UNIVERSAL HEALTH COVERAGE in TURKEY: CHALLENGES and OPPORTUNITIES September 29, 2011 1
OUTLINE • Universal Coverage • Global Status Global Status • Status in Turkey – Prior to 2003 – Health Transformation Program / 2003-2011 • Achievements and Lessons from Turkish Experience • What is next on the agenda? Wh t i t th d ? 2
UNIVERSAL COVERAGE “ Universal Health Coverage (UHC) is defined as access for all to appropriate promotive, preventive, curative and p , p , rehabilitative health care at an affordable cost in case of need ” * cost in case of need. * WHO 3
UNIVERSAL COVERAGE Universal coverage Universal coverage • better health status better health status • equity of access • financial protection 4
5 GLOBAL STATUS
WHERE THE WORLD STANDS TODAY? Commitment from the Member States Commitment from the Member States (World Health Assembly, 2005) • Access for all to health care services • Financial protection Financial protection WHO • Practical guidance on ways to finance health care. 6
WHERE THE WORLD STANDS TODAY? So what happened? pp Millions of people are still at risk of falling into a downward spiral of sickness and poverty downward spiral of sickness and poverty. 7
WHERE THE WORLD STANDS TODAY? Health expenditures p Severe financial burden: 150 million people / year * P Poverty: 25 million households / year * t 25 illi h h ld / * *WHO estimates 8
WHERE THE WORLD STANDS TODAY? It is time for action! It is time for action! 9
STATUS in TURKEY STATUS in TURKEY PRIOR to 2003 PRIOR to 2003 10
STATUS in TURKEY / PRIOR to 2003 • Fragmented health financing system g g y • Disturbed actuarial balances • Disturbed actuarial balances • Problems in risk pooling 11
STATUS in TURKEY / PRIOR to 2003 • No “national health accounts system” • Insufficient budget allocated for preventive and primary health care 12
STATUS in TURKEY / PRIOR to 2003 • Problems in access to health care services (even for majority of insurees) • 112 Emergency Health Services delivered g y as paid services for citizens - both insured and uninsured 13
STATUS in TURKEY / PRIOR to 2003 B th th Both the health service provider h lth i id and the receiver were the victims of the system 14
HEALTH TRANSFORMATION 15 PROGRAM 2003-2011
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Human-centered ethical understanding aiming at equal access by citizens to quality y q y health services . Structural, planned and sustainable system that is in conformity with the socio- economic realities of our country . 16
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Getting Health Reform Right: M Roberts et al 2004 (Referred after modification) Getting Health Reform Right: M. Roberts et al, 2004 (Referred after modification) 17
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Performance ‐ based payment Performance based payment Institutional quality criteria system included for performance Right to choose physician Free primary care for all Private pharmacies open for SKK enrollees Free emergency and intensive care Green Card holders covered for treatments outpatient services Ambulances with snow SSK hospitals transferred to MoH p pallets Air ambulance system Free ambulance services UHI implementation. No more pawns at hospitals Tobacco Control Law Law on Public ‐ private Total Quality Management Partnerships (PPP) for Health Partnerships (PPP) for Health 2004 2006 2008 2010 2003 2005 2007 2009 Full ‐ Day Law Family Medicine New Health Budget Law (SUT) Family medicine pilot implementation countrywide adopted implementation Home care New licensing regulations for pharmaceuticals DRG Patients Rights Units in Performance ‐ based every MoH Hospital Mobile Pharmacy payment system Pharmaceutical Tracking Global budget System pilot implementation Law 5502 on integration of social Reimbursement Commission Central Patient Appointment security institutions System pilot implementation Health Information Pharmaceutical expenditure tracking Communication Center ‐ SAB İ M system and MEDULA system and MEDULA
HEALTH TRANSFORMATION PROGRAM / 2003-2011 At the beginning of the Transformation t t e beg g o t e a s o at o • Well-aware of the situation Well aware of the situation • Committed team • Theoretical works • Field Works Country examples, discussions with managers and practitioners 19
HEALTH TRANSFORMATION PROGRAM / 2003-2011 So what did we do? • Focus on human • Political commitment Support of the Prime Minister, the Cabinet and the National Assembly • Public support by fast improvements No more pawns at hospitals Free 112 Emergency services Free 112 Emergency services 20
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Extensive transformation process p • Free primary health care services for all • Free primary health care services for all • Citizens able to receive service from private Citizens able to receive service from private sector using their public health insurance • Poors able to benefit completely from public healthcare 21
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Extensive transformation process • Reorganising public hospitals under a single g g p p g roof • Family medicine implementation • Free primary health care services for all • Performance-based payment system P f b d t t • Reference pricing system Reference pricing system 22
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Many simultaneous improvements 23
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Objections and opposition (political parties, professional associations, parties, professional associations, administrative courts…) Interests and status quo “To be or not to be. That is the question. … And thus the native hue of resolution Is sicklied over with the pale cast of thought.” W Shakespeare W. Shakespeare 24
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Our resolution never Our resolution never weakened in the face of weakened in the face of those oppositions pp 25
HEALTH TRANSFORMATION PROGRAM / 2003-2011 How sustainable is the system? How sustainable is the system? • Increase in health expenditures parallel to economic growth 26
HEALTH TRANSFORMATION PROGRAM / 2003-2011 How sustainable is the system? How sustainable is the system? • Increased efficiency – Distribution of human resources Distribution of human resources – Incentives – Outsourcing – High-tech services with low costs (MR: 40 $; CT: 35 $) High tech services with low costs (MR: 40 $; CT: 35 $) – Decrease in pharmaceutical prices up to 80% ... 27
HEALTH TRANSFORMATION PROGRAM / 2003-2011 How sustainable is the system? How sustainable is the system? • Very comprehensive services with 500-600 USD USD per capita it – Free vaccines (including the most recent ones) ( g ) – Free air ambulance services – Free emergency and intensive care even in private sector... 28
HEALTH TRANSFORMATION PROGRAM / 2003-2011 2000 2003 2006 2008 29
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Rate of people paying for their own medicine and treatment costs (%) 35 32,1 30 28,2 26,1 25 19 19 20 20 16,5 14,9 14,7 15 11,7 11,7 10 5 5 0 2003 2003 2004 2004 2005 2005 2006 2006 2007 2007 2008 2008 2009 2009 2010 2010 30
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Share of out-of-pocket health expenditure in total health expenditure (%) 35,0 29,1 29,1 30,0 27,6 22,8 22,8 25,0 22,0 21,8 18 5 19,2 , 19,8 19,8 18,5 20,0 17,4 15,0 10,0 5,0 0,0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
HEALTH TRANSFORMATION PROGRAM / 2003-2011 Number of Per Capita Visits 7,6 2009 6,5 2008 6,0 2007 5,3 2006 2,9 2,9 2002 0,0 2,0 4,0 6,0 8,0 32
HEALTH TRANSFORMATION PROGRAM / 2003-2011 H Health system indicators before and after the HTP lth t i di t b f d ft th HTP 2002 2010 Immunization Ratio (%) 97 78 (DaBT 3) Hospital Births (%) 78 92 Per Capita Visits to Health Care 7,6 2,9 Facilities Facilities 33
HEALTH TRANSFORMATION PROGRAM / 2003-2011 H Health system indicators before and after the HTP lth t i di t b f d ft th HTP 2002 2010 Maternal Mortality Ratio 70 (1998) 16,4 (per 100.000 live births) Infant Mortality Rate 10,1 26,7 (per 1000 population) (p p p ) 73,7 Life Expectancy at Birth 70,8 34
HEALTH TRANSFORMATION PROGRAM / 2003-2011 H Health system indicators before and after the HTP lth t i di t b f d ft th HTP 2002 2010 Measles Incidence 0,009 11,09 (per 100.000 population) 0 Malaria Cases 10.224 51 Typhoid Fever Cases yp 24.390 35
36 ACHIEVEMENTS LESSONS and and
ACHIEVEMENTS & LESSONS OECD R OECD Reviews of Health Systems, Turkey i f H lth S t T k “Health Transformation Program represents both an improvement in Turkey’s social welfare in Turkey s social welfare system and a “good practice” example for other countries struggling with the same gg g issues.” 37
ACHIEVEMENTS & LESSONS OECD R OECD Reviews of Health Systems, Turkey i f H lth S t T k • “The Turkish health system • The Turkish health system performs quite well in terms of equity and financial protection” 38
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