2014年-世界发展银行全球_Universal_Health_Coverage_for_Inclusive_and_Sustainable_Development___Country_Summary_Report_for_Turkey_22页_586kb

Summary of the Country Summary Report for Turkey: Universal Health Coverage

Core Content

This report outlines Turkey's progress in achieving Universal Health Coverage (UHC), highlighting its legal framework, financial mechanisms, service delivery, and human resources for health (HRH) policies. It is part of the Japan-World Bank Partnership Program for Universal Health Coverage, which aims to share experiences and lessons across countries pursuing UHC.

Main Goals of UHC

The goals of UHC in Turkey include:

• Ensuring access to quality health services.
• Safeguarding the population from public health risks.
• Protecting people from impoverishment due to illness, whether through out-of-pocket (OOP) payments or loss of income.

Current Status of UHC

Population Coverage

• Universal Health Insurance (UHI) is mandatory for all Turkish citizens.
• In 2011, 97% of the population was covered by the UHI program according to the Social Security Institution (SSI), while household data indicated 90% coverage.
• Certain groups, such as military conscripts, foreign nationals with their own insurance, and prisoners, are excluded from the UHI program.

Services Covered

• The benefit package includes:
  • Preventive care and substance abuse prevention.
  • Outpatient and inpatient services, including medical consultations, diagnostics, treatments, and emergency care.
  • Maternal and child health services, including delivery and newborn care.
  • Pharmaceuticals, medical devices, and equipment.
  • Free health care for children under 18 regardless of insurance status.
  • In-vitro fertilization, blood and blood products, vaccines, and prosthetics.

Financial Protection

• Out-of-pocket (OOP) payments are low and progressively structured.
• Copayments are waived for family medicine visits, and vary by hospital type:
  • University and MOH hospitals: TL 8 per visit.
  • Private hospitals: TL 15 per visit.
• Pharmaceuticals: 20% copayment for most, 10% for retirees.
• Private hospitals can charge up to 70% extra over SSI tariffs, based on a five-tier classification system.

Governance Structure

Goal Setting

• The Ministry of Health (MOH) is the steward of the health system, responsible for policy-making, regulation, and monitoring.
• The Public Health Institution provides primary and preventive care.
• The Public Hospital Institution manages secondary and tertiary care.
• The SSI acts as the single purchaser of health services in the public system.

Financing

• Total health expenditure (THE) as a % of GDP was 6.74% in 2010.
• SSI accounted for 43.9% of health funding in 2008, with other government sources contributing 27.6%, OOP payments 17.4%, and private sources 9.6%.
• The Green Card Program (non-contributory) was the main social protection program, funded by the national budget, and expanded significantly from 2.5 million to 9.1 million beneficiaries between 2003 and 2011.

Payment Systems

• The health system employs various payment mechanisms:
  • Case-based payments (CP): Used for inpatient services, emergency care, and some outpatient services.
  • Preference price system (RP): Subsidizes pharmaceuticals and medical goods.
  • Capitation (CAP): Monthly base payments to family physicians based on the number of registered patients.
  • Performance-related pay (P4P): Linked to meeting specific health outcomes, such as maternal and child health (MCH) targets.
  • Fee for service (FFS): Applied to outpatient specialist contacts and some diagnostic services.
• The Family Medicine Program uses five components of payment to family medicine staff, including capitation, service credits, operational costs, reimbursements for lab tests, and mobile health service fees.

Equity and Solidarity

Financial Protection

• The system is highly equitable and solidary, with coverage for all population groups.
• Premiums are income-based, with the poorest groups (G0) receiving free coverage.
• The HTP has improved financial protection, reducing the risk of catastrophic health spending and impoverishment.

Targeting for Priority Groups

• The Family Medicine Program includes performance-based incentives to focus on MCH.
• Family physicians are paid more for enrolling pregnant women and children under five, with coefficients of 3 and 1.6 respectively, compared to 0.79 for the general population.
• These incentives encourage providers to improve access for vulnerable groups.

Human Resources for Health (HRH)

Current Status

• Turkey has seen improvements in the distribution of HRH, especially in rural areas, due to the HTP.
• The personnel gap between the highest and lowest provinces decreased significantly:
  • Specialists: from 1:14 to 1:2.7.
  • General practitioners: from 1:9 to 1:2.3.
  • Nurses and midwives: from 1:8 to 1:4.
• In 2011, the physician-to-population ratio was 1.69 per 1,000, with higher concentrations in Western Anatolia (2.6) compared to Southeastern Anatolia (1.16).
• Nurse and midwife density was highest in the Eastern Black Sea (1.84 times that of Southeastern Anatolia).

Education and Training

• Medical education is regulated by the Higher Education Council (YÖK).
• The State Planning Organization, State Department of Personnel, and MOH are responsible for HRH policies.
• The General Directorate of Health Services manages workforce planning.
• Medical specialization requires passing the central medical specialization examination and completing further training.

Labor Market Dynamics

• The Family Medicine Program encourages rural service through:
  • Adjusted monthly base payments based on the socioeconomic development index.
  • Assignment of midwives to family practitioners in rural areas.
  • Periodic mobile outreach services.
• A Regulation on Appointment and Transfer was introduced to ensure balanced distribution of health professionals.
• Specialties are assigned through a computer-based lottery.
• A Distance Health Education System was introduced in 2006 to expand access to health education.

Key Lessons

• Turkey's UHC strategy, embedded in the Health Transformation Program (HTP), has led to significant improvements in health outcomes, financial protection, and equity.
• The Green Card Program played a critical role in expanding coverage, especially for low-income populations.
• The Family Medicine Program has been instrumental in improving access to primary and preventive care, with performance-based incentives to target vulnerable groups.
• The SSI has become the central purchaser of health services, enhancing efficiency and financial sustainability.
• The use of capitation, performance-based payments, and sliding scale service credits has helped reduce disparities in HRH distribution.
• Regular policy adjustments and systematic cost management have ensured value for money and sustainability in health financing.

Conclusion

Turkey has made remarkable progress in achieving UHC through a combination of legal reforms, financial mechanisms, and HRH policies. The country has managed to expand coverage, improve health outcomes, and enhance equity in access to care. The lessons from Turkey's experience can be valuable for other countries aiming to implement UHC strategies.