Health Policy & Equity
Investing in health care policies that improve the delivery, efficiency, and financing of services and that improve equitable distribution of services to the poor can be an important tool in the fight against poverty. At Development Analytics, we focus on topics related to the financing and delivery of healthcare, access to care and quality of care and health equity. We also specialize in the measurement of maternal and child health care indicators, and focus our attention on the delivery of particularly primary health care to children and mothers, while also focusing on topics such as nutrition of mothers and children - as this links to our work on early childhood development.
Turkey Health System Policy Dialogue: Synthesis paper on the Turkey Health Reform
October 2013 - January 2014
This synthesis report summarized Turkey’s efforts under the Health Transformation Program for reaching Universal Health Coverage. The final deliverable paper from this assignment will be showcased as one of the country case studies under the Japan-World Bank Partnership Program (JPP) on Universal Health Coverage (UHC).
Women and Health: Analysis of the Economic Value of Informal Health Care by Women in Turkey
Harvard School of Public Health and the LANCET Commission on Women’s Health
May 2013- September 2013
The study estimated the economic value of the amount of time Turkish women spend on unpaid, informal health care using the Time Use Survey. The estimation was carried out using an opportunity cost method for calculations as well as the proxy good methods. Turkey Survey of Income and Living Conditions (SILC) (2011) and the Time Use Survey (2006) were used as the primary data sources for the study. The findings of the study served as background information to the LANCET Commission Paper on "Women and Health".
Analysis of the Impact of Turkey Health Transformation Program on Health Utilization and Outcomes using Turkish Household Level Micro Data Sets
The Ministry of Health Turkey
November 2012 - April 2013
The paper measured the extent to which improvements in health outcomes observed in the years 2003-2008 were due to the expansion of the demand-side health insurance subsidy to the poor and to what extent they could be attributed to other supply-side changes taking place in the health sector in the same time period. This paper used 4 cross-sectional Demographic and Health Surveys for Turkey in 1993, 1998, 2003, and 2008 to look at changes over time in insurance coverage, and health care utilization in the antenatal period, during birth, and the early postnatal period for children. Four different health care utilization variables were used: (i) whether the mother has received any antenatal care during pregnancy, (ii) whether the birth was given at a health facility (public or private), (iii) whether the birth was attended by skilled staff (a doctor, midwife or nurse) and (iv) whether the child has received a complete set of vaccinations. The variables are defined in the data for all children in the 0-4 age group (with births in the past 4 years) for the first three variables and for children in the 12-23 month group (1-year-olds) for the vaccination variable.
The paper was utilized as a background paper for the LANCET Report "Universal Health Coverage in Turkey: Enhancing Equity".
Maternal and Child Health in Turkey Through the Health Transformation Program
Meltem A. Aran, Nazlı Aktakke, İpek Gürol, Rıfat Atun
Improving maternal and child health outcomes is a major development objective. Targets related to these outcomes were included in the United Nation’s Millennium Development Goals and they continue to galvanize global support through the Sustainable Development Goals (under Goal 3 health targets). Turkey is among the few successful middle-income countries that have significantly reduced the under-5 mortality rate below the MDG 2015 target levels. This study analyses improved demand-side (health insurance, conditional cash transfers) and supply-side inputs (expanded health services) in Turkey’s health system as part of the Health Transition Program (HTP), as well as contextual improvements (such as improved economic well-being and increased maternal educational attainment), to identify how these input factors have advanced health outcomes. The results show that while demand-side measures, such as universal health coverage through the extension of health insurance to low-income families (Green Card program), improved health utilisation variables, the main impact of on maternal and child health was through supply-side improvements which expanded for all women access to free antenatal and midwifery care, regardless of health insurance status.
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Turkey on the Way of Universal Health Coverage Through the Health Transformation Program (2003-13)
The World Bank Group
Beginning in 2003, Turkey initiated a series of reforms under the Health Transformation Program (HTP) that over the past decade have led to the achievement of universal health coverage (UHC). The progress of Turkey’s health system has few — if any — parallels in scope and speed. Before the reforms, Turkey’s aggregate health indicators lagged behind those of OECD member states and other middle-income countries. The health financing system was fragmented, with four separate insurance schemes and a “Green Card” program for the poor, each with distinct benefits packages and access rules. Both the Ministry of Labour and Social Security and Ministry of Health (MoH) were providers and financiers of the health system, and four different ministries were directly involved in public health care delivery. Turkey’s reform efforts have impacted virtually all aspects of the country’s health system and have resulted in the rapid expansion of the proportion of the population covered and of the services to which they are entitled. At the same time, financial protection has improved. For example, (i) insurance coverage increased from 64 to 98 percent between 2002 and 2012; (ii) the share of pregnant women having four antenatal care visits increased from 54 to 82 percent between 2003 and 2010, and (iii) citizen satisfaction with health services increased from 39.5 to 75.9 percent between 2003 and 2011. Despite dramatic improvements, there is still space for Turkey to continue to improve its citizens’ health outcomes, and challenges lie ahead for improving services beyond primary care. The main criticism of reform has so far come from health sector workers; the future sustainability of reform will rely not only on continued fiscal support to the health sector but also on the maintenance of service provider satisfaction.
Early Childhood Health and Education Outcomes and Children's Exposure to Multiple Risks in Turkey
Meltem A. Aran, Cristobal Ridao-Cano
This paper considers changes in children's early health and education opportunities and outcomes in Turkey. The study aims to look at changes in health utilization, nutrition, access to early childhood education, and school enrolment rates for children between 2003 and 2008. The findings suggest that health utilization has improved over time in these years and access to health care has increasingly become delinked from the initial circumstances of children in the household, in parallel to Turkey's expansion of the Health Transformation Program. On the other hand, nutrition outcomes remained correlated with maternal education and household wealth status. Access to early childhood education and care programs also came out to be highly regressive, with only households and children in the top quintile having access to childcare programs outside the home. The paper also considers later educational attainment outcomes for older children, by circumstance groups and finds that while some progress has been made in enrolment in basic education in these years, variables that define gender, mother tongue is spoken at home and parental education remain significant determinants of early drop-outs as of 2008. In the final section, the paper investigates the exposure of a certain small group of children in Turkey to multiple risk factors at the same time and evaluates the incidence by circumstance group the probability of facing overlapping risks in early childhood. the paper argues that children in these circumstance groups, and that have exposure to multiple risk factors, should be the primary target of social protection and early childhood intervention programs.
Universal Health Coverage in Turkey: enhancement of equity
Rifat Atun, Sabahattin Aydin, Sarbani Chakraborty, Safir Sumer, Meltem Aran, Ipek Gurol, Serpil Nazlioglu, Senay Ozgulcu, Ulger Aydogan, Banu Ayar, Ugur Dilmen, Recep Akdag
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).
Protection in Good and Bad Times? The Turkish Green Card Health Program
Meltem A. Aran, Jesko Hentschel
This paper evaluates the equity and financial protection implications of the expansion of the Green Card (Yesil Kart) non-contributory health insurance program in Turkey during the growth years from 2003 to 2008. It also considers the program's protective impact during the economic crisis in 2009. The authors find that the rapid expansion of the program between 2003 and 2008 was highly progressive. It led to significant gains in coverage of the poor but offered limited financial protection as out-of-pocket expenditures even before the introduction of the program had been limited. Using a specialized welfare monitoring survey, fielded in 2009, the authors estimate the impact of the program on household-level health care utilization during the first phase of the economic slowdown in Turkey. Using three different estimation techniques, they find that the Green Card program had a significantly positive impact on protecting health care utilization during the crisis.
Meltem Aran, Ph.D.
Meltem is a human development economist with research focusing on poverty, inequality, and overall distributional impact of social policies. Since 2004, she has been involved in various research projects and impact evaluations relating to poverty and human development with the World Bank in East Asia, ECA, and MENA regions.
Sapna Desai, Ph.D
Sapna is a public health researcher and epidemiologist whose work focuses on women’s health, reproductive health, community health workers, and program evaluation. Recent research includes leading a cluster randomised trial that evaluated the effect of health education on women’s treatment-seeking behaviour and a mixed-methods study to investigate hysterectomy in India.
Şenay is a cultural anthropologist and a researcher. Her research areas include international migration, refugees, Turkish state’s refugee policies, politics of humanitarian aid.
Zeynep is currently a Doctoral Candidate at the Department of Political Science at Northeastern University. She passed doctoral exams in the fields of comparative politics, public policy, and research design and methodology. She studies forced migration, social policy and welfare provision mostly in the Middle East and Balkans.
National Health Expert
Safir Sumer is an international development specialist with extensive experience in health systems. She is a national of Turkey, with over 20 years of human development experience. She consulted for the World Bank, WHO, Ministry of Health and Ministry of Development in Turkey, Merck Pharmaceuticals, and the EU Commission on health sector-related projects. Her health sector experience includes results-based financing, health systems, and policy analysis, strategic planning, universal health coverage, public health, health budget and financing, people-centred health care, and integrated care.
Senior Quantitative Research Analyst
Nazli is a senior quantitative researcher at Development Analytics with experience working on a wide range of topics including cash transfer programs, labour force participation of women, and health and education outcomes of children.