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PRESİDENT OF TURKİSH ASSOCİATİON OF FAMİLY PHYSICIANS

Prof. Dr. OKAY BAŞAK

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HEALTH CARE REFORMS IN

TURKEY:WHAT HAS CHANGED?

Prof. Dr. Dilek GüldalDokuz Eylül University

Medical SchoolFamily Medicine Department

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Turkey’s population is 76.667.864(December 31st, 2013)

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TURKEY

One of the GIANT economies of 2050 (Malaysia, Indonesia, Nigeria & Turkey)

Most VULNERABLE economy (Brazil, India, Indonesia, Turkey and South Africa)

first 20% gets 46.6% of the total income while the last 20% only gets 5.9%

Last 20%Forth 20%

Third 20%

Second 20%

First 20%

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General Demographic Variables, Turkey

Annual population growth rate was ‰12 in 2012 and increased to ‰13.7 in 2013

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Early 90’s

• Discussion on the health care reforms was started

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Health Transformation Program 2003:FRAMEWORK

1. Ministry of Health as the planner and supervisor,2. Universal health insurance 3. Widespread, easily accessible and friendly health service

system,a) family medicine in PCb) referral chain, c) administrative and financial autonomy,

4. Strong Health manpower5. Education and science institutions to support the system,6. Accreditation 7. Rational management of medicine and supplies, 8. Health information system

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(NO)administrative autonomy Health Care Organization and Primary Care

CounsellorsMinister of Health

Undersecretary

Vise Minister

Provincial Organization

Affiliated Divisions

Central Organization

Health of borders and costs

Drugs and Med. Devices

Union of State Hospitals

Public Health Agency

Public Health Implementation

Family Medicine Implementation

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Family Medicine Implementation

• Family Healtcare Centers (A,B,C,D)• Family Healthcare Units Each unit have:

• A family physician• A healtcare worker (usually a nurse)• A patient list• Individual practices

– No gatekeeping– Contracted doctors and nurses– Per capita and negative performance based remuneration– Practice expenditures are paid by the FPs.– Laboratory facilities (in the HCU and public health laboratories) – Patient participation in drug expenditures (also for hospital visits-

cought at the pharmacy)

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Number of Primary Care Health Services According to Years

Health Centers

Family Health Care Centers

Health Houses

Tbc D&T Centers

Emergency Stations

Family Health Care Units

Public Health Care Centers

Mother and Child Health Center

Cancer Screening and Education Centers

Public Health Labs

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Life Expectancy at Birth (Years) 1990, 2000, 2009, 2011 Turkey

International Comparison of Life Expectancy at Birth (2011)

Reference: WHO, World Health Statistics, 2011

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Key Message #1

It is distinguished that the determinant of the success is continuity of the policies rather than

the health care system itself.

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International Comparison of Infant Mortality Rate (for each 1.000 live births) 2011

International Comparison of (DTaP+IPV+HiB)Immunization Rates (%) 2011

International Comparison of Mortality Rate Under 5 Years of Age (for each 1.000 live births) 2011

International Comparison of Maternal Mortality Rate (for each 1.000 live births) 2010

Reference: Turkish Public Health Agency, WHO World Health Statistics, 2013

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Every Day Tobacco Use on the Bases of Countries (%) 2012

International Comparison of Obese (BMI>30) Individuals on the Bases of their Gender

DM Prevalance:• 7.2% in 1998 (TURDEP I)• 13.7% in 201 (TURDEP II)

Hypertension Prevalance(Turkish Association of Hypertension and Kidney Diseases)

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Key Message #2

It is important to determine burden of the diseases of a country but it is much more

relieving to find out that «there are lots of people like us»

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Comprehensive Care(Job Definition of Family Physicians)

• Preventive, diagnostic, therapeutic, rehabilitative health services• Planning• Home visits• Annual examination• Mother and child care and reproductive health• Screening programs• Education• Mobile health services• Official health reports• Referral • Management • …• …• AND ANY OTHER JOB DEEMED SUITABLE BY THE MINISTRY OF HEALTH

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Additives…• Forensic Shift• Death Report – Interment Shift• Emergency Room Shift• Sports Games• Home Care • Directly Observed Therapy (Tuberculosis)• Immigrants and Refugees • Conditional Cash Transfer (Monthly reports of those who have benefits

from district governorate for their babies)• Take appointments from the hospitals (MHRS)• Detect the possibility of the home births and evaluate them as a

guest/visitor mother and provide them to admit to a special unit.

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Tasks of Preventive Medicine and Health Promotion

• Pregnancy Follow-Up• Women in childbearing age

– 15-49 yrs-old– Two times a year

• Infant monitoring • Postpartum/Maternity follow-up• All vaccines

• Additives– Obesity– Smoking– Alcohol– Exercise

NEGATIVE PERFORMANCE

– Diabetes Follow-up – Screening tests in neonates

• PKU• Hypothyroidsm• Biotidinase def.

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Comprehensive care Accessibility

• Number of application to the primary care• Referral to the hospitals• Number of direct application to the hospitals

Number of FPsRatio of FPs to all doctorsAvarage time spent for per visitAvarage patient number per FP

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Number of Health Personnel on the Basis of Years

• Ratio of FP’s are decreasing in total number of doctors• In 2013 there were 21.175 Family Health Units

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International Comparison of Total Number of Physicians per 100.000

Person, 2011

International Comparison of Number of Nurses and Midwives per 100.000 Person,

2011

Reference: Directorate General of Health Services, WHO, World Health Statistics, 2013, The EU in the World 2013

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Population per actively working family doctor

• Avarage number of patients per doctor:3634• Avarage number of daily visits: 47• Avarage duration of a visit per patient: 11

min. (Kringos, 2008)

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HEALTH CARE UTILISATION

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COMPARING WITH OTHER COUNTRIES

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Research results (Kringos)

• TR has relatively medium strong PC structure dimensions (PC governance, PC economic conditions and PC workforce development).

• However, it has relatively low strong PC process dimensions (PC access, comprehensiveness, continuity of care, coordination of care).

Kringos DS, Boerma WGW, Bourgueil Y, et al. The strength of primary care in Europe: an international comparative study.

Br J Gen Pract 2013; 63: e742-50.

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Utilisation of primary care

Community-based surveys First contact with health centres –

- 11-95% – Several regional surveys (before 2006)

- 25.9% – Turkey Health Services Utilisation survey (1995); 21% for mental health services (1997) First contact with family health centres –

49.7% (Kayseri, 2012); (56.1% before 2006)

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First contact with PC for patients applying to PC health centres – 67% (Ankara, 2006)

First contact with PC for patients applying to hospitals – 17-36% (before 2006); 12-40% (after 2006)

Purposes: prescription requests – 56% (Kayseri 2013, İstanbul 2013); control visits – 20% (Kayseri 2013)

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Because….

• Decrease in referrals is not true • No gatekeeping – No referral system • Most of the GP’s are not FM specialist or get re-training

certificate (people prefer to be taken care by specialists for «important» health problems)

• Easy access to hospitals • Monthly salary & positive performance system in

hospitals (money follows the patient) • But per capita system in primary care (money follows

the registered patients)

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Key Message #3

Statistics need to be interpreted

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Key Message #4

Transition requires time for observation, making preparations, feedback and reflection

It should not be rushed!!

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Consequences of this Picture…

• Increase in health expenditures

• Misuse of hospital services

• Patients unable to reach the services they need

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Under these circumstances;We expect an increase in health expenditures

Health Expenditure & Drg Consumption

Increase in Health Expenditure on the Basis of Years

1.912.2

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2013

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PRECAUTIONS

• Regulations– Reduction in drug prices– Contribution to drug

reimbursement– Contribution to cost of doctor

visits– Same medicine cannot be

prescribed before a certain period of time

– Some drugs can only be prescribed by physicians of certain disciplines

– E-prescribing

• Training of Physicians– Rational drug use– Preparation of evidence based

guidelines

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COMPONENTSOF

HEALTH INFORMATION SYSTEM

•Electronic patient records (a unique ID number for each citizen)

•Electronic provision and billing

•Central database

• Information entegration with social security organizations

• e-Radiology

• Distant learning

• Reliable data for health policy makers

PRIMARY CARE/FAMILY HEALTH CENTERS

• No vertical connection between PC and hospital information systems

• Guest patients data• Feedback and benchmarking• Publication limits• Former data of newly registered patients

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PROGRAM USED FOR DATA COLLECTION IN PRIMARY CARE

• AHBS program was free but very difficult to use (now it is not free but the cheapest one)

• The best program is about 400 US dollars/year• It is possible to get so many reports such as

the number of certain registered population, the number of people with certain disease, vaccination gaps etc.

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PUBLIC DEBATE?• Who is the «master» of the patients?• Are our health records in safe hands? • With whom are they shared with?

What happens if the patients are not master of their health records?

• BOOK BY: Dr. Leyla Keser Berber, Dr. Mahir Ülgün

• NEWS: YASEMİN ARPA• ntvmsnbc• 2009

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TURKISH CONSTITUTION

Article 20 states that ‘’everyone has the right to request the protection of his/her personal data... The principles and procedures regarding the protection of personal data shall be laid down in law.

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A new law against to Turkish Constitution state that these records ‘may be shared with third parties and government institutions’They have been sold to so many firms by government for money.

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Continuity of Care

• Repeated contacts• Population cannot be reached– Mobile population– Those who don’t come– Those who prefer other institutions– “Guest/Visitor Patient” concept

• No horizontal or vertical continuity between institutions

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Coordination of Care

• No referral system

• FPs are not at the center of the patient care

• No communication – connection between health care units

• There is no decentralization in terms of family doctors. They have to work in line with the orders of Ministry of Health.

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Patient Satisfaction!!!Rate of Satisfaction with Health Services in Turkey and EU

Reference: Bulletin of World Health Organization 2009;87:271-8; EU Social Climate Report 2012; TUIK Life Satisfaciton Study 2012

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Satisfaction with Health Services (%) 2012 and Public Health Expenditure per Person 2012

Reference: OECD Health Data; WHO World Health Statistics 2012; EU Social Climate Report 2012; TUIK Life Satisfaction Study 2012

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ARE FPs SATISFIED?

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Violence Against Physicians

Dr. Ersin Aslan

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MONDAY SYNDROME!

• Average daily patient contact 45.7• Prescription request is reason for encounter for one

fourth of patients (28%); 34% for chronical diseases• Preventive medicine for other one fourth of patients

(27%)• Administartive reasons 10%• Clinical complaints 28% (39% of them is related to

the pulmonary system, 17% related to pain, 12% related to digestive system

(Yavuz et al. 2014, unpublished data)

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FAMILY PHYSICIANs have burned out!

• The studies carried out in Ankara, İstanbul and Kayseri show that more than two thirds of FPs are burned out.

• The nearly only motivator that keeps them in family practice is the income they earn.

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FROM THE POINT OF FAMILY DOCTORS

• Efficiency of work – no change • Motivation to work – decreased • Work load and work stress – increased• Working hours – increased• Time spared for personal life – decreased• Time spared for professonal development

– decreased• Competition and ethical corruption –

increased

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• Relations– upset• Burnout – increased• Wages (income) – increased• Expectations provided - 56%• Happy to be family physician – 51.8% (decreased in time)• Positive correlation between total working year as FP

and burning out…

(Baykan et al. Burnout status of family physicians and related factors.

Türk Aile Hek Derg 2014; 18 (2): 64-74.)

AS A CONCLUSİON

People, in general, utilize PC facilities less than hospitals and hospital specialists…

No change from the previous to the current organization of PC…

Patients seem not to see PC physicians as the coordinator of their care

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THANK

YOU

HVALALEPO