries of Health and Education but, with the exception of vaccination programmes, they have structural deficits. Secondary and tertiary care Turkey has about 25 hospital beds per 10 000 population. However, the distribution of hospital beds across the country is uneven, ranging from 3 to 60 beds per 10 000 population. 0 1 2 3 4 5 6 7 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Bulgaria Greece Italy Romania Turkey EU average 6HiT summary: Turkey, 2004 The Ministry of Health owns about half of all hospital beds. The SSK is the second largest provider with 16% of all hospital beds, university hospitals provide 14% and the Ministry of Defence 9%. Although the private sector is developing rapidly, private hospital beds only account for 8% of the total number of hospital beds in Turkey. The occupancy rate for acute hospital beds is just under 60% , but varies considerably between hospitals. In case of emergency, patients can make use of any hospital, but once their condition has stabilized, they may be referred to other institutions that can provide the necessary diagnostic or curative services. University hospitals serve as referral centres for the region in which they are located. However, the quality and the range of services they provide varies widely across the country, and many patients travel from remote parts of the country to use university hospitals in metropolitan areas. University hospitals are open to members of the general public, provided that they or their referring institutions are able to pay the fees. Ministry of Health hospitals do not require referrals. Patients referred from health centres to hospital outpatient departments comprise less than 2% of the total number of outpatients seen in Ministry of Health hospitals. Bag-Kur members are restricted to using hospitals with which the organization has an agreement and that are in the province in which they live. Government employees and people insured by the GERF are eligible to use university hospitals and GERF will pay the hospital directly, while SSK members and Green Card holders need to be referred by an authorized institution, such as an SSK hospital. Before the 1990s, private hospitals served as operating theatres for privately practising specialists, but recent changes have brought about a new form of service. Well-established outpatient departments make private hospitals a convenient one-stop centre for patients. Private hospitals vary with the income levels of their target patients, ranging from basic structures to luxurious centres with high-tech equipment. Lack of professional management is an important concern for hospitals in Turkey. During the economic liberalisation of the late 1980s, the government provided substantial incentives for investment in private health care, such as generous public subsidies, reductions in import regulations and easier ways of financing the purchase of equipment. By the end of the 1990s, over 100 new private hospitals had been established, mainly in the largest cities. Growth has slowed since the economic crisis of 2001. Rapid expansion of the private sector has contributed to the development of health care infrastructure – particularly in terms of the accumulation of high technology – and may satisfy patients who are able to pay for private care, but it exacerbates existing inequalities in access to health care between those with different levels of income and those living in different parts of the country. The development of an unregulated private sector also raises concerns about quality and service outcomes. Human resources and training The geographical distribution of secondary and tertiary health services and personnel is very uneven and secondary and tertiary centres in urban areas tend to be used for primary care purposes. One third of hospital beds and almost half of all doctors are concentrated in the three largest cities and there are fewer personnel per capita in less developed regions of the country. Specialists are most unevenly distributed: Istanbul has almost 14 times as many specialists per capita as the eastern provinces of Mus and Van. As in other countries, these variations arise from socioeconomic and climatic differences between regions and the absence of strong financial or other incentives to encourage personnel to practise in less favourable regions. Doctor and nurse to population ratios are comparatively low in Turkey, although the number of health personnel increased sharply , 7HiT summary: Turkey, 2004 during the 1980s and 1990s. The skill-mix of health personnel also restricts the delivery of effective health services, with too few nurses and midwives in relation to doctors and, until recently, too many specialists in relation to general practitioners. Pharmaceuticals Turkey obtains pharmaceuticals through domestic production and import. In 1997 the total consumption of pharmaceuticals was US $2070 million at ex factory prices, or US $32 per person. These figures are low when compared to pharmaceutical consumption in western European countries. Pharmaceutical consumption grew dramatically between 1997 and 1998, rising to US $3310 million, but there is no clear explanation for this rapid growth. According to more recent Ministry of Health data, pharmaceutical consumption was equal to between US $4000 million and US $4500 million in 2001, or about US $60 per person. The pharmaceutical industry is regulated by the government. New licensing regulations that closely resemble EU regulations came into force recently, and a national patent law has been in effect since 1 January 1999. Although Turkey has an unofficial list of essential drugs, the list has no practical implications for the pharmaceutical sector. The three social security schemes have negative lists for prescriptions. There have been a number of unsuccessful attempts to promote the use of generic drugs, but doctors generally prescribe by brand name. Pharmacies are staffed by a pharmacist, one or more supervisors and an assistant supervisor. A system of green and red prescriptions is used to control the sale of certain drugs. Health care technology assessment The lack of regulation and control of medical technology, combined with economic incentives to import high-tech medical equipment, has led to dramatic increases in the use of such equipment. Much privately-owned diagnostic equipment is used inefficiently, mainly to generate profit. Financial resource allocation Third-party budget setting and resource allocation Turkey’s government budget allocation for health care resembles that of low-income countries, despite its middle-income status. Relative under-spending in the health care sector is most marked in public expenditure on health care, which is responsible for at least part of the poor performance of Turkey’s health care system. Payment of hospitals Ministry of Health hospitals receive 80% of their funding from general government revenue and 15% from insurers or individuals (paid into revolving funds). Since 1988, the remaining 5% has been obtained from earmarked excise taxes on fuel, new car sales, cigarettes and alcohol. The Ministry of Health allocates resources from the general budget in cooperation with the Ministry of Finance. The amount is ratified by the Grand National Assembly before the start of each fiscal year. In recent years the rapid rate of inflation has been a major challenge in reporting, monitoring and controlling public expenditure. With public sector salaries being adjusted twice a year and the costs of material inputs rising constantly, the initial allocation is routinely increased by supplementary allocations during the fiscal year. Revolving fund revenue, obtained from fees paid by insurers or individuals, is retained by the hospital generating the revenue. Revolving funds have become progressively more important as a source of funding. 8HiT summary: Turkey, 2004 A commission with representatives from the Ministry of Health and the Ministry of Finance determines the fees for different health services, without considering the actual cost of these services. Funding for university hospitals comes from general budget allocations made by the Council of Higher Education and revolving funds. SSK health services are primarily funded by employees’ and employers’ contributions, but also through co-payments for outpatient drugs and fees paid by non-members using SSK facilities. The SSK allocates funds to hospitals similarly to the Ministry of Health. Payment of physicians Doctors working in the Ministry of Health, university or SSK hospitals receive government salaries. They also receive bonuses from revolving funds. While public sector doctors’ salaries are fairly uniform, doctors in less-developed parts of the country, particularly the eastern part, earn more due to government incentives to encourage doctors to practise in these areas. Some public sector doctors, particularly specialists, establish independent private practices, which allows them to charge on a fee-for-service basis. Doctors working in private hospitals earn more than public sector doctors as they are usually paid for overtime and receive large extra payments for working night shifts. In general, however, doctors’ incomes have declined substantially over the last 15 years. Health care reforms The government made its most structured attempt to establish a national health service and extend coverage across the country during the 1960s through the 1961 Law on the Nationalization of Health Care Delivery. Unfortunately, the initiative fell short of its goals, largely due to limited financial and human resources. At the same time, the growth of the SSK and GERF and the establishment of Bag-Kur led to the creation of a de facto system of multiple insurance schemes providing coverage to some, but not all, of the population. In 1987 the government passed the Basic Law on Health Services, which defined the steps needed to establish a universal health insurance scheme. The law also envisaged decentralizing state hospitals and allowing them to employ their own personnel. However, the Constitutional Court struck down some crucial provisions of this law, and although the law is still in force, none of it has been implemented. Between 1988 and 1993 the Ministry of Health was active in implementing a national health policy and a programme of health care reform known as the First Health Project. The issue of universal health insurance was revisited during the First National Health Congress held in 1992. A policy document, including a reform proposal, was presented at the Second National Health Congress in 1993. The proposed changes included decentralization, the establishment of a universal health insurance scheme, introducing gate-keeping and improving management information systems. The proposed changes required a radical overhaul of the existing legislation, much of which dated from the 1920s and 1930s. However, the reform programme was interrupted by a change of government in 1993. The main aspect of the programme to be implemented was the Green Card scheme for low earners. More recently, the government has published plans for a ‘health transformation programme’ to be implemented over the next few years, the main components of which are as follows: • restructuring of the Ministry of Health to enhance its core functions of setting priorities, ensuring quality and managing public health processes, including preventive services • introducing compulsory statutory health insurance for the whole population, with the possibility of supplementary private health insurance operated by private insurers 9HiT summary: Turkey, 2004 • increasing access to health care by making use of private facilities where necessary, strengthening primary care, improving the referral system and giving institutions more administrative and financial autonomy • improved and more appropriate training for doctors, nurses and administrators and better incentives to encourage a more even distribution of personnel across the country • establishing a school of public health and a national quality and accreditation agency • supporting more rational use of drugs and medical devices through the establishment of a national drug agency and a medical device agency • improving health information systems. Conclusions Universal coverage remains an elusive goal in the Turkish health care system. Major health care challenges include the following: • improving health status and reducing regional and urban/rural inequalities in health status • increasing population coverage • increasing access to quality health services • reducing high levels of out-of-pocket expenditure • achieving a more equitable distribution of health services and health care personnel • tackling inefficiencies in delivery, including the lack of a proper referral system and relatively low occupancy rates in hospitals • improving doctors’ training and management skills • improving preventive health services • improving accountability and transparency • introducing health technology assessment The last few years have seen a rapid expansion of the private health care sector in Turkey. The expectations of those with high incomes provide incentives for further expansion and encourage the private sector to play a larger role in the health care system. However, this process is likely to exacerbate existing inequalities in access to health care and raises concerns about quality and service outcomes. It is to be hoped that the Turkish health care system can move forward by addressing the deficiencies of the public sector identified elsewhere in this report, rather than by encouraging further privatization. Table 1. Inpatient utilization and performance in acute hospitals in the WHO European Region, 2001 or latest available year Country Hospital beds Admissions Average Occupancy per 1000 per 100 length of stay rate (%) population population in days Bulgaria – 14.8e 10.7e 64.1e Greece 4.0b 15.2c – – Italy 4.0a 16.0a 7.0a 75.5a Turkey 2.1 7.6a 5.4 58.8 EU average 4.1a 18.9b 7.7b 77.4c Source: WHO Regional Office for Europe health for all database. Notes: a 2000, b 1999, c 1998, d 1997, e 1996, f 1995. 10HiT summary: Turkey, 2004 HiT summary Turkey Health Care Systems in Transition European Observatory on Health Systems and Policies The HiT for Turkey was written by B. Serdar Savas (United Health Systems), Ömer Karahan (Group Health Management Inc) and R. Ömer Saka (United Health Systems and LSE Health and Social Care), and edited by Sarah Thomson and Elias Mossialos. The research director for the Turkish HiT was Elias Mossialos. The European Observatory on Health Care Systems is grateful to Gazanfer Aksakoglu (Department of Community Medicine, Dokuz Eylul University, Izmir), Dogan Fidan (United Kingdom National Institute for Clinical Excellence) and Salih Mollahalilo Glu (Health Project General Coordination Unit, Turkish Ministry of Health) for reviewing the report; Meltem Ceylan (Dr Siyami Ersek Hospital, Turkish Ministry of Health) for her comments on an earlier draft; and the Turkish Ministry of Health for their support.The Health Care Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of each health care system and of reform initiatives in progress or under development. The HiTs are a key element that underpins the work of the European Observatory on Health Systems and Policies. The Observatory is a unique undertaking that brings together the WHO Regional Office for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. This partnership supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health care systems in Europe. Attempts to reform the Turkish health care system have been hampered by political instability – between 1993 and 1997 Turkey had six different Ministers of Health – and fragmented policy making. In future, however, there is scope for improvement, particularly in terms of publicly funded and provided health care. Internal and external pressures – notably the prospect of accession to the EU – could precipitate changes to public structures more generally, which may lead to increased transparency and greater pressure for accountability. Such changes may also encourage improvements in the performance of the health care system and the state of the population’s health.

Turkey

Health Care Systems in Transition

Written by B. Serdar Savas, Ömer Karahan and R. Ömer Saka

Edited by Sarah Thomson and Elias Mossialos

Health Care Systems in Transition

2002

The European Observatory on Health Care Systems is a partnership between the World Health Organization Regional Office for Europe, the Government of Greece, the Government of Norway, the Government of Spain, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

Turkey

European Observatory on Health Care Systems

Keywords

DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration TURKEY

This document may be freely reviewed or abstracted, but not for commercial purposes. For rights of reproduction, in part or in whole, application should be made to the Secretariat of the European Observatory on Health Care Systems, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark. The European Observatory on Health Care Systems welcomes such applications.

The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Care Systems or its participating organizations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this document are those which were obtained at the time the original language edition of the document was prepared.

The views expressed in this document are those of the contributors and do not necessarily represent the decisions or the stated policy of the European Observatory on Health Care Systems or its participating organizations.

European Observatory on Health Care Systems: WHO Regional Office for Europe Government of Greece Government of Norway Government of Spain European Investment Bank Open Society Institute World Bank London School of Economics and Political Science London School of Hygiene & Tropical Medicine

EUR/02/5037245 (TUR) 2002 ISSN 1020-9077 Vol. 4 No. 4

Suggested citation: Savas, B. Serdar et al. In Thomson, S. and Mossialos, E., eds. Health care systems in transition: Turkey. Copenhagen, European Observatory on Health Care Systems, 4(4) (2002).

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Foreword ............................................................................................. v

Acknowledgements .......................................................................... vii

Introduction and historical background ......................................... 1 Introductory overview .................................................................... 1 Historical development of the health care system ....................... 16

Organizational structure and management .................................. 23 Organizational structure of the health care system ...................... 23 Planning, regulation and management ......................................... 23 Decentralization of the health care system .................................. 37

Health care financing and expenditure .......................................... 39 Main system of financing and coverage ...................................... 39 Complementary sources of financing .......................................... 48 Health care expenditure ............................................................... 54

Health care delivery system ............................................................ 63 Public health services ................................................................... 63 Primary health care ...................................................................... 66 Secondary aned tertiary care ........................................................ 69 Human resources and training ..................................................... 77 Pharmaceuticals ........................................................................... 85 Health care technology assessment .............................................. 86

Financial resource allocation .......................................................... 89 Payment of hospitals .................................................................... 89 Payment of doctors ....................................................................... 91

Health care reforms ......................................................................... 93 Conclusions ....................................................................................... 97

References ......................................................................................... 99

Bibliography ................................................................................... 101 Appendix: List of terms ................................................................ 105

Contents

Turkey

European Observatory on Health Care Systems

Turkey

Health Care Systems in Transition

Foreword

The Health Care Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of a health care system and of reform initiatives in progress or under development. The HiTs

are a key element of the work of the European Observatory on Health Care Systems.

HiTs seek to provide relevant comparative information to support policy- makers and analysts in the development of health care systems in Europe. The HiT profiles are building blocks that can be used:

• to learn in detail about different approaches to the organization, financing and delivery of health services;

• to describe the process, content and implementation of health care reform programmes;

• to highlight challenges and areas that require more in-depth analysis; and

• to provide a tool for the dissemination of information on health care systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries.

The HiT profiles are produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides the detailed guidelines and specific questions, definitions and examples needed to compile a HiT. This guidance is intended to be flexible to allow authors to take account of their national context.

Compiling the HiT profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health care system and the impact of reforms. Due to the lack of a uniform data source,

Turkey

European Observatory on Health Care Systems

quantitative data on health services are based on a number of different sources, including the WHO Regional Office for Europe health for all database, Organi- sation for Economic Cooperation and Development (OECD) Health Data and data from the World Bank. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series.

The HiT profiles provide a source of descriptive information on health care systems. They can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health care systems. This series is an ongoing initiative: material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT profiles are most welcome and can be sent to observatory@who.dk. HiTs and HiT sum- maries are available on the Observatory’s website at www.observatory.dk. A glossary of terms used in the HiTs can be found at www.euro.who.int/ observatory/Glossary/Toppage.

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Acknowledgements

The HiT for Turkey was written by B. Serdar Savas (Chief Executive Officer (CEO), United Health Systems), Ömer Karahan (CEO, Group Health Management Inc) and R. Ömer Saka (Project Assistant, United

Health Systems and Research Assistant, LSE Health and Social Care), and edited by Sarah Thomson and Elias Mossialos. The research director for the Turkish HiT was Elias Mossialos.

The European Observatory on Health Care Systems is grateful to Gazanfer Aksakoglu (Professor and Head, Department of Community Medicine, Dokuz Eylul University, Izmir), Dogan Fidan (Health Economist, United Kingdom National Institute for Clinical Excellence) and Salih Mollahaliloglu (Deputy Coordinator, Health Project General Coordination Unit, Turkish Ministry of Health) for reviewing the report; Meltem Ceylan (Dr Siyami Ersek Hospital, Turkish Ministry of Health) for her comments on an earlier draft; and the Turkish Ministry of Health for their support.

The Observatory is a partnership between the WHO Regional Office for Europe the Governments of Greece, Norway and Spain, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

The Observatory team working on the HiT profiles is led by Josep Figueras, Head of the Secretariat, and research directors Martin McKee, Elias Mossialos and Richard Saltman. Technical coordination is carried out by Suszy Lessof.

Jeffrey V. Lazarus managed the dissemination, production and copy-editing, with the support of Shirley and Johannes Frederiksen (layout) and Misha

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Hoekstra (copy-editor) and Anna Maresso (proof-reading). Administrative support for preparing the HiT on Turkey was undertaken by Uta Lorenz and Myriam Andersen.

Special thanks are extended to the WHO Regional Office for Europe health for all database for data on health services; the OECD for data on health services in western Europe; and to the World Bank for the data on health expenditures in central and eastern Europe. Thanks are also due to the various national statistical offices that have provided national data.

Turkey

Health Care Systems in Transition

Introduction and

historical background

Introductory overview

Country brief

Turkey is the confluence of East and West, a historical country where the two

continents and cultures of Europe and Asia meet and blend. Geographically,

Turkey is located in the Northern Hemisphere, almost equidistant to the North

Pole and the equator. Mainland Anatolia, the birthplace of many great

civilizations, has always been a bridge for commerce and a gateway between

cultures because of its land connections to three continents and the sea

surrounding it on three sides.

The land area of Turkey, including lakes, is 814 578 km 2

. Turkey is bordered

by Georgia and Armenia to the north-east, the Islamic Republic of Iran to the

east, Iraq and Syria to the south and Greece and Bulgaria to the west.

The Mediterranean Sea turns into the Aegean Sea along the west coast of Turkey, facing Greece. In the northern part of the Aegean, Çanakkale Bogazi (the Dardanelles) give passage to the Marmara Denizi (Sea of Marmara), which then opens into the Black Sea through the Istanbul Bogazi (the Bosporus). This spectacular strait separates the European from the Asian side of Turkey’s largest city, Istanbul.

The Republic of Turkey was created in 1923 from the Turkish remnants of

the Ottoman Empire, once one of the largest empires in the world. The Ottoman

Empire collapsed after the First World War, and Kemal Atatürk, the founding

father of the Republic, fought Italian, French, Greek and British armies to

reclaim the land that Turkey now possesses. The Republic was proclaimed on

29 October 1923.

Turkey

European Observatory on Health Care Systems

Fig. 1. Map of Turkey 1

The maps presented in this document do not imply the expression of any opinion whatsoever on the part

of the Secretariat of the European Observatory on Health Care Systems or its partners concerning the legal

status of any country, territory, city or area or of its authorities or concerning the delimitations of its

frontiers or boundaries.

Source: World Factbook 2002.

Atatürk transformed his military leadership into leadership in economics,

political science, manufacturing and engineering. Forced to rebuild a country

that had been destroyed by war, he aimed to modernize it as quickly as possible.

After Atatürk’s death in 1938 two major parties ran the government for many

years. In 1945 Turkey joined the United Nations, and in 1952 it became a

member of the North Atlantic Treaty Organization (NATO). During this time,

Turkey’s most pressing problems were economic. Political struggles between

those on the left and those on the right emerged during the 1960s, leading to

military coups on 27 May 1960, 12 March 1970 and 12 September 1980. The

periods of military rule were relatively short, however, lasting for only three

years in each case, before giving way to more democratic systems of

government.

Turkey’s political life has been characterized by numerous elections and

governments, particularly in the last two decades. Political instability has

prevented stable, long-term strategies and policies, as new administrations have

tended to put a stop to the policies of their predecessors and adopt a “different”

approach.

Bulgaria

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Greece

Georgia

Azerbaijan

Armenia

Iran

IraqSyria

Cyprus

Black Sea

Mediterranean Sea

Aegean Sea

Lake Van

Van

Istanbul Bosporus

Sea of Marmara

Kocaeli (Izmit)

Gemlik Bursa

Balikesir

Manisa

Izmir

Antalya

Konya

Kayseri

Kahramanmaras

Içel (Mersin)

Adana Gaziantep

Anatolia

Iskenderun

Sanli Urfa

TigrisDiyarbakir

Erzurum

Trabzon

Hopa

Euphrates ANKARA

Samsun

Sivas Eskisehir

0 75 150 km

0 75 150 miles

Turkey

Health Care Systems in Transition

Political and administrative structure

Turkey’s first constitution was prepared in the second half of the nineteenth

century and adopted in 1876, during the last period of the Ottoman Empire.

The second constitution (1921) was promulgated during the war of

independence following the First World War and included rules necessitated

by the conditions and requirements of the struggle for independence. Since the

founding of the Republic, three different constitutions have been introduced in

Turkey, in 1924, 1961 and 1982.

The military coup of 27 May 1960 was an important turning point in Turkey’s

history. One of the major changes caused by this event was the preparation and

implementation of a new constitution. This constitution was presented to the

public in a referendum on 9 July 1961, and a substantial majority voted in

favour of it (61.5%, with a turnout of 81%). The new constitution was a long

and detailed document, introducing a number of key changes, including the

separation of powers. Legislative power was vested in two chambers: the Grand

National Assembly and the Republican Senate. Executive power rested with

the President and the Council of Ministers, provided that their actions were

within the limits delineated by law. Judicial power was to be exercised in

independent tribunals on behalf of the nation. An important addition was the

introduction of the Constitutional Court to ensure that laws were compatible

with the constitution. The government was given responsibility for establishing

various social regulations and reforms. In terms of basic rights and freedoms,

the 1961 constitution was also detailed. It remained in force (with additions by

the 1971 military regime) until 1982.

The 1982 constitution was approved by an even higher majority in a public

referendum (91%, with a turnout of around 90%). Unlike the 1961 constitution,

this constitution introduced regulations to restrict freedom in the country,

widening the executive reach of government. While these changes allowed

successive governments to operate more easily, it inevitably led to a neglect of

human rights and related problems. In response to growing public and

international concern for rules that would ensure more democratic decision-

making, the government and the Grand National Assembly pledged to amend

the constitution, and even to change it completely. Some minor attempts were

undertaken, but the pledge has never been fulfilled.

According to the 1982 constitution, Turkey is a republic and a nation vested

with unconditional, unrestricted sovereignty. The Republic of Turkey is a

democratic, secular, social and legal state. The people exercise their sovereignty

directly through elections, and indirectly through the authorized branches within

the constitutional framework. The legislative, executive and judicial branches

exercise power. Legislative power is vested in Turkey’s parliament, the Grand

Turkey

European Observatory on Health Care Systems

National Assembly, and cannot be delegated. The President of the Republic

and the Council of Ministers exercise executive power and carry out functions

in accordance with the constitution and other laws. Independent courts exercise

judicial power.

The state is organized centrally and locally. The central administration,

excluding the legislative and the judicial branches, comprises the Prime

Minister’s office and the various ministries. In addition, there are organizations

related to the ministries.

The legislative branch

The Grand National Assembly has 550 elected members and carries out its

activities in accordance with internal regulations. The constitution and the

internal regulations specify that the Grand National Assembly should carry

out its work through commissions. Commissions are formed to cover different

policy areas and prepare legislation, although the General Assembly of the

Grand National Assembly has the final word on legislation. Citizens can lodge

complaints with the Petition Commission. In addition to the special functions

and authority mandated by the constitution, the Grand National Assembly

adopts, amends and abrogates laws, supervises the Council of Ministers, gives

authority to the Council of Ministers to promulgate decrees having the force of

law and adopts the budget.

The executive branch

The executive branch is comprised of the President and the Council of Ministers.

Some administrative units are specifically mentioned in the executive section

of the constitution. They include higher education institutions, public

professional organizations, the Turkish Radio and Television Corporation, the

Atatürk High Institution of Culture, Language and History and the Department

of Religious Affairs.

The judicial branch

Independent courts and supreme judiciary organs exercise judicial power. The

judicial section of the constitution establishes the principle of the legal state

and is based on the independence of courts and judges and the guarantee of the

rights of judges. The Constitutional Court, the High Court of Appeal, the Council

of State, the Military High Court of Appeal, the High Military Administrative

Court of Appeal and the Jurisdictional Conflict Court are the supreme courts

mentioned in this section of the constitution. The Supreme Council of Judges

and Public Prosecutors and the Audit Court have special functions in accordance

with the judicial section.

Turkey

Health Care Systems in Transition

The President

The President is the head of state and as such represents the Republic of Turkey

and the unity of the Turkish nation. The President enforces the constitution

and coordinates the work of the different state branches. He or she has

legislative, executive and judicial functions and powers. The President’s

legislative functions consist of convening the Grand National Assembly when

required, publishing laws and sending them back to the Grand National

Assembly to be discussed again (as needed), holding referenda on constitutional

amendments when he or she considers it necessary, filing suits with the

Constitutional Court if the constitution is violated by law or by the internal

regulations of the Grand National Assembly, and deciding to call new Grand

National Assembly elections. The President’s judicial functions are limited to

selecting members of the supreme courts.

The Council of Ministers (the Cabinet)

The Council of Ministers is comprised of the Prime Minister and various other

ministers. The Prime Minister is appointed by the President from the Grand

National Assembly. The Prime Minister chooses ministers from the Grand

National Assembly, or from those eligible for election as members of the Grand

National Assembly, and they are appointed by the President. Because ministers

are usually members of the Grand National Assembly, it is not always clear

whether they operate on behalf of the executive or legislative branch of the

government. Governments take on their duties when they obtain a vote of

confidence from the Grand National Assembly. Members of the Council of

Ministers are jointly responsible for executing general policies. The creation,

abolition, functions, powers and organization of the ministries are regulated

by law. Every ministry has a separate function and system of organization.

The National Security Council, presided over by the President, is composed

of the Prime Minister, the Chief of the General Staff, the Minister of Defence,

the Minister of Interior Affairs, the Minister of Foreign Affairs, the Commanders

of the Army, Navy and Air Force and the General Commander of the Armed

Guard. 2

This council makes decisions regarding national security policy and

informs the Council of Ministers of these decisions. The Council of Ministers

gives priority to the decisions of the National Security Council on the measures

it deems necessary for preserving the existence and independence of the state,

the integrity and indivisibility of the country and the peace and security of

society.

The Armed Guard is a special division of the armed forces and is responsible for security matters within

the armed forces and in areas where it is logistically difficult to have a civilian police force (such as rural

areas).

Turkey

European Observatory on Health Care Systems

Administrative divisions

For administrative purposes, Turkey is divided into 80 provinces (il) and 900

districts (ilce). Population centres are designated as cities (sehir), towns (ilçe)

or villages (koy), depending on the size of their population. The organization

and functions of the administration are based on the principles of centralization

and local administration, and regulated by law.

The Ministry of Interior Affairs appoints the provincial governor (vali) and

the district administrator (kaymakam). They represent the state at the provincial

and district levels, where they coordinate and administer state policy. Provinces

are subdivided administratively into cities, districts, towns and villages.

Locally elected assemblies include the general provincial assembly (il genel

meclisi), the municipal assembly (belediye meclisi) and the village council of

elders (ihtiyar heyeti). The mayors of cities, district centres and towns are also

directly elected, as are village heads (muhtar).

Economic policy

Prior to 1980, Turkey followed an economic policy based on substituting goods

manufactured in Turkey for imports. In January 1980, a comprehensive stability

programme aimed at launching substantial economic reforms was prepared

and implemented by Süleyman Demirel’s government. These reforms marked

a turning point in Turkey’s economic, political and social life. Huge steps were

taken towards liberalizing the economy. The military coup in September

interrupted the process of reform, but once the army took over, a new

government was set up and Turgut Özal (previously Undersecretary of the

State Planning Organization) was appointed as the Minister of State for the

Economy. He became Prime Minister after the 1983 elections. The reforms

implemented during this period changed the economic structure of Turkey from

a system that relied on central administration to one based on market

mechanisms.

In the last two decades, Turkey’s economy has been characterized by erratic

bouts of rapid short-term growth and high inflation, preventing the economy

from fulfilling its long-term growth potential. From 1994 onwards, high public

deficits and net repayment of public external debt increased the pressure on

Turkey’s financial markets. This pressure, combined with these markets’ lack

of depth, led to sustained, high real interest rates. A further factor contributing

to high real interest rates was the high and volatile inflation rate. Between

1992 and 1999, the annual real growth rate averaged less than 4%, but the real

interest rate paid on domestic debt averaged 32%. Such rates increased the

public sector’s borrowing requirements, creating a vicious cycle of debt and

Turkey

Health Care Systems in Transition

interest payments, pushing Turkey into an increasingly difficult financial

position. As the impact of rising real interest payments made itself felt in the

second half of the 1990s, it became clear that the revenue and expenditure

balance of the public sector needed to be permanently improved in order to

stop the cycle of increasing debt and interest rates.

The following expenditure factors have contributed to the rising public deficit

of the past decade:

• an increase in the unmonitored expenditure of extrabudgetary funds,

revolving funds and local administrations, together with increases in

expenditure by the state banks and in their financial losses generated by

bad debts and unpaid credits (the latter mostly credits given for political

purposes);

• a lack of transparency in public expenditure that undermines fiscal discipline

and the integrity of the budget;

• excess employment in the public sector and wage and salary increases not

linked to productivity;

• a large increase in the number of public investment projects, many of which

are costly and unproductive;

• rapidly increasing deficits of the social security institutions due to a

deteriorating actuarial balance;

• agricultural support policies that do not meet real needs; and

• the existence of a large system of inefficiently managed state economic

enterprises operating at high cost and low productivity.

High growth between 1995 and mid-1998 was followed by a recession, the

economy having weathered the Asian crisis but proving vulnerable to the

emerging-market crisis following the default of the Russian Federation. The

second half of 1998 was also difficult because economic activity declined and

international confidence weakened as a result of the world financial crisis, but

the Turkish policy response, building on an anti-inflationary programme

launched in early 1998, stabilized the macroeconomic environment and

instigated a decrease in the inflation rates.

A comprehensive economic programme was adopted in early 2000 to reduce

inflation and provide a favourable environment to revive growth. In addition to

a tight fiscal policy and comprehensive structural reforms, exchange rate targets

were announced in line with the target for inflation and monetary policy, which

was set in a framework that strictly linked liquidity creation to the inflow of

external capital. The programme aimed to reduce inflationary expectations

quickly, but the current account deficit seriously exceeded the programme’s

Turkey

European Observatory on Health Care Systems

level due to the real appreciation of the Turkish lira above initial expectations

as a result of inflation rates higher than envisaged, rapid recovery of domestic

demand, rising prices of crude oil and natural gas and the continuing fall of the

euro against the United States dollar. This development led to growing concerns

in both domestic and international markets about whether the exchange rate

regime could be sustained and to doubts about financing the current account

deficit. In February 2001, negative developments just prior to the Treasury

action led to a total loss of confidence in the government’s programme and a

serious run on the lira. On 19 February, demand for foreign exchange reached

US $7.6 thousand million, leading to another economic crisis, probably the

most severe to date. In April 2001, another programme was put into place to

overcome Turkey’s economic problems through restructuring and the achieve-

ment of lasting stability.

National income reached US $204 thousand million in 1998, with a gross

domestic product (GDP) per person of US $3171 (Table 1, Fig. 2). The recent

economic crisis, from which Turkey has not yet recovered, caused a decrease

in GDP in 2001.

Table 1. GDP per person at current prices, 1980–2001

Year US $ (2001 prices) US $PPP

1980 1 570 2 299

1982 1 412 2 768

1984 1 238 3 179

1986 1 487 3 598

1988 1 693 4 119

1990 2 711 4 699

1992 2 757 5 143

1994 2 169 5 362

1996 2 947 6 123

1998 3 171 6 256

2000 2 987 6 359

2001 2 143 6 082

Source: State Planning Organization 2001.

GDP: gross domestic product; PPP: purchasing power parity; US $: United States dollars.

Income in Turkey is very unequally distributed, which has important

consequences for the structure of Turkish society. Studies of income distribution

have been carried out since the 1960s, with little improvement in the situation

over time. Surveys reveal that the share of the lowest household income quintile

has ranged from 3 to 5% and the share of the middle income quintile from 10

to 14%, while the share of the highest income quintile has been over 50% for

three decades (see Table 2).

Turkey

Health Care Systems in Transition

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Table 2. Income distribution by household quintile, selected years (in %)

1963 1968 1973 1986 1987 1994

First (lowest) quintile 4.5 3.0 3.5 3.9 5.2 4.9

Second quintile 8.5 7.0 8.0 8.4 9.6 8.6

Third quintile 11.5 10.0 12.5 12.6 14.1 12.6

Fourth quintile 18.5 20.0 19.5 19.2 21.2 19.0

Fifth (highest) quintile 57.0 60.0 56.5 55.9 49.9 54.9

Source: TUSIAD 2002.

Turkey is a candidate country for membership of the European Union (EU).

EU acknowledgement of Turkey’s candidacy at the Helsinki Summit held in

December 1999 marked a substantial improvement in Turkey’s relationship

with the European Union. 3

The National Programme for the Adoption of the Acquis was approved by

the Cabinet in March 2001. Harmonization measures taken by the Ministry of

Health include work on the Law on Health Professions’ Associations and

Federations, and the Regulation on specialty training has been revised within

the framework of EU directives.

Fig. 2. GDP per person at current prices, 1980–2001

Source: State Planning Organization 2001.

GDP: gross domestic product; PPP: purchasing power parity; US $: United States dollars.

At the Luxembourg Summit in 1997, Turkey had not been accepted as a candidate country, although 11

other European countries were. In response to that decision, Turkey froze its relations with the EU for

almost two years.

Turkey

European Observatory on Health Care Systems

Turkey expects to be given a date to begin accession negotiations at the EU

summit in Copenhagen in December 2002. Possible reasons for the delay in

receiving a date include violations of human rights within Turkey. However,

the Turkish parliament has recently passed a number of laws with a view to

taking important steps towards meeting the Copenhagen criteria.

Demographic indicators

Turkey’s population is approximately 66 million (see Fig. 3 and Fig. 4). The

annual population growth rate is 1.5%. The population growth rate has steadily

declined from 2.5% in 1980 to 2.2% in 1990 and 1.5% in 1995 and 1999. The

population of Turkey is projected to be about 90 million by 2025.

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Fig. 3. Population (millions), 1927–1997

Source: State Institute of Statistics 2000.

One of Turkey’s most important demographic characteristics is the high

proportion of young people in the population. Children 4 years and younger

constitute 29.5% of the population, while individuals aged 65 and above con-

stitute only 5.5%. Table 3 shows that the Turkish population is expected to

undergo a demographic transition, ageing considerably by the year 2025. The

proportion of the population between 0 and 14 will probably decline to less

than a quarter of the population, and the proportion of elderly people will

almost double, although the age composition is still expected to be much

younger than that of western European countries.

Turkey

Health Care Systems in Transition

Table 3. Historical and projected percentages of the population in different age

groups, 1990–2025

1990 2000 2010 2020 2025

0–4 35.5 29.5 26.0 23.6 22.7

5–64 60.5 65.0 67.9 68.7 68.3

65+ 4.0 5.5 6.1 7.7 9.0

Source: TUSIAD 2002.

There have also been striking changes in the urban and rural populations

(see Fig. 5). In 1960, 70% of the population lived in rural areas and 30% in

urban areas. Today, 25% of the population lives in rural areas and 75% in

urban areas. This ratio is projected to be 14% rural and 86% urban in 2025.

Rapid urbanization has been mainly caused by high rates of migration from

rural to urban areas and from the eastern part of the country to the western

part, rather than by changes in death and birth rates. Administrative

reclassification has also contributed to the increasing percentage of people

described as living in urban areas.

Fig. 4. Population projections (millions), 2000–2025

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Source: United Nations Population Reference Bureau 1999.

Turkey

European Observatory on Health Care Systems

Health indicators

High infant and adult mortality rates demonstrate that the health status of Tur-

key is poor compared to other countries with similar per person income levels.

Infant mortality per 1000 live births in Turkey was 36.8 in 1999 (1), compared

to 9.6 in Poland in 2000, 5.6 in the Czech Republic in 2000, 14.7 in Lithuania

in 1997, 9.1 in Hungary in 2000 and 9.2 in Slovakia in 2000 (2). There are

significant regional variations in infant mortality. Under-five mortality is also

high, at 52.1 per 1000 in 1999; again, the rate varies according to region. In

1999, the crude birth rate was 21.4 per 1000, the crude death rate 6.8 per 1000,

and the annual population growth rate was 1.5%. According to statistics from

the World Health Organization (WHO), the maternal mortality rate in 1998

was 130 deaths per 100 000 live births (2), although other sources quote a

much higher rate of 180 (3).

The latest estimates put life expectancy in Turkey at 71 years for women

and 67 years for men (4). This is well below the 1998 EU average life expectancy

at birth of 80.5 years for women and 74.4 for men (5). It is also lower than the

1999 average for all of Europe of 77.6 years for women and 69.5 years for men

(2). There are also regional variations within Turkey in life expectancy at birth.

Fig. 5. Population of rural and urban areas (millions), 1960–2025

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Source: United Nations Population Reference Bureau 2002.

Turkey

Health Care Systems in Transition

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Fig. 6. Life expectancy at birth, 1945–1999

Source: Ministry of Health 2001a.

Table 4. Basic health indicators, 1965–1999

Annual Crude birth Crude death Infant mortality Total Life

population rate (per 1000 rate (per 1000 (per 1000 fertility expectancy

growth (%) population) population) live births) rate at birth (years)

1965–1969 2.52 30.0 13.5 158.00 5.31 54.9

1970–1974 2.50 34.5 11.6 140.40 4.46 57.9

1975–1979 2.06 32.2 10.0 110.79 4.33 61.2

1980–1984 2.49 30.8 9.0 82.96 4.05 63.0

1985–1989 2.17 29.9 7.8 65.22 3.76 65.6

1990–1994 a

1.85 23.5 6.7 50.56 2.80 67.3

1995–1999 a

1.62 21.4 6.5 39.02 2.45 68.6

Sources: State Institute of Statistics 2000, State Planning Organization 2002.

Note: a

average end-of-year estimates for the five years in the range.

Table 5. Rankings of healthy life expectancy at birth based on disability-adjusted life

expectancy (DALE) in countries with similar income levels

Country Overall Males Females

Croatia 73.00 69.12 76.68

Hungary 71.93 67.61 76.25

Poland 73.95 69.80 78.09

Slovakia 73.45 59.15 72.36

Russian Federation 65.43 69.26 77.64

Turkey 69.80 67.00 72.10

Source: WHO Regional Office for Europe health for all database.

Turkey

European Observatory on Health Care Systems

Because Turkey’s health information systems are poor, the exact preva-

lence and incidence rates for various diseases and causes of death cannot be

determined. Table 6 and Fig. 7 show the most important diseases in Turkey’s

epidemiological profile.

Table 6. Main causes of death by age, 2000

Stage in life Main causes of death

0–12 months Infectious and perinatal diseases

1–5 years Infectious diseases and complications typically associated with

malnutrition

Adolescence to 24 years Accidents

25–44 years Heart disease and accidents

45–64 years Heart disease and smoking-related respiratory disorders

Source: Ministry of Health 2001a.

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Fig. 7. Major causes of mortality (annual deaths per 10 000 population), 1995

Source: Ministry of Health 1997.

Turkey

Health Care Systems in Transition

Inequality in health status is widespread. Infant mortality is a good indicator

of the unequal distribution of health and unequal access to preventive health

care services. Fig. 8 shows the differences in neonatal, postneonatal and infant

mortality rates between western and eastern Turkey and between rural and

urban areas. While the quality of epidemiological data in Turkey is questionable,

particularly for rural areas, it seems clear that the most important causes of

mortality among children aged 1–4 years old are infectious diseases and their

complications, mostly associated with malnutrition.

Turkey’s current vaccination schedule is based on WHO criteria. Vaccination

rates vary among different regions and settings (see Fig. 9). Other measures

such as the correct implementation of the schedule also vary substantially.

Vaccination rates are higher in the urban and western regions of Turkey and

are positively correlated with the educational status of the mother.

Fig. 8. Infant mortality per 1000 live births, 2000

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Source: State Institute of Statistics 2000.

Turkey

European Observatory on Health Care Systems

Historical development of the health care system

The first years of the Republic and the era of Dr Refik Saydam

Under the Ottoman Empire, the only laws passed regarding health care

concerned emergency services during times of war. These services were carried

out by the Health Directorate under the Ministry of Interior Affairs. A Ministry

of Health was established in May 1920, and arrangements for health care

services were institutionalized during the early years of the Republic. The

Republic’s first Minister of Health, Dr Refik Saydam, contributed to the

construction and organization of health services. During this period, the main

objectives of the health care system were to establish preventive care and

eradicate highly prevalent infectious diseases.

Refik Saydam created incentives for medical education by offering free

accommodation and scholarships. As a result, the number of doctors grew from

554 in 1923, to 1182 in 1930 and 2387 in 1940, when the population was about

13 million. Most nurses and health officers at the time were male; the

conservative mores of a relatively closed society prevented girls from going to

Fig. 9. Percentage of fully immunized children (vaccinated once for bacillus

Calmette–Guerin (BCG) and measles, and three times for diphtheria, pertus-

sis and tetanus (DPT) and poliomyelitis), 1998

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Source: Hacettepe University 1998.

Turkey

Health Care Systems in Transition

school in the early years of the Republic. Preventive care was given top priority,

and the doctors assigned to this work had extra incentives, which secondary

and tertiary care doctors did not. Private practice was forbidden and all doctors

were obliged to work for the Ministry of Health, but they were well paid.

Refik Saydam believed that local governments (municipalities) should

provide curative services, so local authorities delivered secondary health care.

He also believed that the central government should take responsibility for

guiding and coordinating these curative services. During this period, the first

model hospitals were built and institutions were created to combat common

diseases such as malaria, tuberculosis and syphilis. The Ministry of Health

was organized vertically, with an emphasis on specific diseases.

Developments from 1945 to 1960

The Second World War affected every sector of the Turkish government.

Although Turkey was not involved in the war, health indicators deteriorated

during the war, and there were malaria, typhus and smallpox epidemics. In

1945, the Extraordinary Law on Malaria Prevention was passed, and in 1949,

it was agreed that the Tuberculosis Prevention Association would combat

tuberculosis in urban areas, while the Ministry of Health would be responsible

for addressing it in rural areas. Unfortunately, the Ministry of Health was not

as successful as expected, and in 1960 it established the Tuberculosis Prevention

Directorate. Today, tuberculosis control is organized through five regional tu-

berculosis control commissions. Each province also has tuberculosis control

groups, which in turn operate 260 tuberculosis control dispensaries.

The Social Insurance Organization (Sosyal Sigortalar Kurumu, abbreviated

SSK) was founded in 1945, initially to provide manual labourers with social

insurance. Mother and child health centres were set up in 1952 to provide

prenatal and postnatal health.

After the Second World War, it was argued that preventive and curative

services should be provided together. This integrated service approach gained

increasing attention and led to a change of attitude in the provision of health

services. Health centres were established with the new goal of carrying out

curative services alongside preventive services. Each centre was assigned

2 doctors and 11 other health care personnel to serve an average population of

about 20 000.

In the post-war era, the Ministry of Health was given responsibility for all

health care services. Municipal hospitals were handed over to the Ministry of

Health and preventive care personnel moved to hospitals, planting the seeds of

the present situation, in which preventive care is almost totally neglected.

Turkey

European Observatory on Health Care Systems

Focusing on curative services did not solve Turkey’s health problems and

actually increased the shortage of human resources for primary care. The lack

of nurses was a major factor in the underperformance of curative services during

this period.

The nationalization of health services

The 1960s saw significant developments in Turkish health care. The Law on

the Nationalization of Health Care Delivery (Law Number 224) and the Law

on Population Planning (Law Number 554) introduced major changes. It was

acknowledged that health care services should be delivered equitably,

continuously and in accordance with the population’s priorities. In comparison

to health policy in the early years of the Republic, the aim of policies in this

period was to provide integrated health services in a horizontal structure.

More specifically, the 1961 Law on the Nationalization of Health Care

Delivery attempted to establish a national health service. It aimed to provide

health care to citizens free (or partly free) of charge, subsidized by contributions

from citizens and allocations from the government budget (tax revenue). The

law’s objective was to extend health care, including preventive and

environmental health services and health education, to the whole country, and

to make it easily and equally accessible to everyone.

In 1963, health care delivery and infrastructure planning were included in

the five-year development plans. The objectives of the first five-year

development plan were:

• to give preventive care top priority;

• to plan public health services through the Ministry of Health;

• to distribute health care personnel evenly;

• to promote community health services;

• to encourage the domestic pharmaceutical industry and the establishment

of private hospitals;

• to establish universal health insurance; and

• to set up revolving funds in government hospitals. 4

The extent to which these objectives have been met is still subject to much

debate.

Revolving funds (döner sermaye) are legal institutional arrangements used to collect additional resources

for government institutions. Health institutions establish financial relations with public or private

organizations or individuals and charge them directly for services provided. The revenue raised from these

charges is then distributed to members of staff.

Turkey

Health Care Systems in Transition

The first five-year plan aimed to have one health post per 7000 population

and one health centre per 50 000 population. In the third five-year plan, the

targets were to have one health post per 3000 population, a health centre per

10 000 population, 26 hospital beds per 10 000 population and an extension of

the nationalization programme to cover two thirds of the country. The fourth

five-year plan aimed for 18.5 beds per 10 000 population and to socialize the

health care system for the entire country. In the fifth five-year plan, the aim

was to have 26 beds per 10 000 and set up 720 new health centres and 4215

new health posts. Five-year plan targets generally involved improving the health

care system’s infrastructure, but the sixth five-year plan included targets that

would demonstrate Turkey’s improving developmental status, such as reduc-

ing the infant mortality rate to 50 per 1000 live births and increasing life ex-

pectancy at birth to 68 years. The sixth five-year plan also aimed at increasing

the number of health care professionals such that there were 1011 people for

every doctor, 4845 people per dentist, 3655 people per pharmacist, 736 people

per nurse–midwife and 2838 people per health officer or male nurse.

Health insurance for all remains an issue, and the nationalization of health

services has not been entirely successful. Of the 67 provinces that then

comprised the country, 19 were included in the nationalization programme in

1972 and 49 in 1983. Shortages of human resources and misinterpretation of

the legislation on nationalization delayed the achievement of these targets, and

the lack of doctors and medical and technical equipment were an important

reason why the government did not achieve satisfactory results. The introduction

of compulsory government service for doctors in 1982 partially compensated

for the shortage of human resources, but it did not prove to be as effective as

intended due to the lack of infrastructure at health centres.

The goal of enabling people to go first to health centres instead of to hospitals

could not be achieved. This problem persists today as a major issue. Inequality

in the distribution of health services and insufficient equipment are also ongoing

issues.

Between 1986 and 1989, the government adopted the Basic Law on Health

Services, the Education, Youth, Sports and Health Taxes Law and the Law on

Launching Health Insurance through Bag-Kur (the Social Insurance Agency

of Merchants, Artisans and the Self-employed), as well as amending health

care laws already in force. The issue of general health insurance, which was

addressed in the first five-year plan, was revisited during the First National

Health Congress held in March 1992.

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European Observatory on Health Care Systems

A new national health policy and a growing private sector

Between 1988 and 1993, the Ministry of Health was active in implementing a

national health policy and a programme of health care reform (the first health

project). The Ministry of Health and the State Planning Organization carried

out a major study to identify current needs and set objectives for future action

with sound and achievable targets. During the same period, the Ministry of

Health developed a new national policy. However, the reform programme was

interrupted by a change of government in 1993, and a new round of political

power struggles pushed the reform agenda further down on the list of priorities.

Between 1993 and 1997, Turkey had six different Ministers of Health.

Health care reform was discussed extensively at the First National Health

Congress in 1992 (see the section on Health care reforms). Activities aimed at

implementing the resolutions of this congress were intensified in subsequent

years. A loan agreement between Turkey and the World Bank for the Second

Health Project was signed in 1994. A series of draft laws on issues such as

health care funding, the personal health insurance system, the integration of

basic health services with curative health services, primary health care and

family medicine were submitted to the Grand National Assembly at the

beginning of 1995. When the Draft Law on Primary Health Care Services and

Family Medicine becomes law it will be extended across the country in stages,

using pilot projects.

The programme of health care reform prepared by the Ministry of Health in

1996 was also included in the seventh five-year plan, covering 1996–2000.

The studies carried out in conjunction with this programme established several

main objectives:

• to initiate the implementation of universal health insurance as soon as

possible, with the goal, based on principles of social justice, of providing

everyone with access to health care;

• to separate service provision from financing in order to ensure the support

of those who need health services rather than of the institutions providing

health services;

• to give hospitals autonomy in order to help them provide efficient high-

quality services and free them from centralized administration, thereby

initiating competition among state-controlled health services;

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Health Care Systems in Transition

• to adopt the family medicine model 5

in primary health services and to

promote preventive as well as curative health services; and

• to structure the Ministry of Health so that it can determine health policies

for the whole country, establish and monitor high standards in health care

delivery and provide preventive as well as curative health services.

The plan to attract private sector investment in health services was successful,

particularly during the second half of the 1980s, largely due to generous

government subsidies. Government incentives for private hospital investment

have resulted in the building of many private hospitals in the last 15 years,

especially with the support of other incentives, such as the subsidy of imported

equipment.

Nevertheless, these health care reforms did not succeed in solving long-

standing problems such as the loss of confidence in public health services, the

fact that a significant proportion of the population remained without any form

of social security coverage, the concentration of one third of the hospital beds

and almost half the doctors in the three largest cities or other inequalities in the

geographical distribution of health care personnel. The targets of successive

five-year plans were often copied from one plan to another, while the same

criticisms of the health care system were articulated in nearly identical sentences

in each plan. The plans have been therefore little more than expressions of

good intentions.

The adoption of the family medicine model has been controversial in Turkey. While family doctors are

synonymous with general practitioners in most countries, they are distinct here. All medical school graduates

can work as general practitioners, who are not regarded as specialists. These doctors usually work in

health centres providing preventive and primary health care. Family doctors are specialists, receiving an

additional three years of training with a largely curative focus. They are eligible to fill any post, although

they mainly work in mother and child health care and family planning units. The number of family doctors

increases every year despite strong opposition to the family doctor scheme, particularly from some public

health professionals who fear that primary health care will be adversely affected by further expansion of

the scheme.

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European Observatory on Health Care Systems

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Health Care Systems in Transition

Organizational structure and

management

Organizational structure of the health care system

urkey’s health care system has a highly complex structure that is at

once centralized and fragmented. The current system is the result of

historical developments rather than a rational planning process.

Consequently, decision-making and implementation bodies vary in form,

structure, objectives and achievements.

Health care is provided by public, quasi-public, private and philanthropic

organizations, but relations among them are not well structured or regulated.

Health care is financed by the government (through the Ministry of Finance),

social security institutions (the Social Insurance Organization (SSK), the Social

Insurance Agency of Merchants, Artisans and the Self-employed (Bag-Kur)

and the Government Employees’ Retirement Fund (GERF)) and out-of-pocket

payments. For more information on these different sources of funding, see the

section on health care financing and expenditure.

Table 7 groups the agencies directly and indirectly involved in health care

according to whether they formulate policy, have administrative jurisdiction

over the delivery of health care, provide it or finance it.

Planning, regulation and management

Health policy-making in Turkey is fragmented and unevenly distributed among

different stakeholders. The overall responsibility for planning, coordinating,

financially supporting and developing health institutions to provide equitable,

high quality and effective health services is divided among the Ministry of

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European Observatory on Health Care Systems

Health, the military, parliamentary commissions (see the section on political

and administrative structure) and others.

The Grand National Assembly is the country’s ultimate legislative body

and regulates the health care sector as well as all other aspects of government

policy. It is responsible for approving the five-year development plans submitted

by the State Planning Organization, which reports directly to the office of the

Prime Minister.

The State Planning Organization has two separate planning roles. It is

responsible for strategic planning, which takes the form of preparing five-year

development plans, and it is also responsible for investment appraisal and

planning, and must approve any new capital investment in health care.

Unfortunately, there appears to be a significant lack of coordination between

the State Planning Organization’s strategic and investment roles in the planning

Table 7. Organizations involved in the health care system

Role Organization

Policy formulation Grand National Assembly

State Planning Organization

Ministry of Health

Council of Higher Education

Constitutional Court

Administrative jurisdiction Ministry of Health

Provincial health directorates

Health care provision: public Ministry of Health SSK University hospitals Ministry of Defence Other

Health care provision: private Private hospitals Private practitioners and specialists Outpatient polyclinics and diagnostic centres Laboratories and diagnostic centres Pharmacists Other

Health care provision: philanthropic The Red Crescent Foundations

Health care financing Ministry of Finance SSK Bag-Kur GERF Private health insurance companies Self-funded schemes International agencies

Bag-Kur: Social Insurance Agency of Merchants, Artisans and the Self-employed, GERF: Government Employees’ Retirement Fund, SSK: Social Insurance Organization.

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Health Care Systems in Transition

process. This lack is partly due to an inadequate strategic planning process;

because policy objectives are not determined in a sufficiently detailed and

systematic fashion, they cannot provide a well-defined framework for

investment planning. The procedure for investment planning is more clearly

established and more detailed, and the State Planning Organization’s influence

in this area is stronger, as it has the power to veto capital investment for statutory

health care providers, whereas its role in implementing strategic plans is

restricted to monitoring only. Under such circumstances, there is a danger that

investment planning will take place without reference to changes in policy

determined by strategic planning.

Though the Ministry of Health has some has responsibility for setting policy

objectives for the health sector or for planning the delivery of health care, it is

primarily concerned with administering the health services provided under its

auspices (that is, through its hospitals and other health facilities).

Once the government has approved its budget, the Ministry of Health

allocates resources for recurrent expenditure and capital investment. The

Research, Planning and Coordination Unit in the Ministry of Health coordinates

budget-setting and budget allocations. It also monitors the implementation, by

the ministry’s general directorates and departments, of specific measures related

to the annual programmes of the five-year plans. See below for more informa-

tion on the role and structure of the Ministry of Health.

Although the Council of Higher Education is responsible for university

hospitals (see below), it does not contribute to formulating health policy when

it is consulted by the State Planning Organization and the Ministry of Health

during the planning process. Each university hospital is an autonomous agency

and does not come under the jurisdiction of any central planning authority.

Individual hospitals are not involved in planning cycles in which strategic

objectives, short-term measures and implementation are monitored and adjusted.

The Constitutional Court ensures that existing laws and legislation conform

to the constitution.

Government involvement in the health care system

Fig. 10 presents the organizational structure of the statutory health care sector.

The Ministry of Health is the major provider of primary and secondary health

care and the only provider of preventive health services in Turkey. At the central

level, the Ministry of Health is responsible for Turkey’s health policy and health

services. At the provincial level, health services provided by the Ministry of

Health are administered by provincial health directorates accountable to

provincial governors.

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European Observatory on Health Care Systems

The Ministry of Health

The central level

The Ministry of Health operates an integrated system of health care, providing

primary, secondary and tertiary care. It is responsible for:

• global planning and programming of health care delivery systems;

• approving capital investment (although this function is defined in legislation,

as explained above, the State Planning Organization performs global

planning);

• developing programmes for communicable and noncommunicable diseases;

• implementing some environmental health programmes;

• promoting mother and child health and family planning;

• regulating the production, prescription and dispensing of pharmaceuticals;

• producing and/or importing vaccines, serum, blood products and

medications;

• maintaining health precautions in ports of entry; and

• building and operating health care facilities.

Fig. 10. Organization of the statutory health care sector

Source: Ministry of Health 2001a.

Grand National Assembly

Council of Ministers

Provincial Health Directorate

Higher Health Council

Governor

University hospitals

MOD hospitalsState Insurance Organization

hospitals

Ministry of Health (MOH)

Ministry of Interior Affairs

Ministry of Labour and

Social Security

Higher Education Council

Ministry of Defence (MOD)

Maternal and child health

centres

MOH hospitals

Health posts

Health centres Tuberculosis dispensaries

Family planning centres

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Fig. 11. Central organization of the Ministry of Health

Source: Ministry of Health 1997.

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Turkey

European Observatory on Health Care Systems

Fig. 11 shows how the Ministry of Health is organized at the central level.

At the top of the ministry is the Minister of Health, supported by a private

secretary. The Council of Inspectors and a group of advisers report directly to

the Minister. The Council of Inspectors is responsible for inspecting legislative

procedures, monitoring the activities of ministry personnel and ensuring that

hospitals satisfy the criteria established by law and by Ministry of Health policy.

The Higher Health Council

The Higher Health Council meets approximately twice a year, at the Minister’s

request, to discuss health status and major health problems in the country. The

Council is made up of experts from the Ministry of Health and the Ministry of

Labour and Social Security who are approved by the President. It is also the

ultimate consultative and decision-making body in malpractice cases.

The Undersecretary and deputy undersecretaries

Below the Minister are the Undersecretary and five deputy undersecretaries.

The deputy undersecretaries do not have specific responsibilities. The Research,

Planning and Coordination Unit, the Legal Consultancy and the Public Relations

Consultancy report to the Undersecretary. The General Directorate (GD) of

Border and Marine Health and the Refik Saydam Hygiene Centre also report

to the Undersecretary. While both of these bodies are affiliated to the Ministry

of Health, their budgets remain outside the Ministry. The Refik Saydam Hygiene

Centre acts as the referral centre for provincial public health laboratories across

the country.

General directorates

The next level down in the Ministry of Health hierarchy consists of general

directorates and departments responsible for delivering health services. The

General Directorate of Primary Health Care is in charge of the strategic and

operational management of health centres, health posts and, to a lesser extent,

some environmental health services. It is also responsible for controlling

communicable diseases, for instance through immunization programmes. The

General Directorate of Curative Services is in charge of Ministry of Health

hospitals and develops programmes for noncommunicable diseases. The

General Directorate of Mother and Child Health and Family Planning

implements programmes for maternity, family planning and selected childhood

problems through health centres. The General Directorate of Health Education

primarily operates vocational schools for training nurses, midwives, health

officers and other personnel. However, since vocational schools were transferred

to the Council of Higher Education in the early 1990s, this general directorate’s

responsibilities have been less clear cut. The General Directorate of Pharmacy

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Health Care Systems in Transition

and Drugs is responsible for regulating drugs, including their licensing,

registration and pricing. In addition to these five general directorates, there are

three vertically organized departments for the control of tuberculosis, malaria

and cancer. Finally, additional support functions within the Ministry are fulfilled

by the General Directorate of Personnel, the Department of Administrative

and Financial Affairs and the Civil Defence Secretary. 6

The provincial level – provincial health directorates

Provincial health directorates administer the health services provided by the

Ministry of Health at the provincial level. Each of the 80 provinces has a health

directorate led by a director who is accountable to the governor of the province

(see Fig. 12). The provincial governor is appointed jointly by the President, the

Prime Minister, the Minister of the Interior and, technically, the Minister of

Health, and is accountable to the central government. The Ministry of Health

appoints provincial health directorate personnel with the approval of the

provincial governor.

The directorates’ administrative responsibilities are primarily personnel and

estate management. They also make technical decisions pertaining to health

care delivery, such as the scope and volume of health services. Units that provide

health care or have health care-related functions at the provincial level consist

of:

• health centres

• health posts, mainly in rural areas

• mother and child health and family planning centres

• tuberculosis dispensaries

• hospitals

• public health laboratories (in some provinces).

For further information on these various entities, please see the health care

delivery section.

Coordination among different levels of the Ministry of Health

There are several key issues regarding the organization of the Ministry of Health,

both at the central and the provincial level. At the general directorate level

within the Ministry, the demarcation of health service responsibility into defined

areas of activity is, in principle, good management practice. However, there is

considerable overlap of responsibility among the general directorates, which

The Civil Defence Secretary organizes the population in the event of natural disasters or wars, initiating

and coordinating an immediate civil response if statutory or military forces should prove insufficient.

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European Observatory on Health Care Systems

Fig. 12. Provincial organization of the Ministry of Health

Source: Ministry of Health 1997.

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causes some difficulty in coordinating the overall operation of the ministry.

This lack of coordination is a major management weakness.

The Ministry of Health is expected to deliver effective health care across

the country, with appropriate distribution to different provinces and service

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Health Care Systems in Transition

areas. The existing level of coordination among general directorates does not

appear to be sufficient to ensure the desired distribution of resources to each

area of service delivery. Responsibilities and lines of accountability are not

defined well enough to enable the performance of individual directorates to be

monitored effectively.

Communication links between the Ministry of Health and the provincial

health directorates are also weak, leading to delays and difficulties in carrying

out instructions. This weakness is partly due to the organizational structure at

the central level, because instructions to the provinces are issued by more than

one general directorate or department.

Communication must be directed through the office of the provincial

governor, which can lead to delays. As a result general directorates sometimes

communicate directly with the corresponding branch managers in the provincial

health directorates. Under such circumstances, confusion may well arise,

especially if more than one general directorate is attempting to communicate

with the provincial health directorates.

Upward communication from individual health posts through provincial

health directorates and on to the Ministry of Health may also experience some

delay, which can cause problems for individual health posts trying to obtain

swift responses to emergency requests, particularly if a general directorate is

contacted by several provincial health directorates at once. This problem is

compounded by the fact that provincial health directors appear to need to refer

even relatively minor decisions to a higher level. There are two possible

explanations for this phenomenon. On one hand, provincial health directors

are unlikely to have appropriate training and often lack the relevant capacity

and necessary skills to either carry out their responsibilities or make decisions.

On the other hand, a very centralized decision-making process does not leave

the provincial health directors with sufficient room to act on their own initiative.

They therefore find it easier and more expedient to refer decisions to a higher

level, in order to avoid the possibility of making the wrong decision and losing

their current position. A recent survey of provincial health directors in the

23 cities covered by the Second Health Project and in the cities affected by the

recent earthquakes showed that they retain their posts for an average of

approximately two years.

The Ministry of Finance

The general state budget administered by the Ministry of Finance is the main

source of financing for health care services provided by the Ministry of Health,

the Ministry of Defence, university hospitals and other public institutions in

Turkey. The General Directorate of Budget and Fiscal Control is positioned

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European Observatory on Health Care Systems

under the Department of Administrative and Financial Affairs in the Ministry

of Health, but although it is fully engaged in preparing Ministry of Health

budgets, it is under the jurisdiction of the Ministry of Finance. The Ministry of

Finance also manages the GERF, for which it determines contribution rates

and benefit conditions (see below, and the section on health care financing and

expenditure).

The Ministry of Defence

The Ministry of Defence has its own health care infrastructure, with 42 hospitals

run exclusively for the use of military personnel and their dependants. One of

these hospitals provides undergraduate and postgraduate medical education;

another provides postgraduate education only for military medical staff.

The Council of Higher Education

The Council of Higher Education is responsible for university hospitals. During

the 1980s and 1990s, the number of medical faculties increased, and there are

now 50 medical schools in Turkey. Each medical school has its own university

hospital, which acts as a referral centre for tertiary care but also provides primary

and secondary care. These hospitals are each directed by a chief doctor

(bashekim), a managerial position filled by a clinician who reports to the dean

of the medical faculty.

The Ministry of Labour and Social Security

The Ministry of Labour and Social Security has jurisdiction over the SSK,

which is the second largest provider of health care in Turkey.

Other public entities

As Ministry of Health hospitals do not always provide effective service, other

public entities have, over time, established their own hospitals and polyclinics

– for example, the Ministry of National Education, the Ministry of Internal

Affairs, the postal service and the railways.

Social security institutions

Turkey has three main social security institutions:

1. the SSK, the insurance scheme for private sector employees and blue-collar

public sector employees;

2. Bag-Kur, the insurance scheme for self-employed people; and

3. the GERF, which insures retired civil servants.

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Health Care Systems in Transition

SSK (Social Insurance Organization)

The SSK was founded in 1945 as a pension fund for workers in the private

sector. It was placed under the authority of the Ministry of Labour, with benefits

restricted to contributing workers and their dependants, as at that time there

was no well-structured Ministry of Health from which health services could be

purchased. Even though the reforms of the 1960s led to a substantial

improvement in the health services provided by the Ministry of Health, these

services were not enough to handle high levels of demand. The SSK therefore

set up its own health facilities for exclusive use by its members, creating another

major player in the health care system (see the section on health care financing

and expenditure). Today, the SSK insures private sector employees and blue-

collar public sector workers.

Bag-Kur (Social Insurance Agency of Merchants, Artisans and the Self-em-

ployed)

Bag-Kur added health insurance to its traditional role as the pension fund for

self-employed people in the late 1980s. Contributing members are entitled to

benefits covering all outpatient and inpatient diagnosis and treatment. Unlike

the SSK, Bag-Kur does not operate its own health facilities, but contracts with

other public providers, including the SSK. For further information on Bag-

Kur, see the section on health care financing and expenditure.

GERF (Government Employees’ Retirement Fund)

The GERF is primarily a pension fund for retired civil servants, but also provides

other benefits, including health insurance. For further information on this fund,

see the section on health care financing and expenditure.

Private providers of health care

Private hospitals

Before the late 1980s, a few private hospitals, mainly in Istanbul, were

established by ethnic minorities (such as Greeks and Armenians) and foreigners

(Americans, the French, Italians, Bulgarians and Germans). Private Turkish

enterprises were limited to small clinics with fewer than 50 beds, often

specializing in maternity care and functioning as operating theatres for private

specialists.

During the economic liberalization of the late 1980s, the government

provided substantial incentives for investment in private hospitals. A few

initiatives took place in the early 1990s, and by the end of the decade over 100

new private hospitals had been established across the country, particularly in

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European Observatory on Health Care Systems

the larger cities. In contrast to the first generation of private hospitals established

prior to liberalization, many of these new hospitals offer integrated diagnostic

and outpatient services and luxurious inpatient hotel facilities to attract self-

paying, fee-for-service patients. According to the Ministry of Health, Turkey

had 83 private hospitals in 1981 and 257 in 2001.

Health care provided by private entities appears to be more responsive to

demand. As a result, government agencies purchase some of their services

from private hospitals. For example, the SSK already purchases cardiovascular

surgical services from private hospitals and has recently decided to purchase

other services, such as cataract surgery.

Most private hospitals are located in cities with large populations such as

Istanbul, Izmir and Ankara. However, they often build their facilities in less

developed parts of these cities and provide an inexpensive and poor quality

service. Some of these hospitals fail to meet the minimum requirements of the

Ministry of Health, sacrificing quality for the sake of low prices, which suggests

that the Ministry of Health does not manage its regulatory function well with

respect to private hospitals.

A recent development in the last ten years has been the establishment of

private medical schools, which either have their own private hospitals or contract

other private hospitals as teaching facilities. However, the quality of training

they provide and the value of this development have been questioned and are a

matter of concern.

Private practitioners

There is a long-standing tradition in Turkey that most doctors working for

public agencies also work privately after office hours, because public sector

salaries are low and patients think that they can obtain better service from

private practitioners. Patients visiting private practitioners pay for services out

of pocket, regardless of their membership of any social insurance organization.

Patients with voluntary (private) health insurance might receive partial

reimbursement from their insurance companies.

Outpatient polyclinics, laboratories and diagnostic centres

In parallel to the establishment of private hospitals, the 1990s saw the

development of private polyclinics and diagnostic centres, primarily when

specialists with private practices banded together to set up outpatient centres

to generate more income through diagnostic services. These polyclinics and

diagnostic centres are convenient for patients, who can access a range of services

under one roof.

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Health Care Systems in Transition

Doctors specializing in fields such as microbiology, biochemistry, radiology

and pathology operate their own laboratories and diagnostic centres. Economic

liberalization in the 1990s led to a reduction in import regulations and a rise in

convenient methods of financing the purchase of equipment. Since then, the

lack of regulatory and planning measures has caused a boom in the amount of

high-technology diagnostic equipment available in Turkey.

Pharmacists

As Turkey has no self-dispensing doctors, private pharmacists have a monopoly

on the sale of all outpatient drugs. (Hospital pharmacies provide inpatient drugs.)

Health centres also provide medicines for specific programmes and for areas

without private pharmacies. Social security institutions pay individual private

pharmacies directly for the prescriptions of their members.

Others

With the exception of acupuncturists, other private providers of health care are

neither legally recognized nor permitted to practise in Turkey. 7

Though rare,

some people do practise as dentists and chiropractors without any official

training, while others, mainly from the newly independent states of the former

Soviet Union and countries in east Asia, practise alternative medicine. The

exact number of these providers is not known.

Philanthropic providers of health care

The Red Crescent

The Red Crescent was founded in 1868. Its main function is to provide aid in

natural and war-related catastrophes. It also provides health care through its

dispensaries and rehabilitation centres and during military manoeuvres. In

addition, it provides health and social services to Muslim pilgrims en route to

Makkah (Mecca) and Al Madinah (Medina) in Saudi Arabia, and to Christian

pilgrims in Efes (Ephesus).

The Red Crescent in Turkey consists of the General Headquarters in Ankara

and 648 local branches across the country, at city and district levels. Members

are elected to the General Headquarters and the local branches and carry out

their tasks on an honorary basis. A Directorate General, made up of experienced

and expert paid staff, was established to regulate the services of the General

Headquarters according to the aims and principles of the Turkish Red Crescent.

A committee established under the Ministry of Health’s General Directorate of Curative Services examines

and approves licenses for acupuncturists.

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European Observatory on Health Care Systems

The Directorate General has 18 departments devoted to activities such as

financial donations, blood donations, disaster relief, international action and

first aid, working at the General Headquarters and various units in the provinces.

In addition to a central warehouse in Etimesut (Ankara) and 7 regional

warehouses, the Turkish Red Crescent also runs 22 blood centres, 7 blood

stations, 38 dispensaries (of which 1 is a medical centre), 21 soup kitchens, 6

day nurseries and 4 houses for the elderly.

Foundations

Foundations are traditional entities that have existed in Turkey since the time

of the Ottoman Empire. Up until the 1980s, the inefficiencies and constrained

budgets of statutory social services created a fertile ground for foundations,

but new laws introduced during the period of economic liberalization in the

1980s created many more opportunities for foundations by encouraging the

formation of nongovernmental organizations to provide social services

previously only provided by government agencies. The easy process of

establishing a foundation, with added incentives such as tax exemption, led to

the emergence of new foundations in many areas, including health care. The

inadequacy of statutory social services, combined with a growing belief that

the state is not solely responsible for providing social care, created an

environment in which these new foundations flourished.

Some of the health care-related foundations in Turkey deal with public health

problems, particularly family planning issues. There are also numerous

foundations working on specific diseases such as diabetes, cancer, phenylke-

tonuria and AIDS.

Most public hospitals, including the university hospitals, have created

foundations (quasi-public non-profit institutions with tax-exempt status) to

bypass cumbersome bureaucratic rules for recruiting personnel and spending

their own revenue. However, some of these foundations may have developed

into instruments to further private interests rather than public services.

Other organizations

The Turkish Medical Association and other professional organizations are

neither well organized nor distinguished by clearly defined responsibilities. In

future, their responsibilities might expand to include the adaptation of clinical

practice to European norms, at least in some areas of specialization.

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Decentralization of the health care system

As described above, Turkey’s health care system is centralized yet fragmented.

Decision-making and implementation bodies vary in form, structure, objectives

and achievements.

The Ministry of Health is strongly centralized (see Fig. 11). Even though

each province has its own provincial health directorate structured to solve a

wide range of health problems (see Fig. 12), local decision-making is not

encouraged. Dealing with local health problems that require local solutions is

therefore extremely difficult and becomes a bureaucratic process, since the

central organization must be informed of or consulted in every decision. See

above for a more detailed discussion of the lack of coordination between the

central and provincial levels of the Ministry of Health.

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European Observatory on Health Care Systems

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Health Care Systems in Transition

Health care financing and expenditure

Main system of financing and coverage

Sources of health care financing

echanisms for financing health care in Turkey have never been clearly

defined. The 1961 attempt to establish a national health service

envisaged the use of substantial tax revenue, although it also made

some reference to patient contributions. However, the growth of the Social

Insurance Organization (SSK) and the Government Employees’ Retirement

Fund (GERF), as well as the establishment of the Social Insurance Agency of

Merchants, Artisans and the Self-employed (Bag-Kur), set in motion a system

of health insurance, and a universal health insurance scheme has been an

objective of every five-year plan since 1963.

Today, Turkey has three main sources of health care financing:

1. the general government budget funded by tax revenue and allocated mainly

to the Ministry of Health, the Ministry of Defence, university hospitals,

other public agencies and the health care expenditure of active civil servants;

2. social security contributions obtained from members of the SSK, Bag-Kur

and the GERF; and

3. out-of-pocket payments in the form of direct payments to private doctors

and institutions, premiums paid for voluntary health insurance and co-

payments.

Health care financing in Turkey is complicated by the high number of

agencies involved in providing and financing health care and the many

transactions that take place among them. The agencies involved in financing

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European Observatory on Health Care Systems

health care are discussed in the following sections. For a discussion of out-of-

pocket payments, please see the section on complementary sources of financing.

The general government budget

The general government budget is funded by tax revenue and prepared by the

Cabinet, the State Planning Organization and the Higher Planning Council. It

is then discussed and amended by the Grand National Assembly and

administered by the Ministry of Finance. It is the main source of financing for

the health services provided by the Ministry of Health, the Ministry of Defence,

university hospitals and other public agencies. Health services for active civil

servants and their dependants are also financed through this general government

budget.

The Ministry of Health, the largest single provider of health care in Turkey,

is predominantly financed by tax revenue that is channelled through the general

government budget (see Tables 8 and 9). Since 1988, a major additional source

of tax revenue has become available to the Ministry of Health through special

funds from earmarked excise duties on fuel, cigarettes, alcohol and the sale of

new cars. A third source of income for the Ministry of Health is the revolving

funds, into which fees are paid by insurers and individuals. These have become

progressively more important as a source of financing.

Table 8. Sources of Ministry of Health income (millions of US dollars), 1992–1998

Source 1992 1993 1994 1995 1996 1997 1998

General government budget 1 451 1 647 1 022 1 208 1 379 1 602 1 720

Revolving funds 231 226 235 376 479 530 701

Special funds 140 88 36 41 29 49 60

Total 1 822 1 961 1 293 1 625 1 887 2 181 2 481

Sources: Tokat 1996, 1997 and 1998.

Table 9. Sources of Ministry of Health income (%), 1992–1998

Source 1992 1993 1994 1995 1996 1997 1998

General budget 79.6 84.0 79.0 74.5 73.0 73.4 69.4

Revolving funds 12.7 11.5 18.2 23.0 25.4 24.3 28.2

Special funds 7.7 4.5 2.8 2.5 1.5 2.3 2.4

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Sources: Tokat 1996, 1997 and 1998.

The general government budget provides about 70% of the Ministry of

Health’s income. The Ministry of Health’s budget had been decreasing as a

proportion of the general government budget, but after economic growth

Turkey

Health Care Systems in Transition

resumed in 1996, its percentage increased considerably in 1997, before declining

to 3% in 1998 (see Table 10). It has since declined even further.

Table 10. Percentage of the general government budget allocated to the Ministry of

Health, 1993–2002

Years 1993 a

1994 a

1995 a

1996 a

1997 a

1998 a

1999 b

2000 b

2001 b

2002 b

% 4.56 3.72 3.70 2.76 4.00 3.00 2.81 2.26 2.66 2.4

Sources: a

Tokat 1996, 1997 and 1998 and b

Ministry of Health 2002.

Table 11. General government budget allocations for health care to public agencies

(millions of US dollars), 1992–1998

1992 1993 1994 1995 1996 1997 1998

Ministry of Health 1 820 1 960 1 292 1 626 1 888 2 181 2 480

University hospitals 553 595 433 475 697 742 1 127

Ministry of Defence 285 315 227 283 340 401 506

Other ministries 421 435 465 440 578 655 635

Total 3 080 3 305 2 417 2 824 3 503 3 979 4 748

Sources: Tokat 1996, 1997 and 1998.

The Ministry of Health spends a major portion of its budget on curative

services (see Fig. 13).

The Green Card scheme was established in 1992 and is directly funded by

the government for people earning less than a minimum level of income (defined

by law). In 1997, almost a million Green Cards were issued (see Table 12).

Green Card holders have free access to outpatient and inpatient care at Ministry

of Health hospitals and when referred to university hospitals. The scheme also

covers their inpatient pharmaceutical expenses, but it does not cover the cost

of outpatient drugs. Since 1994, expenditure has exceeded government

allocation, leading to annual deficits.

Social security schemes

Turkey has three main social security schemes:

1. the SSK, the insurance scheme for private sector employees and blue-collar

public sector employees;

2. Bag-Kur, the insurance scheme for self-employed people; and

3. the GERF, which insures retired civil servants.

Turkey

European Observatory on Health Care Systems

Table 12. Green Card applications and expenditure, 1992–2001

Year Number of Green Cards Government Total

applications granted allocation expenditure

(millions of liras) (millions of liras)

1992 a

910 873 365 509 127 650 7248

1993 a

2 060 849 1 845 832 761 975 668 248

1994 a

1 498 213 1 460 111 1 352 000 2 250 000

1995 a

1 507 504 1 325 276 3 718 465 5 992 752

1996 a

970 889 716 338 7 187 500 9 710 532

1997 a

1 298 526 953 912 18 998 950 23 159 012

1998 b

1 345 953 1 093 465 30 000 000 53 579 962

1999 b

1 352 148 961 186 36 970 000 111 880 334

2000 b

1 610 828 1 404 677 90 000 000 167 091 891

2001 b

1 674 706 1 300 309 85 634 921 304 471 251

Sources: a

Tokat 1996, 1997 and 1998 and b

Ministry of Health 2002.

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Fig. 13. Distribution of the Ministry of Health’s budget, 2002

Source: Ministry of Health 2002.

Tuberculosis control, Malaria control, Cancer control; b

MCH: Mother and child health,

FP: Family planning.

Turkey

Health Care Systems in Transition

SSK (Social Insurance Organization)

The SSK is an integrated institution that insures private sector employees, blue-

collar public sector employees and their dependants and provides them with

health services. Its different branches cover health care, maternity care,

occupational diseases and injuries, and pensions. While it is estimated that the

SSK covers 7 million active workers, 3 million pensioned individuals and 24

million dependants, the number of dependants covered may be overestimated,

as discussed in the section on levels of coverage.

SSK health services are funded almost entirely through contributions made

by employees and employers. Contribution rates are specified as a fixed

percentage of an employee’s salary, as shown in Table 13. Further sources of

funding include:

• fees paid on behalf of non-members using SSK facilities (such as Bag-Kur

members); and

• co-payments to cover part of the cost of outpatient drugs (20% for active

members and their dependants and 10% for pensioned members).

Table 13. SSK contribution rates as a percentage of total salary

Type of premium Employees Employers

Health care 5.0 6.0

Maternity 0.0 1.0

Occupational disease and injury 0.0 1.5–7.0

Pension 9.0 11.0

Total 14.0 19.5–25.0

Source: State Insurance Organization 1999.

SSK health care funds are spent on health services provided by:

• its own health facilities;

• other health facilities (such as Ministry of Health hospitals, university

hospitals or private institutions); and

• contracted doctors.

SSK benefits are restricted to contributing workers and their dependants.

SSK provides its 34 million beneficiaries with health care benefits in kind

through its network of approximately 120 hospitals, 214 health stations and

168 dispensaries (which are for exclusive use by its members). SSK hospitals

may have one or more dispensaries and polyclinics connected to them, but

these facilities are not necessarily in the same province as the hospital. Members

normally use SSK health services, but they may also be referred to Ministry of

Health hospitals, university hospitals or, less frequently, private institutions.

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European Observatory on Health Care Systems

An agreement signed between the SSK and the Ministry of Health in 1989

enables SSK beneficiaries to be treated in Ministry of Health facilities. With

prior approval, SSK members can also be treated in university hospitals. In

1991, the SSK began to contract with private hospitals and diagnostic centres

for selected services such as cardiovascular diagnosis and surgery, microsurgery,

magnetic resonance imaging (MRI) and computed tomography (CT) scanning.

The SSK pays for the cost of drugs, spectacles and dental and other prostheses

supplied by private retailers. It does not provide or pay for preventive services.

SSK also produces generic drugs, mainly for cost-containment purposes,

although in the past it has been criticized for the poor quality of these drugs.

There are four levels to the SSK central authority. Central health department

managers (curative services, health disability and health services procurement)

report to five assistant general managers, who report to the General Manager,

who in turn reports to the Minister of Labour and Social Security. Regional

health offices have been established in four regions: Ankara, Istanbul, Izmir

and Zonguldak. Each region has several hospitals and many dispensaries.

Regional managers responsible for these facilities report directly to the manager

of one of the three central health departments. The hospitals’ chief doctors,

who act as hospital managers in areas without a regional management structure,

also report to one of these central health department managers. Therefore, many

staff members, often more than 50, report to a single manager. Organizationally,

this is not the most effective way to maintain control, and the central managers

can be overloaded.

Historically, the contributions collected for health care have exceeded the

SSK’s expenditure on health care. Although efforts were made to ensure that

the various insurance branches of the SSK were self-financing, surplus income

from health care contributions was used to subsidize the activity of other

branches, such as pensions. In 1994 and 1995, however, health care expenditure

actually surpassed health care contributions (see Table 14). This deficit was

caused by the inefficient provision of health services, poor control over

contracted health services and the absence of a proper management information

system. Since 1995, the SSK has also suffered from an overemphasis on cost-

containment at the expense of quality. Today it is common for SSK members

to complain about the accessibility and quality of its health services.

The SSK finds it difficult to collect contributions from employees and

employers on a regular basis. When it experiences a deficit because it is unable

to collect all its contributions, the government steps in to make up the differ-

ence, thereby adding to Turkey’s chronic high inflation. In 1998, health care

expenditure per active member of the SSK reached US $277, although the

estimated expenditure per person covered is only about US $50 (see Table 26).

Turkey

Health Care Systems in Transition

If, however, there are fewer dependants covered than estimated, this per person

figure would be correspondingly higher.

Table 14. SSK health care contributions and expenditure (millions of US dollars),

1992–1998

1992 1993 1994 1995 1996 1997 1998

Health care contributions 1 321 1 417 758 698 1 078 1 414 1 622

Health care expenditure 1 062 1 099 788 980 1 060 1 279 1 533

Surplus or deficit 259 318 –30 –282 18 135 89

Sources: Tokat 1996, 1997 and 1998.

Note: The significant fall in contributions and expenditure between 1993 and 1994 can be

attributed to the economic recession and the devaluation of the Turkish Lira against the US

dollar during this period.

Bag-Kur (Social Insurance Agency of Merchants, Artisans and the Self-em-

ployed)

Bag-Kur added health insurance to its traditional role as the pension fund for

self-employed people in the late 1980s. Beginning in 1986 with a few pilot

provinces, the health insurance scheme now covers the whole country.

Bag-Kur insures an estimated 15.0 million people, of which 3.3 million are

active members, 1.3 million are pensioned and 10.4 million are dependants.

As discussed in the section on levels of coverage, the accuracy of these figures

can be questioned, based on the large proportion of the population without

health insurance. A substantial proportion of these uninsured people are eligible

for membership of Bag-Kur (because they are self-employed) but choose not

to become members, either because they are unable or unwilling to make

contributions, or because the administrative procedure is inaccessible. However,

Bag-Kur’s main problem is the low rate of participation in the health insurance

scheme; only about 3.3 million members make contributions to the scheme.

Contributions to the health insurance scheme are collected along with

contributions for pensions and other benefits. The contributions for pensions

and other benefits are calculated at a rate of 20% of the average notional income

of insured individuals, and health insurance contributions at a rate of 12% of

the same fi

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Publications

Дата принятия 1 января 2002 г.

Источник Всемирная организация здравоохранения