Turkey. Health Systems in Transition. Health system review. Vol. 13 No

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1 Health Systems in Transition Vol. 13 No Health system review Mehtap Tatar Salih Mollahaliloğlu Bayram Şahin Sabahattin Aydın Anna Maresso Cristina Hernández-Quevedo

2 Anna Maresso and Cristina Hernández-Quevedo (Editors) and Elias Mossialos (Series editor) were responsible for this HiT Editorial Board Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom Series editors Reinhard Busse, Berlin University of Technology, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene & Tropical Medicine, United Kingdom Richard Saltman, Emory University, United States Editorial team Sara Allin, University of Toronto, Canada Jonathan Cylus, European Observatory on Health Systems and Policies Matthew Gaskins, Berlin University of Technology, Germany Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Dimitra Panteli, Berlin University of Technology, Germany Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Anna Sagan, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies Ewout van Ginneken, Berlin University of Technology, Germany International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Global Fund, Switzerland Johan Calltorp, Nordic School of Public Health, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Republic of Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, Rand Corporation, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russian Federation Peter C. Smith, Imperial College, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland

3 Health Systems in Transition Mehtap Tatar, Department of Health Care Management, Hacettepe University, Ankara Salih Mollahaliloğlu, Turkish School of Public Health (TUSAK), Ankara Bayram Şahin, Department of Health Care Management, Hacettepe University, Ankara Sabahattin Aydın, Istanbul Medipol University Anna Maresso, European Observatory on Health Systems and Policies Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Health System Review 2011 The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

4 Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS organization and administration TURKEY World Health Organization 2011, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publication to: Publications, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/en/what-we-publish/ publication-request-forms). The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation country or area appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed and bound in the United Kingdom. Suggested citation: Tatar M, Mollahaliloğlu S, Şahin B, Aydın S, Maresso A, Hernández- Quevedo C. : Health system review. Health Systems in Transition, 2011, 13(6): ISSN Vol. 13 No. 6

5 Contents Contents Preface v Acknowledgements vii List of abbreviations ix List of tables, figures and boxes xi Abstract xiii Executive summary xv 1. Introduction Geography and sociodemography Economic context Political context Health status Organizational structure Overview of the health system Historical background Organizational overview Decentralization and centralization Patient empowerment Financing Health expenditure Population coverage and basis for entitlement Revenue collection/sources of funds Pooling and allocation of funds Purchasing and purchaser provider relations Payment mechanisms Regulation and planning Regulation Planning and health information management

6 iv Health systems in transition 5. Physical and human resources Physical resources Human resources Provision of services Public health Patient pathways: referral and centre-referral system Primary/ambulatory care Secondary care: specialized ambulatory care/inpatient care Emergency care Pharmaceutical care Rehabilitation/intermediate care Long-term care Services for informal or unpaid carers Palliative care Mental health care Dental care Complementary and alternative medicine Health care for specific populations Principal health reforms Analysis of recent reforms Future developments Assessment of the health system The stated objectives of the health system The distribution of the health system s costs and benefits across the population Efficiency of resource allocation in health care Technical efficiency in the production of health care Quality of care The contribution of the health care system to health improvement Conclusions Appendices References Useful web sites HiT methodology and production process The review process About the authors

7 Preface Preface The Health Systems in Transition (HiT) series consists of country-based reviews that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each review is produced by country experts in collaboration with the Observatory s staff. In order to facilitate comparisons between countries, reviews are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a report. HiTs seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used: to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; to describe the institutional framework, the process, content and implementation of health care reform programmes; to highlight challenges and areas that require more in-depth analysis; to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policymakers and analysts in different countries; and to assist other researchers in more in-depth comparative health policy analysis. Compiling the reviews poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including

8 vi Health systems in transition the World Health Organization (WHO) Regional Office for Europe s European Health for All database, data from national statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, data from the International Monetary Fund (IMF), the World Bank s World Development Indicators and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate review. A standardized review has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. HiTs can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to HiTs and HiT summaries are available on the Observatory s web site (http://

9 Acknowledgements Acknowledgements The HiT on was produced by the European Observatory on Health Systems and Policies. This edition was written by Mehtap Tatar, Salih Mollahaliloğlu, Bayram Şahin, Sabahattin Aydın, Anna Maresso and Cristina Hernández-Quevedo. It was edited by Anna Maresso and Cristina Hernández-Quevedo. The basis for this edition was the previous HiT on, which was published in 2002, written by B. Serdar Savaş, Ömer Karahan and R. Ömer Saka and edited by Sarah Thomson and Elias Mossialos. Significant changes to the health care system have occurred since The Observatory and the authors are grateful to Professor Rifat Atun and Professor Dr Haydar Sur for reviewing the report and for their important contributions. The authors would like to extend a special thanks to Dr Berrak Bora Başara, Hakan Oğuz Arı, Dr Hasan G. Öncül, Serap Taşkaya, Dr Hakkı Gürsöz, Dr Mustafa Kosdak, Dr Nazan Yardım and Pınar Yalçın Balçık for their assistance and contributions during the process of writing the report. Special thanks go also to Professor Dr Recep Akdağ, the Minister of Health, and everyone at the Ministry of Health and its agencies for their assistance in providing information and for their invaluable comments on previous drafts of the manuscript and suggestions about plans and current policy options in the Turkish health system. Thanks are also extended to the WHO Regional Office for Europe for their European Health for All database from which data on health services were extracted and to the OECD for the data on health services in western Europe. Thanks are also due to the Turkish Statistical Institute (TURKSTAT), which provided a range of data. The HiT reflects data available in early 2011 unless otherwise indicated.

10 viii Health systems in transition The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. The Observatory team working on HiTs is led by Josep Figueras, Director, Elias Mossialos, Martin McKee, Reinhard Busse and Suszy Lessof. The Country Monitoring Programme of the Observatory and the HiT series are coordinated by Gabriele Pastorino. The production and copy-editing process of this HiT was coordinated by Jonathan North, with the support of Caroline White, Jane Ward (copy-editing), Mathew Chambers (typesetting) and Aki Hedigan (proofreading).

11 List of abbreviations List of abbreviations Abbreviation English Turkish (where relevant) Bağ-Kur Social Insurance Agency for Merchants, Artisans and the Self-employed CARK Central Asian republics and Kazakhstan CIS Commonwealth of Independent States DaPT-IPA-Hib Combination vaccine for diphtheria, acellular pertussis, tetanus, inactive polio and Haemophilus influenzae type b DRG Diagnosis-related group Teşhisle ilişkili grup EU European Union Eur-A Countries in the WHO European Region with very low child mortality and very low adult mortality Eur-B+C Countries in the WHO European Region with low child mortality and low or high adult mortality GDP Gross domestic product GERF Government Employees Retirement Fund Emekli Sandığı GHIS General Health Insurance Scheme Genel Sağlık Sigortası GP General practitioner HIG Health Implementation Guide Sağlık Uygulama Tebliği HTA Health technology assessment Sağlık teknolojileri değerlendirme HTP Health Transformation Program Sağlıkta Dönüşüm Programı IBRD International Bank for Reconstruction and Development ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Revision IMF International Monetary Fund IMR Infant mortality rate Bebek ölüm hızı IT Information technology MEDULA Electronic information management system for the SSI MMR Measles, mumps and rubella NGO Nongovernmental organization NHA National Health Accounts Ulusal Sağlık Hesapları NUTS Nomenclature of territorial units for statistics OECD Organisation for Economic Co-operation and Development OOP Out-of-pocket expenditure Cepten yapılan harcama PPP Purchasing power parity

12 x Health systems in transition SHA System of Health Accounts SHÇEK Social Services and Child Protection Agency Sosyal Hizmetler ve Çocuk Esirgeme Kurumu SPO State Planning Organization Devlet Planlama Teşkilatı SSI Social Security Institution Sosyal Güvenlik Kurumu SSK Social Insurance Organization Sosyal Sigortalar Kurumu TURKSTAT Turkish Statistical Institute Türkiye Iṡtatistik Kurumu TUSAK Turkish School of Public Health (former Turkish Institute of Health) VAT Value added tax VHI Voluntary health insurance Gönüllü Sağlık Sigortası TL a Turkish lira Türk lirası YTL a New Turkish lira Yeni Türk lirası a From 2005 through to 2008, s currency was called the new Turkish lira. From 1 January 2009, the new was dropped and the currency became again known simply as the Turkish lira.

13 List of tables, figures and boxes List of tables, figures and boxes Tables page Table 1.1 Population/demographic indicators, (selected years) 2 Table 1.2 Macroeconomic indicators, (selected years) 5 Table 1.3 Mortality and health indicators, (selected years) 10 Table 1.4 Main causes of death, Table 1.5 Health-adjusted life expectancy and loss of healthy life expectancy for all age groups at the national level for males and females, Table 1.6 Factors affecting health status, (selected years) 13 Table 2.1 Health care organizations by functions in 20 Table 3.1 Health expenditure in, (selected years) 40 Table 3.2 Trends in health expenditure in, (or latest available year) 41 Table 3.3 Health expenditure and GDP (at current prices), Table 3.4 Total health expenditure by type of service and financing agent, Table 3.5 Health insurance coverage and contribution rates 48 Table 3.6 Sources of revenue as a percentage of total expenditure on health, Table 3.7 Coefficients used to determine family practitioner payments 68 Table 4.1 Health system legislation in 73 Table 5.1 Hospitals (public and private) and their bed capacities in, (selected years) 88 Table 5.2 Operating indicators for selected hospitals, Table 5.3 Items of diagnostic imaging technologies by region, Table 5.4 Health care workforce in, Table 5.5 Health care personnel in, Table 6.1 Vaccination schedule for children 118 Table 6.2 Drug expenditure for outpatient treatment in, Table 7.1 Major health reforms and policy measures in,

14 xii Health systems in transition Figures Fig. 1.1 Map of 1 Fig. 2.1 Overview of the health system 23 Fig. 2.2 Central organizational structure of the Ministry of Health 24 Fig. 2.3 Organizational structure of the Ministry of Health in provinces 25 Fig. 3.1 Financial flows in the Turkish health system 39 Fig. 3.2 Fig. 3.3 Trends in health expenditure as a share (%) of GDP in and selected other countries, WHO estimates, Total health expenditure per capita (US$ PPP) in the WHO European Region, 2008, WHO estimates 43 Fig. 3.4 Percentage of total expenditure on health according to source of revenue, Fig. 5.1 Fig. 5.2 Fig. 5.3 Fig. 5.4 Fig. 5.5 Fig. 5.6 Fig. 5.7 Fig. 6.1 Beds in acute hospitals per population in and selected countries, 1990 to latest available year 89 Number of physicians per population in and selected countries, 1990 to latest available year 100 Number of nurses per population in and selected countries, 1990 to latest available year 100 Number of physicians per population in the WHO European Region, latest available year 101 Number of nurses per population in the WHO European Region, latest available year 102 Number of dentists per population in and selected countries, 1990 to latest available year 103 Number of pharmacists per population in and selected countries, 1990 to latest available year 104 Outpatient contacts per person per year in the WHO European Region, 2009 or latest available year 126 page Box page Box 2.1 Health insurance funds transferred to the SSI in 2008 and

15 Abstract Abstract has accomplished remarkable improvements in terms of health status in the last three decades, particularly after the implementation of the Health Transformation Program (HP (Sağlıkta Dönüşüm Programı)). Average life expectancy reached 71.8 for men and 76.8 for women in The infant mortality rate (IMR) decreased to 10.1 per 1000 live births in 2010, down from in Despite these achievements, there are still discrepancies in terms of infant mortality between rural and urban areas and different parts of the country, although these have been diminishing over the years. The higher infant mortality rates in rural areas can be attributed to low socioeconomic conditions, low female education levels and the prevalence of infectious diseases. The main causes of death are diseases of the circulatory system followed by malignant neoplasms. s health care system has been undergoing a far-reaching reform process HTP since 2003 and radical changes have occurred both in the provision and the financing of health care services. Health services are now financed through a social security scheme covering the majority of the population, the General Health Insurance Scheme (GHIS (Genel Sağlık Sigortası)), and services are provided both by public and private sector facilities. The Social Security Institution (SSI (Sosyal Güvenlik Kurumu)), financed through payments by employers and employees and government contributions in cases of budget deficit, has become a monopsonic (single buyer) power on the purchasing side of health care services. On the provision side, the Ministry of Health (Sağlık Bakenlıgı) is the main actor and provides primary, secondary and tertiary care through its facilities across the country. Universities are also major providers of tertiary care. The private sector has increased its range over recent years, particularly after arrangements paved the way for private sector provision of services to the SSI.

16 xiv Health systems in transition The most important reforms since 2003 have been improvements in citizens health status, the introduction of the GHIS, the instigation of a purchaser provider split in the health care system, the introduction of a family practitioner scheme nationwide, the introduction of a performance-based payment system in Ministry of Health hospitals, and transferring the ownership of the majority of public hospitals to the Ministry of Health. Future challenges for the Turkish health care system include, reorganizing and enforcing a referral system from primary to higher levels of care, improving the supply of health care staff, introducing and extending public hospital governance structures that aim to grant autonomous status to public hospitals, and further improving patient rights.

17 Executive summary Introduction Executive summary 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 is a parliamentary democracy with a clear separation of executive, legislative and judicial powers. The 1982 Constitution describes 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, 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. has accomplished remarkable improvements in terms of health status in the last three decades, particularly after the implementation of the HTP in Major health indicators such as the infant mortality rate (IMR), life expectancy and maternal mortality have improved considerably. Average life expectancy reached 71.8 for men and 76.8 for women in 2010, with the linear improvement between 2003 and 2010 being the fastest in the WHO European Region and narrowing the gap that existed previously. The IMR decreased significantly to 10.1 per 1000 live births in 2010, down from in 1980, while maternal mortality has declined rapidly (5.5% annually) over the last 10 years. Despite these improvements, there are still discrepancies in terms of IMR between rural and urban areas, and between different parts of the country, although these also have been diminishing over the years. The higher IMR

18 xvi Health systems in transition in rural areas can be attributed to low socioeconomic conditions, low female education levels and the prevalence of infectious diseases. The main causes of death are diseases of the circulatory system followed by malignant neoplasms. Organization s health care system has been undergoing a far-reaching reform process since 2003 and radical changes have occurred both in the provision and financing of health care services. Health services are financed through a social security scheme, the GHIS, which covers the majority of the population, and services are provided by both public and private sector facilities. The SSI, financed through payments by employers and employees, and government contributions in cases of budget deficit, has become a monopsonic power on the purchasing side of health care services. On the provision side, the Ministry of Health is the main actor and provides primary, secondary and tertiary care through its facilities across the country. Universities are also major providers of tertiary care in the system. The private sector has gained power over recent years, particularly after arrangements paved the way for private provision of services to the SSI. Financing Total expenditure on health as a proportion of gross domestic product (GDP) has risen from 2.4% in 1980 to 6.1% in The share of health expenditure from public sources as a proportion of total health expenditure was 73% in Health expenditure between 2000 and 2004 increased mainly because of reform initiatives that improved access to health care services and changes in the provider payment system. This trend has continued, with a rise in the share of public expenditure on health as a proportion of GDP from 2.9% in 1999 to 4.4% in This increase is mainly the result of improvements in the public provision and financing of health services that have decreased the share of out-of-pocket (OOP) expenditure. finances health care services from multiple sources. Social health insurance contributions take the lead, followed by government sources, OOP payments and other private sources. According to the most recent National

19 Health systems in transition xvii Health Accounts (NHA) data, 43.9% of funds were from social health insurance in 2008, followed by 29.1% from government sources, 17.4% from OOP payments and 9.6% from other private sources. Data on the distribution of health expenditure by types of expenditure come from the NHA study in 2000; figures for more recent years are not available. Inpatient care and public health care services, on the one hand, were predominantly paid for by public sources in On the other hand, private sources (that is, private insurance, OOP payments and other private sources) and public sources (central and local government plus social insurance funds) contributed more or less equally to outpatient services. The estimates for 2000 show that 83.1% of total current health expenditure was on personal health care services and goods, which included inpatient and outpatient services as well as pharmaceuticals and other medical goods. Nearly 60% of this expenditure was derived from government sources, with social security funds providing the largest share. The share of OOP payments was 17.4% of total health care expenditure in 2008, with a decrease from 27.6% in The decrease can be mainly attributed to reforms that improved health coverage of the population. OOP payments can be in the form of direct payments or cost-sharing. There are both direct and indirect cost-sharing in. Direct cost-sharing occurs as co-payments for prescriptions, medical devices and outpatient care. Extra billing and reference pricing are new methods of indirect cost-sharing that were introduced after Cost-sharing exemptions exist for emergency care, intensive care and for people suffering from chronic diseases such as diabetes and cancer. Voluntary health insurance (VHI) provides a relatively small share of health expenditure; it was estimated as 3.7% of total health expenditure in Currently, there are no complementary private health insurance schemes. Individuals or companies purchase private insurance for their employees at their discretion. Companies provide VHI for profit and currently there are no non-profit-making companies operating in the sector. Premiums, duration of insurance, coverage rules and all other rules are set within individual policies bought by the insured.

20 xviii Health systems in transition Delivery of services A comparative analysis with other European countries clearly shows the scarcity of health care personnel in in relation to its population. In particular, while the number of physicians per people (167 in 2010) has grown moderately but steadily since the early 1990s, it is still significantly lower than that of other Mediterranean countries such as Greece, Italy, Spain and Portugal, as well as of the average for the European Union (EU). 1 Similarly, the number of nurses per people (156 in 2010) is the lowest among the selected countries mentioned. Despite insufficient overall numbers, a significant improvement has been made in the geographical distribution of health care personnel, particularly general practitioners (GPs), since the early 2000s. Compulsory service and strictly applied health care personnel transfer rules are used as tools to balance geographical inequalities in deprived areas. Public health activities are mainly the responsibility of the Ministry of Health and municipalities. The Ministry mainly undertakes health promotion and prevention activities while issues such as environmental health or food hygiene are under the responsibility of other ministries and municipalities. Recent reforms have put special emphasis on the reorganization and strengthening of primary care services. A family practitioner system was first introduced as a pilot programme and was extended to cover the whole country at the end of Family practitioners (aile hekimi) are GPs and family physician specialists providing primary care to the population on their lists. They are paid on a capitation basis with incentives for preventive activities. The major drawback of the system is the lack of a referral system between primary, secondary and tertiary care. In other words, patients are free to enter the system at whatever point they prefer, and the primary care level is not working as effectively as it should. However, a new system of co-payment exemptions for primary and higher level care has been implemented as an incentive for people to visit their GP first and to receive a referral to secondary or tertiary care. The main reasons underlying the lack of a compulsory referral system are the general undersupply of doctors nationwide and, in particular, the insufficient number of doctors working at the primary care level who can act as gatekeepers. Currently, outpatient care, either primary or specialist, is provided by family practitioners, hospital outpatient departments (public and private) and private practitioners. 1 It should be noted however, that Italy and Greece, in particular, have an oversupply of doctors compared with the rest of Europe.

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