2003年-世界发展银行全球_Turkey___Reforming_the_Health_Sector_for_Improved_Access_and_Efficiency_Volume_1_Main_Report_96页_6mb

Summary of "Reforming the Health Sector for Improved Access and Efficiency" (Turkey, 2003)

Core Content

This report, prepared by the World Bank in 2003, analyzes the state of the health sector in Turkey and proposes a comprehensive reform strategy to improve access, efficiency, and health outcomes. It is structured into two volumes and includes detailed background studies, key findings, and a set of reform measures aimed at addressing systemic inefficiencies and disparities in the Turkish health system.

Main Findings

1. Health Status of the Population

• Turkey's health status lags behind most middle-income countries.
• Life expectancy is nearly ten years below the OECD average.
• Infant and maternal mortality rates are among the highest in middle-income countries.
• Less than two-thirds of mothers receive antenatal care, and less than one-third receive full tetanus toxoid injections.
• Only 2 out of 5 child-births are attended by a physician, compared to over 90% in middle-income countries.
• Immunization rates for children are low, with 2 out of 3 children not receiving full immunization.

2. Utilization of Health Services

• A significant proportion of the population, especially the poor, does not have access to health services.
• There is a notable disparity in health service utilization between urban and rural areas, and between rich and poor.
• The poor are significantly less likely to seek treatment when ill compared to the non-poor.

3. Supply of Health Care

• Public health facilities are understaffed and under-resourced.
• Many health centers lack even one physician, particularly in rural and Eastern regions.
• There is a concentration of physicians in urban areas, with rural areas significantly understaffed.
• A large number of small hospitals under the Ministry of Health suffer from outdated equipment and lack of manpower.
• People tend to use larger, more equipped facilities even if they are farther away, leading to low bed-occupancy rates in smaller hospitals.

4. Human Resources in the Health Sector

• There is an imbalance between primary care and specialty care physicians.
• Almost half of all physicians in patient care are specialists.
• Preventive care and maternal and child health receive minimal attention in terms of funding and policy.

5. Health Financing

• Health insurance coverage is uneven, with over 50 provinces having 10% or more of their population without coverage.
• Public expenditures on health are not distributed equitably, with richer regions receiving more funding per capita.
• The current system of multiple payers and revolving funds creates perverse incentives and limits access for vulnerable populations.

6. Pharmaceutical Consumption and Production

• There is a significant gap in the availability of pharmaceutical products, especially in rural areas.
• Preventive care and maternal and child health are underfunded.

7. Impact of Economic Shocks

• Economic crises have affected health service demand and insurance coverage.
• The Green Card program has been an important tool for financial protection, but its reach is limited.

8. Health-Related Millennium Development Goals (MDGs)

• Turkey faces significant challenges in meeting health-related MDGs by 2015.
• Access to basic health services, especially for the poor, is a major obstacle.

Key Reform Strategies

1. Universal Coverage through Social Health Insurance

• A compulsory universal social health insurance system (Health Fund) should be established.
• This system would consolidate the existing health insurance schemes (SSK, Bagkur, Emekli Sandigi) and integrate the Green Card program.
• The Health Fund should be an autonomous legal entity, ideally under the Ministry of Labor and Social Security.
• It should cover a wide range of services, including routine visits, emergency care, immunizations, and prescription drugs (generics where available).
• Optional private insurance can cover non-essential services such as brand-name drugs, cosmetic surgery, and non-emergency care.

2. Essential Services Package and Targeted Public Spending

• A package of essential services should be developed, including evidence-based interventions such as WHO's "Making Pregnancy Safer Initiative" and "Integrated Management of Childhood Illness."
• This package should also include health education, clean water, sanitation, and immunization programs.
• Incentive-compatible strategies should be used to encourage medical staff to work in underserved areas, such as extra remuneration, shorter postings, and admission to specialization programs.
• Cluster staffing could be used to deploy physicians to traditionally shortage areas.
• Paramedical staff should be considered for delivering essential services, especially in areas with limited physician access.

3. Reorganization of Public Hospitals and Autonomy

• All public hospitals, particularly those under the Ministry of Health (MOH) and Social Security Institutions (SSK), should be granted administrative and financial autonomy.
• The reorganization should be done in two phases:
  • Phase I: Consolidate hospitals under quasi-public legal entities and provide them with autonomy.
  • Phase II: Grant autonomy to individual facilities on a selective basis, after demonstrating readiness for self-governance.
• Employees in Phase I retain civil servant status, while in Phase II, they become contract employees.

4. Consolidating Institutional Responsibilities

• The Ministry of Health should focus on policy formulation, regulatory oversight, and public health functions.
• The Ministry of Labor and Social Security should oversee the universal health insurance system.
• Both ministries should work collaboratively, with shared values and goals, rather than in an adversarial manner.

5. Strengthening Primary Care Services

• Primary care is underdeveloped and lacks the power to influence other levels of care.
• The concept of family medicine should be adopted to improve integration and continuity of care.
• Family physicians should provide a wide range of services, including diagnostics, consultations, and health education, under a single-window system.

Conclusion

The report emphasizes the need for fundamental and systemic changes in the Turkish health sector. These include improving resource mobilization and allocation, enhancing access and utilization, increasing efficiency, and improving clinical effectiveness. The proposed reforms aim to create a more equitable and sustainable health system, with a focus on universal coverage, institutional reorganization, and enhanced primary care delivery. A two-phase implementation plan is recommended to allow for gradual change and to minimize disruption during the reform process.