Owner of Report : Association of Public Health Specialists (HASUDER)

Date : 10 July 2007

Preparation of Report: This document has been prepared through contributions made by the Public Health Branches of the Medical Faculties of Universities, to the report prepared by Prof. Dr. Zafer Öztek, who had been appointed as rapporteur by HASUDER.

HASUDER has launched a study to evaluate the MoH Health Transition Program and produce a view on how healthcare services should be provided in our country. This study has commenced with the preparation of an expert’s report, and Prof. Dr. Zafer Öztek, who has been appointed as rapporteur, has prepared a technical report to this effect. The draft text formed on the basis of this report has been submitted to public health specialists and Public Health Branches at universities for comments, and in the light of feedbacks and contributions, it has been rearranged as “HASUDER Report on Views and Recommendations regarding Health Services Provision in Turkey”.

The principles and rules as to how healthcare services will be organized and provided in Turkey are set out in the Law No. 224 dated 1961 on “Socialization of Healthcare Services”, which forms the basis of health policies of Turkey.

The education of doctors and other healthcare staff focuses largely on the diagnosis and treatment of diseases. For this reason, there is a common misconception among the healthcare staff that their primary duty is to offer curative services. More important and dangerous is the fact most of the public is of the same opinion. People first think of hospitals when one talks about healthcare services. Both the beneficiaries and providers of healthcare services put curative healthcare services, primarily including hospitals, on the foreground. This is a fact of not only our country, but also of many countries. This is mainly because the second degree healthcare services have been organized before the first degree healthcare services in our country. This is because inpatient treatment institutions have been established before outpatient treatment institutions and funds have almost entirely been allocated to the construction and operation of hospitals instead of preventive healthcare services. Consequently, hospitals have been faced with patient admission requests beyond their capacities, hospitals and specialized doctors have been busy with persons who indeed do not need themselves, some of the patients awaiting admission at hospital gates have given up their admission requests and thus they have lost the chance to have their diseases treated in a timely manner.

This was the outlook of Turkey in the 1960s. The hospitals concentrated in city centers could not respond to excessive patient applications. In particular, the rural population did not have adequate access to healthcare services. The government doctors in rural areas spent much of their working hours by official correspondence and bureaucratic procedures. This outlook was not conforming to the principles of contemporary healthcare organization. The Law No. 224 on the Socialization of Healthcare Services, which was adopted in 1961, was intended to correct this situation, resolve the issues in the healthcare organization and in the provision of services, and to introduce modern principles of healthcare services provision. This law lays down the principles that govern the overall healthcare services in Turkey.

The principles set out in the Law No. 224 on Socialization of Healthcare Services are as follows:

1. Principle of healthcare services provision to everybody, anywhere and any time.

2. Provision of all preventive and curative healthcare services by the same unit (local health center) (wide variety of services in a small area)

3. Prioritization of preventive healthcare services and healthcare problems critical for public health.

4. Provision of healthcare services to non-applicants as well (mobile service).

5. Gradual service (forwarding chain) principle.

6. Involvement of public in the decisions on planning and provision of healthcare services.

7. Principle of service provision according to population and designated geographical region.

8. Team service (doctor, nurse, midwife, health officer) principle.

9. Planned service principle.

10. Evaluated service principle (every health institution constantly keeps records and evaluates them).

11. Flexible model principle (service provision adjusted according to the characteristics of the beneficiary population).

The principles of this law are not out-of-date, but are still modern. However, although it was successfully enforced initially, very serious problems have arisen in time, due to certain administrative reasons. Because of these problems, a misconception has arisen to the effect that this law does not fit our country’s circumstances and has become inapplicable.

The socialization of healthcare services has been very successful in the first 10-15 years. In particular, significant success has been achieved in the practice of “Health Education and Research zones” attached to the provinces in Eastern and Southeastern Anatolia regions and to universities. For instance, when Etimesgut Health Education and Research zone started service in 1967, the infant mortality rate was 142 per thousand, whereas it declined to 29 per thousand by 1989. During the same period, the life expectancy period for men increased to 72 years from 56, and the life expectancy period for women increased to 76 from 57. The success of Etimesgut Health Education and Research zone was achieved by other regions in the country as well.

In order to fully comprehend the problems we encounter today in healthcare services, we need to know the problems encountered in the practice of socializing healthcare services.

The problems arisen by the deviations observed in time from the principles of socialization model are as follows:

1. Lack of adequate and continuous policy determination.

2. Giving up the full-time working principle. According to the law, the doctors of local health centers were required to work on a full-time basis. Later on, doctors started to work half-time for health centers, and spare their time for their private offices and pharmacies. Thus the allowance of first degree doctors in the region to work in both the public and private sector has negatively affected public services.

3. Giving up the principle of integrity within the province. According to the law, “healthcare services are integral within the province”. This means that sub-provincial boundaries cannot be taken as a basis in the location of local health centers, rather provincial boundaries have to be taken as a basis. However, through an amendment made to the Civil Servants Law No. 657 in 1983, sub-provincial governors have become the registry and disciplinary authority of all civil servants in the sub-province, including health center doctors, and sub-provincial governors have become directly responsible for healthcare services. This amendment represented return to the former “government doctor” practice.

4. Failure to transfer the health institutions of other agencies to the Ministry of Health. The Law provided that all hospitals and other health institutions belonging to the public agencies in the province be transferred to the Ministry of Health (Article 3, 8, 30/d). In 2005, i.e. 44 years after the adoption of the subject law, the health institutions of SSK and other public agencies, were transferred to the Ministry of Health. Although it is not possible to state that this transfer procedure was in tune with the transfer rationale of Law No. 224, this involves positive aspects in terms of the principle of management from a single point.

5. Giving up free care practice. According to Article 14 of Law No. 224, examinations, life-saving medicines and all preventive services are free of charge at health centers. The patients who are forwarded to hospitals from health centers are also treated for free of charge. However, the patients who directly apply to hospitals pay their fees. This practice was intended to incentivize citizens to apply to health centers first, but could not be enforced.

6. Negative discrimination by social security organizations against health centers. Social security organizations such as SSK, Pension Fund and BAĞ-KUR did not pay for the first degree healthcare services, although they paid for hospital services.

7. Failure to run the patient forwarding chain. Patient forwarding chain was first introduced in Turkey through the socialized healthcare services model. Various researches conducted during the period when the law was successfully enforced demonstrated that the rate of patients forwarded from health centers to hospitals was around 6-10 percent. However, the patient forwarding chain, which had been enforced successfully at the beginning, could not be run thereafter. At present, excluding the employees of public agencies, patients can directly go to hospitals. This simply represents the abolition of the first degree curative services practice.

8. The term “socialization”: The term “socialization of healthcare services” has insistently been considered as part of an ideology by certain circles, which has led to a reaction to this model.

9. Delay in spreading the practice over the entire country. This organization model has for along time been implemented in mainly rural provinces, and there has been delays in spreading it over the western provinces and big cities.

10. Urban-type health centers. The diagnosis and treatment facilities of health centers in urban areas could not be developed in such a manner that they can respond to their needs.

11. Focus on curative services. Especially in the 2000s, the health centers, particularly those in urban areas, have been pushed away from preventive services and their focus has been on curative services.

12. District outpatient clinics. The state hospitals in some big cities have opened units called “district outpatient clinics” in some districts of cities. In such an organization, health centers had to compete with district outpatient clinics in the area of curative medicine.

13. Inappropriateness and inadequacy of staff education and training. The education offered at both faculties of medicine and other health schools could not provide education that responds to the importance of first degree healthcare services. The vacant positions at health centers and health houses could not be filled and the staff requirements could not be met. Two thirds of almost 11,000 health houses do not have midwives. These health houses do not have buildings either.

14. Lack of staff, buildings and equipment. The physical infrastructure and diagnostic and therapeutic equipment of the health centers especially in urban areas are not appropriate for service provision. The lack of vehicles (cars) and drivers, which are of vital importance particularly for offering the mobile services at rural health center has further aggravated service provision.

15. Vertical organization could not be removed. Before 1961, services were organized “vertically” according to the principle of “single-purpose service in a broad area” (e.g., tuberculosis dispensaries, malaria dispensaries, mother and child health and family planning centers, etc.). However, the socialization of healthcare services introduced the principle of “wide variety of services in small area”.

16. Population could not be determined, forms could not be used. One of the “sine qua non” principles of health centers is to constantly determine the population of the region. A “household register form” is filled in for each household and a “personal health form” is filled in for each individual in the region. Difficulties are encountered in determining the population of regions due to the high rates of immigration in urban areas, the fact that family members are not at home during daytime, the fact that urban people are not accustomed to population census and midwife visits and therefore they do not accept the visiting officers.

17. Political pressures. Political pressures on the selection of locations where health centers will be established, appointment of staff members and allocation of resources.

18. Inadequate management capacity. The most important issue experienced in health centers has perhaps been the inadequate management capacity. Especially at the provincial and sub-provincial levels, mostly administrators with no management knowledge and skills have been appointed, whereas the human resources trained in this area (such as public health specialists) have not been appointed for such positions.

19. Failure to ensure public involvement. Although a regulation issued in 1969 required the establishment and functioning of “health center medical boards”, this regulation could not be enforced.

The main problems of the current healthcare system in our country are as follows:

1. System Chaos and Service Dilemmas. Although the model of “single-purpose service in wide area”, which was introduced in the early years of the republic, and the model of “wide variety of services in a small area”, which has been introduced through socialization in place of “vertical organization”, are alternatives to each other; both of these models are currently being implemented together, and the institutions established according to vertical organization as well as the health programs designed according to vertical organization continue providing service all around the country.

2. Centralization. Thousands of healthcare institutions all around the country are tried to be administrated from Ankara. The powers assigned to local organizations are limited.

3. Ministry’s central organization. The Ministry of Health was organized according to a decree in the force of law issued in 1981. Because there was no systematic approach in the establishment of main service units, some units have been organized according to services (such as Curative Services Directorate general) while some units have been organized according to diseases (such as Malaria Department). For this reason, there are overlapping duties among units. The work loads of certain units are so heavy that these units cannot fulfill their duties. The high-level officials and specialists of these units cannot spare time for thinking and planning due to their busy bureaucratic procedures.

3.2. Problems regarding Healthcare-Human Resources.

1. Number and employment of healthcare staff. There are regional imparities, rural-urban inequality and quantitative inequalities (significant inadequacies in the number of non-medical staff members).

2. Idle capacity and insufficient staff. Inequality in the distribution of staff (inadequate rural doctor, almost no midwives). Although the compulsory service produced a partial solution for this issue, problems regarding personnel rights have been ignored.

3. Appointments not fitting educational qualifications. A significant portion of staff members who have received skills training and education on specific fields (public health specialists, etc.) are being employed in positions which do not fit their educational qualifications.

4. Problems in the education of doctors. While there are adequate number of doctors in our country, the number of graduates is excessive due to political factors and new faculties of medicine which are opened without any planning. The continuous training of doctors and other healthcare staff is very weak. The faculties of medicine which raise doctors in the family medicine pilot implementation provinces are faced with a dilemma as to which organizational system they will take as a basis in raising doctors.

5. Education and research zones. The “health training and research zones” established under universities in order to ensure the pre-graduation and post-graduation training of doctors and other healthcare staff and to conduct researches have been shut down by past governments.

6. Doctor-industry relations. The relations between doctors and the companies producing and marketing pharmaceuticals and medical devices and equipment has reached striking levels.

7. Employment Rights of Staff. The financial and other employment rights as well as working conditions of healthcare staff are not encouraging. As a result of the practice introduced in the name of performance evaluation has led to large gaps between the wages of staff members. In addition, the payment of high remunerations to family doctors in a continuous manner and without any identified source in the provinces where the Family Medicine Pilot Implementation has started, has led to a sharp wage discrimination between the family doctors and other doctors working in the same province.

1. Fund Utilization Problems. Although the total amount of funds allocated to health cannot be underestimated in our country, these funds cannot be used efficiently due to disorders in the financing system. Most of the funds are spent for curative services. A significant portion of the Ministry budget has been allocated for personnel payments. Sufficient amount of funds cannot be allocated for investments. Pharmaceutical expenditures have a relatively high share in the health expenditures. According to “National Health Accounts – 2002” survey conducted by the Ministry of Health, the annual per capita health expenditure in our country is USD 202. However, there are publications which demonstrate that per capita health expenditure has risen to USD 450 as of 2006. The factor underlying this increase is the increase in the prices of healthcare services as a result of privatization. A substantial portion of these expenditures are financed by the Pension Fund, SSK and Bağ-Kur, but it is of no doubt that these institutions will not be able to finance such high costs and will result in an ever-growing “black hole” in the government budget. Now, the cost of healthcare services in Turkey has gone beyond the economic power of the country.

2. Poverty. In terms of health, one of the most critical social parameters is poverty, undoubtedly. As of 2000, the share of Turkish citizens who are apparently poor or economically vulnerable is above 15 percent, which is too high. The insufficient access of these people to facilities and resources regarding nutrition, hygiene and education, which are closely related with health, must be eliminated on a priority basis in order to mitigate poverty.

3. Profit-driven healthcare institutions. Although healthcare service is a human right and they constitute a kind of social service, the institutions providing these services are increasingly becoming profit-driven institutions. This practice is undermining non-profitable services such as preventive services for individuals and environment, family planning, pregnancy and infant follow-up and public education. One of the key principles of healthcare services is to “deliver services to individuals who do not apply to healthcare institutions”: those who are under risk (danger) indeed are the individuals who do not go to a doctor although they are sick. However, when these services are executed with commercial motives, these individuals who are under risk may be ignored and the health education, family counseling and mobile services may be impaired. Today, the actual goal of doctors and other staff has become to engage in higher-income works and reap a greater share. This is only possible by examining more patients and conducting more tests. Even, doctors are incentivized by their managers, through performance scores and bonus payments, to have more tests conducted to enable their institutions to gain more money. As a matter of fact, the allegedly increased number of outpatient visits largely stems from repeated prescriptions. It is observed that most of the increased tests yield positive results. This demonstrates that such increase is artificial and stems from unnecessary tests.

1. Building Issues. Some of the health centers, especially those in urban areas, are located in buildings which are not appropriate for service provision.

2. Medical Equipment Issues. The rapidly developing medical technology is very expensive. There is a regulatory vacuum over the inspection of these technologies.

3. Lack of transport vehicles. A key feature of local health center services is the importance of mobile services. However, a vast majority of health centers lack motorized transport vehicles. This lack leads to disruptions in the provision of health and supervision services especially in rural areas.

4. Lack of diagnosis facilities. Diagnosis facilities are insufficient especially at health centers. Many of them do not have laboratories. However, in the last couple of years, laboratory tests in some sub-provinces have been centralized. In case some financial problems observed in this practice are resolved, this method is expected to be useful. As a matter of fact, the initial figures obtained from this practice are positive.

1. Inadequacy of management capacity. The rules governing the training and appointment of individuals to manage healthcare services in Turkey are very insufficient. Instead of training managers and appointing them on a merits basis (trained, experienced, etc.), managers are appointed in a nepotistic manner.

2. Lack of supervision. Health administrators confuse the modern concept of “supervision” and the traditional concept of “inspection”.

3. Limps in patient forwarding chain. Hospitals intensively examine outpatients like first degree treatment institutions and hospital outpatient clinics face a significant work load. The concept of patient forwarding chain is such an unfamiliar concept for the administrators and planners that it has not been possible to execute this basic practice even under the newly introduced family medicine pilot practice, and the phrase “patient forwarding not necessary” had to be clearly indicated.

4. Treatment based on possible diagnoses rather than precise diagnosis. A doctor who is under an extremely heavy outpatient load at a hospital or health establishment can only spare a few minutes for each patient, which is too insufficient. Fore this reason, the rate of possible diagnoses is increasing inevitably. Consequently, doctors suggest several medicines for each potential diagnosis. One of the key factors underlying the pharmaceutical extravagancy in our country is this fact.

5. Inability of public to get involved in services. Although a regulation was issued in 1969 (Regulation on Health Centre Medical Boards”, this regulation could not be enforced. This is mainly because the Ministry of Health (and provincial health directorates) has not attached importance to this matter. Nor is it possible to state that healthcare staff and public are aware of this regulation.

1. Inadequate use of services by public. Due to the inadequacies in the infrastructure of services, the people who live in rural areas can benefit from healthcare services at a lower level as compared with the urban people. This gap is getting wider and wider. While the annual number of visits to doctor has reached 5 in urban areas in the last 2 years, this number is still 1-2 for rural areas. This fact leads to the deterioration of the principle of equality in access to healthcare services. The main factors underlying this fact are the lack of staff in rural units, transport problems, financial problems and the lack of public habit for utilizing healthcare services.

2. Inadequacy of service quality. All factors that negatively affect organizational structure and management prevent the public from receiving adequate and high-quality healthcare services.

3. Inadequate service provision for other risk groups (the elderly and the disabled). Special service provision models have not been developed for these groups.

4. Environmental and labor health issues. Inadequate inspection of wastes, power confusion in food control activities (among Ministry of Agriculture, Ministry of Health and Municipalities), provision of clean potable water, urban noise and urban safety problems are getting worse.

5. Drug Issues. Drugs, which are the most fundamental elements of healthcare services, are largely import-dependent in terms of raw materials. There are no R&D activities. The foreign trade deficit in the pharmaceuticals sector is growing increasingly. There is no adequate incentive for production and there are no legal arrangements for especially the production of bio-technological drugs. Drug use is not rational.

Attempts have been made intensively for the solution of the abovementioned problems especially for the last 5 years. These measures are in the form of the introduction of a new model which is considered to be more appropriate, rather than the rehabilitation of the existing system. The changes intended to be made in the national health system may be outlined under two main headings:

1. Restructuring of public administration. The health-related principles in the draft law prepared by the Government to this effect are as follows:

(a) The local organization of Ministry of Health will be abolished. The responsibility for provision of healthcare services will be assigned to special provincial administrations.

(b) The institutions attached to the Ministry (Refik Saydam Hygiene Center, Border and Coast Health Directorate General, etc.) may have local organizations.

(c) Training hospitals will continue to be operated by the Ministry of Health.

(d) Some public hospitals will be given an autonomous status, other hospitals will be transferred to special provincial administrations.

(e) National programs will be executed by the Ministry of Health (probably the programs on fighting malaria, tuberculosis, trachoma; immunization; family planning; phenylketonury scan; fighting anemia, etc.)

(f) As they deem appropriate, special provincial administrations may transfer health institutions to municipalities, universities, professional organizations and private sector.

(g) Ministry of Health will be restructured. It is understood that the Ministry will be downsized and will mainly undertake a regulatory, standard-setting and supervisory role.

(h) A strategy development unit and a performance evaluation unit will be established under the Ministry. Annual plans will be prepared.

2. Health Transition Program. The basic arrangements of the Ministry of Health regarding the services are included in the program which has been introduced as “Health Transition Program”. This program has three main components: (1) Family Medicine, (2) Autonomous Hospitals, and (3) Universal Health Insurance. With respect to family medicine, the Law No. 5258 on “Pilot Implementation of Family Medicine” was adopted and put in force on 24 November 2004. The enforcement of the Law No. 5510 on Social Insurance and Universal Health Insurance has been postponed by 6 months by the Constitutional Court. The Hospital Unions Draft Law (autonomous hospitals law) is being prepared.

The key differences of the family medicine practice from the currently effective Socialized Healthcare services may be listed as follows:

1- The principle of “broad and comprehensive service in narrow geographical region” under the socialization model has been converted to the principle of “non-integral service divided as preventive and curative, based on family without any geographical definition and focusing on only curative services” under the Family Medicine Pilot Practice Law and related legislation texts.

2- The “team” service under socialization has been replaced with “doctor-focused” service.

3- The principle of “healthcare services to everybody, everywhere, any time and service provision to non-applicants as well” has been replaced with the principle of “service provision only to applicants and to those who have access”.

4- The patient forwarding chain, which is an indispensable element of universal health organizations has been completely abolished under the family medicine pilot practice.

5- Under the pilot practice, records are kept only for the contracted individuals, services are not supervised on a demographic and settlement place basis, and therefore planning and evaluation are not possible.

6- The family medicine pilot practice has further deepened the urban-rural and urban-suburban inequalities, and the ability of rural population to have access to healthcare services has been further restricted. Although this issue has been realized, the “Public Health Centers” approach introduced as an alternative is far from being integral and from responding to the public’s need for curative services. What’s more, while local health centers are established in settlement units with population of 10-15 thousand, this threshold has been set as 100,000 for Public Health Centers. The functions of these centers are not clear yet, either.

7- In general terms, the pilot practice seems to be intended to care for the relatively developed urban settlement areas through a populist approach, rather than producing solutions for the problems of poor individuals who need healthcare services more. This cannot be expected to raise the general health level of the society.

The draft law on “Universal Health Insurance”, which allegedly was intended to produce solutions for the financing issues of healthcare services, has been turned down by the judiciary. The institutions financing and offering the service are privileged; a premium-based universal health system will be established. Although this insurance system is told to be organized in tune with the social insurance model, it is understood that private insurance will also be incentivized. The way how insurance premiums will be collected is unclear. However, it is anticipated that a special insurance organization will be established to collect these premiums. This financing system, whereby the healthcare services are limited by “security package”, is not an appropriate financing method for our country due to both the fact that health is an unforeseeable phenomenon in its nature and the possibility that it will incentivize additional payments by individuals.

The basic principles regarding the organization and provision of healthcare services must be as follows:

1- It is the primary duty o states and governments to offer health, education, security and justice services to their citizens.

2- The healthcare services of each country must be peculiar. It is not possible to argue that the models applied successfully in other countries will be successful in our country as well.

3- The health organization in our country must be as simple, accessible and extensive as possible and its supervision and coordination must be easy.

4- Basic healthcare services are “sine qua non” and must be offered to everybody for free of charge as a principle. What these services are may be determined through laws. However, the following services must definitely be free of charge: immunization (vaccination), family planning, prevention of risky pregnancies, fighting tuberculosis, malaria, trachoma; programs for reducing infant mortalities (including diarrhea, pneumonia-penicillin), pre-delivery care, deliveries, health education, school health, forensic medicine, environmental protection services (clean water supply, removal of wastes, etc.) first degree examination services, life-saving medicines, health improvement programs regarding the prevention of common diseases.

5- Because health is a human right, healthcare services must be provided to everyone, any where and any time. Based on this view, the “same” healthcare service system must be run nationwide.

6- No public agency other than the Ministry of Health, Armed Forces and universities must provide patient care services.

7- A hybrid method may be followed in financing healthcare services. Every citizen of the Republic of Turkey must have health insurance. However, the abovementioned Basic Health Services must be financed from the government budget. Beneficiaries may directly contribute to certain expenditures. Governments must determine which services will be financed from public funds, which services will be financed by individuals and at what rates. When determining these, the principle that funds be allocated mainly from public resources and the criteria of fairness must be observed.

8- Healthcare services must be organized according to population and the principle of “wide variety of services in small area”.

9- It is essential that preventive and curative services be provided together (integrity).

10- In the organization of services “individual” (rather than patient) and “healthcare services (rather than medical services) must be taken as a basis. Based on this view, the healthcare team providing basic healthcare services is responsible for raising the health level of their society.

11- Healthcare services necessitate a team work. Each member of healthcare teams is important and valuable.

12- Local differences must be taken into consideration in the provision of healthcare services.

13- It is essential that the administrators at all levels of healthcare services be equipped with the both technical and administrative skills and knowledge (on merits basis). The public health specialists raised with such an education must be used as administrator and advisor at all levels of healthcare services.

14- It is essential that services be supervised continuously and in a planned manner.

15- Healthcare staff must be trained and used in line with the quantitative and qualitative planning across the country.

16- At least one training and research zone must be operated at each university in order to train doctors and other healthcare staff. The Ministry of Health and related universities must act together in the management of these zones.

17- Performance evaluation in healthcare services may be in the form of measuring the improvements in the health level of society and evaluating the overall success of healthcare team.

18- It is essential that healthcare staff be encouraged and incentivized. These incentives may be in the form of material or non-material rewards.

19- One of the principles of healthcare services provision is to prioritize the individuals at risk. According to this principles, those who are actually at risk are the individuals who do not go to doctor. Therefore, healthcare teams (including doctors) must work within a model whereby they can reach out the individual who do not apply to them.

20- Due to the change in the demographic structure of our country and the variations in the disease patterns, importance must be attached to the studies and programs towards problems of the elderly and the early diagnosis and treatment of chronic diseases, within the framework of basic healthcare services.

21- Healthcare service must not be conceived merely as an “individual work”, but it must be addressed at the community level and public interests must be kept on the foreground in healthcare services. That is, the task of healthcare services must be to meet the needs of the society, rather than the needs of individuals.

22- Healthcare services are such multi-dimensional that they cannot be provided only by the health sector, and inter-sectoral cooperation must be essential.

23- It is essential that the public get involved in the planning and provision of healthcare services.

As in the case of every change to a system, the changes planned to be introduced in the area of healthcare services by our Government have positive and negative aspects, undoubtedly. The important point is that the positive aspects of the new system and its superiorities over the former system must overweigh its negative aspects. If it can be proven that the positive aspects of the government’s “health transition” model overweigh the negative aspects, this attempt should undoubtedly be accepted by HASUDER as well. The only way to prove this is to have the pilot practices evaluated by an independent agency according to scientific principles. However, unfortunately, it is understood that such an evaluation cannot be undertaken and that the Ministry of Health is the only authority which will decide whether the new system is successful or not. Whereas, the monitoring and observation of the practices to date reveal that the “health transition program” and particularly the “family medicine practice” have aspects which do not comply with the above listed principles and which will have irreversible consequences. These drawbacks and mistakes demonstrate that the negative aspects of health transition program overweigh its positive aspects.

Some of the important drawbacks are as follows:

1- Uncertainty. Although a pilot implementation law has been passed for family medicine, the regulations issued for the enforcement of the law are amended frequently. It is understood that the Ministry has not decided how a “reform” will be undertaken and the system is tried to be developed by finding solutions as problems emerge during implementation. Therefore, the family medicine model implemented in Turkey does not resemble any of the models in other countries. As a matter of fact, Düzce Provincial Health Director has described this model as “Düzce model”.

2- Complicated organization. Healthcare services in Turkey are rather complicated. If the local healthcare services are transferred to special provincial administrations, healthcare services will become even more complicated. If the “Public Administration Basic Law” is adopted (or the principles of this law are incorporated into other laws), both many institutions will come up and these institutions will not be permanently attached to the dame authority but will shift frequently. For instance, a unit transferred by the special provincial administration to a municipality may be transferred to another institution later on. In such a complicated structure, it will be quite difficult to offer services, and we even worry that such a structure will start a chaos in service provision.

3- Healthcare services provision by municipalities. Healthcare services are technical services by their nature and must be executed in a professional manner. It is not possible to argue that the structural problems, resources and human resources of municipalities will enable the execution of these services. It would be more rationale that municipalities get engaged in environmental improvement, food control, etc., which indirectly relate to health.

4- A model that does not fit national circumstances. Although the proposed complicated model is not implemented in any country, it is understood that the some western and north European countries have been taken as a basis in the preparation of the model which is defined as family medicine. These countries are very different from Turkey economically, socially and geographically. It is doubtful that the model implemented in these countries successfully will be successful in Turkey as well. For example, neither the rural structures nor the educational, economic and cultural levels of countries like Denmark, UK and the Netherlands resemble Turkey.

5- Difficulty of supervision. It will be difficult to supervise the proposed complicated model. In an environment where there is uncertainty as to which institution will be responsible from which tasks and from which regions, it is not possible to make supervision and there will be a vacuum in service provision. Since there is already an overall weakness in supervision activities in our country, such a complicated structure will be very dangerous. Healthcare services in Turkey must be organized as simple as possible such that they can be easily supervised.

6- Uncertainty over the type of family medicine. In the regulations issued for the family medicine practice, it is stated that family doctors can make medical interventions allowed by their own educational background but cannot make other interventions. That is, the powers of practitioner and specialist family doctors are different. Even, the powers of a family doctor specialized on family medicine and a pediatrician family doctor will be different. Therefore, a standard family doctor type has not been defined under the existing practice. This is very dangerous and it is not possible to supervise it. This may lead to many legal problems. In a country, all doctors working in the first degree must be equipped with the same powers.

7- Definition of “family doctor” is wrong. When one talks about “family doctor”, we understand a family doctor who is responsible for all members in a family. However, according to the practice in our country, members of a family may choose different family doctors. The doctor defined as “family doctor” in our country is indeed an “individual doctor”.

8- Coordination difficulty. Under the proposed complicated structure, the coordination among institutions and establishment will also be difficult. Ministry of Health will have to deal with many institutions. For instance, a circular issued from the center will reach all healthcare institutions (most of which will be private) in a long period of time. Difficulties may arise in disaster and crisis management.

9- A model conflicting with the principle of integrated service. Under the family medicine model, a “public health center” will be established in every sub-province (or for every 100,000 people). This center will execute administrative procedures, provide preventive services for the environment and certain individuals, and execute community programs (malaria, etc.). Thus, although preventive and curative medicine services are required to be provided integrally (under family medicine), it is understood that these services have been unbundled. On the other hand, considering the mission assigned for these centers, which are planned to be established for every 100,000 people, this figure is obviously very insufficient.

10-Status of non-regional patients is unclear. In this system, problems may be encountered in the examination of individuals who have temporarily gone to a settlement unit from another. In the Düzce practice, it has been reported that the guests coming to the city and the non-residents of that city are being examined at public health centers. This practice may be possible in provinces like Düzce where the number of non-resident patients is fairly low. But, it cannot be implemented in tourism resorts such as Bodrum, Antalya and in big cities.

11- A system excluding rural sector. The basic principle of the family medicine practice is the freedom of doctors to provide service anywhere they wish. This means, doctors decide where they want to work. Apparently, doctors will consider the development level of the cities were they will work. Therefore, it may not be possible to provide services in deprived regions in the near future, under this system. In this case, doctors will primarily prefer developed regions, and there will be doctor insufficiency in rural and underdeveloped regions until the developed regions become saturated. For this reason, under the existing pilot practice, people living in urban areas can choose their family doctors whereas people living in rural areas are registered on the lists of appropriate family doctors. In other words, the family medicine system excludes rural people. This approach is in conflict with the principle of “freedom to choose doctor” in the family medicine model. In short, the family medicine model adopted in Turkey is for urban areas, but rural areas have been ignored.

12- A system with no backup. Although it is argued that doctors will work under contracts, nobody can guarantee that a doctor who has agreed to work in a region will not leave that region after a short while by regret. This will have the following concrete consequence: Say, two family doctors have started working in a settlement unit with a population of 6,000. If one or both of them leave that settlement unit or die, it uncertain how this vacuum of duty will be eliminated.

13- Treatment-focused service. It is a fact that the family medicine model being implemented is a treatment-focused model. It would not be realistic to foresee that these doctors will visit villages, provide mobile service and reach out the non-applicant or at-risk population. Preventive services have been largely neglected under this model. As a matter of fact, the pilot practice observed to date demonstrate that there has been an apparent regression in individual preventive services primarily including family planning, vaccination, pregnancy-infant follow-ups.

14- Individuals with chronic diseases may be excluded. One of the basic principles of family medicine system is the freedom to choose doctor. However, where there is a freedom to choose doctor, there will also be “freedom to choose patient”. For instance if a person who chooses a doctor is not accepted by that doctor, he cannot be listed by him. Doctors may not choose to accept old people, infants, patients with chronic diseases or problematic cases. Similar problems have been experienced in the UK. The UK has solved this issue by paying more money to doctors for such patients.

15- Expensive system. Family medicine system is an expensive system. The number of family doctors needed for our country has been roughly estimated as 28,000. Assuming that YTL 7,500 will be paid on average to each family doctor per month, YTL 2.5 billion will be paid only to family doctors in a year. This figure is more than half of the annual budget of the Ministry of Health. What’s more, if the fee-for-service payment system is adopted (both some services of family medicine and hospital expenditures will be financed as such), the resources of our country cannot finance these services. The performance evaluation practice under the fee-for-service practice will further increase the funds to be spent for healthcare services. This because, doctors will focus on money-making services in order to get a greater share. Furthermore, special provincial administrations may transfer any health institution to the private sector if they decide so. This practice will further increase the cost of services. On the other hand, the high diagnosis technology they will use will play a key role in family doctors’ contracting with individuals. The doctors who have higher technology equipment will be preferred more, which will encourage the use of inappropriate, expensive, imported equipment.

16- Privatization. The primary damage of health transition program will be the privatization of healthcare services. The family doctors in this model are in fact private doctors who have signed contracts with the Ministry of Health. In other words, the Ministry of Finance has chosen to outsource its first degree services by using private doctors. The same approach has also be adopted for hospitals. The same approach is also observed in the law adopted by the Parliament on 13 February 2007, which allows foreign doctors to establish private hospitals and work in Turkey. The planned Universal Health Insurance system is a product of the same approach.

17- Labor security. Under the model proposed by the Government, contracted doctors and family medicine staff will be employed as explained above. Employment of contracted staff will eliminate labor security and the non-employed people will become totally unemployed. Healthcare labor force will become cheaper, and healthcare services, which cannot be put under risk under no condition, will be left to health workers who do not receive what they deserve for their efforts.

In recent years, together with the globalization all around the world, the fact that access to healthcare services is a right acquired at birth has been ignored and a process has started to eliminate the public service status of these services. Unfortunately, this applies to our country as well. The “Health Transition Program”, which introduces radical changes to the health organization and financing in Turkey, created an impression that it provides unlimited access to healthcare services for our people at first sight, and has started to be implemented without accounting for any financial resources. Transfer of unlimited funds by social security organizations is an unacceptable practice in health management models. When the limited resources of our country are depleted, we may be at a no-return point, unfortunately. HASUDER is for the provision of continuous, high-quality and efficient healthcare services to our country through efficient and effective use of our country’s financial resources. In this context, the Health Transition Program being executed by the Ministry of Health is threatening the health of our public, and our association does not support this program.

On the other hand, concurrently with the Health Transition Program, the “Family Medicine Organization” pilot practice has been introduced. When importing system from developed countries, their compliance with the socio-cultural and cultural circumstances of our country must be evaluated. This practice, which has been introduced without undertaking such an evaluation, is unfortunately focused solely on treatment, and preventive services are planned to be provided to only those individuals who request them. However, as everybody knows, the disadvantaged groups who need highest level of preventive services primarily include people with low socio-cultural level. Everybody knows that our country cannot even meet even the insufficient service demand of these poor and uneducated groups. For these disadvantaged groups who currently do not have adequate access to healthcare services, it will become even more difficult to have access to curative services. As known, the word “pilot” means “trial-experiment” and is applied in a limited area for a certain period of time, after which an evaluation is undertaken. Depending on the results of such evaluation, it is either adopted partially or wholly, or rejected. However, these scientific requirements are not fulfilled in our country. The pilot practice irreversibly violates the currently effective Law No. 224 in the provinces where it is implemented, and reversibility has become impossible in case of any failure of the pilot practice. Furthermore, even without evaluating the results of pilot practice and solving the problems detected, pilot practice is introduced in new provinces and the new system is actually spread all over the country. This practice is spread without putting in place a new legal basis and without taking into account the existing law. This seems to be a non-scientific and illegal practice.

The Association of Public Health Specialists (HASUDER), to which more than 75 percent of public health specialists in Turkey are members, wants all obstacles be removed on the path of making healthcare services accessible by all members of our public on a fair basis. HASUDER is ready to cooperate with all related parties, primarily including the Ministry of Health and Turkish Medical Association, in order to ensure the provision of healthcare services to all people in the best way possible. HASUDER recommends that the “Family Medicine Pilot Practice “ be ceased urgently within its irreversible consequences emerge.

1- HASUDER wants the principles of the currently effective Law No. 224 be maintained and enforced. The practice of the socialization of healthcare services must be evaluated through scientific methods and the problems therewith must be determined. There is no need to conduct a new research to this effect; researches have already been conducted and the assessments of the experts who have conducted these researches are adequate. Our association is aware of the fact that there are significant problems in the enforcement of Law No. 224. A significant portion of their problems stem from implementation. The primary factor underlying these practical problems is the fact that administrations do not have a decisive policy for providing first degree healthcare services as comprehensive, public and integrated services and making it the core of the entire healthcare system.

2- First degree healthcare organization must be region-based, rather than individual/family-based, and must observe the principle of team service in small area. Local health centers (First Degree Health Institutions) must be preserved. However, the services of local healthcare services may be planned as “small region-based (district-based). Each district defines an area that has a population of minimum 2,000 and maximum 3,000, corresponding to the Health House/Midwife Area as defined in the Socialized Health Organization. The responsibility of each district region must be assigned to a team consisting of one doctor and –depending on the priority health problem of the region- minimum one midwife or nurse. The annual preventive and curative service achievements of individuals served by a district doctor/team must be evaluated periodically and this evaluation must also be taken into account in the evaluation of the team’s success in addition to the satisfaction of people.

3- The first degree health service model must be a flexible model to respond to the needs of various sections of the society, the mobile nature of service for risk groups must be preserved, but mobile service (care and follow-up at home) must be planned according to different risk groups in regions. For instance, in regions with high birth rate and common and priority women and child health problems, mobiles services must be planned towards women and children, whereas the elderly must also be included in the scope of these services in regions where the problems of old people are common. Risk groups must be further diversified according to the characteristics of the region, and individuals must be able to be invited to health centers via various means of communication in socio-economically developed regions.

4- At the urban health centers (especially those in big cities), specialized doctors primarily including family medicine specialists, internal diseases specialists and specialist pediatricians must be able to be employed. Such specialist doctors will serve as consultants for the district/regional doctors at health centers, but will not be directly engaged n patient examination, by-passing the district/regional doctors. The education of family medicine specialists must be supported with adequate preventive medicine and health administration training, and these specialists may assume administrative duties in urban health centers.

5- The region-based organization unit (local health center) to be restructured –especially the selected health centers in big cities-must be supported with mouth-dental health, physical therapy and rehabilitation and chronic patient follow-up technologies as well as competent non-doctor health human resources in these fields (physiotherapist, dietician, laboratory assistant).

6- The powers and responsibilities of health directors must be reviewed in order to ensure the coordination, supervision and orientation of health centers and their district teams as well as service-priority based planning at the provincial level. Implementation must be undertaken accordingly. Public health specialists must take administrative positions in various units of the central and local organizations of the Ministry of Health.

7- Healthcare services are so multidimensional that they cannot be provided only by the health sector and they necessitate inter-sectoral cooperation. Regarding the public health-related activities currently performed by the Ministries of Environment and Agriculture as well as municipalities; the powers of the Ministry of Health as the primary responsible agency must be re-defined in cooperation with these agencies, and it must become a coordinating unit for these activities.

8- District/first degree doctors must constantly cooperate with second degree health service units (hospitals) and the patient forwarding chain must be strengthened with feedbacks.

9- The health centers laboratory development practices currently implemented by the Ministry of Health at some health centers has been successful. The Ministry of Health ahs proven that health centers may be upgraded to keep up with the changing conditions and that this can be successful. This practice must be expanded and all health centers must be equipped with adequate diagnostic-therapeutic technologies. To this effect, adequate human resources (laboratory assistants) must be raised and employed.

10- The teaching programs of faculties of medicine and health higher schools must be society-focused, and the continuous training healthcare staff must be planned and executed together with vocational higher schools, universities and the Ministry. The credits obtained as a result of these training programs must be positively reflected to their personnel rights. The practitioner doctors working at health centers must be able to participate in Medical Specialization Programs (General Practitioner Specialization, family Medicine Specialization, etc.) which are executed in their city or region by the Ministry of Health, Higher education Council and Turkish Medical Association and which fit their working schedule.

11- The principle that “each individual living in rural areas must have an accessible healthcare staff within reach” must be preserved. The currently effective Socialized Health Organization which has been implemented successfully all around the world for more than 40 years is indispensable and has no alternative for rural areas. Budgetary support for healthcare services provision in rural areas must be increased; wages of healthcare staff working at rural health centers must be increased and their transportation, infrastructure and vehicle-equipment (including medicines) problems must be solved.

12- Contracted staff employment cannot be accepted as a staff employment model. The Healthcare Staff Law must be passed urgently and harmonization must be ensured between this law and the law governing the service model. Thus, the uncertainties over the employment, waging and other personnel rights of healthcare staff must be eliminated. Sub-contracted service provision, which has become increasingly more common among health institutions, is not favorable for the employees and also threatens public health.

13- HASUDER believes that universal heath insurance cannot and must not be implemented through the method of premium collection. The health financing system must be a social security system based on fund–raising (taxation) according to income and service provision according to needs. That is, primary source of healthcare services financing must be the taxes and government budget, and UHI must be implemented this way. However, in order to support the government budget, a “Social Health Security Agency” covering every individual living in the country must be established. This agency may be in the form of a country-wide expansion of the “Pension Fund Model” which is applied for civil servants in our country. It is essential that healthcare services be financed from the government budget. The premiums to be paid by employers for their employees must be directly paid to the Social Health Security Agency.

14- The additional payment (performance) system which is currently applied mainly in the form of payment per patient examined, through an improper, unlimited and populist approach, is not appropriate and scientific-based at both hospitals and health centers; this system is wasting our resources. Conceptually, it may be a good approach to reward the working staff members in order to increase institutional efficiency. For instance, in the UK, additional payments are made on the basis of activities such as follow-up of risk groups, rather than per outpatient diagnosis service. These additional payments are financed from the budget. This is a practice that must be supported in order to raise the quality of service. In Turkey, this additional payment/promotion system must be revised such that it will cover all services of district teams –mainly preventive healthcare services- and will be reflected to their retirement and personnel rights. However, as compared with the wages of employees, these additional payments must not constitute their main income source, but must be limited to a certain rate of their wages. To the extent possible, additional payments must be financed directly from the budget of Ministry of Health. The direct relation of social security organizations and health institutions must be disconnected, and this relation must be established via the Ministry of Health (social security system contribution to general budget).

The Association of Public Health Specialists (HASUDER) hereby shares the above listed recommendations with our people, government, political parties, professional chambers, labor unions, non-governmental organizations and organs of press. We reiterate our call for a real and constructive cooperation for the health of our nation, before getting into a no-return path.