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Less than a decade ago, the health system in Turkey was considered a laggard, not only rela-tive to the rest of the Organisation for Economic Cooperation and Development (OECD) but to other high middle income countries. A major discrep-ancy existed between constitutional aspirations of equitable access to healthcare for all citizens and the reality on the ground. Health mattered, yet was seldom addressed on the political agenda. Today, the health system in Turkey is transformed, not quite to the point of favourable comparison with the rest of the OECD and most of the European Union, but fast closing the gap in health outcomes, responsiveness, and fair financing. We describe the Health Transformation Programme (HTP) launched in 2003, analyse the reasons behind its achievements, and share the lessons learnt.

An underachieving health system Turkey’s health system was highly fragmented: it was governed by two ministries and financed and regulated through three separate statutory health insurance schemes. The system covered all of the employed population and a large proportion of the self employed, though with significant variations in the scope and depth of benefit packages. Direct and copayments at the point of service and sub-sidies from the state budget were the norm, and included the Green Card scheme, a health insur-ance plan for the poor, covering inpatient care for about 2.5 million people. Overall, about 65% of the population was covered. In 1998, Turkey spent 3.6% of its gross domestic product on healthcare, or about $295 per capita at purchasing power parity (£191; €220 at current exchange rates). About 40% of total health expenditure was private and out of pocket.1

Service provision was also highly fragmented. Several ministries and health insurance schemes offered or purchased different service pack-ages from public or private providers. Despite a reasonable level of coverage, most people turned to the private sector to receive more responsive and higher quality care. Most physicians remained on the public payroll for job security and benefits, but supplemented their low salaries by taking under

the table payments in public facilities or working part time in private. Rampant absenteeism and low productivity and technical quality, especially in primary care, was common, with unnecessary referrals to outpatient specialist services. Further issues were severe inequalities in rural areas, especially in the east and south east of the coun-try, and inequalities in access to services because of shortages of facilities, technology, and skilled health workers. Public health and primary care were given little attention, evidenced by lower life expectancy and higher maternal and child mor-tality relative to other middle income countries.2 3

Political change spearheaded transformation Turkey entered the 21st century with a broad based consensus on the need to strengthen its health sys-tem governance, introduce universal coverage, and expand and streamline service delivery. But after two decades of ineffectual coalition govern-ments, the country was without the leadership or political commitment to implement these goals. The 2002 elections, in the aftermath of a major financial crisis, propelled a new majority Justice and Development Party (Adalet ve Kalkınma Partisi, or AKP) government into power. The new government understood the urgency of the need to transform the health system. It was quick to realise that the popular mandate would quickly dissipate if the government could not deliver on its promise of putting the state at the service of its citizens—a fundamental shift in Turkish political culture—but also understood the importance of reducing inter-regional inequalities in access to health and other social services in safeguarding social peace and stability in the country. There was also the constant embarrassment of facing international criticism for appallingly high maternal and infant mortality.

Transformation in Health, a white paper issued by the Ministry of Health in December 2003, pro-vided a candid assessment of the shortcomings of the existing system. It also laid out the guiding prin-ciples of the Health Transformation Programme: a people focused approach, pluralism, separation of power, decentralisation, and competitiveness. These goals entailed radical restructuring, such

as the redefining of the roles and responsibilities of the Ministry of Health towards “more steering and less rowing”; separation of the provision and financing of healthcare to achieve more efficient resource allocation and use; the introduction of universal health insurance; increasing the financial and administrative autonomy of public hospitals to improve technical efficiency and strengthen management; and the introduction of family medicine to integrate and streamline the delivery of primary and inpatient care.4

The effects of health reforms seven years onTable 1 compares health and health system out-comes before and after the start of the transforma-tion programme, using the WHO health system framework.5 There have been reductions in infant and maternal mortality and substantial increases in access to and use of services and in patient sat-isfaction, especially in primary care. Table 2 shows an improvement in Turkey’s rankings compared with 16 high middle income countries.

There are three reasons for the improvements. First is the political commitment at the highest level. Health has been placed at the top of the policy agenda and reforms implemented with-out any major setbacks during a period of politi-cal stability and sustained economic growth. Concrete examples of this political commitment include the prime minister’s frequent references to health and the health system, and the substan-tial increase in share of the government budget allocated to health expenditure—from 11.5% in 2000 to 16.5% in 2008—especially in view of the concurrent fast growth in government revenues and expenditures by about 5% a year.10 The rapid growth of the economy after the 2001 financial crisis also helped: while total health expenditures rose from TL44bn (£18bn; €21bn; $28bn) in 2003 to TL61bn in 2008, a 40% increase in real terms, its relative share in gross domestic product only rose from 6.2% to 6.4%. In 2009 it stood at 5.7%.11

Secondly, the Ministry of Health, which had previously been one of the weakest ministries, assumed more assertive leadership in the health sector. Five previous attempts to pass a law on

Healthcare in Turkey: from laggard to leaderEnis Barişs and colleagues observe that a political commitment to universal health coverage together with a significant investment in health has seen Turkey’s health indicators catch up and surpass other middle income countries

•bmj.com/podcasts Turkey’s health minister, Recep Akdag (above), talks about the strides his country has made in providing healthcare

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universal health insurance had failed. Other laws that were passed were either overturned by the constitutional court or could not be implemented because of lack of further regulation and enforce-ment. It was unclear who had the primary respon-sibility for policy and planning, regulation, and financing because of overlapping political and administrative authority across the Ministries of Health, Finance, and Labour and Social Security, as well as provincial governments and municipalities. Despite ongoing political bickering, turf wars, and legal challenges, the Ministry of Health asserted its position as the steward of the health system in charge of policy making, planning, regulation, and oversight. The National Health Insurance Fund (NHIF), under the political authority of the Ministry of Labour and Social Security, assumed responsibility for revenue collection, pooling, and purchasing, effectively splitting financing and pro-vision, and ending vertical segmentation of statu-tory entitlements by making all services accessible to all, regardless of affiliation with previous health insurance schemes. The playing field in service provision was levelled as both public and private providers could now be contracted by the NHIF and reimbursed for services rendered to the population.

The third reason for improved indicators was the understanding that performance improve-ment would require well designed financial and nonfinancial incentive schemes to increase satis-faction of health professionals. The introduction of family medicine and the prorated capitation payment significantly raised the income of gen-eral practitioners and nurses working in primary care. Similarly, a performance based supplemen-tary payment system adopted in public hospitals brought about a major reduction in part time pri-vate practice and a threefold to fivefold increase in the income of specialists. The new payment system, which incentivises team work and sense of ownership of health facilities, resulted in sub-stantial investment in technology, infrastructure, and amenities, and an increase in productivity. Absenteeism has fallen, and both outpatient and inpatient utilisation rates have more than doubled, mainly as a result of a major increase in the propor-tion of physicians opting to work full time in the public sector (table 1).

Achievements and lessons Health for all in Turkey is no longer merely an aspi-ration. Universal health coverage is ensured as a result of a high level of political commitment.12 Today, catastrophic health expenditure impover-ishes only 0.4% of the Turkish population.7

Equally important is the growing international recognition that it is indeed possible to improve health outcomes in such a short span by investing in health systems. Turkey is now frequently cited as a success story, rather than as an underper-former, having improved its health outcomes at a

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Fig 2 | Change in maternal mortality ratio (millennium development goal five) between 1990 and 200915

Table 1 | Health system indicators before (2000) and after (2008) the Health Transformation Programme in Turkey1 2 6-9

Health system goals and functions 2000* 2008† Health improvementLife expectancy at birth (both sexes, in years) 70 73Infant mortality (1000 live births) 38 19.4Under 5 mortality (1000 live births) 44 23Maternal mortality ratio (100 000 live births) 70 19.8Measles incidence (100 000 population) 11.1 0.004Responsiveness (public sector only)Patient satisfaction, overall (%) 39.5 66.5In primary care (%) 41 70.6With Ministry of Health hospitals (%) 39.4 66.6Financial access‡Total expenditure on health (% GDP) 3.6 5.6General government expenditure on health as percentage of total government expenditure 11.5 16.5Per capita government expenditure on health (purchasing power parity $int) 213 461Out of pocket expenditures on health as percentage of total health expenditures 27.6 19.3Health insurance coverage (%) 66 87Healthcare resourcesAcute care hospital beds per 100 000 193 232Doctors per 100 000 103.6 158.2General practitioners per 100 000 41.1 52.6Ministry of Health doctors working private part time (%) 89 25Geographical distribution (ratio of best to worst endowed provinces): Specialists 13.7:1 3.5:1 General practitioners 8.3:1 2.8:1 Nurses 7.9:1 3.6:1Medical technology (no of units): Computed tomography 121 329 Magnetic resonance imaging 18 200 Intensive care beds 869 6633 Ambulances 618 2029 Neonatal intensive care beds 665 2918No of separate examination rooms for doctors: Ministry of Health hospitals 6643 18 807 Primary care 6308 16 055Service deliveryFull vaccination coverage (%) 78 96Pregnant women delivering in hospital (%) 78 92Average no of visits to physicians per capita/year 2.4 6.3Acute inpatient care admissions/100/year 7.5 13.1Emergency medical service calls/year 350 000 1.5 million*Mid-year population 66.4 million; Gross national income per capita in purchasing power parity (PPP) international dollars: 8730.†Mid-year population 73.9 million; GNI per capita (PPP international dollars): 13 770.‡Expenditure data for 1998.

Fig 1 | Change in mortality among children under 5 (millennium development goal four) between 1990 and 200914

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pace and to a level almost unheard of in middle income countries,8 9 and in the case of health related millennium development goals, well before the 2015 deadline (figs 1 and 2).13-15

The recent Turkish experience provides at least three key lessons for other high middle income countries. One obvious lesson is the need to invest in health systems.16 17 Among the OECD countries, Turkey allocates the largest proportion of its pub-lic health budget, about 7.7%, to investment, compared with the OECD average of 4.2%.18 The budget allocated to expanding prevention and primary healthcare to underserved areas has also increased 58% in real terms.6 The 112 emergency telephone line now serves rural areas as well as cities. Seventeen air ambulances routinely serve geographically remote areas, transporting high risk pregnant women and sick children to bet-ter equipped urban facilities.6 An additional 111 000 health workers have been recruited. The health workforce is now distributed more equita-bly in geographical terms6 resulting in reduced inequalities in access to care among the poorest. The urban/rural and rich/poor ratios are now 1:1 for both birth attendance by skilled health staff and measles immunisation coverage (table 1).6

A second and less obvious lesson is the impor-tance of encouraging demand for essential health services by reducing sociocultural barriers and offering financial incentives. Pregnant women who live in remote areas are provided with free accommodation in cities for up to one month before delivery. Since the programme began in October 2008, close to 7000 pregnant women have used free predelivery care. In 2004, Turkey introduced a conditional cash transfer scheme, about TL17 per month payable to mothers, to encourage pregnant women, mothers, and their children to visit health facilities regularly, with an additional payment of about TL55 if women delivered their babies in public hospitals.6 As a result, the proportion of women who have attended at least four prenatal visits rose from 53.9% in 2003 to 73.7% in 2008 and the proportion of births attended by skilled health staff rose from 83% to 91.3% over the same period.13 Also in 2008, measles immunisation cov-erage reached 96%, from 82% in 2002. As a result, there were only four measles cases in 2008, down from 30 509 in 2001.6

The third lesson is the importance of vision and leadership to set values and guiding principles, and the determination to follow through policy implementation. A shift of perspective has placed the patient or citizen as the basis of all policy goals and performance evaluation. Reference to, and continuous monitoring and evaluation of, responsiveness to patients’ needs and prefer-ences and patient satisfaction figure prominently in policy papers, reports, and public speeches, and have been introduced as benchmarks into various supplementary payment schemes that

Table 2 | Life expectancy, health expenditures, and overall economic and human development in Turkey compared with highest value in 16 other high middle income countries before (2000) and after Turkey’s transformation programme*10

2000 Latest value† Ranking for TurkeyMain indicators Turkey Highest Turkey Highest 2000 Latest change

Life expectancy at birth (years) both sexes 70 77 73 78 12 8 +4Total expenditure on health as percentage of gross domestic product

3.6‡ 9.3‡ 5.6 10.1 16 12 +4

General government expenditure on health as percentage of total government expenditure

11.5‡ 19.6‡ 16.5 17 6 2 +4

Per capita government expenditure on health (PPP international dollars)

213‡ 594‡ 461 869 12 5 +7

Gross national income per capita (PPP international dollars)

8 720‡ 10 580‡ 12 970 17 840 6 6 0

Human development index 0.76 0.85 0.81 0.88 12 12 0Gini index 41.5 60.7 43.2 58.5 7 10 -3PPP=purchasing power parity.*Argentina, Brazil, Bulgaria, Chile, Colombia, Croatia, Malaysia, Mexico, Poland, Romania, the Russian Federation, Serbia, South Africa, Thailand, Ukraine, and Venezuela.†Latest available data since 2006.‡Expenditure data for year 1998 instead of 2000.

The Green Card insurance scheme covers inpatient care for about 2.5 million poor people

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are performance based and measured regularly through patient satisfaction surveys.4-19 The popu-lation’s satisfaction is now, at 67%, at the highest level since regular polling of patients began and service utilisation is at an all time high (table 1).8 19

Finally, considerable investment has been made to improve data availability, quality, and time-liness, complemented by household and user sur-veys. A nationwide survey on maternal mortality in 2006 put an end to the large disparity that had existed between national and international esti-mates and set the benchmark against which future progress will be assessed. All maternal deaths are now investigated, at times by the health minister himself, to identify the cause of death and take corrective action. Onsite oversight is routine, with the minister and his field coordinators reportedly having travelled 600 000 km and visited all 81 provinces, often more than once a year.6

Unfinished agendaHealth systems alone can only do so much to improve health without concurrent improvement in human development and increase in equality of opportunity. This is particularly true in Turkey, where income inequality is rising and literacy is yet to be universal (table 2). A large gender gap persists as a result of lower enrolment and participation of girls and women in education and labour.20 Regardless of the socioeconomic differences, non-communicable diseases are rising because of unhealthy lifestyles: Turks still smoke a lot, and as they rapidly urbanise, they also become less physically active and more obese. A rapidly ageing population, especially in the west of the country, is already using health services more often as a result of improved access, demanding higher quality and more user friendly care.

All these factors mean that the much improved health system needs constantly to adapt to chang-ing health and healthcare needs. The emerging challenges are now more programmatic and less structural, such as further embedding health in all policies, especially in relation to environmental and behavioural determinants of health; establishing disease prevention and health promotion services in all family based and community based primary care services; and improving public knowledge about healthy behaviour and healthier living and ageing.8

ConclusionIn just seven years, Turkey’s Health Transfor-mation Programme has been able to ensure universal health coverage for essential care and significantly improve health outcomes. The major challenge now is how to steer a much more complex health system in the right direction and adapt it to the changing needs and preferences of an increasingly assertive citizenry and a democratic and pluralistic gov-ernance structure, while improving efficiency

and financial sustainability. These are the same challenges that the rest of OECD and EU member states face today.9

Enis Bariş director, Division of Country Health Systems, WHO Regional Office for Europe, Copenhagen, DenmarkSalih Mollahaliloğlu head, School of Public Health, Ministry of Health, TurkeySabahattin Aydın deputy undersecretary, Ministry of Health, TurkeyCorrespondence to: E Baris

5, The World Bank, Room H9-271,

1818 H Street NW, Washington, DC 20433, USA ebaris@worldbank.orgWe thank the minister of health, Recep Akdag, and Nihat Tosun, undersecretary of health, for their encouragement and support. We also thank Francesca Seneca and Mary Stewart Burgher from WHO for help with data compilation and editing.Contributors and sources: This article draws on authors’ extensive involvement in the Health Transformation Programme (HTP) from its early conceptual phase to date. EB’s involvement was through external technical assistance during HTP’s design phase, whereas SM and SA were directly involved in HTP design and implementation. At the time of writing EB was Director, Division of Country Health Systems, WHO Regional Office for Europe; he is currently with the World Bank. At the time of writing SA was deputy undersecretary, Ministry of Health, Turkey; he is now president of Istanbul Medipol University. EB prepared the initial draft of this article. SM and SA contributed to the final draft. EB is guarantor.Competing interests: None declared.Provenance and peer review: Commissioned; externally peer reviewed.1 Serdar Savas B, Karahan O, Ömer Saka R. Healthcare systems

in transition—Turkey. European Observatory on Health Care Systems, 2002. www.euro.who.int/__data/assets/pdf_file/0007/96415/e79838.pdf.

2 World Bank.Turkey: reforming the health sector for improved access and efficiency. Vol. 1, 2. World Bank, 2003.

3 World Bank.Turkey: health transition project. Vol. 1, 2. World Bank, 2004.

4 Health Transformation Program. Ministry of Health, 2003.5 Murray CJ, Frenk J. A framework for assessing the performance

of health systems. Bull World Health Organ 2000;78:717-31.6 Akda R. Health Transformation Program in Turkey. Progress

report. January 2009. Ministry of Health, 2009. www.tusak.saglik.gov.tr/pdf/kitaplar/TurkeySPDEng.pdf.

7 Yardim MS, Cilingiroglu N, Yardim N. Catastrophic health expenditure and impoverishment in Turkey. Health Policy 2010;94:26-33.

8 World Health Organization. The European health report 2009: health and health systems. WHO Regional Office for Europe, 2010. www.euro.who.int/InformationSources/Publications/Catalogue/20091218_1.

9 OECD, World Bank. OECD reviews of health systems: Turkey. OECD, 2008.

10 World Health Organization. World health statistics 2009. WHO, 2009. www.who.int/whosis/whostat/2009/en/index.html.

11 OECD. Health at a glance 2009. OECD, 2009. www.oecd.org/health/healthataglance.

12 Garrett L, Chowdhury AM, Pablos-Méndez A. All for universal health coverage. Lancet 2009;374:1888.

13 Hacettepe University Institute of Population Studies. 2008 Turkey demographic and health survey TDHS-2008. Hacettepe University Institute of Population Studies, 2009. www.hips.hacettepe.edu.tr/eng/tdhs08/index.shtml.

14 UNICEF. Levels and trends in child mortality, report 2010. Estimates Developed by the UN Inter-Agency Group for Child Mortality Estimation. Unicef, 2010.

15 World Health Organization, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2008. Estimates developed by WHO, Unicef, UNFPA and the World Bank. WHO, 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf.

16 World Health Organization. Health and the millennium development goals 2005: keep the promise. WHO, 2005.

17 Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 2004;364:900-6.

18 Organisation for Economic Co-operation and Development. OECD health data 2007. OECD, 2007.

19 World Bank. Implementation completion and results report. Turkey Health Transition Project. World Bank, 2010.

20 World Bank. Turkey: Expanding opportunities for the next generation; a report on life chances. Report No 48627-TR. World Bank, 2010.

Cite this as: BMJ 2011;342:c7456

Immunisation really is the bread and butter work of global public health. Thus, when asked by a team at the London School of Hygiene and Tropical Medicine in the spring of 2009 if I wanted to participate in a set of studies undertaken to provide input into decisions around measles eradication, I did so without hesitation.

Our work was to be the health systems part of a three part look at measles eradication sponsored by the World Health Organization. The two other studies were on the economics of eradication.

Before our first meeting on this topic with representatives from the expanded immunisation programme and the Ministry of Health and Family Welfare and with officials from WHO and non-governmental organisations in Bangladesh, I wondered whether they would reject the idea of moving towards eradication, in light of the failure to eradicate polio globally and the big push to meet the United Nations’ millennium development goals. Would there be an appetite to look at another major undertaking? Should measles be next on the list for global eradication?

What we know is that seroprevalence studies indicate that vaccination coverage of 90-95% is needed to eliminate measles from a setting. In Bangladesh routine measles vaccination coverage rates have only recently reached 80-85%.

In January 2011 WHO’s strategic advisory group of experts recommended that measles can and should be eradicated. However, rather than moving immediately towards setting a date for global eradication, the group recommended that nations and regions should move towards their own elimination goals by strengthening routine immunisation systems.

I am left with the sense of having been on the ground at the start of something massive. However, with the need to introduce new vaccines, such as Haemophilus influenzae type B (Hib) and rotavirus, and to determine the best ways to reach children in remote corners of the nation, living on islands, or hidden among the urban homeless, the demands of today call me back from the prospect of a world free of measles.

Tracey Koehlmoos is programme head for health and family planning systems at the International Centre for Diarrhoeal Disease Research, Bangladesh, and adjunct professor at the James P Grant School of Public Health, BRAC University, Dhaka.

ЖRead this blog in full and others at bmj.com/blogs

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