HEALTH TRANSFORMATION PROGRAM IN TURKEY PROGRESS REPORT. September 2010

Transcription

1 HEALTH TRANSFORMATION PROGRAM IN TURKEY PROGRESS REPORT September 2010

2 Editor Prof. Dr. Recep AKDAĞ Republic of Turkey, Ministry of Health Publication No: 807 ISBN:

3 Content Foreword...5 Preface...7 Remarks...9 Introduction Chapter One: Our Health Policies from the Past to the Present Health Policies between the Years Health Policies between the Years Health Policies between the Years Health Policies between the Years Health Policies between the Years Health Policies after 2003: Health Transformation Program in Turkey Chapter Two: Ethical, Political and Methodological Principles of Health Transformation Program Problem Identification and Diagnosis Policy Development Political Decisions Implementation Evaluation Chapter Three: A New Era in Health Change of Mentality towards Human-Centered Service Understanding Extensive and Equal Health Assurance: Universal Health Insurance Campaign for Preventive and Primary Health Care a) New Era in Primary Health Care: Family Medicine b) New Era in Emergency Healthcare Services c) Healthcare Organization in Disasters and National Medical Rescue Teams (UMKE) d) Social Movement and Awareness for Chronic Diseases e) New and Effective Approach in Cancer Control f ) Effective Communicable Diseases Control g) Assurance of Our Future: Mother and Child Health h) Immunization Programs: Vaccines i) Sexual Health and Reproductive Health Program Transformation in the Primary Health Care: Family Medicine Change of Mentality in Hospital Services a) Eliminating Discrimination in Health: Uniting Public Hospitals under a Single Umbrella... 73

4 b) Decentralized Management of Hospitals c) Restructuring in Hospital Services d) Prevention of Hospital Infections e) Opening Private Hospitals Doors to Everyone f ) Triage and Registration at Emergency Departments g) Planning for Cardiovascular Surgery (CVS) Centers h) Restructuring in Burn Treatment i) Blood Services Performance Based Supplementary Payment, Quality and Accreditation Human Resources Management in Health a) Determination of Human Resources Situation and Solution Planning b) Breakthrough in the Health Human Resources Employment c) Transparency in Personnel Appointments d) Health Personnel Training National Drug Policy a) Reduction in Drug Prices b) Opening Pharmacies to Everybody c) Drug Consumption Health Information System/ e-health Implementations Rationalism in Investments A Health City/ Health Campus for Each Health Region a) Healthcare Service Planning b) Campuses, New Structuring and Hospital Roles Evaluation of Provinces: Step by Step 81 Provinces Dynamic and Healthy Foreign Affairs Restructuring the Ministry of Health Health Expenditures Satisfaction with Healthcare Services Chapter Four: Towards New Horizons Full-time Implementation Services under development a) Home Health Care b) Central Hospital Appointment System (CHAS) c) Mobile Pharmacies d) Diagnosis Related Groups (DRG) e) Administrative Unit Performance f ) Turkey Stem Cell Coordination Centre (TÜRKÖK) g) Pharmaceutical Tracing System (PTS) Planned Legislation Closing Remark References Chapter Five: Annexes a) Strategic Plan b) Public Hospital Unions Draft Law on Public Hospital Unions

5 Foreword We have put into effect what we have promised in our Government Program and our Urgent Action Plan one by one in order to provide effective, equitable, accessible and high-quality health services for our citizens. We have been implementing the Health Transformation Program and we continue our services in this field all along the line. Keeping in mind that health services is one of the most important criteria making a country livable, we have mobilized all of our sources to provide highquality, easily-accessible and patient-friendly services for our people. We, as the Government, have always prioritized and cared about that our citizens trust their state in this most vulnerable field for them, the health services, and that they receive these services without being bothered and troubled. Thus, we wanted all our citizens to have a State to be proud of when having their children, spouses and parents treated and a State where they can experience its endless compassion.

6 As a result of the successful implementation of the Health Transformation Program in a serious, determined and careful manner, all of our citizens are now able to receive their medication and health services without any discrimination, as equal and honorable citizens, from any health institution they wish. Our hospitals are more modernized, and this modernization process is continuing swiftly. While accomplishing all these, we have conceived the delivery of modern and qualified health services not as a favor but as our responsibility and our main duty. Because we think that the essence of both politics and action is human. The philosophy of let the man live so that the state lives is our maxim. While working to ensure that mothers give birth to healthy babies and individuals are assured of their parents health, we have bravely conducted new arrangements that will please every member of the health staff within our existing means. Towards a healthy community, crowning our efforts in other fields with the health services is our most important goal. Because, we know that our nation deserves the best of all services, and we continue on our path by saying human first. I would like to congratulate everyone who are involved in the implementation of Health Transformation Program and present my gratitude on behalf of my nation. With all my respect Recep Tayyip ERDOĞAN Prime Minister

7 Preface As you know, we have accomplished an important transformation in the field of health in eight years through the Health Transformation Program. The main goal of this transformation is to make the health system of the Republic of Turkey compatible with the vision of 21st century and to provide our people with the high-quality health service that they deserve. As the 58th, 59th and the 60th Government of the Republic, we set out our way believing that we have the power to deliver the citizens a humane, equal and modern healthcare. We have strengthened this belief by evaluating all the efforts that have been made in the field of health since the foundation of our Republic. We analyzed and assessed the health systems of many developed countries on site, and we combined it with our inheritance; thus we have developed the Health Transformation Program, which is a unique and human-centered model for Turkey. We have

8 implemented all the components of this model with the strength we gain from our nation, the instructions of our Prime Minister, the determination of our Governments and the support of Turkish Grand National Assembly. Today we all experience the most important outcomes of this program and its contributions to a healthy life. And we strongly believe that we will accomplish better results in the future. The responsibilities of detecting the current status and transferring our vision to all stakeholders have made us share this progress report with you. At the end of this efficient process, when we look back, the progress achieved by our government can be seen clearly. Of course, this is not enough for us. We have a lot more to do, a lot more service to provide and a long way to go. On this occasion, I would like to express my gratitude to everyone -physicians, nurses, midwives, technicians, officers, drivers, in short, to the health community- that grasp the essence of health transformation and work day and night altruistically for public health. Yesterday was not like this; tomorrow will be much better. With all my respect Prof. Dr. Recep AKDAĞ Minister of Health

9 Remarks The data used in this book for 1996 and 2002 covers all figures such as those pertaining to the facilities and personnel that belong to the public institutions and agencies that the Ministry of Health took over in 2005.

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11 Introduction Throughout the Republic era, the health policies implemented in our country went through some fundamental changes. Some of the important milestones are Refik Saydam era (1923), Behçet Uz era (1946) and the introduction of socialization in health services led by Prof. Dr Nusret Fisek (1963). Health Transformation Program is the last one of those milestones. On the other hand, during the World Health Assembly in 1977, attention was drawn to the roles that the governments would undertake so that all the people in the world could lead socially and economically efficient lives. And the foundations of the policy Health for All in the 21st Century were laid in 1978 at the Alma Ata Conference. In 1984 World Health Organization European Region Health for All Strategy and Objectives were accepted.

12 Implementation of those global policies and objectives in our country has unfortunately remained as a political desire for 20 years. Health Transformation Program, which we have started to implement in 2003, is a comprehensive program that takes all the works made so far into consideration and that aims at generating the most suitable solution with the participatory and democratic decision processes. The aim is to organize, finance and deliver the health services in an effective, efficient and equal fashion. While accomplishing the said goals Health Transformation Program pays attention to the Health for All in the 21st Century policy of the World Health Organization, Accession Partnership Document declared by the European Union and the other international experiences. The center of the Health Transformation Program is the human. The bottom line is to protect the individual s health along with the public health. For that reason the main idea of this program is accessible, high-quality and sustainable health service for all. The 9th Development Plan, which was prepared in accordance with the aims of Health Transformation Program in 2006, aims at facilitating access to health services, improving the service quality, strengthening the planning and supervising role of the Ministry of Health, developing health information systems, ensuring the rational use of medicines and supplies, and establishing a universal health insurance system. Since 2003, that is, since the introduction of the Health Transformation Program, most of those aims have been achieved. Some of the most important components of the program, which are universal health insurance, facilitating access to health services, improving the service quality, have already been realized. Also significant progress has been made in terms of the health information system, rational use of medicines and supplies and strengthening the planning and supervising role of the Ministry of Health. Detailed information on those topics can be found in the relevant parts of this report. Being executed on this axis Health Transformation Program is a supplementary part of the national policy. With the implementation of this program health services has gained a dynamic ground that can meet the rapidly-changing health priorities of the future. We have brought the progress we have made with the Health Transformation Program, which we developed as unique Model for Turkey by making use of the recent health policy works, into your attention with examples in the recent years. In this book, you will find the updated versions of the success stories that we previously published in the books titled Progress So Far: Turkey s Health Transformation Program and Health Transformation Program in Turkey, Progress Report, August 2008, with new annexes.

13 CHAPTER 1 OUR HEALTH POLICIES FROM THE PAST TO THE PRESENT

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15 OUR HEALTH POLICIES FROM THE PAST TO THE PRESENT Our Health Policies from the Past to the Present Along with the continuity of the Seljuk-Ottoman medical tradition, a cultural unity stands out in the organization of the health services. While this structure was being developed since the foundation of our young Republic, a western-oriented path was mostly followed for organizing the state and its institutions and establishing service policies. Within this process, health policies could not remain independent of global trends, and demonstrated basic preference changes. Health Policies between the Years The Ministry of Health (MOH) was established by the Law no: 3 and dated 3 May 1920 following the opening of the Turkish Grand National Assembly. The first Minister of Health was Dr. Adnan Adıvar. An opportunity of regular recording did not exist in this period. The focus was mostly on healing the damages of the war and developing the legislation. The important point here is that Ministry of Health was one of the first ministries to be established within the young state that was organized before the foundation of the Republic and during the most difficult days of the struggle for existence. The Government of the Turkish Grand National Assembly continued to work for the institutional arrangements of the health services even during the difficult years of warfare. In this period, Law no. 38 on Forensic Medicine (1920) was passed. Health Policies between the Years During his office starting from the foundation of the Republic until the year 1937, Dr. Refik Saydam made great contributions to the establishment and development of the health services in Turkey. According to the records, health services were provided by the government, municipality and quarantine centers, small sanitary offices, 86 inpatient treatment institutions, hospital beds, 554 physicians, 69 pharmacists, 4 nurses, 560 health officers and 196 midwives in Turkey in

16 Health Transformation Program in Turkey September 2010 In this period the following Laws, which are still in effect, were passed: - Law no. 992 on Bacteriology and Chemical Laboratories (1927), - Law no: 1219 on the Practice of Medicine and its Branches (1928) - Law no on Pharmaceuticals and Medical Preparations (1928), - Law no: 1593 on General Hygiene (1930) - Law no on Radiology Radium and Treatment with Electricity and Other Physiotherapy Facilities (1937) Health policies of the Refik Saydam era were centered on the following four principles: 1- Central execution of the planning, programming and administration of the health services by sole authority, 2- Separation of preventive medicine and curative services by deploying their implementation to respectively central administration and local administration, 3- In order to meet health manpower demand, improving the attraction to Medical Schools, opening dormitories for medical school students, establishing compulsory duty for medical school graduates, 4- Introduction of control programs for communicable diseases such as malaria, syphilis, trachoma, tuberculosis and leprosy. In the light of these principles; - The health services were conducted with the single-purpose service in a wide area/ vertical organization model, - Preventive medicine concept was developed through legal regulations; the local administrations were encouraged to open hospitals; and government s local public doctors were assigned in every district. - Diagnosis and treatment centers have been established in district centers beginning from the places with high population (150 district centers in 1924 and in 20 district centers in 1936); physicians were prohibited to work independently. - As a guide for the cities, Ankara, Diyarbakır, Erzurum, Sivas Numune Hospitals were opened in 1924; Haydarpaşa Hospital was opened in 1936; Trabzon Hospital was opened in 1946 and Adana Numune Hospital was opened in Health Policies between the Years The First Ten-Year National Health Plan, which can be called the first health plan in the history of the Republic, was approved by the Higher Council of Health in This plan was announced by the Minister of Health, Behçet Uz, in 12 December However, before the adoption of this plan, which had been prepared through a hardworking process, Behçet Uz had to quit his office as the Minister of Health.

17 OUR HEALTH POLICIES FROM THE PAST TO THE PRESENT When Dr. Behçet Uz was re-appointed as the Minister of Health in the government of Hasan Saka (10 August 1947/10 August 1948), the National Health Plan, which became a draft law in one and a half year, was negotiated and approved by the Cabinet and the four commissions of the Turkish Grand National Assembly. However it could not be adopted as a law due to the change in the government. The predecessor Minister of Health, Dr. Kemal Bayazit, withdrew the plan. Although National Health Plan and the National Health Program could have been turned into a legal document or implemented entirely, majority of their notions deeply influenced the health structuring of our country. The inpatient treatment institutions, which were basically under the supervision of the local governments until that day, were started to be managed from the center. National Health Plan, in the framework of the principle of bringing health organization to the villages and the villagers, envisaged the establishment of a ten-bed health center serving 40 villages each and to provide curative medicine and preventive health services together. Efforts were made to assign two physicians, a health official, a midwife and a visiting nurse to those centers along with village midwives and village health officers, who would be assigned to serve for a group of ten villages. In 1945, there were 8 health centers; which were increased to 22 in 1950, to 181 in 1955 and to 283 in Under the Ministry of Health, the Division Directorate of Mother and Child Health was established in A Mother and Child Health Development Center was established in Ankara in 1953 by providing cooperation and assistance from international organizations such as UNICEF and World Health Organization High infant mortality incidence and mortality due to infections in that period led to elaborate the implementation of policies addressing the promotion of population growth. In this framework, significant progress was achieved in terms of health facilities and human health resources aiming health centers, maternal hospitals and infectious diseases. Average life expectancy at birth was 43.6 years in , 52.1 years in , 57.9 years in As a continuation of the first Ten Year National Plan, National Health Programs and Studies on Health Bank was announced by Dr. Behçet Uz on 8 December 1954 and it became one of the foundation stones for the health planning and the organization for our country. The National Health Plan categorized the country in seven regions, and hence envisaged establishing a medical school in each region and increasing the number of physicians and other health staff (Ankara, Balıkesir, Erzurum, Diyarbakır, İzmir, Samsun, Seyhan). The National Health Program foresaw a structure composing of 16 health regions and the planning was completed accordingly (Ankara, Antalya, Bursa, Diyarbakır, Elazığ, Erzurum, Eskişehir, İstanbul, İzmir, Konya, Sakarya, Samsun, Seyhan, Sivas, Trabzon, Van). 17

18 Health Transformation Program in Turkey September In order to establish human resources infrastructure, Ege University Faculty of Medicine was opened for student admissions in 1955 after the Faculties of Medicine of Istanbul and Ankara Universities. When the years 1950 and 1960 are compared, it can be seen that the number of physicians increased from to 8.214, nurses from 721 to 1658, midwives from to More than a 100 % increase was ensured for all 3 occupations in 10 years. The numbers of hospitals and health centers were increased and within the same framework the increase in the number of beds was also ensured. Among the special service fields, the increase in the numbers of peaediatric hospitals, maternal hospitals and tuberculosis services was quite promising. Even though these numbers are affected by the devolution of management power from the local administration to the central administration, when we take into consideration the number of hospital beds per a hundred thousand people, its rate increased to 16.6 in 1960 from 9 in Along with these positive developments in health institutions and hospital beds, there were very promising improvements in the health indicators. Tuberculosis related mortality had a significant decrease in this period. There were also significant outcomes in infant mortality. While the tuberculosis related mortality rate in city and districts in Turkey in 1946 was 150 per a hundred thousand, it decreased to 52 per a hundred thousand in Both the National Health Plan and the National Health Program had aims such as insuring the citizens in return for a fee, meeting the costs of the uninsured people and the people could not afford for treatment from a special administrative budget, establishing a health bank and financing the health expenditure from this bank, auditing the production of medical materials including medicine, serum and vaccine and establishing industrial institutions which would provide child food like milk and infant formula. In this framework, Biologic Control Laboratory was established in 1947 under the Refik Saydam Hygiene Center Presidency and a vaccine station entered into service. From that year onwards intra-dermal BCG vaccine has been produced. The production of pertussis vaccine was started in 1948 Again in the same framework, Workers Insurances Administration (SSK Social Insurances Agency) was established in Starting from 1952, health institutions and hospitals were opened for the insured workers. In this period, activities were continued regarding the establishment of the Retirement Fund, thus the coverage of the social security started to expand. In this period, legislation was also formed which carry the legal infrastructures of the non-governmental organizations and some medical occupations to present day:

19 OUR HEALTH POLICIES FROM THE PAST TO THE PRESENT - Law on the Turkish Medical Association (1953/6023) - Law on Pharmacists and Pharmacies (1953/6197) - Law on Nursing (1954/6283) - Law on Turkish Association of Pharmacists (1956/6643) Health Policies between the Years The Law no. 224 on the Socialization of the Health Services was adopted in The socialization actually had begun in 1963 and became widespread in the country in A structure was established as health posts, health centers, and province and district hospitals through a widespread, continuous, integrated and gradual approach. Law no: 554 on Population Planning was adopted in Thereby, anti-natalist policy (population control) was adopted instead of pro-natalist (rising population) policy. Multi-dimensional service in narrow area approach was adopted as an alternative to the single dimensional service in a wide area. Although a draft law on Universal Health Insurance was prepared in 1967, it could not be forwarded to the Council of Ministers. In the 2nd Five Year Development Plan in 1969, the initiation of the General Health Insurance was foreseen again. Draft Law on Universal Health Insurance was conveyed to the Turkish Grand National Assembly in 1971 but it was not adopted. In 1974, the draft which was presented to the National Assembly was not negotiated. In 1978, Law on the Principles of Health Personnel s Full Time Working was adopted. Physicians working for the public sector were prohibited to open private practices Then this Law was repealed with the Law on Amends and Working Principles of the Health Personnel in 1980 and public doctors were permitted to open private practices again. Health Policies between the Years The 1982 Constitution includes provisions both regarding the citizens having social security right and the State s responsibility towards realizing this right. According to the 60th Article of the Constitution, Everyone has a right to social security, and the State shall take the necessary measures and establish the necessary organization to provide this security. Additionally according to the 56th Article of the Constitution, To ensure that everyone leads their lives in conditions of physical and mental health and to secure cooperation in terms of human and material resources through economy and increased productivity, the State shall regulate central planning and functioning of the health services. The State shall fulfill this task by utilizing and supervising the healthcare and social institutions both in the public and private sectors. This article also includes a provision stating Universal Health Insurance may be introduced by law. 19

20 Health Transformation Program in Turkey September 2010 Basic Law no on Health Services was adopted in However because the necessary regulation for the execution of this Law was not made and some of its articles were repealed by the Constitutional Court, the Law was not put into effect in full. As the finance management in health gained importance, Universal Health Insurance came to the agenda once again in However, the legal regulations on this matter could not be implemented and also in 1986 health benefits were introduced for the Bağ-Kur enrollees thus a 3-headed structure emerged in public health insurance. The most significant outcome of this development was that three institutions had separate schemes and pricing regarding the same health service. While some institutions covered the price of a certain service in their payment list, the others did not. In 1990, the State Planning Organization (SPO) prepared a basic plan on the health sector, and in line with this plan 1st National Health Congress was held in This Master Plan Study on Health Sector, which was conducted by the MoH and the SPO, in a sense, is the beginning of the health reforms. The First and Second National Conferences on Health were held, and the theoretical studies on health reform gained acceleration. Green Card implementation has been introduced in 1992 with the Law no for the low income citizens are not covered by social security scheme. Thus, people with low income who do not have adequate economic means to access to health services were ensured to be covered by the health insurance scheme even limitedly. National Health Policy, which was prepared by the Ministry of Health in 1993, included 5 main chapters, which were assistance, environmental health, lifestyle, delivery of health services and goals for healthy Turkey. In 1998, Universal Health Insurance was presented to the Parliament by the Cabinet under the name Law on Personal Health Insurance System and the Establishment and Operation of the Health Insurance Institution but it was not adopted a law. In 2000, a draft law on the Health Fund was presented for the opinion of the ministries however it was not concluded either. 20 The main components of the Health Reform activities conducted in 1990s were: 1- Establishment of a Universal Health Insurance by gathering the social security institutions under one umbrella, 2- Development of the primary care services in the framework of family medicine, 3- Transformation of the hospitals into autonomous health facilities, 4- Providing Ministry of Health with a structure that plans and supervises the health services and prioritizes preventive healthcare services.

21 OUR HEALTH POLICIES FROM THE PAST TO THE PRESENT Consequently, this was a period in which theoretical studies were conducted but not put into practice sufficiently. Health Policies after 2003: Health Transformation Program in Turkey According to World Health Organization (WHO), the health system of a country should be designed in a way to ensure the delivery of high quality health services for all people. This service should be effective, affordable and acceptable to the overall society. Each country is recommended to develop its own unique health system taking into consideration those factors. Since health is an inherent right, the health services should be organized to ensure equal access for all. In line with the principles of justice and equity, health insurance should be provided for all; distinctions such as gender, social status or social class should not hinder benefiting from health services; health services should be easily accessible; and the health services provided should be modern and effective. At the end of 2002, the status of the Turkish health system made it necessary to undertake radical changes in many areas from service delivery to financing and from human power to information system. If a country aims at improving its health systems, the first thing to do is to sustain the support of the political authority in that country. The financial and social aspects should also be taken into account. It should also be known that many interest groups will stand in the way of reform. It is essential to have a prime minister, a president, a cabinet, an assembly that stands by you, supports you and encourages you. Otherwise success cannot be achieved. Health Transformation Program in Turkey is formulated based on this fact. Another aspect of the issue, which is as important as this, is that the health professionals believe in the spirit and necessity of this transition and work with humanitarianism. Moving from those basic facts Health Transformation Program has been introduced in This program is prepared by getting inspiration from past experiences, particularly the socialization of health services, the recent works for health reform and the successful examples in the world. All the steps taken in health since the Republic were assessed, the project works implemented within the Ministry were reviewed and the positive inheritance of the past was embraced. It is certain that the program will seriously affect not only the present but also the future, and that it will be a significant milestone in achieving the objectives set in the field of health. Ministry of Health has shown its decisiveness for the implementation of this program and reaching the desired point in the field of health, and has put many implementations into practice. 21

22 Health Transformation Program in Turkey September In this period, the steps easing the lives of our citizens are taken with courage and determination. With this understanding, the hospitals of other public institutions, including the SSK ones, were transferred to the Ministry of Health. The coverage of green card have been widened for low-income groups; the health services and the pharmaceutical expenses of the green card holders within the scope of outpatient services are also now covered by the state. The VAT of the pharmaceuticals has been reduced and the medicine pricing system has been changed. In this way, a big discount has been achieved in pharmaceuticals prices, and the burden of pharmaceutical expenses both on the public and on the citizens has lightened a lot. Those arrangements have played an important role in expanding the access to pharmaceuticals. 112 Emergency Health services are delivered not only in cities but also in villages. The numbers of stations are increased and the ambulances are equipped with the state of art technology. Sea and air transportation vehicles are integrated into the system. Primary healthcare services, including preventive healthcare and mother-child healthcare services, are strengthened; Family medicine implementation, which is an element of modern health understanding, has been launched and spread out. In terms of infant mortality rate; our country has managed to achieve the progress made in 30 years by the developed countries within the last eight years. The same success was also achieved in maternal mortality rate, and again the progress made in 20 years by the OECD countries in terms of maternal mortality was achieved with the last eight years by our country. Preventing ill-health and premature deaths related to non-communicable diseases has constituted the core of important health programs of our term. In this scope, national programs are planned and implemented for certain diseases such as cardiovascular diseases, cancer, diabetes, chronic respiratory tract diseases, stroke, and kidney failures. Our indicators for communicable diseases have reached the level of the developed countries after the implementation of Health Transformation Program has started. The regions lacking building, equipment or health personnel are accepted as priority areas and the imbalances of this sort have largely been eliminated. In the last eight years, a total of new health facilities including 476 independent hospitals and new hospital buildings were opened for service. In the same period, the number of personnel working in the public health institutions has increased by 183 thousand people with service procurements. Although a large-scale transformation program appreciated by the world has been implemented for the last eight years, it is seen that the increase trends in the primary overall public expenditures and in the public health expenditures are parallel. Public resources have started to be used efficiently with the Health Transformation Program. Eventually, financial sustainability has been taken assured with the medium term financial plan covering the years 2010, 2011 and 2012.

23 OUR HEALTH POLICIES FROM THE PAST TO THE PRESENT The actions are so widespread and effective that they foretell what will and can be done from now on. In 2003, the level of satisfaction with health services was 39,5% and in 2009 this figures reached 65,1%. As a result of this satisfaction our people have started to demand better service and their trust and expectations have risen. It is necessary to complete the ongoing services and to undertake new enterprises in order to meet these expectations. In this period several legal arrangements have been made as the legal complementary of the Health Transformation Program: - Law no on Employing Contracted Health Personnel in the Places Experiencing Difficulty in Staff Supply and Amending Some Laws and Decree Laws (2003) - Law no on Family Medicine Pilot Implementation (2004) - Law no on Employing Contracted Health Personnel in the Places Experiencing Difficulty in Staff Supply and Amending Some Laws and Decree Laws, Amending the Health Services Basic Law and Decree Law on the Organization and Tasks of the Ministry of Health (2005) - Law no on the Transfer of Health Units of the Some Public Institutions and Agencies to the Ministry of Health (2005) - Law no on Amending the Health Services Basic Law, Law on the Compensation and Working Principles of the Health Personnel, Civil Servants Law and Law on Practicing Medicine and Decree Law on the Organization and Tasks of the Ministry of Health (2005) - Law no on Social Insurances and Universal Health Insurance (2006) - Law no on Social Insurances and Universal Health Insurance (2006) - Law no on Blood and Blood Products (2007) - Law no on Amending the Law on Nursing (2007) - Law no on the Full-time Working of University Staff and Health Personnel and Amending Some Laws (2010) 23

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25 CHAPTER 2 ETHICAL, POLITICAL AND METHODOLOGICAL PRINCIPLES OF THE HEALTH TRANSFORMATION PROGRAM

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27 Structural Human centered Planned Sustainable

28 Health Transformation Program in Turkey September 2010 (Modified from M. Roberts and et al., 2004) The process is continued by solving the existing, looming or emerging problems through the same methodology by remaining within the framework of the program. The decisions are taken within the framework of the fundamental ethical approaches all through the process. 1. Problem Identification and Diagnosis The concept of health is interconnected with every moment of an individual s life. It is one of the major factors that affect the social welfare. Considered in this framework, existence of health problems is inevitable in any country and at any time. Therefore it is more productive to act with an understanding that prioritizes the problems that are not expected to exist in the current level of development. Identifying the current status of the health system, determining the performance objectives and defining problems in this respect is a realistic way of developing sustainable and strong policies. Some specific criteria are applied in order to objectively reflect the current situation. The first of those criteria is the primary care indicators. In addition, financial risk protection and citizen satisfaction are important in terms of the comprehensiveness of the health system. 28 a) Primary indicators Major primary care indicators that can reflect the status of the health system are as follows: Infant mortality rate, Maternal mortality rate,

29 ETHICAL, POLITICAL AND METHODOLOGICAL PRINCIPLES OF THE HEALTH TRANSFORMATION PROGRAM Average life expectancy, Incidence of infectious diseases, Incidence of vaccine preventable diseases, Incidence of waterborne and food borne diseases, Prevalence of chronic diseases and some risk factors, Routine vaccination rates (BCG, Tdap-IPV-HiB3, Hep-B3, MMR, Td+2) Full immunization ratio, Ratio of health expenditures within GDP. b) Protecting citizens against financial risks This is the primary aim of the health sector policies and the most important focal point of the health reform policies. It means an assurance through which an individual receives his or her medical treatments without facing financial difficulties. There should be assurance that no disease would create a financial burden for the patients or their families that would affect their daily lives or impoverish them. These assurances may be constructed under different models. Such protection is largely affected by how the sector is financed. The scope of the protection against risks may be defined by taking objectives, such as providing adequate services regardless of financial constraints of individuals and compensating financial losses due to malpractices, into consideration. c) Citizen satisfaction This is the satisfaction level of citizens from the services provided by the health sector. It is common perception that it cannot demonstrate the efficiency or the quality of health services on its own. However, it is not possible for a system, which is not citizen-oriented and cannot meet people s expectations, to obtain good results. Adoption of services by citizens will enable participation in the process and help obtain results much faster. Therefore, satisfaction is considered to be one of the main criteria and policy is developed by taking into account how people assess the health services they receive. The waiting periods in the health institutions, the complexity level of hospital procedures and processes, the time saved for each patient, and information mechanisms are all taken into consideration during these evaluations. 29

30 Health Transformation Program in Turkey September Policy development It follows the identification of health problems and the development of policies to overcome such problems under the program. While the problems studied on might vary, it is universal because it aims at overcoming the problems and reaching the established targets. Within this framework of universality, each society develops its own policies in accordance with its conditions. Within the framework of the Health Transformation Program, policy development takes into account the prioritized criteria particularly access, quality, equality and efficiency. The scope of responsibility while developing reform plans is both analytic and politic. The process of policy making should be designed to be technically strong and politically adoptable. Hence, the principles provided below should be taken into consideration while developing policies under the Health Transformation Program: The principle of health for all should always be given priority. International experiences are reviewed, and successful examples are tailored according to our own conditions. Cautions should be taken against ideological approaches, and practices that would emphasize individual or group interests. The political, economic and cultural realities of our country should always be taken into account. Possible implementation problems (sources, potentials and administrative law, etc.) should be regarded. 3. Political Decisions Accepting transformation in the health sector is not only related with the political will. It is a problem of formatting an effective policy strategy as well. Whether a reform proposal will be adopted is dependent on the willingness, interest and capability of the parties and the political strategies they use. The political stand of the authority behind the implementation facilitates the adoption of the transformation by the implementing bodies and the ones affected by the transformation. Particularly the support of the government authorities along with the commitment of the ministers is of great significance. The contribution of Mr. Prime Minister has played a significant role in implementing many radical changes and accomplishing them under the Health Transformation Program Implementation As in all the reform processes, it is necessary to monitor and observe the transformation in the health sector for an effective implementation. Thus the problems likely to emerge during the process may be identified and corrective measures can be taken. In this respect, the key to a successful implementation is an appropriate supervision and reporting system.

31 ETHICAL, POLITICAL AND METHODOLOGICAL PRINCIPLES OF THE HEALTH TRANSFORMATION PROGRAM The major inputs of the system are the provision of effective, high-quality and accessible health care services. The aim of those inputs is to reach the outcomes indicating to the success of the system. These outcomes, in other words the performance indicators, are the targeted health indicators, a comprehensive financial protection and citizen satisfaction. In order to direct the outcomes of the health system, some important tools which can be regarded as control mechanisms may be used. It is possible to affect the performance of the system and the expenditures through such mechanisms. There are some other factors that may alter the system standards involuntarily except for the control mechanisms (for example, wars, natural disasters, epidemics, etc), and we can change their inevitable results in a positive way by making a few alterations. Nevertheless, sometimes it is necessary to address a couple of control mechanisms together. The control mechanisms in question are the health service financing, the method of payment for services, the organizational structure of the health sector, arrangements and the behaviors of the actors playing a role in the sector. a) Finance It is the way to provide financial sources for the system. Here the idea is to distribute the burden in a fair and equal way, to make it politically and socially acceptable, and to adjust it to the economic conditions of the country. b) Payment It refers to paying for the services provided and ensuring the sustainability of the services. Every payment system has its own logic, a scale and a rate. The payment method we may use is related with the service delivery system. Payment methods are almost always conflicting; the payers want to pay less and the service providers want to get more. There is no perfect payment system; every payment system provides certain negative and positive incentives. The important thing is to know which problems we will encounter when we choose a specific payment model. Payment can be made to the health institutions per service, per hospitalization day, per patient admission or per capitation through allocation from the general budget. Payment can be made to the health personnel per service, as salary, as salary + incentives, per capitation + incentives. Every Payment Method Has Certain Handicaps: In Austria, where payments are made per hospitalization days, patients were hospitalized for longer periods. When the payment is made per patient admission, patients are hospitalized for shorter periods and more patients are admitted. When health professionals are paid per service, their service amount increases. It is observed that they work inefficiently when they receive mere salaries. 31

32 Health Transformation Program in Turkey September 2010 c) Organization Organization means organizing the service-provider institutions and their functions at the macro level. At the micro level, it means the internal structuring of the organizations. The legislative arrangements, audits, incentives and employment policies within the system directly affect this type of organization. d) Regulation Regulation is established through the exercise of power by the competent health authority, i.e. the government in order to form the behaviors of the actors in the health sector. The purpose of regulation is to construct the health sector, to protect service receivers and to correct the problems in the health sector. What is needed most for regulation is the reception of timely, accurate and sufficient data. Therefore, regulating bodies need welldesigned information systems. Regulation Process: Since the actors are inclined not to change, they will try to resist and affect the process indirectly. The best way is to agree on objectives and rules. If the harmonization level is high, negligence and violation will be low; if people are not convinced, forcing may not result in the desired change. Technical competency, sufficient sources and political support have great significance. 32 e) Behavior The behavior of the service receivers is as important as and maybe even more important than the behavior of the service providers. The behaviors and attitudes of citizens are of great importance in preventing the communicable diseases and counteracting chronic diseases. Provision of services (access, quality, prices) is dependant on the functioning of the system. However, demand on the services (senses, attitudes, expectations and beliefs) is directly dependant on individuals and patients. All these shape the patient behavior. Changing people s behaviors is a challenging process. People believe that the things they are asked to do should comply with their beliefs and values. Persuasion does not happen only through knowledge; it is necessary to use additional communication tools to affect behaviors. 5. Evaluation Evaluation of a new program cannot be postponed until this program is completely implemented. Before implementation basic data should be collected and administrative systems to carry out evaluation should be created. The easiest evaluation approach is the before and after comparison. Evaluations should be evidence-based, and data should be collected in accordance with this. The data should be standardized beforehand and should be sufficient. Irrelevant and unnecessary data results in information pollution. Data collection method and the data diversity should be simple enough not to disturb sustainability. The data acquired should definitely be evaluated and used in the continuity of the policy.

33 CHAPTER 3 NEW ERA IN HEALTH

34 34 Health Transformation Program in Turkey September 2010

35 NEW ERA IN HEALTH New Era in Health 1. Change of Mentality Towards Human-Centered Service Understanding Health related needs cannot be postponed. This fact has unfortunately been ignored for years in our country. We started off with an approach which leaves institutional concerns and priorities aside and puts human beings at the centre of services. We have taken the human first approach as the basis of our Health Transformation Program. We are fully aware that the health service provision is not a mercy of the state but the delivery of a fundamental right. Those days when our patients were pledged, refused by the emergency departments, charged fee for ambulance service are well behind. We are living in an era when 112 Emergency Healthcare services are provided in villages as well as cities, 93% of the cases are reached in 10 minutes, doors of the citizens in rural areas are knocked by mobile services, dialysis patients are picked up from their homes. We have gradually removed all barriers preventing the access of our citizens to health services. Today all citizens freely consult to the health institution of their choice. They can buy their drugs from the pharmacy of their choice. They do not have to stand in queues for hours. The family medicine implementation initiated in Düzce five years ago has been expanded to 63 provinces as of September More than 42 million citizens are benefiting from the implementation and choosing their own physicians. We are monitoring pregnant women and babies very diligently. We have achieved a lot in terms of health personnel attendance during delivery, use of most developed vaccines and full vaccination. We established the greatest medical rescue team in Europe, the National Medical Rescue Team (UMKE), in the year By the end of 2009, we are ready to act in disasters with our 2643 specially trained health personnel in 81 provinces. 35

36 Health Transformation Program in Turkey September 2010 We are eradicating communicable diseases such as malaria, typhoid, and rubella in our country. We now have patient rights units in all hospitals and we have the option to be examined by the physician of our choice. Our hospitals do not suffer from lack of medical devices and equipment. We have increased our capacity by twenty eight thousand new patient beds. In the new hospital projects, we place bathrooms and toilets in the patient rooms and place maximum two beds per room. We have increased the bed capacity in intensive care units by nine folds. The patient rooms now have beds for companions, television and refrigerator. We have taken very significant steps to increase the income levels and improve the working conditions of our health personnel, who have engaged in all our efforts with such devotion. However we do not consider these accomplishments sufficient; we will increasingly continue our efforts. We have substantially removed the imbalances country-wide by giving priority to those places without sufficient buildings, equipment and health personnel. 36