The Metamorphosis of the Turkish Health System under the AKP

Health care is one of the most challenging public service domains in Turkey and one that has a crucial effect on the government's public approval rating. Since the foundation of the Republic, successive single party governments, and especially the coalition governments of the 1990s, attempted to solve problems related to resource availability and redistribution in care delivery via numerous programs. However, they failed to prevent the flows of patients and resources between public and private practices. This created an imbalance in the supply-demand equilibrium and paved the way for a government deficiency in the provision of health services. Inevitably, all these resulted in suboptimal use of specialized secondary and tertiary healthcare services,[1] poor quality care delivery and financial deprivation due to unregulated prescription practices. This was the grim picture of the public health services sphere when the Justice and Development Party (Adalet ve Kalkınma Partisi - AKP) took office in November 2002.

Bearing in mind the substantial impact of health services on the daily lives of the Turkish constituency, upon rising to power the AKP initiated a series of radical public administration reforms in 2003. Certainly, the Health Transformation Program (Sağlıkta Dönüşüm Programı - SDP), which was designed to restructure the national health system, can be highlighted among the most significant reforms in the health sector. The SDP sought to improve the quality of care and the delivery of services, enhance access as well as minimize financial deprivation in the value chain. The program entailed various institutional and structural changes, such as administrative and functional re-organization of the Ministry of Health, implementation of universal health insurance, instituting autonomous hospitals and redesigning the primary care system under the family medicine model.[2] These structural changes were coupled with heavy investment in health-focused information systems, including a national e-health platform called “Saglik-NET”.[3]

Looking at the statistics, the outcome of the SDP was impressive. Within a decade, access to healthcare measured by the number of per capita visits to healthcare facilities rose from 3.2 in 2002 to 8.3 in 2015.[4] Since control over the prescription chain was fully achieved by e-prescription, a substantial part of unnecessary prescriptions and the concomitant financial losses were significantly reduced. Furthermore, hospital productivity improved significantly[5]. Indeed, the SDP was one of the crucial milestones on the roadmap towards AKP's “New Turkey”. Apart from pleasing its constituency, the subtle driving force behind this transformation program was the AKP administration's agenda geared towards fulfilling the requirements of the European Union Accession Process. Certainly, the sponsorship of the international agencies like the World Bank and the World Health Organization (WHO) played a crucial role in shaping the SDP. In short, the SDP was a commitment of the AKP government to the “New Turkey,” with the full support of international actors.

Therefore, through its reforms, the AKP government sought to please simultaneously both its constituency and international organizations. As part of the SDP, the Turkish Ministry of Health adopted another ground-breaking reform, called the Family Medicine System (Aile Hekimliği Sistemi – AHS).[6] In line with the United Nations' 2011 Millennium Development Goals, the AHS particularly sought to reduce child mortality and improve maternal health. Under this framework, the Ministry created a new specialty and service delivery approach covering preventive care, outpatient care, infant and maternal health services as well as vaccination. Prior to the transformation, public primary care services were rendered since the early 1960s by health centers and maternal/infant care centers.  However, both the number of these centers, and the scope of their services, were insufficient in rural and urban areas alike.[7] Under the AHS, their essential functions are divided between public health centers and independent family medicine units (Aile Hekimliği Birimi-AHB). While the public health centers perform community-level activities, such as collecting statistics, tracking diseases, and delivering environmental, occupational and school-oriented health services,  independent family medicine units focus on pre- and postpartum care, maternal and infant health monitoring, and vaccinations.[8] An AHB consists of a family medicine physician (either a general practitioner or a specialist) and a nurse or a midwife. Instead of being a public employee, as previously was the case in the former health centers, AHB personnel are privately contracted by the Ministry of Health.

The nationwide transition to AHS was gradually implemented during 2005-2010, with Istanbul being the last city to adopt the the new care delivery model in 2010.[9] Similar to the SDP, the AHS yielded impressive results. Major health-related indicators, such as the maternal and infant mortality rates improved considerably; they respectively decreased from 28.5 per 100,000 live births in 2006 to 14.4 per 100,000 live births in 2017, and from 31.5 per 100,000 live births in 2002 to 9.7 per 100,000 live births in 2016. In 2016, the rate of full vaccination coverage reached 98%.[10] Hence, population-level goals were fulfilled and these achievements of the AKP government were cheered by international agencies such as the WHO and the World Bank.

Yet, looking beyond the statistics, recent field studies have reported concerns about the new AHS with respect to primary care’s four main pillars (first contact for care delivery, coordination across service levels, longitudinality of the physician - patient relationship, and comprehensiveness of health services).[11]

First, many citizens, especially those from disadvantaged groups, are not fully served by the AHB. 40-60% of citizens do not apply to AHBs as their primary contact, despite the fact that they are assigned to one. Awareness among citizens about family medicine services is still low. Moreover, there is an asymmetry in usage. While some patient groups have limited access to health services, some other groups use the AHBs extensively, even unnecessarily. The Ministry prioritizes patients such as pregnant women, puerperants and infants up to 5 years of age. Furthermore, vaccination and maternal/infant care services are tied to a negative performance scheme for the caregivers, where missing one mother or infant leads to deductions from salaries. Therefore, in line with developmental targets and performance requirements, the AHS better serves these prioritized groups, whereas other patients with chronic diseases (such as diabetes or obesity) or those who demand “non-primary” services, such as family planning, might be neglected. This creates another gap in care delivery. 

Second, the AKP government did not implement the referral chain across care levels; direct access to secondary or tertiary care levels without a family medicine physician’s referral is not restricted. Consequently, the patients continue to utilize specialists at secondary and tertiary levels where convenient to them, even in cases which fall well within the scope of primary care.  As a result of the above, the AHS could hardly avoid bottlenecks in care delivery as promised. Instead, it led to suboptimal allocation and the waste of valuable resources in the national health system. Moreover, the health information systems used at the three care levels are not integrated. Thus, the exchange of patient health information about diagnosis and treatment across institutions and care levels is inhibited.[12] Unless the patient shares this information with caregivers, it is impossible to aggregate the patient’s health information and capture the whole health history. This setting prevents coordination across care delivery levels and limits the comprehensiveness of health services.[13]

Third, although in principle the AHS facilitated longitudinality of the physician-patient relationship, the fact that patients arbitrarily choose the point of first contact for health services endangers the quality and consistency of the patient-physician relationship, and limits the ability of a physician to deliver care according to practice norms.

Finally, as anecdotal evidence indicates, the workload of physicians is extremely high compared to that in developed countries. Measured in patient visits per day, it can vary between 40-70 and in some cases can even reach 90. These results in limited time allocated to individual patients. Performance criteria for physicians do not include indicators for quality and efficiency of care delivery and patient satisfaction[14], and physicians are demotivated by the negative performance scheme. As a result, despite the fact that the Ministry possesses a strong decision making authority on the allocation of resources, it cannot offer incentives that will attract new family physicians and in turn reduce clinician workload and increase the time allocated to patient visits.  It must be noted that the bottlenecks in primary care delivery are enhanced by a number of additional challenges now facing the Ministry, such as the migration of 3.6 million Syrians into Turkey[15] , rapid urbanization, and the negative perceptions of citizens about primary care.[16] Nevertheless, this situation endangers the quality of services provided.

Looking back at the last 15 years, one cannot deny the success of the AKP administration’s family medicine system, compared to pre-AKP health centers, in improving macro-level primary care health indicators. However, the way the government implemented the system, and its priorities regarding the implementation, could not produce equal value for all citizens. One can argue that implementation of the health reform was heavily shaped by the populist concerns of the government. Whatever the case may be, the fact remains that there are gaps in provisioning and utilization of primary care services across different population segments.

On the supply side, the AKP government did not fully resolve problems of resource scarcity by increasing the number of facilities and family medicine physicians in the system.  Due to resource bottlenecks and political concerns, the referral system to secondary level was not implemented. Therefore, resource allocation and utilization problems in the national health system persist and may even increase alongside population growth, which will lead to additional future asymmetries. Moreover, while the prioritization of health services increased the quality of services provided for some patient groups, such as pregnant women, mothers and infants up to 5 years, it happened inevitably at the expense of other patient groups. 

On the demand side, as expected, the primary care services are used extensively by women and infants in socio-economically disadvantaged neighborhoods. Concerns about quality, coupled with a scarcity of primary care providers in terms of both numbers and specialization, has led to negative perceptions and suboptimal utilization of services by citizens belonging to stronger socio-economic groups. Anecdotal evidence suggests that citizens still do not consider a family medicine physician to be a specialist responsible for first contact. The majority visit the AHBs for prescriptions only and prefer to directly access secondary or tertiary care levels, or alternatively, turn to private outlets for treatment. It may soon come to pass that the AKP administration's decisions about primary care, coupled with chronic resource problems and demographic changes, may reverse the success of the SDP and in fact may even lead to a decay in population-level health indicators.  In the long-run, this may result in even greater social and financial consequences.

Dr. Melike N. Findikoglu, is an Assistant Professor in the College of Business at Ozyegin University, Istanbul, Turkey. She teaches courses in information systems, e-business models, IT project management, and strategic management. She is a member of Academy of Management, Association for Information Systems and Strategic Management Society. Participating in the Initiative for Academic Collaboration in the Middle East and North Africa, she collaborates with Tel Aviv University and IDC Herzliya among others. melike.findikoglu[at]ozyegin.edu.tr