Universal health coverage (UHC) is an important way to expand access to effective health-care services, reduce financial hardship during illness, and improve health outcomes.1 In addition to appropriate legal provisions, which mandate access to necessary health services,2 UHC needs to be underpinned by a well-functioning health system that provides high quality, affordable, accessible, and efficient health services.
Recent experience from middle-income countries, including China,3 Mexico,4 and Thailand,5, 6 shows that expanded pre-pooled financing mechanisms, such as health insurance or social insurance, help to improve access to health-care services, while providing financial protection. Cross-country analyses suggest that, in general, broader health coverage and pooled financing lead to expanded access to necessary care, with improvements in population health, particularly for poor people.7
Additionally, many other middle-income countries, such as Brazil, Indonesia, the Philippines, Turkey, and South Africa, have sought to address inequalities in access to health care and in health outcomes through UHC by introducing pre-pooled health insurance schemes and health system-strengthening programmes. 22 low-income and middle-income countries are actively pursuing policies to achieve UHC.1 Hence, experience from different settings is crucially important to address the evidence gap7 on introduction of UHC and its effects on health service access, financial risk protection, health outcomes, and user satisfaction. Evidence from Turkey is especially timely for countries pursuing reforms to achieve UHC because, after 30 years of slow progress, since 2003 Turkey has been able to design and implement wide-ranging health system reforms8 to achieve UHC that substantially reduced inequities in health financing, health service access, and outcomes.
Key messages
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The Health Transformation Program in Turkey has introduced major changes to health system functions of stewardship and organisation, financing, resource management, and service delivery to achieve universal health coverage (UHC).
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UHC led to rapid expansion of health insurance coverage and access to health-care services for all citizens, especially for the poorest population groups. In particular, access and use of key maternal and child health services improved to help substantially reduce under-5, infant, and neonatal mortality, especially for socioeconomically disadvantaged households.
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Turkey shows the effectiveness of UHC as a platform to achieve health system goals and improve equity, with an enhanced level and distribution of health, fairness in financing with reduced catastrophic health expenditures, and substantially improved population satisfaction with the health system.
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Simultaneous improvements in the health system, on both the demand side (increased health insurance coverage, expanded benefits, and reduced cost sharing) and the supply side (expansion of infrastructure, health human resources, and health services), were crucial to accomplish improvements in use and outcomes.
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Economic growth provided the fiscal space for increased health expenditures to achieve UHC. Political stability, sustained leadership, a committed transformation team, positioning of health as a fundamental right, creation of a receptive context, a comprehensive transformation strategy, rapid policy translation, a flexible implementation approach with ongoing learning, and the combination of demand-side and supply-side changes were crucial factors that enabled the introduction of UHC.
We traced the trajectory of changes in Turkey in the journey towards UHC. We used a proprietary analytic framework (figure 1 and appendix p 1) that draws on previous studies9, 10 to provide a systems view11, 12, 13 of the contextual drivers of changes in the Turkish health system, transformations introduced in health system functions, and their effects on health system goals. We used qualitative and quantitative research methods, including documentary and policy analysis, and interviews with key stakeholders (appendix pp 2–13) to analyse transformations in key health system functions aimed at addressing inefficiencies and inequities in the Turkish health system and at achieving UHC. In particular, we analysed the transformations in governance and organisation, financing, resource management, and service delivery functions from 2003 onwards—the period coinciding with the Health Transformation Program (HTP) that rapidly intensified efforts towards UHC.
We used quantitative analysis, including econometric methods (appendix pp 2–13), to explore how the HTP and UHC helped to address three major health system problems in Turkey: inadequate and inequitable health financing with a fragmented health insurance system, low insurance coverage for the poorest populations, and high out-of-pocket expenditures; inequitable distribution of health infrastructure and human resources that led to inequalities in health service access; and inequities in health outcomes, with east–west, poor–rich, and rural–urban divides. We used maternal and child health services (antenatal care by trained staff, births in a facility, births attended by trained staff, and immunisation uptake) and health outcomes for children (under-5 mortality, infant mortality, and neonatal mortality) as tracers for health system performance because these areas were a priority for the HTP and for which reliable cross-sectional population data over time are available. We could not study changes in chronic illnesses, despite their importance, since reliable cross-sectional or trend data are scarce.
This report is organised into six sections. After this introduction, we provide a historical overview of key health system changes in Turkey and an analysis of the context preceding the HTP. In the third section, we explore the design and implementation of the HTP. In the fourth section, we present key findings for the achievements of the HTP in relation to health system organisation and governance, health financing (health insurance coverage and targeting poorer segments of the population, out-of-pocket expenditures, and financial protection), human resource management, and service delivery. In the fifth section, we present an analysis of the equity effects of the HTP and UHC on health service use and health outcomes, including an assessment of user satisfaction with the health system. Finally, we summarise the key findings and achievements of the HTP, placing them within the broader UHC literature, and discuss the sustainability of UHC in Turkey, identifying the key risks, challenges, and opportunities that lie ahead. We discuss the lessons learned from the UHC experience and explore how Turkey could be positioned in global health as we approach the 100th anniversary of the Turkish Republic in 2023.