2009年-世界发展银行全球_Health_Systems_Strengthening__Lessons_from_the_Turkish_Experience_4页_645kb

Health Systems Strengthening: Lessons from the Turkish Experience

Core Content

Health Systems Strengthening (HSS) is a central focus of the World Bank's health agenda, aiming to improve health outcomes through better access, coverage, quality, and efficiency. HSS is a complex process requiring both technical and operational strategies. While global evidence on HSS implementation is limited, Turkey provides a valuable case study of successful reform.

Main Viewpoints

• HSS Definition and Importance:
  HSS involves initiatives that enhance the functions of the health system. It emphasizes a comprehensive approach rather than isolated interventions, focusing on governance, efficiency, user and provider satisfaction, and sustainability.

• Turkey's HSS Experience:
  Turkey launched the Health Transformation Program (HTP) in 2003, which aimed to address systemic challenges in the health sector. These included fragmented health financing, poor access in rural areas, and inefficiencies in public health services.

• Key Reforms Implemented:

  • Establishment of a single purchaser in the health system.
  • Restructuring of the Ministry of Health (MoH) to focus on stewardship functions.
  • Integration of social insurance schemes under a unified system.
  • Introduction of performance-based bonuses and public-private partnerships in public hospitals.
  • Expansion of health insurance coverage for the poor through the Green Card program.

• Successes and Outcomes:

  • Health Insurance Coverage: Increased from 2.5 million to 10.2 million people between 2003 and 2006.
  • Out-of-Pocket (OOP) Spending: Reduced to 19% of total health spending in 2006, with a progressive distribution among income groups.
  • Catastrophic Health Expenditure: Lower than the global average, with only 5.3% of households exceeding 10% of total expenditure on health.
  • Health Service Access: Improved significantly, especially in rural areas, with better productivity and satisfaction among health workers and users.

• Impact on Health Outcomes:
  While direct links between HTP and improved health outcomes are not yet clear, there is progress in proxy indicators such as immunization rates and use of prenatal services. Turkey has also achieved near-elimination of measles among under-five children.

• Health Service Responsiveness:
  Patient satisfaction with health services increased from 39.5% in 2003 to 63.4% in 2008, indicating improved quality and accessibility.

Key Lessons

• Political Commitment and Flexibility:
  Political will and a flexible, results-oriented approach are essential for successful HSS implementation. Turkey's experience shows that balancing comprehensive reforms with incremental changes can lead to effective and sustainable outcomes.

• Institutional Reforms and Autonomy:
  Public hospital reform is a critical component of HSS, but it is often politically sensitive. Turkey demonstrated that incremental changes can improve service delivery immediately while laying the groundwork for long-term institutional reforms.

• World Bank's Role:
  The World Bank should support HSS reforms over a long-term horizon, be flexible in the sequencing of reforms, and focus on building monitoring and evaluation (M&E) capacity in client countries to ensure the effectiveness and accountability of reforms.

Conclusion

Turkey's HSS reforms, particularly through the Health Transformation Program, offer important insights for low- and middle-income countries. The country's success in expanding health insurance coverage, improving access to services, and enhancing institutional capacity highlights the importance of political commitment, flexibility, and a long-term perspective in implementing HSS. The World Bank can learn from this experience to better support similar reforms in its client countries.