'Health transformation programme' in Turkey: an assessment

The aim of this study is to assess the 'Health Transformation Programme' (HTP) in Turkey announced in 2003. This assessment has been made according to the ultimate performance goals of a health care system, such as improvement in health status, financial risk protection and satisfaction with health care. This study provides a brief history of health policy since 1980, when the Turkish health care system began to transform with the introduction of both structural adjustment and market-oriented reform policy. The main aim of these reforms was increasing efficiency. Reform proposals of the 1990s focused on the introduction of a general health insurance (GHI) system, decentralization, introduction of a family medicine scheme, purchaser-provider split, contracting-out, quasi-markets and improvement of management information systems. Like the reform proposals of the 1990s, HTP has eight components, the major ones being a new role for the Ministry of Health (MoH), introduction of a GHI system, reorganization of health service delivery and human resources development. No component of HTP has yet been sufficiently realized. Therefore, despite some improvements, Turkish people continue to face low health status and a low level of financial risk protection. More research needs to be done for the determination of satisfaction with health services.     

Evaluation of individuals’ satisfaction with health care services in Turkey

Objectives

To demonstrate whether features related to the institution and service provider affect individuals’ level of satisfaction regarding the public health care services they receive.

Lower utilization of primary, specialty and preventive care services by individuals residing with persons in poor health

BACKGROUND: Since household time and financial resources for health care are primarily spent for those household members with the most urgent health needs, individuals residing with persons in poor health may be at risk of underusing health-care services. We examined whether these individuals had a lower use of primary, specialty and preventive care than those who did not reside with persons in poor health. METHODS: Data collected in 2000 from a representative sample of 8,210 French individuals aged 18 years and older from 3,810 households were analysed with logistic regression models adjusted for health, demographic and socioeconomic variables. RESULTS: We found that individuals residing with one other survey respondent had a higher risk of not using primary care, specialty care and preventive care in the 12 months preceding the study when the health status of the other survey respondent was poorer (fair or alternatively poor versus good). Furthermore, individuals residing with two other survey respondents had a higher risk of not using primary care, specialty care and preventive care in the 12 months preceding the study when they resided with a higher number of respondents in fair or poor health (one or alternatively two versus zero). CONCLUSION: The lower use of health services by individuals residing with persons in poor health may signal a need for health practitioners to broaden the scope of care beyond their patients, and for policy makers to consider the long-term impact of this situation on the health-care system.     

Privatization of health and publicization of violence: violence toward doctors in Turkey

In recent years, health professionals have been suffering from widespread violence in Turkey as well as in the world. Based on the data obtained from a fieldwork in Gaziantep and Kilis, this article aims to discuss neo-liberal transformation of the health sector and the consequences of this transformation in effecting violence toward doctors. The data shows that physicians working at public health institutions are the main victims of verbal and physical attacks coming from mostly patients and their companions. The social and economic context within which the violence toward physicians takes place is a process of restructuring of the provision of health service based on neo-liberal market logic. The health services and field are increasingly being shaped and redefined in accordance with economic logic like efficiency, profit, cost, competitiveness, and so on. These policy changes in the health sector have resulted in differentiation of health services, devaluation of public services, the stigmatization of employment in and consumption of, public health services as signs of low status as well as devaluation of general practitioners’ practices.     

The socio-economic determinants of maternal health care utilization in Turkey

The purpose of this study is to investigate the individual-, household- and community-level factors that affect women's use of maternal health care services in Turkey. The data used for the study come from the 1993 Turkey Demographic and Health Survey (TDHS), a nationally representative survey of ever married women 15 to 49 years of age. In order to assess the impact of socio-economic factors on maternal health care utilization, we use logistical regression techniques to estimate models of the prenatal care use and birth delivery assistance among women who have had at least one birth in the three years prior to the survey. Separate models are also estimated for urban and rural women. The results indicate that educational attainment, parity level, health insurance coverage, ethnicity, household wealth and geographic region are statistically significant factors that affect the use of health care services thought essential to reduce infant and child mortality rates. The results of the model are used to provide insights for both micro- and macro-level planning of maternal health service delivery.     

Are family medicine centres achieving their target in Turkey: Impact on health care utilization of mothers and infants

The family medicine (FM) system was introduced as the main source of primary care in Turkey as a component of the Health Transformation Program reforms. During a gradual implementation process, provinces switched to the FM system at different points in time between 2005 and 2010. In this paper, we use a micro‐level data set to test whether the health care utilization of mothers during pregnancy, childbirth and the postnatal period is affected by the program. Using a difference‐in‐differences method for estimation, we find that the program is only effective for pregnant women who lived in provinces with a limited availability of specialist doctors. As a result of the FM program, women are likely to have their first prenatal consultancy earlier and their probability of seeing a doctor during their prenatal visit and receiving an ultrasound and blood and urine sample checks increases if they live in a province with a low number of specialists per 10,000 people. We find that the impact of the FM program decreases as the rate of specialists in a province increases, which negates any positive effect of the program on health care use.     

The effect of wealth status on care seeking and health expenditures in Afghanistan

This paper analyses the effect of wealth status on care-seekingpatterns and health expenditures in Afghanistan, based on anational household survey conducted within public health facilitycatchment areas. We found high rates of reported care-seeking,with more than 90% of those ill seeking care. Sick individualsfrom all wealth quintiles had high rates of care-seeking, althoughthose in the wealthiest quintile were more likely to seek carethan those from the poorest (odds ratio 2.2; 95% CI 1.6, 3.0).The nearest clinic providing the government's Basic Packageof Health Services (BPHS) was the most commonly sought firstprovider (53% overall), especially for relatively poor households(62% in poorest vs. 42% in least poor quintile, P < 0.0001).Sick individuals from wealthier quintiles used hospitals andfor-profit private providers more than those in poorer quintiles.Multivariate analysis showed that wealth quintile was the strongestpredictor of seeking care, and of going first to private providers.More than 90% of those seeking care paid money out-of-pocket.Mean (median) expenditures among those paying for care in theprevious month were 873 Afghanis (200 Afghanis), equivalentto US$17.5 (US$4). Expenditures were lowest at BPHS clinicsand highest at private providers. Financing care through borrowingmoney or selling assets/land (‘any distress’ financing)was reported in nearly 30% of cases and was almost twice ashigh among households in the poorest versus the least poor quintile(P < 0.0001). Financing care through selling assets/land(‘severe distress’ financing) was less common (10%overall) and did not differ by wealth status. These findingsindicate that BPHS facilities are being used by the poor wholive close to them, but further research is needed to assessutilization among populations in more remote areas. The highout-of-pocket health expenditures, particularly for privatesector services, highlight the need to develop financial protectionmechanisms in Afghanistan.     

实施社区卫生服务收支两条线管理的财政可行性分析

目的了解社区卫生服务收支两条线管理的财政可行性。方法预测试点地区全区域实施社区卫生服务收支两条线改革所需投入水平，以及所预测的投入水平占财政支出和卫生事业支出的比例。结果预测全区域进行社区卫生服务收支两条线改革需要政府投入的水平与目前政府实际投入水平相差不大。结论在东部地区和部分中西部地区，政府已经具备财政能力在全区域实行社区卫生服务收支两条线改革；改革的难点不是财政实力问题，而是相应的监管问题。     

Diffusion of complex health innovations--implementation of primary health care reforms in Bosnia and Herzegovina

Most transition countries in Central and Eastern Europe and Central Asia are engaged in health reform initiatives aimed at introducing primary health care (PHC) centred on family medicine to enhance performance of their health systems. But, in these countries the introduction of PHC reforms has been particularly challenging; while some have managed to introduce pilots, many have failed to these scale up. Using an innovation lens, we examine the introduction and diffusion of family-medicine-centred PHC reforms in Bosnia and Herzegovina (BiH), which experienced bitter ethnic conflicts that destroyed much of the health systems infrastructure. The study was conducted in 2004-05 over a 18-month period and involved both qualitative and quantitative methods of inquiry. In this study we report the findings of the qualitative research, which involved in-depth interviews in three stages with key informants that were purposively sampled. In our research, we applied a proprietary analytical framework which enables simultaneous and holistic analysis of the context, the innovation, the adopters and the interactions between them over time. While many transition countries have struggled with the introduction of family-medicine-centred PHC reforms, in spite of considerable resource constraints and a challenging post-war context, within a few years, BiH has managed to scale up multifaceted reforms to cover over 25% of the country. Our analysis reveals a complex setting and bidirectional interaction between the innovation, adopters and the context, which have collectively influenced the diffusion process. Family-medicine-centred PHC reform is a complex innovation-involving organizational, financial, clinical and relational changes-within a complex adaptive system. An important factor influencing the adoption of this complex innovation in BiH was the perceived benefits of the innovation: benefits which accrue to the users, family physicians, nurses and policy makers. In the case of BiH, policies or the innovation are not simply disseminated, but rather assimilated into the health system. The assimilation and implementation of the new PHC model relied on the consensus of a diverse group of adopters; the changes brought by the reforms were aligned with the expectations of the adopters: this created a 'receptive context' for adoption and diffusion of the innovation. The new family-medicine-centred PHC service model had a major impact on professional identity, inter-professional relationships and organizational routines. The post-conflict context was perceived as an opportunity to introduce the new model and implement transformational change, while the complex government structure meant the process of diffusion was as important as the innovation itself. In BiH, a holistic approach-comprising multifaceted and simultaneous interventions at multiple levels of the health system-reduced 'policy resistance' and enhanced the adoption and diffusion of the PHC reforms.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

The impact of no-fault compensation on health care expenditures: An empirical study of OECD countries

Around the world, governments are faced with spiralling health care expenditures. This raises the need for further insight in the determinants of these expenditures. Existing literature focuses primarily on income, ageing, health care financing and supply variables. This paper includes medical malpractice system characteristics as determinants of health spending in OECD countries. Estimates from our regression models suggest that no-fault schemes for medical injuries with decoupling of deterrence and compensation reduce health expenditures per capita by 0.11%. Furthermore, countries that introduced a no-fault system without decoupling of deterrence and compensation are found to have higher (+0.06%) health care spending.     

Do health care reforms in Turkey have a significant effect in equal access to maternal and child health services in Turkey: An evidence from 20 years

This study aimed to investigate whether there was an improvement in the equitable access to maternal and child health care services by examining the effects of socioeconomic and individual factors in Turkey from 1993 to 2013 and determine the effectiveness of health care reforms implemented mainly under the Health Transformation Program since 2003 on equitable access t;o maternal and child health care services in terms of years. The study used nationally representative 5 Turkey Demographic and Health Surveys (1993, 1998, 2003, 2008, and 2013). Prenatal care utilization rate increased from 67.0% in 1993 to 96.2% in 2013 while the rate of women giving birth at health care facilities increased from 63.8% to 98.1% in 2013. Prenatal care utilization and giving birth at health care facilities were higher among women who were under health insurance coverage, first time mothers, those staying in the western region and urban areas, and those with the highest level of wealth. The findings suggest that the issue of equity in the utilization of maternal and child health care services exists in Turkey, and the latest health care reforms under HTP are not effective in diminishing the effect of wealth.     

How primary care reforms influenced health indicators in Manisa district in Turkey: Lessons for general practitioners

Background: Turkish health reforms began in 2003 and brought some significant changes in primary care services. Few studies in Turkey compare the shift from health centres (HC) to family physicians (FP) approach, which was initiated by reforms.

Objectives: This study compares health status indicators during the HC period before reforms (2003–2007) and the FP period after reforms (2008–2012) in Turkey.

Methods: This study encompasses time series data consisting of the results of a 10-year assessment (2003–2012) in Manisa district. All the data were obtained electronically and by month. The intersection points of the regression curves of these two periods and the beta coefficients were compared using segmented linear regression analysis.

Results: The mean number of follow-up per person/year during the HC period in infants (10.5), pregnant women (6.6) and women (1.8) was significantly higher than the mean number of follow-up during the FP period in infants (6.7), pregnant women (5.6) and women (0.9). Rates of BCG and measles vaccinations were significantly higher during the FP period; however, rates of HBV and DPT were same. The mean number of outpatient services per person/year during the FP period (3.3) was significantly higher than HC period (2.8). Within non-communicable diseases, no difference was detected for hypertension prevalence. Within communicable diseases, there was no difference for rabies suspected bites but acute haemorrhagic gastroenteritis significantly decreased. The infant mortality rate and under five-year child mortality rate significantly increased during the FP period.

Conclusion: Primary care services should be reorganized and integrated with public health services.     

中国农村基本卫生保健工作发展与思考

目的：了解我国农村地区基本卫生保健工作的现状,以及在新世纪第一个十年中取得的成绩和存在的问题,为进一步推进农村基本卫生保健工作提出有针对性的政策建议。方法：按照分层抽样的方法,在全国选择400个县级行政单位,收集当地农村基本卫生保健工作的相关数据。结果与发现：（1）农村基本卫生保健工作得到政府重视,但财政保障仍不足;（2）乡村两级医疗卫生服务体系建设仍需不断完善;（3）基本公共卫生服务在医改政策推动下进展明显,后续要加大力度推进;（4）新型农村合作医疗制度不断完善;（5）基本药物制度实施使基层医疗卫生机构面临发展困境。     

Mental health care roles of non-medical primary health and social care services

Changes in patterns of delivery of mental health care over several decades are putting pressure on primary health and social care services to increase their involvement. Mental health policy in countries like the UK, Australia and New Zealand recognises the need for these services to make a greater contribution and calls for increased intersectoral collaboration. In Australia, most investment to date has focused on the development and integration of specialist mental health services and primary medical care, and evaluation research suggests some progress. Substantial inadequacies remain, however, in the comprehensiveness and continuity of care received by people affected by mental health problems, particularly in relation to social and psychosocial interventions. Very little research has examined the nature of the roles that non-medical primary health and social care services actually or potentially play in mental health care. Lack of information about these roles could have inhibited development of service improvement initiatives targeting these services. The present paper reports the results of an exploratory study that examined the mental health care roles of 41 diverse non-medical primary health and social care services in the state of Victoria, Australia. Data were collected in 2004 using a purposive sampling strategy. A novel method of surveying providers was employed whereby respondents within each agency worked as a group to complete a structured survey that collected quantitative and qualitative data simultaneously. This paper reports results of quantitative analyses including a tentative principal components analysis that examined the structure of roles. Non-medical primary health and social care services are currently performing a wide variety of mental health care roles and they aspire to increase their involvement in this work. However, these providers do not favour approaches involving selective targeting of clients with mental disorders.     

Factors shaping intersectoral action in primary health care services

Objective: To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Methods: Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. Results: The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. Conclusions: While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Implications: Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action.     

Equity in access to care in the era of health system reforms in Turkey

ObjectiveTo evaluate access to healthcare from an equity perspective on the way toward Universal Health Coverage in Turkey.MethodsThe country representative data from 2006 to 2013 Turkey Income and Living Conditions Surveys were analyzed. Private household residents aged fifteen and older were asked for self-reported unmet need for medical care in the past twelve months. The dependent variable had three categories: no unmet need, unmet need due to cost, and unmet need due to availability (waiting list and distance problems). Predictors of unmet need were assessed by a multinomial logistic regression analysis.FindingsThe prevalence of unmet need declined between 2006 and 2013. While educational inequalities in declared unmet need also decreased, the income gradient becomes more important. In 2013, controlling for other factors, the propensity to report unmet need was 10 times higher for those in the poorest-income quintile compared to the richest (versus 7 times in 2006).ConclusionOverall access to healthcare has gradually improved in Turkey in the health reform process, but 9% of people still declared unmet need due to cost in 2013, after the implementation of Universal Health Insurance. This was nearly four times the EU average. Unfavourable economic and labour market conditions can be challenges for effective universal health coverage.