Maternal and Child Health in Turkey Through the Health Transformation Program

Meltem A. Aran, Nazlı Aktakke, İpek Gürol, Rıfat Atun

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December 2015

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

September 2014

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.

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Early Childhood Health and Education Outcomes and Children's Exposure to Multiple Risks in Turkey

Meltem A. Aran, Cristobal Ridao-Cano

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October 2013

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.

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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

June 2013

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).

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Protection in Good and Bad Times? The Turkish Green Card Health Program

Meltem A. Aran, Jesko Hentschel

August 2012

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.

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