Turkey's Health Transformation Program reviewed by the LANCET


by Danya Chudacoff


June 27, 2013

One of the world's leading healthcare journals, The Lancet, recently published a special issue article evaluating the decade-long health transformation program in Turkey that aimed to increase the scope, quality and equity of healthcare throughout the country. The importance and timeliness of the study cannot be overstated, given the significant strides the Turkish government took over the last 10 years in prioritizing the health sector and promoting universal healthcare coverage (UHC), especially among traditionally underserved populations, such as those in eastern regions.


Led by Prof. Rifat Atun at Imperial College London, the published study, Universal healthcare coverage in Turkey: enhancement of equity, analyzes the Healthcare Transformation Program (HTP), spearheaded by the Turkish Ministry of Health in 2003, to assess the program’s outcomes, as well as its contextual environment and implementing mechanisms. To the extent that the HTP was constructed for the sake of accelerating UHC in Turkey and promoting healthcare services as a citizen right, the study demonstrates the ways in which the program was vital for bringing greater healthcare access, particularly in improving the adequacy and equity of such services both geographically and across the socioeconomic spectrum.


In promoting UHC, the HTP aimed to strengthen three areas of the Turkish health system: governance and organization, financing, and service delivery, and the key achievements of the program highlighted in the report can be broken down along these lines. In terms of organization and governance, under the HTP the Ministry of Health undertook a significant restructuring, creating new administrative agencies, improving communication both across the ministry and with professionals and beneficiaries, and boosting patient awareness of healthcare rights. While expenditure on healthcare had been increasing in Turkey since the 1990s, the study found that the greatest levels of increase occurred between 2003 and 2008. Under the HTP, annual growth rates on public sector funding averaged 9.1% per year in 2000-08, while total health expenditure in Turkey grew as a percentage of GDP from 2.7% in 1990 to 6.1% by 2008. The streamlining of health insurance programs (consolidating five separate schemes into one under the new General Health Insurance Law) and improving the Green Card health insurance program serving the poorest population deciles was found to have dramatically improved health insurance coverage across the country, as well as increasing both the benefits received and cost-sharing schemes under these. A new model for primary healthcare provision under the HTP focused on increasing physical and human resources and capacity, and econometric data gathered for the study shows that the incidence of primary healthcare physicians engaging earlier in disease contact and treatment has dramatically improved. The volume of primary healthcare services (the number of visits) increased from 74.8 million in 2002 to 244.3 million in 2011, highlighting the documented increase in Turkish citizens’ usage of and confidence in healthcare provision in their country.


Development Analytics contributed to the research with its evaluation of the program’s impact on maternal and child health, which formed a major component of the report’s overall assessment. Using Turkish Demographic Household Surveys from 1993-2008, the analysis shows that the use of maternal and child health services improved significantly over the time period measured, particularly in rural sections of the country, and especially in the 2003-2008 period. Key indicators along these lines include the increased probability of a mother receiving antenatal care, which rose from 63.0% in 1993 to 93.4% by 2008, with the most intense period of climb between 2003 and 2008. The use of healthcare facilities during birth similarly rose, from 60.1% in 1993 to 85.7% in 2008. The prevalence of complete childhood immunization sets, which had faltered between 1993 and 1998, increased incrementally through 2003 only to see a significant upswing between 2003 and 2008, from 53.2% to 73.7%. Among the most important improvements in this time period has been the significant drop in under-5 mortality, which fell nationally from 52.7 per 1000 live births in 1993, to 18.9 per 1000 live births in 2008, with the most significant drop between 2003 and 2008 (from 33.2 to 18.9 per 1000 live births). Similarly, encouraging drops were observed in infant and neonatal mortality.


Development Analytics’ analysis also included an evaluation of household characteristics to assess the demographic trends behind the patterns in usage (and improvement of usage) of maternal and childhood health services across Turkey. The multivariate regression analysis used here, which controlled for household socioeconomic and geographic characteristics, measured the links between household circumstances and healthcare services usage rates, to test the equity in diffusion and access throughout the country. The analysis showed that the links between circumstances and access to healthcare services weakened during the time measured, indicating an improvement in the availability and usage of service across the country.

Overall, the Lancet article found that Turkey’s HTP program was effective in boosting UHC, especially in terms of equity and improved levels of distribution and financing. These improvements, not surprisingly, have contributed to higher beneficiary satisfaction, which rose from 39.5% in 2003 to 75.9% in 2011. Thanks to economic growth, political stability and supportive institutions, Turkey was able to prove its capacity to flexibly institute the rapid policy transitions that have dramatically improved national healthcare and are expected to continue doing so with the necessary tools and vision in place.


The full paper can be downloaded at this link.