Elsevier

The Lancet

Volume 382, Issue 9886, 6–12 July 2013, Pages 65-99
The Lancet

Health Policy
Universal health coverage in Turkey: enhancement of equity

https://doi.org/10.1016/S0140-6736(13)61051-XGet rights and content

Summary

Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003–13, which coincides with the Health Transformation Program (HTP). The HTP rapidly expanded health insurance coverage and access to health-care services for all citizens, especially the poorest population groups, to achieve universal health coverage. We analyse the contextual drivers that shaped the transformations in the health system, explore the design and implementation of the HTP, identify the factors that enabled its success, and investigate its effects. Our findings suggest that the HTP was instrumental in achieving universal health coverage to enhance equity substantially, and led to quantifiable and beneficial effects on all health system goals, with an improved level and distribution of health, greater fairness in financing with better financial protection, and notably increased user satisfaction. After the HTP, five health insurance schemes were consolidated to create a unified General Health Insurance scheme with harmonised and expanded benefits. Insurance coverage for the poorest population groups in Turkey increased from 2·4 million people in 2003, to 10·2 million in 2011. Health service access increased across the country—in particular, access and use of key maternal and child health services improved to help to greatly reduce the maternal mortality ratio, and under-5, infant, and neonatal mortality, especially in socioeconomically disadvantaged groups. Several factors helped to achieve universal health coverage and improve outcomes. These factors include economic growth, political stability, a comprehensive transformation strategy led by a transformation team, rapid policy translation, flexible implementation with continuous learning, and 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).

Introduction

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

  • 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).

  • 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.

  • 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.

  • 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.

  • 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.

Section snippets

Turkey: key facts

The Republic of Turkey was created in 1923, after the end of the Ottoman Empire, the roots of which date back to 1299. At its largest, the Ottoman Empire covered parts of Europe, Asia, the Middle East, and Africa. Turkey is now an upper-middle-income country of 75·6 million people in 81 provinces, at different stages of socioeconomic development (figure 2), and straddles Asia and Europe. Turkey has undergone rapid economic growth in the last decade, and has the demographic benefit of a young

Acceleration of the journey to UHC in Turkey: implementation of the HTP

To build on and accelerate efforts that began in the 1960s, the HTP articulated a comprehensive strategy to achieve UHC by strengthening key health system functions of governance, financing, and service delivery. The HTP adopted a rights-based philosophy and set out to improve public health, expand access to health insurance for all citizens, ensure provision of high-quality health services, and develop a patient-centred health system to rectify the inequalities in access to health services and

Defining of citizens' rights to health and enhancement of provider accountability

The Directive on Patient Rights45 was introduced in 2003, with effective implementation in 2005, and helped to operationalise the Patent Rights Legislation46 that was enacted in 1998, but not implemented. The directive defined patient rights to health insurance and health services, and specified provider obligations in relation to patient rights, information provision, confidentiality, and patient consent for health interventions, and also provided citizens with the right to choose health-care

Effect of the HTP and UHC on access to maternal and child health services and child mortality

Analysis of the Turkish Demographic and Health Survey 1993–2008 shows that the use of maternal and child health services improved substantially throughout Turkey in this period, and especially in 2003–08. Improvements occurred in all regions of the country, especially after 2003 in the less well-served east region, rural areas, and in socioeconomically disadvantaged groups (table 5).

Discussion

The HTP accelerated six decades of efforts in Turkey to achieve UHC. With sustained leadership from a committed transformation team, Turkey successfully introduced changes in key health system functions of organisation and governance, financing, resource management, and service delivery. These changes helped to address three major problems faced by the Turkish health system: inadequate and inequitable health financing; inadequate and inequitably distributed health infrastructure and health

References (106)

  • J Gruber et al.

    Demand and reimbursement effects of healthcare reform: health care utilization and infant mortality in Thailand. National Bureau of Economic Research Working Paper 17739

    (2012)
  • Successful health system reforms: the case of Turkey

    (2012)
  • B Samb et al.

    An assessment of interactions between global health initiatives and country health systems

    Lancet

    (2009)
  • R Atun

    Health systems, systems thinking and innovation

    Health Policy Plan

    (2012)
  • RD Swanson et al.

    Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change

    Health Policy Plan

    (2012)
  • R Atun et al.

    Health systems and systems thinking

  • World health statistics

  • JA Salomon et al.

    Healthy life expectancy for 187 countries, 1990—2010: a systematic analysis for the Global Burden Disease Study 2010

    Lancet

    (2012)
  • Trends in maternal mortality: 1990–2010. WHO, UNICEF, UNFPA and The World Bank estimates. The Maternal Mortality Estimation Inter-Agency Group

    (2012)
  • Health statistics yearbook

  • WHO vaccine-preventable diseases: monitoring system 2012 global summary. Turkey reported immunization coverage. Last update October, 2012

  • Levels and trends in child mortality. Report 2012. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation

  • Global Health Observatory Data Repository. MDG 4: child mortality: infant mortality by country

  • Global Burden of Disease Study 2010. GBD compare. Turkey

  • OECD Factbook 2009: Economic, environmental and social statistics

    (2009)
  • Turkey Marmara Earthquake Assessment

    (1999)
  • Life satisfaction survey [in Turkish]

  • Frequently requested data

  • WHO Health for all database

  • M Aran et al.

    Protection in good and bad times? The Turkish Green Card Health Program. World Bank Policy Research Working Paper No. 6178

    (2012)
  • European health for all database (HFA-DB). World Health Organization Regional Office for Europe. Updated January, 2013

  • World development indicators 2013

    (2013)
  • R Akdag

    Health Transformation Program 2003–11. Progress Report

    (2013)
  • Hacettepe University, Institute of Population Studies

  • Hacettepe University, Institute of Population Studies

  • Turkey Health Transformation Program

  • Turkey: reforming the health sector for improved access and efficiency

    (2003)
  • The Ministry of Health of the Republic of Turkey

  • The Ministry of Health of the Republic of Turkey

  • OECD/World Bank Review of the Turkish Health System, 2008

    (2008)
  • Patient satisfaction with primary health care services 2011 [in Turkish]

    (2011)
  • The Tallinn Charter: health systems for health and wealth

  • Health system performance assessment

  • Health systems functions

  • R Akdag

    Turkiye Sağlıkta Dönüşüm Programı Değerlendirme Raporu 2003–2010 [in Turkish]

    (2011)
  • Life satisfaction statistics

  • Health satisfaction survey

  • The Directive on Patients Rights

  • The Republic of Turkey. Law on Patient Rights. 1998. Turkish Official Gazette no 23420, 1 August 1998 (Resmi Gazete....
  • World development indicators

  • Cited by (0)

    View full text