Sabahattin AYDIN MD, PhD Dept. Undersecretary of MoH

1. The Success and Challenges in Strengthening Health System Performance through Eliminating Disparities in Health Services: Turkey Perspective Sabahattin AYDIN MD, PhD Dept. Undersecretary of MoH

2. *Health service is a field of constant development in which periodic requirements and strategies may vary. Keeping this aspest in mind, we need to focus many issues and challenges in health service delivery and purchasing Ministry Of Health of TURKEY, 2008

3. Before the reform agenda the main problems of our health system included fragmentation: • Public health care providers were ownd by different institutions. • Existence of multiple public health insurance institutions with different status. • lack of unity in implementation, • Problems which citizens used to suffer in the services because of different status. Ministry Of Health of TURKEY, 2008

4. common challenges: we can also mention about other challenges such as • lack of capacity of service providers in terms of technical, personnel and infrastructure, • long patient queues, waiting periods, • low salaries for physicians and other health personnel working in public sector, • due to low salary policies the increased number of private practices, • lack of an efficient and effective recording system Ministry Of Health of TURKEY, 2008

5. Reform agenda of HTP • Main driving force: • the political authorities ensured their full support and made valuable contributions • significant steps have been taken addressing the strengthening of health services. Ministry Of Health of TURKEY, 2008

6. Reform agenda of HTPp4p • Health personel motivation was achieved by supplementary payment implementation . • An unique model was designed to measure individual performance of physicians • Institutional evaluation of the health providers in terms of quality criteria effected the P4P Ministry Of Health of TURKEY, 2008

7. Reform agenda of HTPp4p • This implementation has resulted in increases in productivity, advancement in technical and physical structure of the hospitals. • The personnel of the institution have become more appertaining to their institutions. • Promoted the modernization of MoH hospitals • Helped harmonisation of public hospitals under the authority of MoH. Ministry Of Health of TURKEY, 2008

8. Reform agenda of HTPPPP Hospitals were allowed to outsource many facilities which induced competetive improvement The controlled share of private sector in service delivery is increased. Investments by PPP /PFI are on the way (?) Ministry Of Health of TURKEY, 2008

9. Reform agenda of HTPUHI • Disparities in service use by the citizens who are covered by different health insurances were aimed to be minimized. • As a first step, outpatient treatment and drug expenses of the green-card holders are covered by the State (insurance for the poor) • Benefits packet of workers was increased (SSK) • Universal Health Insurance Coverage Act was adopted. • Legislative process for harmonisation and universal coveredge was completed. Ministry Of Health of TURKEY, 2008

10. Reform agenda of HTPUHI • SocialSecurityInstitution, being the main authority of UHI, has gained a significant power as the sole purchaser which helped to minimise inequalities. • Through full implementation of universal coverage in 2009 and 2010, disparitiesand inequalitieswill be almost eliminated. Ministry Of Health of TURKEY, 2008

11. Reform agenda of HTPFM • Pilot implementation of family medicine has beenstarted in 2005 • At the mean time FM cevered 22 province with almost 15 million citicens (1/5 of population) • The main idea is to strengthen the primary healthcare services and ensure their efficiency. Ministry Of Health of TURKEY, 2008

12. Reform agenda of HTPHR • Strict human resource policy was adopted • Obligatory service for doctors was rearranged promoting to work in rural • A new ... system with higher salary in the rural area was lounched • Health personel movement within the country was made available according to “planning based on need”. • The ratio of doctor intensity between the highest and lowest changed from 1/14 to 1/4 Ministry Of Health of TURKEY, 2008

13. Reform agenda of HTPHIS • FM implementation was based on electronic recording and central evaluation of the data. • Hospital information systems were established, which enables precise and effective recording systems in terms of procedures and statistical data • Hence, the errors and defects in the recording system are avoided and this has contributed to the strengthening of financial structures of hospitals. • Online electronic controll system by SSI is implemented that prevented inequalities in invoice producing. • More reliable data became available to help policy making Ministry Of Health of TURKEY, 2008

14. Reform agenda of HTPPhr. Pricing Policy • In 2004,transparency is ensured in pricing system based on reference pricing. • This induced generic competition which caused considerably decrease in the prices • Significant alleviation in its burden on public finance helped to eliminate in equalities to access to medicines in different social groups. Ministry Of Health of TURKEY, 2008

15. Despite all political will, support and commitment, there is always a risk of resistance and obstacles in front of the reforms and programme processes. Ministry Of Health of TURKEY, 2008

16. Resistance to reforms • Harmonisation of hospitals drows resistance from different social groups • Integration of different social security institutions with different visions under one roof and establishing a solid new insurance mechanism is a hard process. • You have to deal with and overcome the monetary burden of improvement and development. • The policymakers face the risk of conflicts within different institutions within or outside the government • Convincing the Finance Ministries is the most important task Ministry Of Health of TURKEY, 2008

17. Other challenges • We are all aware of the shortage in qualified health personnel all around the world. • This shortage makes it more difficult during implementation process. • Therefore, the health personnel can suffer from time to time because of heavy burdens and workloads. • Trained and qualified personel easily shifts to private sector where they can earn more Ministry Of Health of TURKEY, 2008

18. Outcomes • Neonatal mortality rate (x/1000) • Maternal mortality rate (x/100.000) Ministry Of Health of TURKEY, 2008

19. The vaccination ratios (x/100) • The number of measles cases Ministry Of Health of TURKEY, 2008

20. Likewise, the prevalence of infectious diseases also decreased. • The number of malaria cases • The number of the typhoid fever cases Ministry Of Health of TURKEY, 2008

21. In addition, several campaigns have been initiated to decrease the prevalence of chronic diseases; • These include healthy nutrition programme, • Cardio-vascular diseases control programme, • Physical activity programme, • Tobacco Control Act, and etc. Ministry Of Health of TURKEY, 2008

22. The ratio of out-of pocket expenditure is recorded Ministry Of Health of TURKEY, 2008

23. After the implementation, the percentage of benefiting from primary healthcare services shows an increasing trend in areas where family medicine is implemented. About 60% admits to primary healthcare services are recorded. Ministry Of Health of TURKEY, 2008

24. Last but not least, access to health services is increased • Consequently the satisfaction of the citizens is increased (x/100) • life expectancy is increased. Ministry Of Health of TURKEY, 2008

25. THANK YOU Ministry Of Health of TURKEY, 2008