Health system reform
Before the HTP, Turkey’s health care system was highly fragmented: two separate ministries held responsibility for governance, three separate health insurance schemes provided funding for the system, and 40 percent of health care spending was private . Patient and provider satisfaction with the health care system was low. Provider dissatisfaction was generally caused by poor training and poor working conditions, and was reflected in high absenteeism rates –. The overall quality of care was also low, particularly at primary health care centers, with low life expectancy, high infant and maternal mortality, and low patient experience measures . Wide disparities in the quality of care and distribution of health care professionals also existed . In 1998, Turkey spent 3.6 percent of GDP on health care, approximately USD$295 per capita .
Health Transformation Plan
In 2002, in his first day in office, Minister of Health Recep Akdağ banned the then common practice of holding patients in facilities until they had paid their medical bills. . This move made clear Akdag’s commitment to reform and generated widespread support that was critical for the initiation of the HTP the following year. The Minister of Health, along with country leadership, created the Health Transformation Plan in 2003 with the aims of ensuring health as a right for all, providing universal health insurance coverage and financial risk protection, increasing satisfaction of patients and providers, and promoting and protecting patients’ rights , –.
The reform included efforts across a range of areas including financial policies, organization of the health care system, and strengthening of human resources. To provide universal health insurance coverage, the Green Card Program was created in 2008 and finalized in 2012. This program consolidated state insurance schemes and extended insurance coverage to all Turkish citizens, including making healthcare and medication free for all citizens under 18 years of age , . Due to increased government remuneration, a significant number of physicians voluntarily switched to solely public practice. This enabled the government to more easily pass a law banning dual public and private practice in 2010 , . Today most physicians are contracted employees of the government . State hospitals were unified under the Public Hospital Institute so that they could be more efficiently managed, and a pay-for-performance finance scheme was also adopted in hospitals to improve quality , . Over the last decade, 111,000 health care workers were added to the health care workforce . The role Ministry of Health was also restructured to transition the Ministry away from direct service provision towards a regulatory and leadership role, as captured by the saying “more steering, less rowing” .
Family medicine reform
Implementing a strong PHC system was enabled by the above reforms, but was dependent on the Family Medicine (FM) reform, the backbone of Turkey’s Health Transformation Program. In 2003, Turkey piloted a primary health care reform that mandated all primary care paid for by state insurance had to be provided in a state-contracted Family Medicine Center. After demonstrating the feasibility and effectiveness of this system, Turkey expanded the program across the country between 2005 and 2010 . The FM program promises to cover all residents of Turkey regardless of age or socioeconomic status and give them high quality primary health care and the right to choose their doctor. .
FM centers are typically led by a physician with a team of one nurse and one or two medical assistants; each team is responsible for providing care for 1,000 to 4,000 people . Today, all family medicine doctors are publicly employed with the local Ministry of Health , ."
The Family Medicine reform is designed to ensure continuity of care and facilitate the formation of longitudinal patient-provider relationships through empaneling, a process of assigning patients to a primary care team using geographic areas to delineate patient grouping. Additionally, the FM model allows for the provision of home care for targeted, high-need patients who have difficulty leaving their homes. Home care is provided by a multidisciplinary home care team comprised of a family medicine physician and a nurse .
The FM reform is financed by a capitation system, where FM physicians receive a set amount of money per patient they treat . For practices in areas with high rates of populations from lower socioeconomic status or very rural areas, the per person rate is increased to compensate for the increased challenges and resources required . This capitation payment was designed to increase (by approximately 10 percent) the wages of FM physicians in Turkey, a financial reform that served to attract more physicians to the specialty.  In addition to the capitation payment and vulnerable population adjustment, FM practices are eligible for additional payments or subject to payment penalties based on the quality of their practices. The main quality measures include antenatal care coverage, immunization coverage, and facility capacities, including heating, adequate number of examination rooms, and availability of necessary equipment and pharmaceuticals . This incentive program has resulted in increased quality of care that physicians provide their patients , , .
An important part of the FM program was the redistribution of physicians from urban areas with a high physician density to rural areas with a scarcity of physicians. Because medical education is free of charge, recent medical school graduates are required to work for the state for a period of 300 to 500 days after graduation . The state sends most recent medical school graduates to rural areas of the country in order to create a more equitable physician distribution across the country . After this service period, however, it is difficult for some physicians to secure employment in urban areas and many physicians are only offered contracts in rural areas; this has made the policy increasingly unpopular among physicians . While the physicians have the option of going into private practice, recent legislation has made that a less lucrative option .
Focus on physician training
Nationwide implementation of the Family Medicine program was estimated to require 20,000-45,000 FM physicians but, in 2004, there were only 1,200 FM physicians in Turkey . In order to address this workforce shortage, Turkey implemented a training program for practicing general or internal medicine physicians to recertify as FM physicians. To encourage participation, the reform mandated that in order to receive compensation from state insurance plans, all physicians providing primary care services needed to be recertified as FM physicians. 
The training was an intensive ten-day program where physicians learned the basics of FM practice . During this course, the trainers assisted physicians in transforming their existing practices into FM centers . The brevity of the course has raised some concerns about the effectiveness of the training to ensure appropriate FM capacity , . To further address the primary care physician shortage in the future, Turkey increased the number of public medical school seats available , .
Field coordinator teams
Continuous monitoring and evaluation has been critical to the success of Turkey’s reform. To facilitate the two-way flow of information from frontline providers and centers to decision makers, Turkey designated a cadre of field coordinators. Working in teams, these coordinators collaborated with FM centers in their first years to better understand what was required of them, to assist them in identifying and overcoming challenges, and to ultimately evaluate their services . The teams served as bridges between the central office of the Ministry of Health and service delivery centers . Overall implementation of the reform was guided by periodic statistical surveys administered by the Turkish Statistical Institute, Hacettepe University and the Ministry of Health, as well as audits conducted by the World Bank, World Health Organization, UNICEF, and OECD .
The scope of this reform was enabled by several important contextual factors, including sustained political commitment, strong leadership and the growth of Turkey’s gross domestic product (GDP). Political commitment was achieved through single-party control of the legislature, political stability, frequent reference to and support of the HTP by the prime minister, and widespread support of the HTP budget , , . Strong leadership, both by the Minister of Health and the HTP leadership team also facilitated the HTP . Notably, Turkey underwent a simultaneous increase in GDP during the first decade of the 21st century . This allowed for an increase in health expenditure from $9 billion in 2002 to $34 billion in 2012, while only increasing the percent of GDP allotted to health from 3.9% to 4.3% .
Major advances in health outcomes
The HTP has resulted in major improvements in health. Turkey reached Millennium Development Goals 4 and 5 for 2015 far ahead of schedule . Life expectancy increased rapidly, maternal and child health outcomes significantly improved and Turkey reached a life expectancy of 75 years 16 years earlier than predicted , . Achievements include:
- Infant mortality decreased by approximately 65 percent from 2003 to 2010, from 29 deaths per 1000 live births to 10.1 deaths , , .
- Under five mortality decreased approximately 50 percent from 2000 to 2008 and continues to decrease .
- The percent of pregnant women who attend at least the four recommended antenatal care visits increased from 70 percent in 2002 to 97 percent in 2012 .
- The percent of births attended by skilled providers increased from 83 percent in 2003 to 91.3 percent in 2008,
- Maternal mortality decreased from 70 deaths per 100,000 live births in 2000 to 19.8 deaths per 100,000 live births in 2008 , .
Comprehensive immunization was incentivized by the pay-for-performance quality measures for FM practices and immunization rates consequently increased. The measles vaccination coverage increased from 82 percent in 2002 to 96 percent in 2008 and the infant vaccination rate increase from 87 percent to 96 percent in 2012 , , .
Health system inputs and processes have also improved over the course of the reform. The number of family medicine consultation rooms has increased from approximately 6,000 in 2000 to more than 16,000 in 2008, a measure of increased primary health care system capacity . Physician absenteeism, a major problem before the reform, has fallen and utilization of health care services increased from 2.4 physician visits per capita per year in 2000 to 6.3 visits per capita per year in 2008 .
In addition, the HTP has significantly reduced the burden of health care on Turkish people . Out-of-pocket costs have been reduced from 20 percent of total expenditures in 2002 to 15 percent in 2012 . Equally important, the percent of households with catastrophic health expenditures is down from 81 percent in 2002 to 14 percent in 2012 ."
The HTP also dramatically increased satisfaction with the health care system. Nearly 90 percent of physicians and 70 percent of nurses report being satisfied with the FM model . The population’s satisfaction with the health care system in Turkey increased from 40 percent in 2003 to 75-80 percent in 2012 , ,  and the majority of Turks (70-77 percent) say they prefer the HTP health care system to the prior health care system . However, although patients were very satisfied with clinical care, other components of the health care system such as appointment systems and waiting times are still sources of dissatisfaction amongst patients, representing areas for ongoing improvement .
The impact of the HTP on disparities is less clear. Some studies have reported reduction of disparities, but others identified that many of the most vulnerable populations in Turkey who are most in need of care have still fallen through the gaps and are not registered with the FM program . The redistribution of physicians to underserved areas has certainly reduced some inequalities, but the research shows that there is still more work to be done .
While Turkey has made great strides in its health care system, there are still areas for improvement. In particular, the system needs more formalized referral networks and gatekeeping, better measurement and accountability, and improved coordination both within and between FM practices , , , . Under the current system, it is very difficult to voluntarily switch physicians or to receive care if one is away from home—a significant problem for some parts of the Turkish population . The challenge to continuity between physicians is in part due to weak eHealth systems, which often act as barriers to, rather than enablers of, physician collaboration , , .
Quality of FM practices is also still a concern. While FM practices are doing demonstrably better in the areas for which they are reimbursed, performance is not as consistent in areas not targeted for performance-based financing . For example, family planning and reproductive health are not explicitly included in the HTP and coverage of these services remains poor . A 2010 study showed that over 90% of women contacted had never had, or even heard of, a pap smear . Similarly, because the HTP does not include post-partum care as one of its FM quality measures, post-partum care is provided sporadically and at the discretion of the FM physician, resulting in inconsistent coverage .
The success of the HTP in increasing health care utilization has created a capacity problem . While the number of family medicine physicians has increased 124 percent from 2002 to 2011, there has been a concurrent increase of 326 percent in the number of family medicine visits . The average number of total physician visits per capita per year was only 3 in 2002 and increased to 8.3 in 2012 . This is a new challenge for Turkey as many FM physicians now are overworked and feel that they are unable to spend enough time with each patient , . In addition, despite the rural relocation policy enacted by the HTP, concerns remain that there are not enough physicians in the most isolated, rural areas of the country . Conversely, many physicians believe that the policy went too far in redistributing physicians, and are dissatisfied with the policy . Though satisfaction with the health care system has increased, some studies still record up to 65 percent dissatisfaction rates, and many FM physicians feel that they are used solely for refilling prescriptions and are thus unable to provide many of their population medicine responsibilities , .
An additional emerging challenge for Turkey is the management of chronic, non-communicable diseases (NCDs). Today, cardiovascular diseases and cancer are the most common causes of death in Turkey . The HTP was designed primarily to manage infectious diseases and maternal and child health (MCH), and is less well equipped to manage NCDs . For example, diabetes control has been seen in only one quarter of patients cared for by the FM centers . It is therefore important that Turkey begin to identify the changes that will be needed to the HTP to ensure that the primary care system is well-positioned to address these emerging threats .
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