Sabahattin AYDIN MD, PhD Dept. Undersecretary of MoH The Success and Challenges in Strengthening...

Sabahattin AYDIN MD, Sabahattin AYDIN MD, PhDPhD

Dept. Undersecretary of Dept. Undersecretary of MoHMoH

The Success and Challenges in The Success and Challenges in Strengthening Health System Strengthening Health System

Performance through Eliminating Performance through Eliminating Disparities in Health ServicesDisparities in Health Services: Turkey : Turkey

PerspectivePerspective

Ministry Of Health of TURKEY, 2008 2

**Health service is a field of Health service is a field of constant development in which constant development in which

periodic requirements and periodic requirements and strategies may vary. strategies may vary.

Keeping this aspest in mind, we Keeping this aspest in mind, we need to focus manyneed to focus many issues and issues and

challenges in health service challenges in health service delivery and purchasingdelivery and purchasing


Before the reform agendaBefore the reform agenda

the main problems of our health system the main problems of our health system included fragmentation:included fragmentation:

• Public health care providers were ownd by Public health care providers were ownd by different institutions.different institutions.

• Existence of multiple Existence of multiple public public health health insurance institutions with different status. insurance institutions with different status.

• lack of unity in implementation, lack of unity in implementation, • Problems which citizens used to suffer in Problems which citizens used to suffer in

the services because of different status. the services because of different status.


we can also mention about other challenges such as

• lack of capacity of service providers in terms of technical, personnel and infrastructure,

• long patient queues, waiting periods, • low salaries for physicians and other health

personnel working in public sector, • due to low salary policies the increased

number of private practices, • lack of an efficient and effective recording

system

common challenges:common challenges:


Main driving force:Main driving force:•the political authorities ensured their full the political authorities ensured their full support and made valuable contributionssupport and made valuable contributions•significant steps have been taken significant steps have been taken addressing the strengthening of health addressing the strengthening of health services. services.

Reform agenda of HTPReform agenda of HTP


• Health personel motivation was achieved by Health personel motivation was achieved by supplementary payment implementation supplementary payment implementation . .

• An uniquAn uniquee model was designed to measure model was designed to measure individual performance of physiciansindividual performance of physicians

• Institutional evaluation of the health Institutional evaluation of the health providers in terms of quality criteria providers in terms of quality criteria effected the P4Peffected the P4P

Reform agenda of HTPReform agenda of HTPp4pp4p


• TThis implementation has resulted in increases his implementation has resulted in increases in productivity, advancement in technical and in productivity, advancement in technical and physical structure of the hospitals. physical structure of the hospitals.

• The personnel of the institution have become The personnel of the institution have become more appertaining to their institutions.more appertaining to their institutions.

• Promoted the modernization of MoH hospitals Promoted the modernization of MoH hospitals • Helped harmonisation of public hospitals under Helped harmonisation of public hospitals under

the authority of MoH.the authority of MoH.

Reform agenda of HTPReform agenda of HTPp4pp4p

Reform agenda of HTPReform agenda of HTPPPPPPP

• Hospitals were allowed to Hospitals were allowed to outsourcoutsource e many facilities which induced many facilities which induced competetive improvementcompetetive improvement

• TThe he controlled controlled share of private share of private sector in service delivery is sector in service delivery is increased. increased.

• Investments by PPP /PFI are on the Investments by PPP /PFI are on the way (?)way (?)



• Disparities in service use by the citizens who are Disparities in service use by the citizens who are covered by different health insurances were covered by different health insurances were aimed to be minimized. aimed to be minimized.

• As a first step, outpatient treatment and drug As a first step, outpatient treatment and drug expenses of the green-card holders are covered expenses of the green-card holders are covered by the Stateby the State (insurance for the poor) (insurance for the poor)

• Benefits packet of workers was increased (SSK)Benefits packet of workers was increased (SSK)• Universal Health Insurance Coverage Act was Universal Health Insurance Coverage Act was

adopted.adopted. • Legislative process for harmonisation and Legislative process for harmonisation and

universal coveredge was completed.universal coveredge was completed.

Reform agenda of HTPReform agenda of HTPUHIUHI


Reform agenda of HTPReform agenda of HTPUHIUHI

• SSocial ocial SSecurity ecurity IInstitutionnstitution, being the , being the main authority of UHI,main authority of UHI, has gained a has gained a significant power as the sole significant power as the sole ppurchaser which helped to minimise urchaser which helped to minimise inequalities.inequalities.

• TThrough full implementation of hrough full implementation of universal coverage in 200universal coverage in 2009 and 9 and 20102010, disparities, disparitiesand inequalitiesand inequalities will will be almost be almost eliminated. eliminated.


Reform agenda of HTPReform agenda of HTPFMFM

• PPilot implementation of family ilot implementation of family medicine medicine has beenhas been started started in 2005 in 2005

• At the mean time FM cevered 22 At the mean time FM cevered 22 province with almost 15 million province with almost 15 million citicens (1/5 of population)citicens (1/5 of population)

• The main The main idea is idea is to strengthen the to strengthen the primary healthcare services and primary healthcare services and ensure their efficensure their efficiencyiency..


• Strict human resource policy was adoptedStrict human resource policy was adopted• Obligatory service for doctors was rearranged Obligatory service for doctors was rearranged

promoting to work in ruralpromoting to work in rural• A new ... system with higher salary in the rural A new ... system with higher salary in the rural

area was lounchedarea was lounched• Health personel movement within the country was Health personel movement within the country was

made available according to made available according to “planning based on “planning based on need”. need”.

• The ratio of doctor intensity between the highest The ratio of doctor intensity between the highest and lowest changed from 1/14 to 1/4and lowest changed from 1/14 to 1/4

Reform agenda of HTPReform agenda of HTPHRHR


Reform agenda of HTPReform agenda of HTPHISHIS

• FM implementation was based on electronic recording FM implementation was based on electronic recording and central evaluation of the data.and central evaluation of the data.

• HHospital information systems were established, which ospital information systems were established, which enables precise and effective recording systems in enables precise and effective recording systems in terms of procedures and statistical dataterms of procedures and statistical data

• Hence, the errors and defects in the recording system Hence, the errors and defects in the recording system are avoided and this has contributed to the are avoided and this has contributed to the strengthening of financial structures of hospitals. strengthening of financial structures of hospitals.

• Online electronic controll system by SSI is Online electronic controll system by SSI is implemented that prevented inequalities in invoice implemented that prevented inequalities in invoice producing.producing.

• More reliable data became available to help policy More reliable data became available to help policy makingmaking


• In 2004,In 2004, transparency is ensured in transparency is ensured in pricing systempricing system based on reference based on reference pricing.pricing.

• This induced generic competition This induced generic competition which caused which caused considerably considerably decrease in the pricesdecrease in the prices

• SSignificant alleviation in its burden ignificant alleviation in its burden on public financon public finance helped to e helped to eliminate in equalities to access to eliminate in equalities to access to medicines in different social medicines in different social groups.groups.

Reform agenda of HTPReform agenda of HTPPhr. Pricing PolicyPhr. Pricing Policy


• Despite all political will, support Despite all political will, support and commitment, there is always a and commitment, there is always a risk of resistance and obstacles in risk of resistance and obstacles in front of the reforms and front of the reforms and programme processes. programme processes.


• Harmonisation of hospitals drows resistance from Harmonisation of hospitals drows resistance from different social groupsdifferent social groups

• Integration oIntegration of different social security institutions with f different social security institutions with different visions under one roof and establishing a different visions under one roof and establishing a solid new insurance mechanism is a hard process. solid new insurance mechanism is a hard process.

• YYou have to deal with and overcome the monetary ou have to deal with and overcome the monetary burden of improvement and development. burden of improvement and development.

• The policymakers The policymakers face the risk of conflicts within face the risk of conflicts within different institutions different institutions within or outside within or outside the government the government

• CConvincing the Finance Ministriesonvincing the Finance Ministries is the most is the most important taskimportant task

Resistance to reformsResistance to reforms


• We are all aware of the shortage in We are all aware of the shortage in qualified health personnel all around the qualified health personnel all around the world. world.

• This shortage makes it more difficult This shortage makes it more difficult during implementation process. during implementation process.

• Therefore, the health personnel can suffer Therefore, the health personnel can suffer from time to time from time to time because of because of heavy heavy burdens and workloads.burdens and workloads.

• Trained and qualified personel easily Trained and qualified personel easily shifts to private sector where they can shifts to private sector where they can earn moreearn more

Other challengesOther challenges


• NNeonatal mortality rate eonatal mortality rate (x/1000)(x/1000)

• MMaternal mortality rate aternal mortality rate (x/100.000)(x/100.000)

OutcomesOutcomes

2002 2008

28.7 19

2002 2008

70 21.3


• TThe vaccination ratios he vaccination ratios (x/100)(x/100)

• TThe number of measles cases he number of measles cases

2002 2008

98 82

2002 2007

7804 3


• Likewise, the prevalence of infectious Likewise, the prevalence of infectious diseases also decreased. diseases also decreased.

• The number of malaria cases The number of malaria cases

• TThe number of the typhoid fever cases he number of the typhoid fever cases

2002 2007

10224 313

2002 2007

24390 1297


In addition, several campaigns have been In addition, several campaigns have been initiated to decrease the prevalence of initiated to decrease the prevalence of chronic diseaseschronic diseases;;

• These include healthy nutrition These include healthy nutrition programme, programme,

• CCardio-vascular diseases control ardio-vascular diseases control programme, programme,

• PPhysical activity programme, hysical activity programme, • Tobacco Control Act, and etc.Tobacco Control Act, and etc.


• TThe ratio of out-of pocket he ratio of out-of pocket expenditure is recorded expenditure is recorded

2002 2007

32,1 16,5

• After the implementation, the After the implementation, the percentage of benefiting from percentage of benefiting from primary healthcare services shows primary healthcare services shows an increasing trend in areas where an increasing trend in areas where family medicine is implemented. family medicine is implemented.

• About 60% admits to primary About 60% admits to primary healthcare services are recorded. healthcare services are recorded.



• Last but not least, access to health Last but not least, access to health services is increased services is increased

• Consequently the satisfaction of the Consequently the satisfaction of the citizens is increased citizens is increased (x/100) (x/100)

• life expectancy is increased.life expectancy is increased.

2003 2008

4 6,5

2003 2008

35 60


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Sabahattin AYDIN MD, PhD Dept. Undersecretary of MoH The Success and Challenges in Strengthening...

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