Health care reform has been given the utmost importance on Turkey's policy agenda since the late 1980s. In 1989, the SPO's Master Plan Study (SPO, 1990), which was developed through a World Bank loan, introduced new concepts to the Turkish health care system. The Plan suggested splitting the functions of purchasing and provision, developing an internal market, implementing general health insurance, formulating a family medicine system at the primary health care level and giving autonomy to state hospitals. From 1990 to 1993, intensive efforts were undertaken to reshape the health care system in a way that reflected global trends and approaches. The World Bank had an important role in developing this process. The National Health Policy (Ministry of Health, 1993) presented the first comprehensive analysis of priority health care policies and also set out future strategies. However, a decade of political and economic instability (1993–2003) led to reform proposals that remained as blueprints with no concrete steps for implementation.
This chapter outlines the principles and practice of regulation and planning in the Turkish health care system. Table 4.1 outlines the main legislative arrangements upon which the health care system is based. As can be seen from Table 4.1, some of the basic legislation used in health care is quite old; however, the dates mentioned are the acceptance dates of the laws and each has undergone several revisions over time, reflecting changes in the health care environment. In the Turkish health care system, decrees and directives also play an important role. Laws create the main legislative framework, and successive decrees and directives may be issued for the purposes of implementation.
Turkey is located in the northern hemisphere and bridges Europe and Asia. The bordering countries are Greece, Bulgaria, Georgia, Armenia, the Islamic Republic of Iran, the Syrian Arab Republic and Iraq. The country has a population of 73 million, 26% being under 14 years of age in 2010. Turkey is a parliamentary democracy with a clear separation of executive, legislative and judicial powers. The 1982 Constitution describes Turkey as a democratic, secular and social state governed by the rule of law. The Turkish Grand National Assembly (Türkiye Büyük Millet Meclisi), or parliament, is the legislative body acting on behalf of the nation. The President, elected by the people, and the Council of Ministers (Cabinet) headed by the Prime Minister, exercise executive power. Independent courts handle judicial power. Administratively, Turkey is divided into 81 provinces headed by provincial governors appointed by the central government. Provincial governors are the representatives of all ministers at the provincial level. All ministries, including the Ministry of Health, have their own local organizations in the provinces and the heads of these organizations are responsible to the provincial governor.
WOS: 000321347000030 ; PubMed ID: 23810020 ; 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). ; World Bank ; RiA has acted as an adviser and a consultant to the Ministry of Health of the Republic of Turkey, including in the Health Transformation Program, and has undertaken consulting assignments in Turkey for the Ministry of Health of Turkey, WHO, and the World Bank. ReA was the Minister of Health of Turkey from 2002 to 2012. SA was the Undersecretary of the Ministry of Health of Turkey from 2002 to 2009. SC works for the World Bank and was involved in the World Bank-funded Health Transition Project in Turkey. SC is on a secondment to Medipol University. SS, MA, IG, and SN have undertaken analytical consulting assignments for the Minstry of Health of Turkey. SO, UA, BA, and UD are employed at the General Directorate of Health Research, The Republic of Turkey Ministry of Health.
