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

37 NEW ERA IN HEALTH New Era in Health 2. Extensive and Equal Health Assurance: Universal Health Insurance In line with the principle of equality, Health Transformation Project aimed at developing a social insurance model in which our citizens would contribute according to their ability to pay and receive the health services they need. Significant steps have been taken to ensure harmony among the existent Social Security Institutions until the legal and institutional infrastructure of the universal health insurance has been formed. The Drug-Pricing Decree in 2004 established the reimbursement commission including the representatives from the SSK (Social Insurance Organization), Bağ-Kur (Social Insurance Agency for Merchants, Artisans and Self-Employed), Government Employees Retirement Fund, Ministry of Finance, Ministry of Health, State Planning Organization and the Treasury. Thus, the type of structuring that would remove different reimbursement mechanisms implemented by different Social Security Institutions and build a common model and strategy, was formed. Regulations regarding the delivery form and pricing of the health services provided by university hospitals and state hospitals to our citizens were made with the participation of the Ministry of Health, Ministry of Finance and the Ministry of Labor and Social Security. Service denominations defining medical services were reviewed and new and detailed lists were prepared by the help of international code systems for service names. This way, important steps were taken for recording the health services provided, establishment of a joint database for all institutions and standardization of service invoices. Radical changes were made to ensure unity between service provision models and the target groups of service providers. The citizens covered by public insurance were given the opportunity to also receive services from private health institutions. Thus, the service presentation forms of the state hospitals and private hospitals were harmonized. On the other hand, the discrimination between state hospitals and SSK hospitals was eliminated and thus, unity in public hospitals operation models was achieved. A joint drug database was created for the use of all Social Security Institutions; an infrastructure enabling the central control and supervision of drugs on the basis of uniform standards was established. Similarly, joint databases were developed for the controlling of progress and services based on a single system. The coverage of the green card (for citizens with a low level of income) implementation was expanded and made more realistic and effective. Thus, the citizens with low income were covered by a health insurance which is not different from the SSK, Bağ-Kur, and the Government Employees Retirement Fund. 37

38 Health Transformation Program in Turkey September The harmonization works carried out by the healthcare service providers and the social security agencies that will pay for this service were the important steps which prepared the background for the universal health insurance. The first step of the Social Security Reform was taken with the Law No and all the security institutions were restructured and unified under the roof of the Social Security Institute. With the Law No. 5510, it was aimed to eliminate the inequalities in accessing health services through defining the rights and responsibilities, besides covering all the population by the social security. Again with the same law, the Cabinet was authorized to determine the amount of additional fees charged to the patients by service providers. This difference, which did not have a limit and was totally under the initiative of the health service provider, has been determined to be 30%-70% by the Cabinet. This way, the citizens would know how much additional fee may be charged for service provision when they apply to a private health service provider within the scope of the universal health insurance. In addition, another novelty introduced by this law is that during serious health threats and sudden disease breakout, the private healthcare providers shall not demand any additional fees from the patients. From now on, fees will not be a concern for the patients while they are receiving health services. Meanwhile, the 2007 Health Budget Law (SUT) of the Social Security Institute marked the beginning of a new era for equal and easy access of our citizens to health services. This way, our citizens under the coverage of different social security systems as per the laws in force, were equalized before the healthcare services. The last part of the steps taken in this field was the enactment of the Law No on October 1st, Beginning from July 2007, no fee is charged to the citizens for primary health care even though they are not covered by social security. The Circular of the Prime Ministry dated June 26th, 2008 ensured that all patients requiring emergency medical intervention are brought to a proper health institution and the required emergency intervention is performed with priority and without any preliminary condition in that health institution. It became obligatory that the transfers and referrals of all patients are made under the coordination of the 112 command and control center, regardless of private and public difference, and thus the harms caused during the transfer of a patient from one institution to another is prevented. In the cases requiring emergent medical intervention; the patients who do not have social security or who cannot afford to pay are not asked for a payment; the service costs are demanded from the social assistance and solidarity foundations/municipalities of the provinces/ districts where the health institutions are located; for the patients who have social security, the private hospitals cannot ask for an additional fee and with all these, the citizens are protected from unjust treatment. The Circular of the Prime Ministry dated August 10th, 2010 reminded that emergency health services should be provided with priority and free of charge under all circumstances.

39 NEW ERA IN HEALTH New Era in Health 3. Campaign for Preventive Services and Primary Health Care Health Transformation Program aims to improve and structure the institutional position of the primary health care in a way to have authority and control over other service levels. The main focus of this transformation is to improve the conditions for the citizens in general and patients and health professionals in particular; and to constitute a starting point for novelties in this field. It is clearly observed that this program takes primary health care as the basis for service provision. A large number of activities and projects have been implemented in the field of primary health care with this approach; a multi dimensional program has been conducted. The current status was not neglected during the course of new regulations; and extensive activities for the improvement of the current status were carried out. The most outstanding feature of the Health Transformation Program is that it embraces the existing heritage and improves it as far as possible during the process of transformation. A campaign for preventive and primary health care was held in this period and the budget of preventive and primary health care, which was 928 million TL in 2002 reached 3 billion 779 million TL in A budget of 4 billion 136 million TL was allocated for preventive services and primary health care in Nominal values increased by four folds in a period of seven years. The resource allocation for preventive services and primary health care in 2009 (real prices) has almost doubled in comparison to the allocation in Graph

40 Health Transformation Program in Turkey September 2010 a) New era in primary health care: family medicine Health Transformation Program strengthened the health center network introduced by the socialization policy in our country; it activated the local administrations as well as the Ministry resources for the improvement of the physical structure of health centers. A room for each physician principle was turned into a campaign. One-toone communication between the public and physicians was promoted and facilitated. Additionally, primary health care institutions were strengthened with revolving fund and the diagnostic equipments were made more common. The health personnel employed in primary health care have been provided performance based supplementary payment, which became a source of economic and personal motivation. Family medicine implementation started a new process of restructuring at primary health care level. A system in the form of Family medicine and Community Health Centers supporting one another and caring for the health of individuals and communities has been developed Number of Active Primary Health Care Institutions (Family Health Center, Community Health Center, Mother Child Health and Family Planning Center, Tuberculosis Control Dispensary and Health Post Total) As of the end of 2009, 7216 primary health care institutions are actively providing services (with physicians). The premises serving in the provinces where FM is under implementation are called Family Health Centers Graph 3 40

41 NEW ERA IN HEALTH Graph 4 The calculations based on the data from family medicine units, healthcare centers and AÇSAP (Mother Child Health and Family Planning Centers) show that the number of consultations made to primary health care was 196 million and the number of physicians employed was 17,419 in the year There will be a total of 20,700 family physicians when family medicine implementation is rolled-out across the country by the end of the year Graph 5 41

42 Health Transformation Program in Turkey September Rate of Referrals from Primary Care to Secondary Care (%) Problems that could be solved in primary health care level are very close to complete solutions. Avoiding the unnecessary use of upper health care services has contributed to source savings. Graph 6 There were 1572 healthcare houses in 2002 (providing services with midwives inside), whereas the number reached 5268 by the end of It has also enhanced the quality and quantity of the healthcare services provided in rural areas. Mobile healthcare provision rate for the population in need of regular mobile service increased from 10% to 99%. The target is to reach 100% by the end of Graph 7 Graph 8 42 b) New era in emergency healthcare services Emergency healthcare service is an important public health matter. It is very important to reach the place of incident, to perform the first intervention and to ensure transportation to a health institution as soon as possible in cases of emergent diseases and injuries.

43 NEW ERA IN HEALTH We are living in an era when 112 Emergency services are provided extensively not only in cities but also in villages. We are providing the air ambulance service, provided in the most developed countries of the world, free of charge. No healthcare institution, including private hospitals, charge fee to the citizens for diseases that require emergent or intensive care. Graph 9 In the last seven years, our capacity to transport emergency patients has tripled. We are fully aware that in emergency cases, every second is important. We can now reach 93% of the cases in cities in the first ten minutes. The number of the fully equipped 112 ambulances, which was 618 by the end of 2002, has reached 2250 by the end of As of the end of June 2010, 2430 ambulances are actively providing services. The increase in the number of ambulances was also reflected in the quality. All our ambulances were brought to compliance with the European Union standard TS-EN The number of the stations, which was 481 by the end of 2002, reached 1460 today. The target has been accomplished on this matter. We are now capable of providing 112 emergency services country-wide. Our Ministry has provided 132 specially equipped ambulances, 114 of which are ambulances with snow pallets and 18 of which are ambulances with patient, for public use in regions with transportation difficulties due to the geographical and climatic conditions. Moreover, we have established emergency intervention teams with motorbikes for replacement in cases the standard ambulances fail to reach the place of incident due to insufficient street width and traffic jam. Experienced personnel with advanced motorcycling skills and emergency intervention training have been assigned in these teams. Motorbike teams continue to provide services with 50 motorbikes. Four sea ambulances of the Ministry have been put into service in İstanbul, Çanakkale, Balıkesir and Gökçeada. 43

44 Health Transformation Program in Turkey September 2010 The air ambulance system, available only in developed countries, has been introduced in 2008 in Turkey. We have deployed 18 ambulances in 15 city centers to reach out to the whole country. Since the beginning of 2010, we also started transporting emergency patients or injured citizens inside Turkey or from abroad by our two plane ambulances. One of plane ambulances is turbojet and for long distance flights, whereas the second one is a turboprop propeller driven plane (capable of landing at airports with short runways). The number of patients transported by ambulance helicopters as of August 2010 is 5971 and the number of patients transported by plane ambulances is 388. While the number of citizens benefiting from 112 Emergency services was 350 thousand in 2002, it reached 1 million 900 thousand in This number represents a fivefold increase in comparison to the figures in Only 20% of the citizens living in rural areas used to benefit from 112 emergency services in 2002, whereas today all citizens in rural areas benefit from this service. Graph 10 Graph 11 44

45 NEW ERA IN HEALTH 45

46 Health Transformation Program in Turkey September 2010 c) Healthcare organization in disasters and national medical rescue teams (UMKE) The Healthcare Organization in Disasters Project was realized in our country in order to respond to possible disasters, primarily earthquakes that may happen. Adequately trained and equipped teams have been established with a view to providing medical rescue services within the shortest possible time; ensuring the fastest and safest transportation of patients or injured citizens in the disasters and organizing the professional management required in such circumstances. The fact that 95% of Turkey is located in the earthquake zone underlines the importance of specializing and being well prepared in this field. We are proud to state that these teams, highly capable of responding to disasters even outside our country, performed their duty in Iran and Pakistan earthquakes, Indonesian earthquake and tsunami disaster, and most recently Haiti earthquake. Under the project, basic and complementary trainings have been delivered to health personnel assigned in National Medical Rescue Teams (UMKE) established in all provinces under the control of the Ministry. UMKE trainings cover the following subjects: UMKE TRAINING Triage, Disaster Psychology, Stress Management, Wreckage Works, Alternative Splints, Crush Syndrome, General Overview of Disasters, Disaster Epidemiology, Stretcher Placement and Transportation, Communication, Basic and Advanced Life Support, Protection from the NBC Attacks, Strategic Team and Conflict Management, Psychological Support and Intervention to Shock, International Signs and Signaling system, Fixation, Identification, Packaging of the Patient/ Injured, Terms of Reference of the Medical Team and Legal Dimensions, 46

47 NEW ERA IN HEALTH The Greatest Medical Rescue Team in Europe We established the Department of Healthcare Organization in Disasters in 2004 with the purpose of reducing death and injury rates to acceptable levels at disasters, particularly earthquakes, through the provision of medical rescue services, transportation of patients/injured citizens in the fastest and safest way, availability of emergency treatment units and services after transportation and the organization of required professional management by adequately trained and properly equipped voluntary teams. In a period of two years, we provided basic training to 2643 personnel assigned in the National Medical Rescue Teams established in 81 provinces on voluntary basis. Medical rescue teams engage in field exercises as well as basic, theoretical and station trainings and are always ready to act. Some of the rescue works undertaken by the National Medical Rescue Teams in our country and abroad are the following: Abroad Turkey Earthquake in Iran, Bam (2003) Konya Zümrüt Apartment Building Collapse (2004) Earthquake in Pakistan (2005) Explosion in Diyarbakır Military Housing (2006) Sudan Humanitarian Aid Organization (2007) Bursa Intam Building Collapse (2006) Flood and Landslide in Afghanistan (2007) Konya-Taşkent Balcılar Building Collapse (2008) Earthquake and tsunami in Indonesia (2009) Rize Flood Disaster (2010) Haiti Earthquake (2010) Pakistan Flood Disaster (2010) 47

48 Health Transformation Program in Turkey September 2010 d) Social movement and awareness for chronic diseases Various Prevention and Control Programs were initiated within the framework of relevant studies aimed at improving the cooperation between primary and secondary level healthcare institutions, settling the system on disease prevention, early diagnosis, adequate treatment and regular follow-up of the patients as well as improving their quality of life by reducing mortality and morbidity. 48 World Health Organization warns that chronic diseases are increasing rapidly and that they will constitute the highest work load in the healthcare systems in the future. Moving from this point, our Ministry revised the structuring for chronic diseases and established two new departments to specialize in chronic diseases and health promotion. Chronic respiratory diseases Smoking is an important public health matter in our country. Our country ranks the third in Europe and seventh in the whole world for tobacco consumption; and the addiction rate is calculated to be around 50% among adult men. Tobacco consumption plays a major role in many diseases, particularly cancer. Minister of Health Recep Akdağ signed the Tobacco Control Framework Agreement prepared by WHO in 2004; and the National Tobacco Control Program, prepared in line with the Agreement in question, was declared by our Prime Minister in December In accordance with the program, amendments were made in the Law No.4207 on the Prevention and Control of Harmful Effects of Tobacco Products and new regulations were introduced for the consumption of cigarette and tobacco products. There has been a great support to the measures, the implementation of which started on May 19th, 2008 and which includes the prevention

49 NEW ERA IN HEALTH of second-hand smoking. Turkey ranks the third in Europe and the sixth in the whole world for national regulations in the field of tobacco control and sets an example for enforcement in the whole world. World Health Organization European Regional Director Dr. Marc Danzon presented an award to our Minister of Health with a ceremony held in Ankara on July 8 th, Later, on July 19th, 2010 our Prime Minister was granted the World No Tobacco Day 2010 Award by the World Health Organization (WHO) General-Director. Web site has been created to raise awareness in the public regarding the harmful effects of cigarette and other tobacco products. Those willing to quit smoking are directed to relevant centers through this web site. All relevant agencies and institutions in our country participated in the GARD-The Global Alliance against Chronic Respiratory Diseases, established under the leadership of WHO to struggle against chronic respiratory diseases. The 3rd Plenary Council of 49

50 Health Transformation Program in Turkey September 2010 GARD was held in Istanbul on May 30-31, "GARD Turkey Action Plan ", which was presented in this meeting as a draft, is the first action plan prepared in the World on this issue and continues to be implemented actively. Counteracting obesity Obesity is a clinical condition, accepted as a disease throughout the world and rapidly increasing in prevalence. If the obesity problem continues to increase with such speed, it is expected to become an ever-growing obstacle in front of the health, economic and social development of the countries in the near future. WHO European Ministerial Conference on Counteracting Obesity was hosted by our country on November 15-17, 2006 with the purpose of drawing attention to this situation, giving necessary priority to the issue and developing international and intersectoral collaboration; and European Charter on Counteracting Obesity was declared at the end of this meeting. This document was signed by the Minister of Health Recep Akdağ on behalf of the European Ministers. Obesity Prevention and Control Program of Turkey ( ) was prepared in line with the European Charter Against Obesity. Addressing the whole community and prepared on the basis of scientific facts, the web address about nutrition, has been activated by our Ministry. Our citizens have access to the most accurate and updated information on nutrition through this web site. World Health Organization supports the web site and also gives link to this page from its own web site. Counteracting cardiovascular diseases Cardiovascular diseases are the leading cause of mortalities, accounting for 48% of all deaths in our country. With the purpose of reducing major risk factors and preventing cardiovascular diseases, Prevention and Control Program of Cardiovascular Diseases in Turkey, Strategic Plan and Action Plan for the Risk Factors has been prepared by our Ministry in cooperation with non-governmental organizations. The aim of this plan is to ensure a healthy quality of life for the people by informing the society on cardiovascular diseases, increasing public awareness and developing positive and permanent behavioral changes in terms of major risk factors. 50 Diabetes WHO estimates that unless urgent action is taken, deaths from diabetes will increase by more than 50% in ten years. According to the Turkish Diabetes Epidemiology study

51 NEW ERA IN HEALTH (TUDEP), the diabetes prevalence in our country is 7.2% (8.0% among women and 6.2% among men). Among the leading causes of death in Turkey, Ischemic Heart Diseases by 21.7% and Cerebrovascular Diseases by 15.0% are the most common causes of death, followed by diabetes ranking the eighth by 2.2%. Turkish Diabetes Control Program Strategic Plan and Action Plan was prepared by the active participation of all relevant sectors. Mental health services Mental Health Action Plan was drafted in line with the Turkish Mental Health Policy prepared with a view to improving mental health services. Under the community based mental health centers project, a total of three Community Mental Health Centers, one of them being in Bolu and two others in Manisa, are providing services. During the next phase of the project, these centers will be expanded country-wide and modern inpatient clinics will be established alongside. In parallel, human resources employed in the field of mental health will be increased. Within the framework of trainers trainings for the prevention of violence against women, 424 trainers were trained in Field trainings were initiated in March 2009 and 42,098 health personnel were trained until the end of the year. Adolescent health and youth program was initiated to improve the health of young people in order to prevent adolescent pregnancies and risky behaviors; strengthen and roll out youth friendly health services in the overall health system. There are 42 Youth Counseling and Health Services Centers across the country. e) New and effective approach in the cancer control Early diagnosis saves lives Cancer is the second most common cause of death after cardiovascular diseases both in our country and other countries of the world; therefore it is an important public health issue. Particularly considering the fact that cancer is a preventable disease in which screening helps to avoid deaths and early treatment significantly improves quality of life, prevention becomes far more important. The most significant type of cancer which may be prevented by primary prevention is the lung cancer; and it is the most prevalent type of cancer both in Turkey and the rest of the world. Successful fight against tobacco will help eradicate particularly lung cancer and other types of cancer such as larynx, bladder, pancreas, cervix, pharynx and mouth cancers. In early 2000s, six million people developed cancer in the world each year; however 24 million people will suffer from cancer until the year 2030 if cancer continues to spread with such speed. 17 million people will die of cancer in the same year; and 75 million people will be living with cancer by the year

52 Health Transformation Program in Turkey September 2010 World Health Organization (WHO) offers different scenarios called cancer control programs based on the budgetary structure and economic status of each country. During the preparation of the cancer control program in Turkey, it is important to prioritize lung and digestive system cancers as the most frequent and preventable types of cancer in our country. If the tobacco prevention is achieved successfully in the following years, it will be possible to control the annual 3-5% increase in lung cancer. Besides smoking, which plays a significant role in most cancers in the digestive system, nutrition is also of great importance. The cancer control program in our country aims at reducing the consumption of cigarette and other tobacco products, increasing healthy nutrition by way of trainings. Among our objectives is the primary prevention of cancer as well as reduction of mortality by early diagnosis. The most important aspect of cancer prevention is the accurate registration of the disease in the country. In the absence of accurate statistical data, it will not be possible to appreciate the importance of cancer, plan human resources realistically or make other strategic plans. In the last few years, rather than registering all cancers from all places, which has been proven to be ineffective, new registration centers representing different regions have been established and significant improvements in cancer incidence have been achieved. Serious measures against environmental cancers, particularly caused by arsenic, asbestos and erionite, have been taken in our country. Due to the geographical structure of our country, natural asbestos is found in land in more 80 residential areas of 61 provinces and reaches a life-threatening level for humans in some of these places. 52

53 NEW ERA IN HEALTH Cancer Early Diagnosis, Screening and Training Centers (KETEM) Moving from the principle Early diagnosis saves lives!, KETEM carries out screening and public training programs for breast, cervical and colorectal cancers. The main objective of KETEM services is to reduce deaths from breast, cervical, colorectal and skin cancers and to increase the health level of the society, particularly women. Other objectives of KETEM services are the following: To raise awareness about cancer in the society by providing relevant information to the men and women included in the target group for screening, To increase the percentage of screening in the target population, To raise awareness in the whole society, To increase the number of people who underwent screening, To reduce the number of cancer cases diagnosed at advanced stage, To reduce the incidence of cancer (cervical, skin). Screening services are provided free of charge to citizens unable to pay for the service Number of KETEMs * Graph 12 (*) KETEMS started working in

54 Health Transformation Program in Turkey September 2010 f) Effective communicable diseases control Malaria The intensive studies of the Ministry in the field of communicable diseases have given fruitful results. Great success was achieved in the field of malaria control. The number of malaria cases was over 10,000 in 2002 and it dropped down to 38 in Malaria, which is no longer a significant problem for our country, is in the process of elimination Number of Malaria Cases Graph 13 New Solutions for the Old Problem: To Forget About Malaria for Good World Health Organization considers Malaria as the third important communicable disease after AIDS and tuberculosis. We have taken brave and rational steps to eliminate malaria within the framework of the WHO strategies and policies of the Ministry. Insecticide groups used in vector control for years have been changed; and more effective and adequate drugs have been administered. Special working programs for vector control have been employed in malaria-intensive places and these programs have been controlled regularly. Coordination has been ensured in malaria-intensive provinces. Joint activities and information exchange have been carried out. Surveillance activities to detect malaria patients have been organized. Mobile teams have been established to support the surveillance and treatment services. Patients diagnosed with malaria have been treated individually. Temporary workers from regions with no malaria or a very low level of the disease have been assigned in malariaintensive regions during the malaria season. Cooperation has been made with municipalities and relevant public institutions. Thanks to the effective control activities, the number of malaria cases, which used to be in 2002 was reduced down to 38 by the end of 2009 Malaria Elimination Program was initiated in The aim of this program is to eliminate malaria in Turkey until

55 NEW ERA IN HEALTH Number of Typhoid Cases Typhoid The number of typhoid cases was 24 thousand 390 in 2002 and it dropped down to 209 in It is estimated that the number of typhoid cases will be less than 100 in Graph 14 Tuberculosis World Health Organization implements a global control program for tuberculosis and in Turkey we have a parallel National Tuberculosis Control Program meeting the same standards. Within the framework of the Millennium Development Goals, WHO World Health Assembly Resolution No and Stop Tuberculosis Strategy, goals of tuberculosis control across the world have been determined. According to the World Health Organization Global Tuberculosis Control Report 2009 data, the incidence of tuberculosis in WHO European region, also including Turkey, was 48 per hundred thousand, whereas the incidence was 30 per hundred thousand in Turkey. The point prevalence of tuberculosis was 39 per hundred thousand in WHO European Region in 2008, whereas the point prevalence was 22 per hundred thousand in Turkey. The goal of WHO for tuberculosis incidence is to halt the increase and reverse the incidence until The incidence rate of tuberculosis has decreased over the years in Turkey and it has dropped down to 30 per hundred thousand in 2008 from 40 per hundred thousand in

56 Health Transformation Program in Turkey September 2010 Graph 15 WHO considers prevalence as the success indicator of tuberculosis control programs. Goal of WHO for tuberculosis prevalence is to halve the prevalence of 1990 by The point prevalence of tuberculosis, which was 53 per hundred thousand in 1990, dropped down to 47 per hundred thousand in Thanks to the tuberculosis control activities under Health Transformation Program, the prevalence goal has been reached in 2005 with the reduction of point prevalence to 26 per hundred thousand. The prevalence was reduced even below the target level in Point prevalence rate of tuberculosis was 22 per hundred thousand in 2008 in Turkey, whereas it was 39 per hundred thousand in WHO European Region. 56 Graph 16

57 NEW ERA IN HEALTH On the other hand, the decrease in point prevalence of tuberculosis was only 11% in Turkey in a period of 12 years between , whereas it was 46% in WHO European Region. The rate of decrease reached 53% in Turkey between the years , whereas the rate was 20% in WHO European Region. Change in TB Prevalence Rates in Turkey and WHO European Region (%) (%) ,3-20, ,2-60 WHO European Region TURKEY -53,2 Graph 17 Successful tuberculosis control activities under the Health Transformation Program enabled Millennium Development Goals and Stop TB Strategy Goals to be reached before Moreover, Turkey has become a country capable of following multi drug resistant cases for two years and report the treatment outcomes. According to the World Health Organization Global Tuberculosis Control Report 2009, only five countries in the world have succeeded in doing this. As a result, Turkey has reached and exceeded the targets set by WHO as of Measles In parallel to the World Health Organization European Region Measles Elimination goal, Turkey aims to eliminate measles and rubella and to achieve control over congenital rubella syndrome until the end of 2010 and has put this goal on the agenda. Upon consideration of the high rate of morbidity and mortality from measles in Turkey and the developments and experiences in the World and the European region in the recent years, Turkey has initiated the Measles and Rubella Elimination and Congenital 57

58 Health Transformation Program in Turkey September 2010 Rubella Syndrome (CRS) Prevention Program covering the period The aim of the program is to eliminate measles and rubella, prevent CRS and maintain the current levels reached. Our target is to halt domestic virus circulation in Turkey until the end of 2010 and to prevent the import of new measles viruses from other countries into Turkey and prevent deaths from measles as of Important developments have been achieved in routine vaccination, as one of the most significant strategies for elimination, and the vaccination rate has exceeded 90%. Measles vaccination rates were 98%, 96%, 97% and 97% respectively for the years 2006, 2007, 2008 and 2009; and it is targeted to keep the vaccination rate above 95%. Considering the epidemiology of measles in Turkey, all children aged 9 months-14 years were vaccinated by a supplementary dosage of measles vaccine in the period and the vaccination coverage reached 96%. It stands as the vaccination activity with the largest target group in the history of the Republic and Europe. Following the supplementary vaccination activity, case and laboratory based measles surveillance was initiated. The number of measles cases was 30,509 in 2001, but it was reduced with the vaccination activities and 34 and 3 cases were diagnosed respectively in 2006 and The number of domestic cases in Turkey was zero in 2008 and Four cases were diagnosed in 2009 and all of them were imported cases or related with imported cases. Thus, the period of elimination has started and prevention of importation has become a priority target gaining more importance every other day. Measles Vaccination Ratios and Number of Cases %84 %78 % Graph 18 58

59 NEW ERA IN HEALTH A dream coming true: An Era of Measles Free Turkey WHO s goal Eradicating Measles within the scope of measles control is about to come true. We are steadily moving towards the goal of halting domestic virus circulation in Turkey until the end of We organized a widespread vaccination campaign between the years Under the scope of School Vaccine Days, all students attending primary education were targeted in 2003, whereas pre-school children, first grade primary school children and the children aged 6-14 not attending school were targeted in We vaccinated 18,217,000 children during the campaign. The vaccination rate of the campaign was 97%. The campaign was the vaccination activity with the largest target population in the history of the Republic and Europe. As a result of the campaign and subsequent vaccination activities, the number of domestic measles cases, which was 30,509 in 2001, has been zero since g) Assurance of our future: mother and child health The number of the Baby Friendly Hospitals aiming at the improvement of infant health was 141 in 2002 and it reached 725 by the end of Today all hospitals where mothers give birth are baby friendly. Number of Baby Friendly Hospitals Graph Every infant born in the baby friendly hospitals are fed with breastfeeding and make a healthy start to their life. In order to protect our infants and mothers from anemia, we started providing free iron supplement to pregnant women. Each year, around 1 million pregnant women benefit from this service. The number of iron supplemented infants exceeded 6 million 276 thousand from the beginning of the project in 2004 until the end of Only in 2009, iron supplement was provided to 1 million 240 thousand infants. We supplied 2,719,625 boxes of iron preparation to mothers and pregnant women in

60 Health Transformation Program in Turkey September 2010 We started disseminating free Vitamin D for supporting the skeletal development of infants. We provided Vitamin D supplements to more than 6 million 24 thousand infants from May 2005 to the end of We distributed 1 million 261 thousand boxes of free Vitamin D in We started reaping the fruits of this project; the studies conducted by Atatürk University Graph 20 School of Medicine in Eastern Anatolia revealed that the incidence of Vitamin D deficiency dependant rickets, which used to be 61 per thousand previously, was noted as 1 per thousand in February Iron-Like Turkey D According to WHO data, it is predicted that approximately 30% of the world s population and more than half of the pregnant women have anemia. Before the Health Transformation Program, anemia was very common in Turkey and the researches revealed that approximately 50% of the children aged 0-5 years, 30% of the school age children and 50% of the breastfeeding women had anemia. Children most frequently develop iron deficiency anemia when they are 6-24 months old. Growth and development of children is the fastest during this period. Nutritional disorders and iron deficiency in this period has negative impact on the later mental, physical and social development of children. The easiest way to prevent such negative effects is to protect children from iron deficiency anemia. With a view to solving this significant public health problem, we started the Iron-Like Turkey program at national level to raise awareness about iron deficiency in the society; to promote breast-feeding during the first six months of, introduce adequate and sufficient food supplements after the sixth month and continue breastfeeding until 2 years of age; to provide free iron supplement to all infants aged 4-12 months for protection and to offer iron therapy for infants with anemia between months. We have provided iron supplement to 6 million 276 thousand infants since the onset of the program. Following the Iron-Like Turkey program, we also undertook the Iron Supplement for Pregnant Women program and further expanded the scope of our activities. We distributed 2,719,625 boxes of iron preparations to pregnant women in In order to examine the effects of Iron Like Turkey program, Iron Deficiency Research was conducted in March-April 2007 with the cooperation of our Ministry and Hacettepe University Faculty of Medicine Department of Social Pediatrics. According to the results of this research, incidence of anemia has decreased from around 30% to 7.8% in children months old. These efforts clearly reveal the steps we have taken to help our infants become healthier and achieve their cognitive potential. 60

61 NEW ERA IN HEALTH Number of Personnel who had Newborn Reanimation Training* Neonatal Resuscitation Program was initiated in 1998 and 26 thousand 561 health personnel were trained until The number of personnel trained under the program as of July 2010 is 28, Today all our units where mothers give birth have trained personnel available. Graph 21 (*): Neonatal resuscitation training was initiated in The neonatal screening program has been scaled-up to provide a healthy beginning for the newborns. Screening for phenylketonuria, which was launched previously, was rolledout throughout the country. Fully aware of the importance for neurological development of children, screening for congenital hypothyroidism was initiated at the end of 2006 and screening for biotinidase was initiated at the end of In this way, our babies are widely protected from phenylketonuria and congenital hypothyroid, diseases that can be prevented easily when detected, but cause irreparable damages such as mental and physical development retardation when missed. 95.3% of the target population was reached Rate of Phenylketonuria Screenings (%) in phenylketonuria and hypothyroidism screening. Under the Newborn Screening Program, 1,245,724 infants were screened in ; treatment was initiated for 252 infants 24 diagnosed with phenylketonuria, 1983 infants 25 with congenital hypothyroidism (including 0 temporary cases) and 170 infants with biotinidase. Graph 22 Newborn Hearing Screening Units have been established in 227 MoH hospitals in 79 provinces and screenings have been initiated. Approximately 441,332 infants underwent hearing screening in the year of these infants were diagnosed with hearing loss and covered under treatment programs

62 Health Transformation Program in Turkey September Number of the Newborn ICU Beds in MoH Hospitals The number of newborn intensive care beds, which was 665 in 2002, was increased to 2140 by the end of In the same period, the number of transport incubators rose from 158 to 440 and the number of ventilators rose from 252 to Graph 23 The rate of hospital delivery was 78% in 2002, whereas it reached 90% in According to Ministry of Health data, hospital delivery rate was 92% in Our target is to increase the rate of hospital delivery to 99% by World Health Organization officially announced in May 2009 that maternal and neonatal tetanus was eliminated in Turkey as a result of the deliveries at hospital environment and in compliance with hygiene rules. Graph 24. (Source: TDHS) According to the results of Turkey Demographic and Health Survey, infant mortality rate, which was 28.5 per thousand in 2003, was reduced to 17 thousand mille in The infant mortality rate was 13.1 per thousand in 2009 and we expect that the rate will be a single-digit number for 2010 as in the developed countries. 62

63 NEW ERA IN HEALTH The infant mortality rate, which is below 5 per mille in the developed countries today, was around 30 per mille in 1960s. The progress made by OECD countries in a period of thirty years was achieved by Turkey in the last 8 years. Our infant mortality rate for 2009 is 13.1 per mille. Graph 25 (*): 1998, 2003, 2008 data are taken from TDHS data is from Ministry of Health value shows the projection based on Ministry of Health data until August Average Infant Mortality Rate According to Years (per thousand) Average Rate for OECD Countries Excluding Turkey and Average Rate for Turkey ,5 Turkey OECD ,0 117, Graph 26 55,4 30,4 24,6 28,9 14,3 17,0 9,6 5,7 4, (Source: OECD Health Data, TDHS, Ministry of Health Data) Families who constitute the poorest 6 % of the population were refused by hospitals not so long ago; but today they are granted monthly allowance amounting to 17 TL for each pregnancy and baby on condition that they continue health checks during pregnancy and infant health checks after birth. Also, pregnant women receive monetary aid of 55 YTL when they give birth at health institutions. We granted a total of 137 million 915 thousand TL of monetary aid to more than 49 thousand pregnant women and more than 753 thousand babies in Total amount of monetary aid extended since March 2004 is around 1 billion 987 million TL. Conscious Mother, Healthy Baby Program was started in 2004 with the aim of reaching all the mothers who give birth at inpatient treatment facilities. One of the objectives of this program is to provide consciousness for mothers on the issues related to them and 63

64 Health Transformation Program in Turkey September 2010 their babies health before they leave the hospitals. Mothers are given basic information on baby care and health after delivery, and receive Guide for Conscious Mothers and Healthy Babies. We have reached almost five million mothers so far. Another initiative under the Health Transformation Program is the Guest Mother Project. Within the scope of this initiative, Women with Risky Pregnancies are hosted in Safe environments. Under this project, pregnant women living in regions with risky seasonal conditions are invited to Guest Mother Hotels/Guesthouses for medical care and sheltering four weeks before they are due; the mothers who accept the invitation receive care before, during and after delivery and are accompanied back to their houses when the road circumstances allow mothers benefited from this service during winter Under Health Transformation Project, maternal mortality rate has been improved significantly beyond comparison with the countries of the same income level (According to WHO statistics for 2009, the maternal mortality rate in countries of the middle-high income group is 91 per hundred thousand). The maternal mortality rate for 2009 was 18.5 per hundred thousand in our country. Our target is to reduce maternal mortality rate below 15 per hundred thousand in Maternal mortality rate in OECD countries was 60 per hundred thousand in The progress made by the OECD countries in the field of maternal mortality in 20 years was achieved by Turkey in the last 8 years. Change in Maternal Mortality Rate According to Years (Per Hundred Thousand) Comparison of OECD Average Excluding Turkey and Turkey Average Graph ,5 11,6 9,6 OECD Turkey 19,4 8, (Source: OECD Health Data, TDHS, OECD 2007 Report)

65 NEW ERA IN HEALTH Mothers will Enjoy their Motherhood Gradually Moving Towards the Target of Preventing Maternal Mortality Access to health services, utilization and quality of these services during pregnancy, delivery and antenatal period; and from a broader perspective, training of women, social gender equality and social conditions are associated with maternal mortality. In this sense, rate of maternal mortality is used as a multi dimensional indicator of development. Maternal mortality covers the mortality of women during pregnancy, delivery and in 42 days period following birth. World Health Organization (WHO) estimates that each year 529 thousand maternal deaths occur worldwide. 99% of maternal mortality is in developing countries. Average speed of maternal mortality is 400 per hundred thousand in the world. Maternal mortality occurs at an average rate of 870 per hundred thousand in Africa, 380 per hundred thousand in Asia excluding Japan, 91 per hundred thousand in WHO middle and high-income countries and 24 per hundred thousand in WHO European region. Until recently, there were not sufficient data on maternal mortality rates in Turkey. The existent data were derived from demographic surveys and reflected the current status at national level. When the maternal mortality records of 615 hospitals in 53 provinces were monitored for a period of one year, it was calculated that hospital mortalities were around 49 per hundred thousand. Adding the out-of-hospital mortalities, this rate was calculated to be 70 per hundred thousand. Survey on Maternal Mortality in Turkey was conducted between the dates June 1st, May 31st, 2006 in order to find out the maternal mortality rate in Turkey. Results were publicized on December 8th, The afore-mentioned study is the only study of scientific competence in the Republic s history. The survey pointed out that the mortality rate for was 28.5 per hundred thousand. For the first time, Turkey found out the current and actual maternal mortality figures with a large scale field study; and proved its success in the reduction of maternal mortality with mortality rates very close to European average. Following the Survey on Maternal Mortality in Turkey 2005, maternal mortality data system was revised based on the survey and used to collect data on maternal mortality in the age group from 81 provinces. In this context, maternal mortality rate for 2009 is 18.5 per hundred thousand. Our target is to reduce maternal mortality rates below 15 per hundred thousand in

66 Health Transformation Program in Turkey September 2010 h) Immunization programs: vaccines Vaccination rate of the targeted child population was 78% across the country in This rate was even below 50% in some provinces of Southeastern Anatolia. We reached a vaccination level of 96% across the country in Even in those provinces with low vaccination levels formerly, vaccination level exceeded 80% in the same period. Vaccination Rates (%) Graph 28 Resources allocated to vaccination increased by only 4 folds during the course of ; whereas it increased by 20 folds in the period Mumps, meningitis and rubella (MMR) vaccinations, which were not included in the standard vaccination program formerly, come to be included in the program. Fivefold combined vaccine (diphtheria, acellular pertussis, tetanus, hemophilus influenza type B and inactive polio virus) started to be used. We started conjugated pneumococcus vaccination in November This way, we started implementing the vaccination programs of the developed countries for our children. We implement all the vaccinations free of charge for all our children. Graph 29 66

67 NEW ERA IN HEALTH i) Sexual health and reproductive health program Turkish Sexual and Reproductive Health Program is implemented in cooperation with the European Union in order to increase the utilization and accessibility of services in the field of sexual and reproductive health, improve service quality to support the MoHconducted studies and to strengthen the collaboration with the NGOs. Turkey Sexual and Reproductive Health Program is conducted in cooperation with the European Union. In 2002, 3,260,000 couples received sexual and reproductive healthcare services from the MoH health institutions, whereas the number of couples reached up to 5,545,050 in 2007 and 7,161,510 by the end of Ministry of Health and Turkish Armed Forces initiated collaborative work for educating men on sexual health and family planning. In this respect, trainers training was provided to military healthcare personnel so that they can give Reproductive Health and Family Planning Counseling Services and Trainings to military men and noncommissioned officers under Turkish Armed Forces. These trained personnel started delivering reproductive health trainings in all platoons and troops. This way, each year 500,000 young men will be trained on reproductive health when released from military service and set off to go back home. Since April 2004, more than 2.5 million military men and noncommissioned officers have received this training. Moreover, screenings are made, possible risks are detected and necessary training on kin marriage and inherited diseases is provided before marriage to men and women living in risky provinces for hemoglobinopathy (inherited blood diseases). In 2009, we provided pre-marriage hemoglobinopathy screening tests to 521,476 individuals in 33 provinces with high incidence of thalassemia. Coverage of pre-marriage screening was 75% in these provinces. 67

68 wv Health Transformation Program in Turkey September 2010 World Health Organization European Health Report 2009, Part about Turkey (page 18) This progress is largely due to making maternal mortality a political priority, funding it accordingly, pursuing policies and providing services in a culturally sensitive manner. This includes establishing predelivery care homes for expectant mothers near a hospital and providing land and air transport free of charge for obstetrical emergency cases, greatly reducing the distance and time needed to access appropriate and high-quality specialized care. 68

69 NEW ERA IN HEALTH New Era in Health 4. Transformation in the Primary Health Care: Family Medicine It was stated that Health Transformation Program puts humans at the center of service. This principle means that the system will take individuals, their demands and expectations into consideration when planning and providing the services. Moving from the point that health is produced in the family environment, individual health is dealt within the concept of family health. We know that sharing responsibilities and approaching individuals from a single perspective in primary health care will increase the rate of success. The opportunity of choosing the physicians who will provide preventive services and primary diagnosis and treatment services has enabled closer relationships between family members and the family physician, thus better clarifying the role of primary health care physician and the personnel in health education, disease prevention and improvement of health. The terms general practitioner, family doctor and family physician have the same meaning in the program. These all refer to physicians who are specially trained to serve at primary care level. A family physician is responsible for the health status, health problems and diseases of all members of all age groups in a family. All health problems of the applicant are dealt within the scope of the primary health care. If the problems of the patient cannot be solved at primary health care level, then the family physician acts as a coordinator and refers the patient to other specialists or the dentist. Therefore, a family physician is the health consultant of patients, s/he is the one who guides patients and defends their rights. The family physician is generally close to the residences of families and is easy to access. The family physician knows the population for which s/he provides services in all aspects and fully comprehends the family, environment and employment relations. S/He is the person with the best knowledge on the health status, living conditions of all the family members and ways to provide preventive healthcare services and health education to these individuals. Family physicians not only deal with disease conditions, but also evaluate patients situation as a whole taking into consideration the risks, health conditions, psycho-social environment and other acute or chronic health problems, if any. According to Prof. Dr. Nusret Fişek Preventive healthcare services, outpatient and home care services should be integrated. ( ) Contemporary family medicine system is the simplest example of this integrated model. Contemporary family physicians examine children periodically and vaccinate them. They train mothers on child care. They also examine elderly people and pregnant women and give advice, if necessary. They train 69

70 Health Transformation Program in Turkey September family members on domestic and personal hygiene. They treat family members who get ill and refer them to a specialist or hospital, if necessary. It is essential that the patient receives primary health care from the physician he/she chooses and trusts. Family physicians have a coordinator role in the health system and they prevent inappropriate referrals, irregularities and unnecessary health spending as well as strengthening primary health care. They prevent unnecessary spending, long waiting lists at secondary health care level, long queues and unjust treatment of patients. A very important study was carried out in order to achieve the goal of family medicine as an important component of the Health Transformation Program. Family Physicians Counseling Committee was set up with the participation of professional organizations and academicians. The committee worked with such diligence and discipline to prepare the training curriculum for general practitioners to be assigned in the family medicine system. The program consists of two stages. First stage consists of short-term orientation training. Second stage has been planned as a long-term training on the update and promotion of professional knowledge and skills and has been put into practice. Community Health Centers were founded in order to provide more effective and efficient health services by unifying all services at primary care level under a single roof except for preventive, diagnostic, curative and rehabilitation services. These centers give free-ofcharge logistic support for priority service fields of family physicians such as vaccination campaigns, mother and child health and family planning services in accordance with the annual program of the Ministry of Health; carry out activities regarding the supervision of family physicians; and provide health services such as environmental health, judicial services, worker and occupational health, which are services of public concern rather than being individual health services. Thus, both family health and community healthcare services were unified and primary health care structure was integrated. As the process moves forward, it is planned to employ family physicians in family health centers and public health specialists in community health centers. This implementation, supported by in-service training at the time being will encourage the training of family physicians to carry out these services. It will further enhance the confidence in primary health care. Turkish Grand National Assembly enacted the Law on Pilot Implementation of Family Medicine in November Pilot implementation was first initiated in Düzce in October We rolled-out the implementation to other provinces over the years. Then implementation was launched in 63 provinces as of September Currently, 11,833 family physicians are working in these provinces. We planned to roll-out family medicine implementation countrywide until the end of Family medicine practice, preliminary results of which are so encouraging and successful, puts primary health care at the top of the public agenda, makes primary health care attractive and thus facilitates widespread provision of preventive services. On the other hand, family physicians reached the point they deserve both in terms of financial benefits and professional dignity.

71 NEW ERA IN HEALTH Health data of individuals are kept on electronic medium by the Family Medicine Information System. Minimal data sets have been formed for this purpose. This practice provides advantages in various fields such as integrity of individual data, performance assessment of family physicians, determining the burden of chronic diseases and identifying health indicators for our country. Family medicine implementation is followed very closely at each and every stage; feedbacks are received and improvements are made where necessary. In this framework, opinion and satisfaction level of our citizens regarding the family medicine practice is followed by internationally accepted EUROPEP scale. EUROPEP Scale Satisfaction Survey in 81 provinces for 2009 EUROPEP Scale: This scale, which mainly focuses on increasing the quality of health service provision at primary health care level, aims to receive feedback from the patients about the physicians and their offices. Standard EUROPEP scale asks 23 questions. Depending on their experience in the last 12 months, the patients are asked to make assessment of physicians, services and/ or facilities where services are provided. The scale is arranged as a five point Likert answering scale and the first 16 questions relate to the clinical behavior of the physician, followed by seven questions on the organization of services. In Turkey, four questions have been added to the standard EUROPEP questionnaire form in order to measure overall satisfaction level and a total of 27 questions were asked in the field. The four questions added are related to the behavior of physicians, organization of services, general physical conditions and overall satisfaction with primary health care respectively. According to the unpublished results of EUROPEP 2009 survey, overall satisfaction level of our citizens with primary health care in the provinces where family medicine has been launched is around 83%. 71

72 vv Health Transformation Program in Turkey September 2010 Preventive Services and Primary Health Care Are Now Free of Charge Today all our citizens receive services from the primary health care institutions across the country without the requirement for any social security coverage. 72

73 NEW ERA IN HEALTH New Era in Health 5. Change of Mentality in Hospital Services a) Eliminating discrimination in health: uniting public hospitals under a single umbrella The principle of efficiency, one of the objectives of the Health Transformation Program, is defined as efficient use of resources to decrease costs and produce more services out of the same resource. It is emphasized that the distribution of human sources, management of materials, rational use of medicines, health administration and preventive medicine will be assessed under the scope of this principle; and efficiency will be improved by including and integrating all sector resources of our country in the system. The principle of uniting all hospitals under a single umbrella aims at mobilizing all resources allocated for service provision to serve for the public. In this period, SSK hospitals were transferred to the Ministry of Health, obstacles preventing the access of patients to the hospitals were removed and discrimination among our citizens was eliminated. Hospitals which suffered from unbalanced workload in the past are opened to all patients regardless of whether they are covered by the SSK, Bağ-Kur, Government Employees Retirement Fund or Green Card. Today, all hospitals do provide healthcare services to all people in a balanced manner and without any discrimination. Most people, who had difficulty in accessing healthcare services formerly, now have the opportunity to utilize these services whenever they need. Unifying SSK and state hospitals not only created different alternatives for people but also granted SSK beneficiaries the right to utilize healthcare services which they could not in the past, although they paid premiums and were covered by the insurance system. b) Decentralized management of hospitals Devolving authority to hospitals, flexibility in management, more autonomy over resource allocation and performance based supplementary payment to the personnel from the revolving fund increased efficiency in hospitals. Healthcare institutions started to become patient-centered service institutions. In order to alter the cumbersome structure of public hospitals, obstacles preventing the purchase of particularly imaging services as well as many other medical services from the private sector were lifted and the service structure of the hospitals started improving rapidly. Thus, the waiting periods for imaging and other tests are shortened substantially. Differences in management models and weaknesses of management were removed by unifying all SSK hospitals and state hospitals under the Ministry of Health s roof. 73

74 Health Transformation Program in Turkey September 2010 In the last 5 years, all hospitals established information processing infrastructure and started recording all the services provided. State hospitals no longer have to wait for years for an allocation to have the equipments they need. It is now possible to contract out some services to the private sector. Today, service means are supplied without putting burden of investment on public and the cost is incurred by the revenues of the institution. Hospitals in Turkey, which gain more autonomy every other day and which are already decentralized in management, are gradually becoming autonomous public facilities. c) Restructuring in hospital services In the framework of the Health Transformation Program, our hospitals, particularly public hospitals, have been renovated by the latest technology and more capacity has been built. Public-private partnership model has been engaged in public hospitals for service provision; and the number of magnetic resonance imaging (MRI) devices, which was 18 in total, was increased to 234 in 2009, whereas the number of computed tomography (CT) devices increased from 121 to Number of Computerized Tomography and Magnetic Resonance Devices of MoH ** 82 4 Computerized Tomography MR 1996* 2002* 2009 Number of Ultrasound Devices of MoH*** * 2002* 2009 Graph 30 (*): 1996 and 2002 figures include the machines in transferred SSK hospitals. (**): 209 of the CT devices and 211 of the MRI devices were supplied by the service procurement method. (***): 77 of the USG devices were supplied by service procurement method. The number of dialysis machines was 5545 in 2002, whereas it increased to 14,503 as of December The number of patients receiving hemodialysis service rose from 23,266 to 48,433. In the past, our patients died due to lack of treatment. Today, our patients survive much longer thanks to the provision of regular and sufficient treatment. Accordingly, the number of patients receiving dialysis service is about to reach 50 thousand, which shortens the waiting period for kidney transplantation. 74

75 NEW ERA IN HEALTH Graph 31 Graph 32 Number of Examination Rooms in MoH Hospitals The situation is not very optimistic for some chronic liver and heart diseases; and due to the absence of auxiliary treatments like dialysis, the patients unable to find the proper organs are bound to lose their lives in a short time. Recently, the preference of kidney transplantation rather than dialysis for patients with kidney failure has both alleviated the burden on the national budget and improved the life expectancy and quality of life of the patients. This situation underlines the importance of organ donation and cadaver organ supply for the provision of organ and tissue transplantation services. One of the most effective ways to shorten the waiting period for organ transplantation is to increase brain-death notifications and cadaver organ donations. The interest of our citizens on this topic is gradually increasing, which is promising for the future. On the other hand, we established organ and tissue transplantation coordination centers across the country to encourage organ and tissue transplantation. We have amended the performance directive accordingly to better return the devoted efforts of the personnel performing organ and tissue transplantations under difficult conditions. We have raised the payment for organ and tissue transplantation services in the 2007 Health Budget Law (SUT) in cooperation with the Social Security Institute Graph In 2002, 20% of our hospitals had electronic information systems, whereas the rate reached 100% in The number of examination rooms allocated to physicians was 6643 by the end of 2002, but it increased by three folds and reached 20,288 in Idle capacity was activated in order to provide one room for each physician. In parallel to this, while 110 million patients were examined at state hospitals (including SSK hospitals) in 2002, in 2009, this number was noted as 228 million. 75

76 Health Transformation Program in Turkey September Total Number of Intensive Care Unit Beds in MoH Hospitals Graph 34 (Source: GDCR Annual Statistics 1996) The number of intensive care beds, which was 869 in 2002, reached 7351 by the end of During our term of office, intensive care units have been staged and the quality of intensive care services has been improved. This way, 2795 of the intensive care beds were staged as first level, 2525 secondary level and 2031 tertiary level. The number of intensive care beds has increased by more than eight folds when compared to the year The number of Oral and Dental health Centers, which was 14 in 2002, rose to 123 in 81 provinces. Additionally, one dental training and research hospital and one dental hospital have been opened. Compared to 2002, the number of dental prosthesis increased by seven folds and the number of fillings increased by 11 folds in state hospitals and oral and dental health centers during Graph 35 Number of Fixed Prosthesis Number of Fillings Graph 36 Graph

77 NEW ERA IN HEALTH Patient rights We target a healthcare system in which patients rights are not violated, patients are informed at all stages of treatment, their consent is taken, confidentiality is respected, patients are given all kinds of curative services without discrimination and they can choose their physicians and institutions. As required by the relevant legislation, Patient Rights Units have been established in all public hospitals. During our government s term of office, we have activated Patient Rights Units in all the state hospitals. Our citizens are free to notify their needs in written or verbal form to the patient rights units, established to ensure that all citizens enjoy their right to receive services. Based on notifications, necessary assistance is provided or corrections are made. Your right to choose your physician We started the right to choose physician, which is one of the most fundamental patient rights, in 11 hospitals in September Until now, we started this in 884 institutions; 794 of them being hospitals and 90 of them Oral and Dental Health Centers (ODHC). We plan to implement the right to choose physician in all hospitals and ODHCs as of November Graph 38 YOU CAN CHOOSE YOUR PHYSICIAN AT OUR HOSPITAL 77

78 v Health Transformation Program in Turkey September 2010 Now it is your right to receive service You can reach the Ministry of Health directly Through ALO SABIM 184 We are at your service 24/7 with 52 operators. We solve the 90% of the applications in the first 24 hours. For the cases which cannot be solved immediately, we resolve the issue and then inform the citizen. Every year we resolve 1 million applications to SABIM. 78

79 NEW ERA IN HEALTH d) Prevention of hospital infections Despite the developments in medicine, hospital infections are a big health problem all over the world. Hospital infections might cause deaths if they are severe, and they pose a great threat especially to patient safety and health professionals, visitors, nonhealth professionals and public health. By taking measures, it is possible to reduce the prevalence of hospital infections, which bring a financial burden to the country s economy by extending the patients length of hospital stay. Just as in the whole world, hospital infections pose an important problem in our country as well. Despite the fact that serious studies have been undertaken in the developed countries on hospital infections for the last 50 years, except for the studies of the relevant specialty fields on the issue, the studies and administrative support in our country has been insufficient. Within our Ministry, the studies in this field were initiated in September Legislative studies in the field of hospital infections were completed in the years The implementations have been executed within the scope of Regulation on Infection Control in Inpatient Healthcare Institutions (dated , Official Gazette No ). The studies, pioneered by our Ministry, have been performed in line with the opinions and decisions of the Hospital Infections Scientific Advisory Board, which is composed of experts of the field from various schools of medicine and training and research hospitals. One of the important tools for improving the quality of service delivery is to train sufficiently qualified human resources required for service provision. In accordance with the relevant Regulation, all inpatient health institutions are obliged to assign an infectious diseases and clinical microbiology specialist per thousand beds as the infection control (IC) physician, preferably having a national/international certificate. They are also obliged to assign one of their nurses holding infection control nursing certificate, issued by the Ministry, as the infection control nurse per two hundred and fifty beds. Thanks to the infection control trainings conducted since 2007 up to the present, 383 infection control physicians and 954 infection control nurses have been granted National Certificates as of June The first Hospital Ventilation and Control Guide was prepared with the efforts of the Scientific Advisory Board. As a result of our serious studies in the field of hospital infections, we have been able to reach national data and develop national policies since As per the relevant Regulation, hospital administrations are obliged to submit their annual activity reports, including hospital infection rates and surveillance results, to the Ministry no later than the end of February each year. With the support of the Scientific Advisory Board, National Hospital Infections Surveillance System was developed by our Ministry in order to collect hospital infection data in a single center, to analyze the data and provide feedbacks, and to develop policies for the prevention and control of hospital infections. Hospital Infections Surveillance Standards determined by the Hospital Infections Scientific Advisory Board have been notified to all hospitals. Moreover Safe Practices for Total Parenteral Nutrition Guide has been published in order to standardize the current and future Parenteral Nutrition units in hospitals and help decrease hospital infections, thus increasing the service quality of the institutions. 79

80 Health Transformation Program in Turkey September 2010 The web based National Hospital Infections Surveillance Network (UHESA) developed under the Ministry and opened to public access in August 2007, collects and analyzes the latest hospital infection data in accordance with the international standards. Hospitals connect to UHESA by using the passwords provided by the Ministry, enter and reach their own hospital infection data. Since May 2008, it is compulsory for inpatient treatment institutions of MoH to join UHESA. e) Opening private hospitals doors to everyone Health Transformation Program envisages to include all sector sources in our country in the system and thus ensure harmonization and enhance efficiency. Unification of hospitals under a single umbrella was a concrete step taken to this end. Another important step is the integration of private sector investments in the system in order for patients to receive services from these institutions under the coverage of their own social security. Now, all sources in the country, regardless of being public or private sources, serve to the public. Public hospitals compete with the private sector for service provision, which increases the quality of service; this effect will become more pronounced over time. The fact that private healthcare facilities opened their doors to those covered by public insurance, has alleviated the burden of state hospitals. So, the excessive workload which was mostly undertaken by public sector in the past is shared with private healthcare institutions and the provision of healthcare services is facilitated. Besides, registered work was encouraged in private sector. As a result, the shares allocated for the public over the values produced also increased. Today, the sector is supervised more carefully. In addition to all these, private health sector gained new momentum with this practice. Significant number of investments has been made in this field. Additional fees charged by the private hospitals were limited in order to protect the patient. These recent implementations direct the majority of the private hospitals to a transition towards becoming public hospitals. Private hospitals are in the process of adapting themselves to this process. 80 f) Triage and registration at emergency departments Communiqué on Rules and Principles of Emergency Service Provision in Inpatient Healthcare Facilities was enforced following its publication in the Official Gazette No on October 16th, The Communiqué applies to all emergency departments, emergency polyclinics and units providing services in public and private inpatient healthcare facilities. The Communiqué has initiated the process of restructuring by defining the minimum personnel and service criteria, physical conditions and ease of transportation, minimum standards regarding materials and medical technological equipment. Patient triage and color coding system has been introduced at hospitals. Emergency on-call services were

81 NEW ERA IN HEALTH regulated in order for emergency departments to provide 24 hours uninterrupted service at specialist level. Effective coordination between 112 Emergency Health Services and emergency departments of hospitals has been ensured. In line with the Communiqué, triage and registration according to their compliance with standards has been undertaken in all emergency departments. g) Planning for cardiovascular surgery (cvs) centers Our population is expected to increase by 13.2% in Moreover, population aged 40 and above, considered to be under risk for coronary heart disease, is expected to constitute 39.7% of the whole population due to the aging of the population. These dynamics suggest that the number of patients with cardiovascular disease will increase. Therefore, efforts to prepare a national plan in line with the National Heart Health Policy are ongoing. In this context, it is targeted to improve cardiology and CVS services and ensure that high-quality services are provided. Under the scope of regional health planning, it has been planned to establish cardiology and cardiovascular surgery centers in 26 provinces and activities have been initiated with the support of seven coordinator hospitals. Trainings have been organized for relevant personnel and have almost been completed. We have been providing cardiovascular surgery services in the centers established in 21 provinces since August Today, CVS services, which require such advanced technology and team-work, are provided to our patients at hospitals in their own neighborhood. h) Restructuring in burn treatment Due to the fact that burn patients are susceptible to infections and other secondary problems, they need special care and attention. When Health Transformation Program was first initiated, there were only 35 burn beds in the MoH hospitals. By the end of 2009, the number of burn beds in MoH hospitals rose to 324, accounting for a total of 493 burn beds countrywide. The number of burn beds in hospitals of the Ministry increased by 9 folds in comparison to For the first time in 2009, MoH Kartal Burn Treatment Hospital was put into service in Istanbul. According to the statistical studies and projections, the target for the number of burn beds was 440 in Turkey and we have already exceeded this target. Graph 39 81

82 Health Transformation Program in Turkey September 2010 i) Blood services Enacted in 2007, the Law no on Blood and Blood Components marked the beginning of the structuring of blood service units in Turkey; and our Ministry assigned Red Crescent Society for the collection and distribution of blood, except for emergencies. Regional structuring is realized by Red Crescent across the country with the support of our Ministry. Having established 15 Regional Blood Centers and 56 Blood Donation Centers, Red Crescent supplies safe blood through the Transfusion Centers in hospitals. Besides, our Ministry opened blood centers in 84 hospitals with very high volume of patients. These centers supply the blood and blood components needed by our patients. In order to ensure the supervision of blood service units and enforcement of the Law on Blood and Blood Components, Supervisor Training was provided to 213 health personnel from all provincial health directorates of the country and physicians with experience of blood banking. Our Ministry has organized campaigns with the involvement of non-governmental organizations in order to underline the importance of blood donation and raise awareness about blood donation in the society. As a result of these efforts, trainings and briefings, the amount of blood donation, which was 326,337 units in 2002, rose to 848,586 in This way, our citizens no longer have to run from pillar to post in order to find blood and blood components in emergencies; and blood components, being so valuable, are not wasted anymore. Graph 40 (Source: Red Crescent Society) 82

83 NEW ERA IN HEALTH New Era in Health 6. Performance Based Supplementary Payment, Quality and Accreditation Before the Health Transformation Program, hospital personnel used to take very little share from the revenues of hospitals from service provision. For this reason, the issue of health services efficiency, registration or return of service cost did not concern most personnel except for few managers, since the personnel was not able to receive any share from the hospital revenue, and unregistered procedures increased at hospitals. In previous implementation, theoretically the upper limit for bonus payment was 100 % of the basic salary, but payment covering this upper limit was not made at all. Upper limit for bonus payment for specialists was 861 TL in 2002 and 265 TL for other health personnel with 2009 figures. The new implementation, on the other hand, offers a supplementary payment varying from 150 % to 800% depending on different professions and work styles. The average supplementary payment for specialists was 4541 TL in 2009, whereas it was 643 TL for personnel in other health services areas. It is necessary to make measurable service definitions in order to motivate health personnel, help them work more productively and encourage the provision of high-quality services. Performance management focuses on different performance indicators to this end. The most important indicators include ensuring the happiness of individuals receiving services (Patient Satisfaction), achieving a better level of health, complying with the process of well-defined high-quality service provision, abiding by norms regarding the infrastructure, human and material resources used for service provision. Health Transformation Program states that performance indicators will be developed and performance-based payment systems will be established. The new implementation, in this context, has brought some changes in many respects. First, a system was set up by bringing the work and monetary contribution in parallel and thus more productive use of time and potential was ensured. It is more equitable that service producers have a share as much as they produce. We observed that such an implementation ensured the efficient use of time and potential in the institutions. The very first benefit of this system is that the services provided in hospitals became measurable. The second benefit is that these measurable services are assessed and reflected on the service providers. In training hospitals, scientific studies, publications and assistant training were also accepted as performance indicators as well as the services provided to patients. Thus, training of assistants and scientific studies were encouraged. Among the important characteristics of the system is that healthcare personnel are rewarded according to the deprivation level of their work place and preventive care 83

84 Health Transformation Program in Turkey September 2010 practices are emphasized as performance criteria. As a result of the performance-based revolving fund payments, personnel have extended work hours voluntarily and operating rooms are now used for a longer time. Most specialists closed their private offices and switched to full-time working in hospitals. This implementation has played an important role in overcoming the patient overload in hospitals, which is a result of patient satisfaction Performance based payment refers to the payment depending on the services provided, and we use it as an incentive boosting service supply and productivity. It is an important instrument which increases motivation to meet the service demand. Prevention of unrecorded work, cheaper supply of materials and decrease in wasting subsidize the performance based payment system to a large extent. Outstanding decrease has been noted in waiting lists. Number of referrals to higher level facilities has decreased to acceptable levels. Income-expenditure balance of health institutions are followed more diligently. Today we are much more capable of fighting with under the table payments to healthcare personnel. with services. By the beginning of 2003, the share of full-time practitioners was 11%, and it rose to 92% through these policies. Thus, efficiency of the physicians, the number of whom still remains to be insufficient, has increased in the public hospitals. Health Transformation Program targets continuous improvement of quality. We developed the performance-based payment system as an implementation peculiar to our country. As a second step we added the quality dimension through the legislations on Institutional Performance and Quality Improvement, which is based on quality in health service provision. Thus, a hospital evaluation system, which facilitated the assessment of the level of access to healthcare services, infrastructure and procedures, measurement of patient s satisfaction and analysis of the achieved goals, was established. Thus, supplementary payments made to the personnel vary according to the results of abovementioned measurements, i.e. quality of services, rather than the quantity of the service provided. 84

85 NEW ERA IN HEALTH Our Ministry has prepared many documents on Performance, Quality and Accreditation: Scientific publications Journal for Quality and Performance in Healthcare Performance, Quality and Patient Safety Agency Congress Scientific Papers Scientific Research and Best Practices Book Publications in the field of healthcare services Performance Management in Healthcare (Turkish-English) Guide for Development of Approach and Quality and Safety Strategies in the Healthcare Development of Hospital Accreditation in Europe Hand Hygiene in Healthcare Services (WHO Guideline English) World Health Organization Surgical Safety Checklist Health Promotion in Hospitals Institutional Performance and Quality Practices in Healthcare Panorama of Performance in Healthcare 85

86 Health Transformation Program in Turkey September 2010 New Era in Health 7. Human Resources Management in Health a) Determination of Human resources situation and solution planning Before the Health Transformation Program, there were significant wrong approaches to health human resources in Turkey. The misconception that the number of physicians is too much has always been on the agenda. There was a similar approach to the number of nurses as well. However the truth is that the important principle of quality in education was used as an excuse in order to shadow the need to increase numbers. At the beginning of the transformation, attention was drawn to the shortfall of personnel by the Minister of Health and the Ministry. As of December 2009, the total number of physicians in Turkey was 112,000 and the number of physicians per 1000 people has been It is important to raise the numbers particularly of the physicians and the nurses without compromising education quality in health human resources. In terms of the number of physicians per hundred thousand, Turkey ranks at the bottom of the WHO European Region. It is interesting that in Romania, ranking right above Turkey in the list, the number of physicians per hundred thousand is 192. Comparison of EU Average, WHO European Region Average and Turkey for the Number of Physicians per 100,000 people Turkey* EU Average WHO European Region Average 340 Graph 41 Source: WHO/European HFA Database, August 2009 *Figures dated 01 June 2010 have been taken as the basis for Turkey; and according to Address Based Population Registration System, the population of Turkey is 72,561,312 as of 31 December

87 NEW ERA IN HEALTH Comparison of EU Average, WHO European Region Average and Turkey for the Number of Practitioners per 100,000 people Turkey* EU Average WHO European Region Average Graph 42 Source: WHO/European HFA Database, August 2009 *Figures dated 01 June 2010 have been taken as the basis for Turkey; and according to Address Based Population Registration System, the population of Turkey is 72,561,312 as of 31 December EU Average, WHO European Region Average and Comparison with Turkey for the Number of Specialists per 100,000 people Turkey* EU Average WHO European Region Average Graph 43 Source: WHO/Europe, European HFA Database, August 2009 *Figures dated 01 June 2010 have been taken as the basis for Turkey; the number 29 shown in light color represents the number of assistants continuing specialty in medicine training. 87

88 Health Transformation Program in Turkey September 2010 The Number of Specialists per 100,000 People in 22 Branches in 21 EU Member States and Turkey Internal diseases Obstetrics and gynecology Child diseases Anesthesiology General surgery Mental health and diseases Radiology Eye diseases Cardiology Neurology ENT diseases Dermatology Chest diseases Urology Gastroenterology Endocrinology and metabolism diseases Surgical oncology Rheumatology Child mental health and diseases Brain and neurosurgery Plastic surgery Child surgery 0,6 0,3 0,0 0,1 2,0 1,9 2,3 2,3 2,2 3,5 3,3 3,8 3,3 2,8 2,1 1,9 1,8 1,5 0,2 1,2 1,7 1,1 0,9 0,8 0,7 2,9 4,4 4,7 4,4 6,0 5,6 5,6 6,1 5,9 6,6 7,1 7,7 10,4 12,5 16,1 16,0 14,9 14,5 22,8 0,0 5,0 10,0 15,0 20,0 25,0 European Countries Average Turkey Graph 44. Source: Eurostat (New cronos Database) *The number of actively working personnel as of 01 June 2010 has been taken as the basis. We have substantial deficiency of personnel in all branches other than brain and nerve surgery. 88

89 NEW ERA IN HEALTH The number of Physicians per 100,000 People in European Countries and Turkey Monaco Greece Belarus Georgia Russian Federation Belgium Lithuanian Netherlands Switzerland Norway Azerbaijan Spain Austria Kazakhistan Iceland Italy Bulgaria Sweden Czech Republic Israel Germany Armenia Portugal France WHO European Region Average Malta Finland Estonia EU Average Denmark Slovakia Moldova Ukraine Latvia Andorra Ireland Luxembourg Hungary Serbia Uzbekistan Croatia Macedonia San Marino Turkmenistan Kirghizistan Slovenia United Kingdom Poland Tajikistan Montenegro Romania Turkey Bosnia-Herzegovina Albania Graph 45 Source: WHO/European HFA Database, August 2009 * Figures dated 01 June 2010 have been taken as the basis for Turkey; and according to Address Based Population Registration System, the population of Turkey is 72,561,312 as of 31 December

90 Health Transformation Program in Turkey September 2010 Comparison of EU Average, WHO European Region Average and Turkey for the Number of Dentists per 100,000 people Turkey* WHO European Region Average EU Average Graph 46 Source: WHO/Europe, European HFA Database, August 2009 * Figures dated 01 June 2010 have been taken as the basis for Turkey. 90

91 NEW ERA IN HEALTH The Number of Dentists per 100,000 People in European Countries and Turkey Greece Monaco Israel Iceland Estonia Norway Finland Bulgaria Belgium Sweden Denmark Luxembourg Germany Croatia Lithuanian Latvia France Czech Republic Italy EU Average Slovenia Ireland Portugal Macedonia Andorra Spain Austria WHO European Region Average Switzerland Netherlands Belarus Slovakia United Kingdom Moldova Malta Hungary Ukraine Montenegro Kazakhistan San Marino Armenia Serbia Albania Russian Federation Poland Azerbaijan Georgia Turkey Romania Kirghizistan Uzbekistan Bosnia-Herzegovina Tajikistan Turkmenistan Graph 47 Source: WHO/Europe, European HFA Database, August 2009 * Ministry of Health Personnel Statistics and the figures dated 01 June 2010 have been taken as the basis for Turkey. 91

92 Health Transformation Program in Turkey September 2010 In Turkey, we have sufficient number of faculty members and students in schools of medicine to ensure success. There are currently 35,454 students enrolled in schools of medicine in our country, and the total number of faculty members amount to The number of faculty members per student is 3.9. The Number of Faculty Members per Student in Some European Countries and Turkey 20,0 Student/Academician 19,8 15,0 10,0 10,8 11,8 14,7 15,0 15,6 16,5 5,0 3,5 3,9 4,7 5,2 6,3 6,7 0 Ireland Turkey Finland Poland Austria Spain France Greece Slovakia Italy Slovenia Bulgaria Germany Graph 48 Sources: 1) Data collected by the Ministry of Foreign Affairs through the Embassies in EU States 2) The European Society for Medical Oncology, Medical Oncology Status in Europe Survey, ) The EHGA White Book 2009, the Current Status of Cardiac Electrophysiology in ESC Countries 4) Physicians in Nordic Countries, Nordic Medical Associations, ) Statistiches Bundesamt, VI B Hochschulstatistik, 2008 The situation is not different in terms of the nurses, physiotherapists, and many other health professionals. The needs of the population and the increasing demand for the healthcare services make it inevitable to increase the number of the physicians and the nurses. At the same time, the education quality must be preserved and even improved. EU Average, WHO European Region Average and Comparison with Turkey for the Number of Nurses per 100,000 People ** 727 Turkey* European Region Average EU Average Graph 49 Source: WHO/europe, European HFA Database, August 2009 * Figures dated 01 June 2010 have been taken as the basis for Turkey. ** The number of actively working nurses per 100,000 people is 141; the number of midwives per 100,000 is 66 in Turkey and the graph represents the sum of the two. 745

93 NEW ERA IN HEALTH The Number of Actively Working Nurses per 100,000 People in Turkey, WHO European Region and EU Member States Monaco Ireland Norway Netherlands Belgium Belarus Sweden Uzbekistan Luxembourg Denmark Iceland Hungary Finland Czech Republic Switzerland Russian Federation France Ukraine Germany Slovenia Moldova EU Average Spain Lithuanian WHO European Region Average Azerbaijan Italy Kazakhistan Estonia Austria Slovakia Malta Israel Serbia Latvia Kirghizistan Croatia Montenegro San Marino United Kingdom Portugal Polona Tajikistan Bosnia-Herzegovina Turkmenistan Bulgaria Armenia Albania Romania Macedonia Georgia Greece Andorra Turkey * 207** Graph 50 Source: WHO/Europe, European HFA Database, August 2009 * Figures dated 01 June 2010 have been taken as the basis for Turkey. ** The number of actively working nurses per 100,000 people is 141; the number of midwives per 100,000 is 66 in Turkey and the graph represents the sum of the two. 93

94 Health Transformation Program in Turkey September 2010 b) Breakthrough in the health human resources employment In the last seven years, 168 thousand new personnel have been employed in public healthcare institutions of the Ministry as of July New employment methods have been applied to assign personnel in the healthcare institutions and regions deprived in terms of personnel for years. To this end, the Law No was enacted in 2004 and a new employment model on contractual basis peculiar to the Ministry of Health has been put into force. This new model is used to employ personnel on voluntary basis; and the personnel, upon their consent, are covered by this Law and gain higher financial rights compared to other personnel of equal position. Moreover, after a contract period of 10 years, the personnel earn the right to become contracted personnel. Besides, the model of contracted employment under Article 4/b of the Law on Civil Servants rarely used in the past has been appointed by the Ministry particularly to regions and facilities deprived of personnel based on the Regulation issued by the Cabinet. This way, 65,000 contracted health personnel under Article 4/b and 19,755 contracted health personnel under Law No have been appointed by the Ministry particularly to the fifth and sixth service regions regarded as deprived regions. In this way, the gap between the best and worst rates were diminished (for specialists: from 1/14 to 1/2.7; for practitioners: from 1/9 to 1/2.2; for dentists from 1/8.5 to 1/4; and for nurses and midwives: from 1/8 to 1/3.6). In the next few years, with balancing efforts for provinces at the top or the bottom of the scale, the distribution of healthcare personnel will be more equitable. Another recruitment model is the recruitment of the staff working in outsourced services such as housekeeping, information processing, security, and catering. The number of these personnel was 16 thousand in 2002 and it is 116 thousand in Graph 51 (The values in the graph represent the provinces with the highest or the lowest number of people per physician. The ratio between the provinces with the highest and lowest number of people per physician was 1/9 in 2002, whereas it decreased to 1/2.2 by the end of 2009.) 94

95 NEW ERA IN HEALTH Net Change in the Number of MoH Personnel (thousand)* The number of personnel employed in the healthcare institutions of the Ministry and SSK was 256 thousand in 2002 and it rose to 441 thousand by December The number of personnel employed by outsourcing was 9906 in 1996 and 11,000 in 2002, whereas it reached 116,000 in Graph 52 (*): The numbers in the graph include the personnel employed by outsourcing. c) Transparency in personnel appointments It is known that unbalanced distribution of personnel was one of the most important problems in our country in the previous period. One of the priorities of the Health Transformation Program is to bring regional disparities in personnel distribution down to acceptable levels, to determine realistic standards for titles in personnel employment and plan human resources accordingly and to establish an objective and equitable system for appointments and transfers. In order to encourage personnel to work in priority development regions, the Law No allowing employment of contracted personnel was enacted. This way, more personnel was attracted to less developed regions with more severe problems of personnel deficiency. There is already a shortage of physicians and it is difficult to employ them in the less developed regions, since most of them like to work in metropolitan cities. Taking health for all policy as the basis, we put into effect the subsidized compulsory service for physicians. Taking the former deficiencies and mistakes in the compulsory service implementations into consideration, we made a more acceptable and sustainable arrangement and identified separate work periods and higher payment policies according to different deprived regions. In order to prevent nepotism in personnel appointment and ensure more balanced distribution of healthcare personnel to all the MoH healthcare facilities, Regulation on Appointment and Transfer was drafted. This way, specialists, general practitioners, dentists and pharmacists are appointed by a computer-based lottery and other personnel are appointed by a central examination conducted in accordance with general provisions. In the new implementation, personnel appointment and transfer proceedings are based 95

96 Health Transformation Program in Turkey September 2010 on the service points that depend on the characteristics of the region they are employed and the duration of employment. A more strict supervision system was introduced for excuses. Use of service points and computerized lottery for appointments put an end to favoritism and nepotism pressures on politicians and bureaucrats as well as some unjust proceedings and speculations. Thus, a marked success is achieved in the equal and balanced distribution of health personnel across the country. d) Health personnel training We attach great importance to the training of health professionals of all levels, current managers and management trainees. On the one hand regional training events on technical topics are organized and on the other hand systematic health management trainings are delivered online by School of Public Health for efficient, effective and collaborative use of resources. In order to improve efficiency and service quality in all MoH institutions, it is targeted by the School of Public Health to provide training to all health personnel particularly managers, management trainees and specialists through the Distant Health Training System (USES), which is an online distant training system of the latest technology. You can visit the training page on More than 10,000 students including more than 1000 managers have so far received these trainings of these students are still continuing various training programs. Until now, around 4000 certificates have been granted to health professionals trained under various training programs in line with the ultimate goals. The first round of Health Management and Administration Distant Training Certificate Program, prepared with an academic perspective on the basis of graduate programs, has been completed successfully by 256 of the 590 participants in total. The second round of this Certificate Program started in 2009 and is attended by 465 new participants. This training has been prepared with the contributions of leading academicians and provided to management level personnel and management trainees in the MoH institutions and organizations. Orientation trainings are provided to family physicians to be assigned in primary health care and other health personnel to be assigned in family medicine. Curricula have already been completed, part of the training materials has been produced and the training has been initiated for the second term of professional training program, which will last longer and will be conducted through USES for the most part. Training materials continue to be produced in parallel to the training. 96

97 NEW ERA IN HEALTH New Era in Health 8. National Drug Policy a) Reduction in drug prices One of the leading findings of the Health Transformation Program about drugs was that the increases in drug prices were not evidence-based in the past. The Ministry of Health is responsible to determine the relevant norms and standards about drugs and pharmaceutical services on behalf of the public. It is also entitled and obliged to carry out inspections in this field and to encourage rational drug consumption in cooperation with other relevant institutions and organizations. As for drug pricing, the program clearly emphasized the need for developing a method mutually agreed by all parties. Decree on the Pricing of Medicinal Products for Human Use of 2004 eliminated all the disturbance and negative aspects and put drug pricing under the light of transparency. Thus, prices have been reduced significantly and brought down to the lowest level in Europe. Reductions ranging from 1 % to 80 % have been obtained in approximately a thousand products. Additionally, determination of price by reference price monitoring contributed to the sustainability of price reductions. Price changes in reference countries are monitored in three-month periods and the price reductions, if any, are reflected in the prices in our country. Thanks to this method, price reductions have been reflected to the prices in Turkey more than 200 times in the period In order to relieve the burden on Public Finance, a Reimbursement Commission has been established and Single Reimbursement System has been introduced under the leadership of the Ministry of Health. With the consensus of the reimbursement institutions, the rule that prescribed medicinal products will be reimbursed on condition that their price is not higher than 15% of the cheapest equivalent drug has been introduced. With this practice, the firms manufacturing the drugs that remain out of this circle have voluntarily reduced their prices in order to benefit from the reimbursement system. Eventually, a significant saving for public finance has been achieved. The VAT rates for drugs have been reduced from % 18 to 8 %, leading to another outstanding decline in drug prices. The negotiations between the sector and public security institutions as the single purchaser for discount in drug prices have further reduced the cost of drugs to the public. Another radical amendment has been made in Decree on Pricing of Medicinal Products for Human Use in 2009 and the rule When a generic of an original product has been marketed, the price of the product may not exceed 66% of the current market price (both for the original and the generic product) has been introduced. 97

98 Health Transformation Program in Turkey September 2010 The reductions in price made by Social Security Institute have also decreased the cost borne by the public for medicinal products. All gains from these decisions have been used to invest in the health of our citizens. b) Opening pharmacies to everybody The reductions in drug prices were directly reflected to our citizens and the obstacles preventing our citizens (particularly SSK enrollees and Green Card holders) from accessing drugs were eliminated. Within the course of the Health Transformation process, decisive steps were taken to ensure easy and economic access to drugs and the result of those steps are observed by the public very closely. People insured by SSK, who could obtain their drugs only from a limited number of hospitals, some of whom could not obtain their drugs from SSK and had to pay out of their own pockets, are now free to obtain their drugs from the pharmacy of their choice like other Turkish citizens. The Green Card legislation has been amended to cover the provision of outpatient treatment to Green Card holders and allow these citizens to supply their drugs from the pharmacy of their choice. All these practices have eliminated the discrimination among citizens that previously prevailed in the health system. c) Drug consumption The amount of drugs consumed reached 1 million 530 million boxes in 2009, with an increase of 118% from During the same period, public spending on drugs has increased from 11 billion 260 million TL to 16 billion 64 million TL with 2009 prices and has increased by only 42%. Graph 53 Graph 54 This saving on drugs has been used to facilitate the access of our citizens to drugs. 98

99 NEW ERA IN HEALTH New Era in Health 9. Health Information System / e-health Implementations In order to have a health community composed of healthy citizens, it is important to take information as the basis of health system policies and management decisions. Health information system cannot be built solely by making investments in technologies. The establishment of the system depends on national and international health informatics standards, coding, classification, determination of terminology, integration of the data collected from different institutional levels, and making this information usable in the decision making processes. In this context, our Ministry has created an e-health vision along with the Health Transformation Program. In this framework, standard coding systems such as standard definitions of the institutions, databank of physicians, internationally accepted disease classifications, coding for drugs and medical supplies have been identified, harmonized and used by the sector while communicating with the institutions. What is e-health? It is the introduction of information technologies in the field of health on the internet for effective and efficient provision of healthcare services, ensuring rapid access and sustainability of data exchange among stakeholders. In this respect, the e-health vision of our Ministry is to establish a national health information system, which may be accessed only by the authorized persons and institutions, in which all persons can access their own health data, which complies with international standards and is supported by decision support systems, which has large band width and covers the whole country; and which is based on the utilization of technologies such as tele-medicine and tele-health in practice. e-training Telemedicine Project Tender Information System Physician Information System Central Hospital Appointment System Medical Device and Material Recording System e-health applications Core Health Resources Management System Basic Health Statistics Module National Organ Transplantation Documentation System Family Medicine Information System e-health portal health net 99

100 Health Transformation Program in Turkey September 2010 Current e-health Projects 1. Health-NET Health-NET is an integrated, safe, fast and expandable information system which aims to improve efficiency and quality of health services by collecting all kinds of data produced in the health institutions in line with the standards and generating information adequate for all stakeholders out of the collected data. Health-NET has a modular structure which may be expanded in case of need and does not rely much on the relationship between the user and service provider. Health-NET has been activated on 15 January 2010 in order to collect electronic health records under a single roof. The number of integrated institutions has increased rapidly; and 600 state hospitals, 60 training and research hospitals and 350 private healthcare institutions have been integrated. 2. Family Medicine Information System Family Medicine practice, initiated under the Health Transformation Program, has introduced innovations both in terms of healthcare service provision and primary health care data collection discipline of our Ministry. The most important innovation is the Family Medicine Information System (FMIS). FMIS is not just a computer program; it is the name given to the new standard of our Ministry for data collection at primary health care level in the provinces where Family Medicine is under implementation. Thanks to FMIS, physicians can record the healthcare service they provided on electronic medium and directly select and report on minimum a data set (Healthcare Minimum Data Sets-HMDS) required by the Ministry on electronic medium Core Health Resources Management System (CHRMS) This project, realized by the Central Organization of the Ministry of Health and 81 Provincial Health Directorates has ensured the provision of accurate and updated information support to managers of all levels in order for the human, material and financial resources to be monitored and directed as required. CHRMS is integrated with other projects and implementations and has become indispensable for the Ministry with its database. Main modules of the Core Health Resource Management System include: Human Resources Management System (HRMS), Material Resources Management System (MRMS), Investment Monitoring System (IMS), Private Healthcare Institutions Management System (HIMS).

101 NEW ERA IN HEALTH HRMS module allows the movements of all personnel to be monitored; transactions related to their payrolls and accrual to be made. MRMS module allows efficient and up-to-date monitoring of resources (durable movables and disposables) under the ownership of the Central Organization and Provincial Health Directorates of the Ministry. With IMS, it is aimed to plan the financial resources of the Ministry of Health according to the needs, distribute them among the units of the Ministry, use and monitor them. This module has been activated in January 2010 and it is planned to use this module to keep updated records of the equipments owned by the Private Healthcare Institutions, their contact information, license information, devices, job starting and leaving date of the personnel employed in the Private Healthcare Institution; and monitor all the steps taken by the Private Healthcare Institution. 4. Green Card Information System Through the Green Card Information System, green card entitlement of the citizens holding green cards is monitored and this information is shared with other stakeholders through web service. 5. Tele-Medicine Project Through the Tele-medicine Project, distant reporting service was introduced in the field of imaging with the use of information and communication technologies; and a total of 68 hospitals, consisting of 58 sender and 10 receiver hospitals, have been integrated in the field of tele-radiology, tele-pathology and the roll-out works are continuing. 6. Decision Support System Decision Support System, which provides analysis, reporting and statistics support for the Health Policy makers, planners and decision makers was put into service. This way, it will be possible to carry out epidemiologic and demographic analysis about the burden of disease. Decision Support Systems, which aim at reaching effective and accurate information to develop a culture of information-based management, speed up the process of decision making and create more effective healthcare policies, constitute an indispensable part of the whole information system of our Ministry. Around 200 reports have been produced for managers of the central and local organization and other stakeholders; all data collected in the information systems are statistically published on daily basis. Data collected from different information systems can be united under the roof of Decision Support System if needed and thus accelerate the process of decision making. 101

102 Health Transformation Program in Turkey September e-training E-training portal has been devised in order to support graduate in-service training of MoH personnel and to provide them training at any place and time they wish. The project was initiated in May 2009 and Microsoft Office 2007 and Information Safety Training have been provided to around 2500 health personnel by way of distant training. 8. Other Projects Through the MoH Tender Information System, it is possible to see the tender results for the procurement of medicines, devices, materials and services in all MoH Provincial Health Directorates, all hospitals, and Hygiene Regional Directorates. Moreover, Pharmaceutical and International Classification of Diseases codes started to be implemented. Within the framework of health informatics, National Health Data Dictionary and Healthcare Minimum Data Sets were prepared for the first time and Health Coding Reference Server was put into service. Again for the first time, Organ Transplantation and Tissue Data Bank were established in order to find the most suitable organ for the citizens waiting for organ transplantation; and to prevent illicit organ transplantation. Through the Physician Data Bank, the diploma and the specialty information of all physicians in the Republic Period are fettered into records. 102

103 NEW ERA IN HEALTH New Era in Health 10. Rationalism in Investments A detailed health inventory has been created with the Health Transformation Program and all the health investments so far have been reviewed. Public health investments have been re-planned. The financial, medical and technical analyses of investments have been re-evaluated. These planning procedures have been carried out on-site at the level of districts, provinces and regions together with the local administrators. The projects have been re-arranged in accordance with the priority and importance level and investment budgets began to be utilized more logically. We prepared the legislation which will enable investments to be made through public private partnership for the construction of new patient centered hospital buildings and hospital campuses and for the revision of some old buildings. In fact, the number of beds per 100 thousand people in Turkey is 285 and this figure seems sufficient in the framework of the new tendencies in the world. However, the existing beds will be replaced by qualified beds and investments to establish accompanying modern structures will continue. In the last seven years, we have built and commissioned 1771 health facilities in Graph 55 (Source: Ministry of Finance-Central Administration Final Account Tables) total, 476 of them being hospitals and 1295 primary health care institutions. The number of patient beds put into service in the previous seven-year period was 7644, whereas the number exceeded 28 thousand in the recent seven-year period. 80% of the patient rooms constructed during this period have bathroom, toilet, television, refrigerator, telephone and companion seat and are in the class of qualified patient bed. The remaining 20% are not included in the class of qualified patient beds due to the projects initiated in the past, about to be completed and not allowing technical revisions. Therefore the percentage of patient beds with bathroom and toilet in the total number of patient beds rose from 9% to 23%. 103

104 Health Transformation Program in Turkey September 2010 During the period , 175 hospitals and new blocks were constructed, whereas during the period , 476 hospitals and new blocks were completed and commissioned. Similar level of success has been achieved in primary health care facilities with a number of 651 facilities constructed during and 1295 new facilities constructed during Graph 56 Graph 57 Graph

105 NEW ERA IN HEALTH New Era in Health 11. A Health City/Health Campus for Each Health Region a) Healthcare service planning In most of the developed countries, the healthcare systems are structured so as to cover the whole population in the framework of quality standards and equality principles. While the approaches might differ, the financing and organization responsibilities of the health services are shared between the central and provincial authorities, but in general the central government is the main determiner. In Denmark, the local administration and the municipalities plan the health regions under the supervision of the government. In UK, national and regional planning are directed by the central government with the participation of the local administrators. In France, regional health associations plan the hospital service within the framework determined by the central government. In Germany, state governments plan the hospital capacities in the framework of the national and regional legislation. In Canada, the planning is under the responsibility of the regional administrations, but the national framework is taken into consideration in some cases. In Canada, France and Germany, the hospital planning covers both the public and the private hospitals. In fact the private institutions are subject to permission within the scope of the planning in order to expand their activity areas. On the other hand, countries like Denmark and the UK limit their plans with the public hospitals. In our country, opinions of the provincial organization by the Ministry were asked during the studies on the regional health plans; attention was paid to the reviews and findings of the central organization in provinces, demographic, geographical structure, region under coverage, distance to the center, transportation, local needs and existing health inventory. Reference hospitals/campuses are planned in order to meet the needs for health training, institutional guidance and reference center in their regions. While before the Health Transformation Program, the delivery of health service was structured with the induction method from bottom to up as health house, health center, district hospital, province hospital and regional hospital; the deduction method is taking the reference center as the basis is foreseen in this planning. Taking the health requirements, geographical structure, patient flow, accessibility, socio-economic structure of the Region into consideration, our Ministry has identified 29 health regions. In this respect, specific health regions to provide services, provinces to act as the health centers of their region in each health region and sub-regions of these central provinces have been identified. It is important to define the service provision roles of the inpatient healthcare facilities, which are already planned or at the phase of investment planning in the sub-regions, strengthened districts and smaller districts. The issues of classification according to the roles and restructuring according to the health requirements and expectations of the target population are also important. 105

106 Health Transformation Program in Turkey September 2010 This planning is made at country level based on the population rate; and regional distribution has been made upon consideration of the adequacy of the physical environment, number of personnel, existence of tools and equipment and the regional disparities among specialty service units (such as ICU, CVS Centers). b) Campuses, new structuring and hospital roles We have made investment planning at the level of provinces and regions through onsite examinations and the participation of local administrators. We have developed expandable and sustainable plans tailored to the socio-economic status of the country for the construction of new patient-centered hospital buildings and hospital campuses, the revision of some old buildings and the repair and maintenance of existent hospitals. We spent efforts to make the most efficient use of financial resources coming from Public Private Partnership, Housing Development Administration (TOKİ) and Line-Item Budget in these plans and programs. Within the framework of region-based healthcare structuring, we made an assessment with universities and private health institutions regarding the health service provision roles to be assumed by public institutions and identified the roles of hospitals accordingly. Determination and grouping of hospital roles on institutional basis A-1 Group General Hospitals: General inpatient healthcare institutions, which are authorized by the Ministry to provide training in at least five branches as per legislation and assigned training cadres accordingly, which provide tertiary level treatment and rehabilitation services, conduct training research activities and train specialists and fellows, are classified as A-1 Group Hospitals. A-Group Branch Hospitals: This group includes branch hospitals which hold training and research hospital status and meet the following criteria; 1- To have training and research hospital status, 2- To have tertiary level intensive care and/or newborn intensive care units as required by its field of specialization, 3- To provide tertiary level emergency services in the branch and/or branches required by its field of specialization, 4- To establish Training Planning and Coordination Board. 106 A-2 Group General Hospitals: General hospitals located in provinces holding regional health center status or in provinces under the coverage of these centers; which do not have training and research hospital status and meet the following criteria are classified as A-2 Group Hospitals.

107 NEW ERA IN HEALTH A-2 Group Branch Hospitals: All branch hospitals lacking training and research hospital status are classified as A-2 group branch hospitals. B-Group General Hospitals: General hospitals which are not included in A-1 and A-2 Group hospitals, which are located in strengthened districts and meet the following criteria, are classified as B-Group hospitals. 1- To be located in provincial center or strengthened district center, 2- Capacity to assign physicians on call from its pool for emergencies in internal medicine and surgery branch on 24 hour basis. 3- To have at least secondary level emergency and secondary level intensive care units. C-Group General Hospitals: C group includes the general hospitals classified according to the below listed criteria. 1- To be located in strengthened districts or smaller districts connected to district centers strengthened under health region planning, 2- To have specialists in four major branches and specialist in minimum two additional branches, 3- To have at least primary level intensive care unit and primary level emergency department. D-Group General Hospitals: AThis group includes general hospitals with minimum 25 patient beds and located in strengthened districts or smaller districts connected to district centers strengthened under health region planning and which meet the following criteria: 1- Under the four major branches; to have minimum one specialist planned for each branch and more than one specialist including the family physician, 2- Under the existent specialties; to provide specialist level polyclinic examination services and specialist level follow-up and treatment of hospitalized patients, 3- To provide emergency healthcare services within the primary level emergency service setting, 4- To have an operating room, post-operative recovery room, dental polyclinic, delivery room, observation room with monitor, 5- Capacity to structure dialysis unit according to the needs. E-Group Hospitals: E-Group hospitals are the integrated district hospitals with less than 25 patient beds. Diagnosis and treatment services are provided in the same setting with primary health care in these institutions. 107

108 Health Transformation Program in Turkey September 2010 Why hospital campuses? Hospital campuses are important: For increasing the health service efficiency in our country; To spread the treatment diversity across the country, To complete the regional development in the field of health, To increase service quality, To deliver cost effective health service... For the needs of the society; To ensure sufficient number of beds and bed quality, To provide a specialized team serving to the whole region, To use new technologies in treatment, To develop new concepts in curative services (daily surgery, day hospital) For the patients; To shorten the length of hospital stay, To reduce the number of patient transfers, To decrease hospital infections, To improve patient safety, To increase patient satisfaction For the personnel; To increase staff satisfaction and safety, To increase the quality of workforce and services, To develop healthcare service performance 108

109 NEW ERA IN HEALTH The approach to solve problems in the field rather at the table 12. Evaluation of Provinces: Step by Step 81 Provinces Field studies aimed at visiting on-site observations and implementation evaluations have enabled the services provided by the personnel of MoH, one of the largest organizations of Turkey, to be monitored on-site. Republic of Turkey Ministry of Health Health Transformation Program Health Services Province of Afyonkarahisar Province Evaluation works Ministry of Health Monitoring and Evaluation Team The amount of distance travelled by the Minister and the field coordinators during the field studies, which have steadily increased in number and coverage since 2006, is 1,500,000 km. It equals to touring around the world more than thirty seven times All of the 81 provinces were visited without any exception. Many provinces were evaluated more than once. We laid the problems of the provinces on the table with the local administrators and shared duties in order to solve these problems. We assigned health managers of different provinces in these visits so that they examine other institutions and compare them with their own. This way, provincial evaluation functioned also as an in- 109

110 Health Transformation Program in Turkey September 2010 service training program. Observing the satisfaction among our citizens as a result of these efforts is a source of pride for us. In-service training We assigned health managers of different provinces in these visits so that they examine other institutions and compare them with their own. This way, HTP provincial evaluation visits functioned also as an in-service training program. Follow-up All information and statistics collected during the field visits were reported so that the progress made was monitored during the next visit. The instructions given during the field visits were monitored through the follow-up reports during the next visit. This way, the message that instructions given to the field would be monitored is communicated and improvements are accelerated. Sharing of Experiences Thanks to such studies, health managers were provided with the opportunity and environment to exchange their experiences personnel from the Central Organization of the Ministry and 2580 local managers were assigned in field Evaluation Studies at different times Broadening Perspectives and Institutional Surveys hospitals, 1250 Oral and Dental Health Centers, primary health care institutions and organization were visited during the visits organized in order to give our managers the opportunity to observe activities outside their institutions. Standardization We made the institutions of similar size and functions feel that they are not alone and comprehend the importance of reaching a common standard with similar other institutions. We created a common language and common vision. Communication and Consultation We created a platform for health managers across the country to meet one another and constantly consult to solve their problems. Encouraging Problem Solving We listened to the proposals of health personnel both during the visits and evaluation meetings. We encouraged them to share and state their opinions. We helped them become a part of the solution, rather the problem itself. Under the Health Transformation Program, 243 provincial healthcare service evaluations have been made since Mr. Minister attended personally 154 of these evaluation meetings. Moreover, field coordinators conducted 16,100 hospital visits, 2350 Oral Dental Health Center visit, 25,500 primary health care institution and organization visits such as visits to health centers, tuberculosis control dispensaries, Mother-Child Health and Family Planning Centers (AÇSAP), family medicine units, community health centers; and made on-site evaluations. 110

111 NEW ERA IN HEALTH New Era in Health 13. Dynamic and Healthy Foreign Affairs There are 75 cooperation agreements with 45 countries. 38 of these agreements were signed in the last 7 years. Minister of Health Prof. Recep Akdağ chaired the 56th WHO European Regional Committee Meeting in Copenhagen which hosted delegations (consisting of health ministers and senior officials) from 53 Member States of the World Health Organization Regional Office for Europe. Minister of Health Prof. Recep Akdağ was also elected as the deputy chair of in the 63rd World Health Assembly organized on May 2010 with the participation of 193 Member States. World Health Organization Ministerial Conference on Counteracting Obesity was hosted by our country in Istanbul and chaired by Minister of Health. In 2006, Deputy Undersecretary Prof. Sabahattin Aydın was elected as the member of the WHO Executive Board 2006 for a term of three years. Aydın is the 4th Turkish scientist who has served in the Executive Board since Medical supplies, drugs, strategic and technical support and medical personnel were provided to countries such as Turkish Republic of Northern Cyprus, Azerbaijan, Kyrgyzstan, Sudan, Iraq, Indonesia, Georgia, Afghanistan, Bulgaria, Pakistan, Iran, Palestine, Lebanon, Kosovo, Algeria, Romania, Haiti, Macedonia, which suffered from natural disasters such as earthquake, flood, tsunami and others. As the Ministry of Health, we organized Turkish Medical Week organizations three times in Afghanistan and once in Sudan and Yemen. 204 operations were performed in the 1st Turkish-Yemen Joint Medical Week on 8-16 April patients were examined and 24 presentations were made. Within the framework of bilateral cooperation agreements, we transferred 1707 patients from Albania, Azerbaijan, Turkish Republic of Northern Cyprus, Yemen, Sudan and Afghanistan to Turkey and treated them free of charge. Moreover, 1315 health personnel from 24 countries were trained between Constant aid and cooperation are maintained especially with Afghanistan, Sudan, Yemen, Macedonia, Kosovo, Bosnia-Herzegovina, Pakistan and Palestine. In the following years, close collaboration will be established and support will be provided to the countries in need, particularly Bangladesh, Moldova and Ethiopia, in addition to the above listed countries. 111

112 Health Transformation Program in Turkey September 2010 New Era in Health 14. Restructuring the Ministry of Health Health Transformation Program provides a vision that develops policies for the Ministry of Health; and develops, monitors and supervises standards; enables effective, productive and equitable use of national resources allocated to health; and provides guidance accordingly. This vision suggests the structuring of MoH Institutions in line with principles of decentralization, and envisages a strategic organizational structure capable of planning for the Ministry. In this way, the Ministry will be able to fulfill its mission of central planning of the healthcare sector, as indicated in the Turkish Constitution. This component of the program aims to put the understanding of effective and participatory administration into practice, which is an important principle of modern public administration. In order for the Ministry to assume the envisaged role, many legislative works, starting with drafting of the Law on the Organizational Structure of the Ministry, were carried out. Besides, steps were taken under the existing legislation. New measures that encourage and promote decentralization have been implemented. Transfer of authority to provincial authorities on issues regarding authorization and closure of pharmacies, monitoring of marketing and consumption of medicinal products subject to control, opening of health centers and neighborhood polyclinics; transfer of authority on issues regarding decisions on continuation of extra working hours and intra-provincial transfer of health personnel; legalization of the purchase of health services by revolving fund corporations; rewarding of health personnel based on their performance, and raise of expenditure limit of revolving fund administrators are worth mentioning among those measures. Such implementations are developed in consistency with the spirit of the program. Works are ongoing for the new Organizational Law, which will further emphasize the fundamental functions of MoH such as laying down rules, guidance, auditing. 112

113 NEW ERA IN HEALTH New Era in Health 15. Health Expenditures Assessing the healthcare service provision from the quantitative and qualitative point of view, it may be concluded that the resources were not used effectively, productively and rationally prior to the introduction of the Health Transformation Program. Health Transformation Program ensured the optimum use of the resources and established an effective, productive and equitable health system. Graph 59 (Source: SPO, Ministry of Finance) In the last seven years, a parallel upward trend has been observed in the non-interest general public expenditures and public health expenditures. In the period , there was a 174% increase in the general public expenditures and 166% increase in public health expenditures. Claims that Health Transformation Program resulted in an excessive increase in health expenditures are proven to be groundless by the figures shown in the table. Moreover, 32.1% of the patients paid out of their pockets for healthcare services in 2003, whereas the ratio was reduced to 14.7% in

114 Health Transformation Program in Turkey September 2010 Graph 60 In our country, the number of consultations to physicians per capita doubled in 7 years. Elimination of the obstacles in front of the citizens in accessing pharmaceuticals and healthcare services within the framework of Health Transformation Program played an important role in this increase. Graph 61 Graph 62 It is a common perception that the use of high technology increases the cost of healthcare service. However, we prevented the high costs that might occur due to the use of high technology in Turkey with the help of our cost effective policies. 114

115 NEW ERA IN HEALTH Radiological Imaging Prices (by the Prices in in TRL) MR Computerized tomography 3 dimensional colored Doppler USG Graph 63 Graph 64 (Source: TurkStat, 2010) The ratio of public health expenditure to GDP was 2% in 1996 and it reached 3.8% in This number was noted as 4.1% in The share of private healthcare expenses in total healthcare expenditures is 1.9%. In the year 2009, 68% of all health expenditures were public and 32% were private healthcare expenditures. 115

116 Health Transformation Program in Turkey September 2010 Graph 65 (Source: TurkStat, 2010) (SGP=Purchasing Power Parity, is the currency conversion ratio which equalizes the price difference among countries) According to the purchasing power parity, health expenditures per capita was 149 USD $ in 1996 and increased to 330 USD $ in The amount was noted as 552 USD $ in Further improvement of the quality and the quantity of the health services is possible by continuing the optimum use of the resources and allocating more resources for healthcare services (as far as the financial means of our country allows). The share of our health expenditure in our GDP is the lowest amongst the OECD countries, and our country ranks the third from the last in terms of public expenditures; however despite those ratios we have reached a position where we are able to deliver effective, qualified and sustainable health services. 116 Medium Term Financial Program Medium Term Financial Program is the program is designed that to ensure effective, economic and efficient use of public resources; accountability and financial transparency. Medium Term Financial Program aims at: Allocation of resources in line with the strategic objectives. Guaranteeing the sustainability of developments recently achieved in Turkey in economic and social field. Providing developing sectors with consistent goals and policies to in line with the macro policy priorities. With a three year perspective the Program, having a flexible structure open to development and change and a three-year perspective, is renewed each year based on the annual implementation results and changes in the country. Program implementations and the developments that may affect the Program are monitored and evaluated. Health related aspects of the program focus on increasing the quality of healthcare services and guaranteeing financial stability. With this program, three-year budget has been allocated for public health expenditures. This way, it will be possible for the sectors to make optimum use of resources.

117 NEW ERA IN HEALTH OECD Review of Health Systems Report, Turkey, Page 65: Nevertheless, based on the overall information available from the latest national health accounts and Household Budget Surveys, it appears that the Turkish health system performs quite well in terms of equity and financial protection, both in absolute terms and relative to other countries. 117

118 Health Transformation Program in Turkey September 2010 The book titled Making Reform Happen Lessons from OECD Countries published in 2010 by the OECD General Secretariat examines the reform practices across different sectors. In the second part of the book, reform activities of 5 different OECD countries have been assessed to set successful and unsuccessful examples of reform. Turkey stands as a successful country example The report contains the following assessment about Turkey: In pre-reform period, Turkish health system suffered from problems such as different insurance coverage for different population groups, restrictions in accessing healthcare services, deficiencies in the primary health care, geographical inequalities, low patient satisfaction and absence of an insurance program to cover the whole society. In order to overcome these problems, Health Transformation Program was initiated in Social security organizations were unified under the roof of Social Security Institute. Moreover, distinction between financial institutions and service providers was made. One of the important contributions of the reform was the introduction of family medicine. Universal health insurance coverage has been achieved for the whole society. Investments in personnel and information technology systems were made and cooperation was established with stakeholders to ensure successful implementation of reforms. International experiences were utilized for designing the process of HTP. Strong leadership shown by the Health Minister is one of the most important factors bringing success. 118

119 NEW ERA IN HEALTH As a result of these changes: There has been a large increase in activity, both in primary health care and in hospitals, Satisfaction with primary health care in provinces which have introduced family medicine and also with the health system as a whole has risen sharply, Although health expenditure has risen, it has risen no faster than GDP, Performance based payment system has been introduced to incentivize staff, Legal arrangements have been made to encourage physicians to work full-time, There has been an apparent increase in productivity per physician, There has been a relative shift in consultations away from hospital outpatient departments towards family practitioners. According to OECD report; Health Transformation Program seems to represent good practice in the development and implementation of major health system reforms and preliminary indications are that it has been successful. Health Transformation Program is still an ongoing process 119

120 Health Transformation Program in Turkey September 2010 New Era in Health 16. Satisfaction with Healthcare Services According to the life satisfaction survey of TurkStat; rate of satisfaction with healthcare services was 39.5% in 2003 and after increasing 25.6 points, it reached 65.1% in During the same period, satisfaction with public order services increased 19.2 points from 57.9% to 77.1%; satisfaction with education services increased 9.4 points from 48.7% to 58.1%; and satisfaction with judicial services decreased 7 points from 45.7% to 38.7%. Graph 66 (Source: TurkStat Life Satisfaction Survey) 120

121 CHAPTER 4 TOWARDS NEW HORIZONS

122 With the patient coming from Gaza by air ambulance.

123 TOWARDS NEW HORIZONS Towards New Horizons Ministry of Health of the Republic of Turkey, since the foundation, has been working in order to ensure that everybody exercises the right to lead a healthy life by mobilizing the resources of the country in order to treat patients and to improve health. Since the early years of the Republic, there have been significant advancements via the planning, implementation and inspection functions of the Ministry of Health in the issues such as improving human power in the field of health, founding and managing health facilities, communicable diseases control and generalizing the preventive health care services. In 2003, through the Health Transition Program put into effect by the 59th government, a series of changes and innovations were implemented in order to ensure the delivery of healthcare services become more efficient, effective and accessible and to render them at modern standards and high-quality. The transformation in health contributed to the citizen satisfaction with the provision of health services and had positive impacts on primary health care indicators as well. The Strategic Plan of the Ministry of Health, prepared for the first time within the framework of the strategic administration and strategic planning approach brought by the Law No: 5018 and in the light of the Health Transformation Program, covers the years of The aims placed in the plan and the objectives complementing to them constitute the focal point of the investments to be performed and the activities to be executed during the 5 years in order to accomplish the duty (mission) of the Ministry of Health. Strategic aims are the general statements describing the 5-year-activities of the Ministry of Health. For each aim, detailed objectives have been determined. In the forthcoming period, to be able to maintain the health care services equally and in good quality, we need to emphasize once more at this point that the most critical step is to make sure that the number of qualified health work force such as nurses, physiotherapists and physicians should be made adequate. 123

124 Health Transformation Program in Turkey September 2010 Full-time Implementation We have enacted full-time law as the meeting point of the patient s right and the physician s honour. With this law, we aimed high standard, good quality, equitable and easily accessed health services. We aimed at balancing the workload of health personnel, who are in inadequate number, removing the direct money relationship between physicians and patients and strengthening the mutual trust. Unfortunately, the Constitutional Court approved this law partially. In spite of this partial approval, we provided some advantages in favour of our citizens and physicians. For instance, the lecturers working at university hospitals on part-time basis used to serve at the hospital until noon; however, with this law we extended their service delivery duration till the end of working hours in the evening. On the other hand, we encouraged physicians in the Ministry of Health Hospitals to work in their institutions after working hours. In addition, we have put an implementation into effect which allows personnel assignment between MOH hospitals and university hospitals when needed. Thus, in one hand, we ensured our citizens to access easily to good quality health services and on the other hand we ensured our physicians to serve efficiently, and also we ensured the economic regulations were put into effect which would remove physicians desire to work in their own practices. The percentage of the physicians without private practices was 11% in December, Through the implementation of performance based additional payment, without performing any legal arrangement, we increased that ratio to 89% in July, Within one month following the partial approval of the full-time law by the Constitutional Court, this figure increased to 92%, this also draws attention. This is actually an indicator of the fact that the physicians are willingly going on closing their own practices and they are supporting the implementations brought by the law. 124 Services under development a) Home health care In our continuously developing world, the roles undertaken by health services are changing accordingly and it is aimed at improving health in its all directions. To this end, the need and the demand for not only curative, but also preventive, supportive, and rehabilitative health and social services has grown. At the same time, the extension of average life span has resulted in the increase of elderly population and chronic diseases. Treatments of late and early complications which emerge depending especially on chronic diseases result in longer use of hospital beds and significant increases in costs. Depending on the longer hospitalization period of these patients, social and psychological discomforts and additional medical problems arise and how to provide home care for these people after the discharge from hospital creates another problem.

125 TOWARDS NEW HORIZONS In developed countries, providing medical care and rehabilitation for elderly or bedridden patients in their own homes and family environment rather than health facilities, and providing home health care services in order to shorten the hospitalization period came into prominence as an implementation field. In the face of these need perceptions, The Regulation on Provision of Home Care, enabling the private health organizations to provide home care, was published by our Ministry on the Official Gazette (dated 10 March 2005, numbered 25751) at first step and came into force; in this wise, the practices performed by the private sector were disciplined. Newly, regarding the provision of home health care services by the health institutions and organizations affiliated to our Ministry, The Directive on the Implementation Principles and Procedures of Provision of Home Health Care by The Ministry of Health was put into effect on 01 February With this directive, under the scope of Health Transformation Program, within the framework of equality and equity principle, it is aimed to ensure the provision of efficient, effective, genial and human-centred health care service to the individuals in need at their own homes and family environment and also to increase the service quality of treatment units as well. In order to execute the implementations of Home Health Care to be performed in accordance with the Directive; as of 15 June 2010, 34 Home Health Care Units were registered by our Ministry and began to act in 15 provinces within the Provincial Health Directorates or hospitals. Necessary works to roll out the implementation gradually to nationwide are continued. b) Central hospital appointment system (CHAS) CHAS is an implementation where citizens can call the 182 CHAS Call Centre for Mouth and Dental Health Centres and secondary and tertiary Hospitals affiliated to the Ministry of Health and can get an appointment from the hospital and physician they choose through the operators. CHAS was put into practice firstly in Erzurum and Kayseri provinces as a pilot. Throughout the pilot implementation, observations were made and then the process was initiated to roll-out it to entire Turkey. Within this scope, as of July 2010, CHAS implementation was initiated in Yalova, Eskişehir, Bilecik, Çanakkale, Edirne, Kırklareli, Sakarya and Tekirdağ provinces. It is aimed that CHAS is to be implemented throughout Turkey by the end of The objectives of CHAS are as follows: To shorten the queues at hospitals and to increase the citizen/patient satisfaction through better planning of resources at hospitals (efficient and effective planning of work force and equipment use). 125

126 Health Transformation Program in Turkey September 2010 To increase the efficiency and quality in the provision of health services through the measurement of resource use and distribution at hospitals (efficient and effective implementation of work force, machines and equipment use). To provide assistance to development of health policies through CHAS data. c) Mobile pharmacies As from September 2009, in accordance with the protocol made with the partnership of the Ministry of Health and Turkish Pharmacists Association, mobile pharmacy system was put into practice which allows obtaining the pharmaceuticals prescribed by the physician for the treatment of people who live in places where a pharmacy is not found. It was aimed to facilitate the people s access to pharmaceuticals in places where a pharmacy is not found and thus contribute to the public health and to ensure the supply of pharmaceuticals by using public resources effectively according to deontology. As of August 2010, the protocol is being implemented in 29 provinces in total including Adana, Adıyaman, Ağrı, Ardahan, Amasya, Artvin, Bayburt, Bilecik, Bingöl, Burdur, Çankırı, Çorum, Denizli, Edirne, Erzincan, Erzurum, Iğdır, Isparta, İzmir, Karabük, Kars, Kayseri, Kütahya, Manisa, Rize, Trabzon, Tunceli, Osmaniye and Kırklareli. d) Diagnosis related groups (DRG) Most of the reimbursement systems known in health field are constructed according to classification approach. HIC (Health Implementation Communique), ICD 10 (International Classification of Diseases version 10) and even CPT (Current Procedural Terminology) can be indicated as examples. These classifications might be based on anatomy or pathologic findings, and sometimes in the form of combination of these. In Diagnosis Related Groups (DRG) approach; not only the classification, but also a grouping logic was formed based on the classified data. Each patient is unique and singular in terms of his/her risk factors, family conditions, and socio-cultural environment. Making comparable classifications among patients with such level of diversity and defining the variety in such acceptable levels constitute the main structure that is to say grouping. In grouping, first of all, the group homogeneity is ensured by starting from the diagnosis and additional diagnoses and by considering the medical procedures as well. Implemented in many developed countries, DRG was started in our country as a joint work of Ministry of Health, Ministry of Finance and Ministry of Labour and Social Security in 2005 and with a research project executed by Hacettepe University was completed in November Concerning the subject, a branch called Diagnosis Related Groups Branch was founded within our Ministry. The main elements of the Diagnosis Related Groups implementation at hospitals are the physicians who create the medical data in inpatient files and the clinical coders who 126

127 TOWARDS NEW HORIZONS transform these data into codes. Clinical coding works is carried out through special software which establishes the connection with the servers of the Ministry of Health via internet in a single unit in each hospital. Within this scope, software infrastructure was developed in order to transform the medical data into clinical codes and then to save them and required trainings were also provided to train the clinical coders. As from 1 January 2011, DRG implementation will be started at MOH Hospitals. The implementation is considered to cover the university hospitals and private hospitals as well. Within this scope, technical support works for university hospitals and private hospitals were initiated. The advantages of our health system after the DRG implementation is started completely will be as follows: The use of produced DRGs as the finance and global budget distribution tool. The use of produced DRGs as the internal management tool in hospitals. The use of produced DRGs as a good tool to perform the quality and use measurements. The use of produced DRGs as a tool to be able to make clinical and financial decisions in hospitals. The use of produced DRGs as a tool to improve the physician relations and use of them as a comparison tool between physicians. Performing performance evaluations and comparison between hospitals. Comparing the care qualities in hospitals. Creating supportive data in the development of clinical guidelines and protocols. Observing the inpatient variety on national basis and determining its regional distribution. Performing some works such as the measurement of clinical activities. e) Administrative unit performance Based on the financial sustainability, a model was developed for the measurement of the administrators who serve as the head physician, deputy head physician, hospital manager, deputy hospital manager and head nurse at hospitals affiliated to our Ministry and it was put into practice as from March In addition to the financial indicators, in this model, some new administrative priorities were identified which are to be taken into consideration by the administrators while performing their duties. In this sense, Management Unit Performance is composed of two main parts. The first part might be regarded as the Main Factor and the second part is considered as the Correction Factor for removing the differences between the administrators. The parameters constituting the main factor are as follows: Regular payment of the supplementary payments of personnel in order to provide better service and not to corrupt the institutional dynamism. Forming a structure which is suitable to generally accepted quality standards in 127

128 Health Transformation Program in Turkey September 2010 delivered services and protecting it. Criteria indicating that the performance objectives defined by the Ministry were met. Some of the parameters constituting the correction factor are as follows: Development level of the region where the hospital is located, Age of the hospital, Financial (turnover) capacity of the hospital. In this model, necessary calculations are performed regularly on a monthly basis, performance coefficient of each administrator is determined, and the determined coefficients are associated with the administrator-specific wages and reflected to their monthly supplementary payment. Consequently, a systematic evaluation model was created by handling the sustainable debt structure, continuity of the quality of service and the performance of the supplementary payments on time and the fulfilment of pre-defined performance objectives and other parameters as a whole. These indicators also put forth the priorities of the administrators. This systematic evaluation, as the first in public sector, will contribute to obtaining more efficient and more positive results in the forthcoming process. 128 f) Turkey stem cell coordination centre (TÜRKÖK) In order to prevent the controversies on stem cell and stem cell treatments which gained importance in recent years, TÜRKÖK was established and put into action with the Ministerial Approval dated and numbered With TÜRKÖK project, the followings are targeted; Gathering the coordination of centres regarding the transfer of hematopoietic blood cells under one roof. Performing activities for increasing the number and capacity of the centres. Ensuring regular data flow from centres. Analyzing the collected data and detecting the shortages of centres. Performing activities to determine the quality control and standards of centres. Through the establishment of National Bone Marrow Bank, decreasing the treatment expenditure for the patients to whom hematopoietic stem cell transfer is to be performed. Catching up with the European Union standards and strengthening the administrative capacity. Through screening the cordon blood donated to National Non-relative Cordon Blood Bank and by voluntary donors in Turkey with various HLA typing, ensuring the coordination for supplying hematopoietic stem cell for the patients who are waiting for the transfer. Ensuring the coordination for supplying hematopoietic stem cell, in the shortest time, from the banks abroad for the patients who are waiting for the transfer, but for whom local donors can t be found in Turkey. In the first five years, obtaining 250,000 registered voluntary donors with various HLA typing from many different geographical regions of Turkey.

129 TOWARDS NEW HORIZONS In the first five years, obtaining 50,000 cordon blood donations in total. Performing 2,500 and more transfers per annum. Achieving 300 and more beds with the widespread distribution of transfer centres in line with the needs of the country. Full capacity use of transfer centres. Establishment of Regional Coordination Centre, at first step, in 29 health regions in order to reach the targeted number of voluntary donors. Establishment of Voluntary Donor Centre at required number to be determined according to the findings of Region Coordinators. Establishment of National Non-relative Cordon Blood Bank and cordon blood collection centres (cordon blood donations from our Ministry, universities, foundations and private maternity hospitals). Through establishing the coordination between the centres in Turkey and abroad, increasing the chance of treatment for the transfer-requiring patients in the shortest time and at the highest quality and decreasing the number of deaths and patients waiting for transfer. Starting the accreditation process and ensuring the integration and coordination of hematopoietic stem cell centres with international institutions such as European Marrow Donor Information System (EMDIS), Bone Marrow Donors Worldwide (BMDW), The World Marrow Donor Association (WMDA), European Group for Blood and Marrow Transplantation (EBMT). Completing the trainings and certification of personnel working in all centres. In the first five years, meeting all establishment costs and having a capacity to meet operational costs without getting any additional allowance. Sponsoring to scientific projects in Turkey and abroad with its income, providing technical support. Contributing to scientific researches and publications with the analyses and statistical results of the collected data. g) Pharmaceutical tracing system (PTS) Called as PTS, Pharmaceutical Tracing System defines an infrastructure which was established to trace each unit of pharmaceuticals in Turkey. Pharmaceutical Tracing System is another form of the structure defined as Track & Trace and applied to pharmaceuticals. Ensuring the serialization of products, square code is used to ensure tracing of the products; through the notifications to the central database from each point where the pharmaceutical is passed, tracing of them is ensured. Production of pharmaceuticals of high quality, distribution and storage of them by considering the quality conditions are among the duties of our Ministry. Pharmaceutical Tracing System is primarily designed to contribute to the aim of on-site detection of problems that might occur in the quality of pharmaceuticals and for rapid response. Through the developed system, all pharmaceuticals in the market are registered with a tracing number on box basis and it is ensured to trace them in each stage from production to consumption. Thus, corrupt practices regarding the drug clippings are prevented and it becomes almost impossible to find counterfeit and unregistered drugs in the market. 129

130 Health Transformation Program in Turkey September 2010 For the pharmaceuticals which were put on the market, in any condition that might emerge afterwards and might expose threats to public health, it would be possible to know where exactly each pharmaceutical is and it would be ensured to collect them easily. The Pharmaceutical Tracing System that we put into practice in Turkey took its place in the literature as a system connected to a Central Database which was introduced for the first time in the world. Beginning with the implementation of the system, it is estimated to make around one billion dollar savings in pharmaceutical expenditures. This will return to our people as easy access to pharmaceuticals. In addition, with the Decision Support System to be established in the second stage, it would be possible to analyze the data to be obtained from the Pharmaceutical Tracing System; in this way, new implementations would be allowed to be put into practice, which would open the way to Rational Use of Medicines. Rational Use of Medicines is according to their clinical findings and personal characteristics, individuals obtaining the appropriate drug in suitable duration and dosage, at the lowest price and with ease. We are systematically tackling the Rational Use of Medicine issue as well. We are continuing our activities under three titles including training and promotion works, monitoring and evaluation works, administrative arrangements and planning. As from 1 January 2010, it is obligatory for all products to carry square codes on them and be notified to the system by their manufacturers/importers. As of 1 July 2010, clipping cutting procedure was closed down at pharmacies and the products began to be sold by being notified to the PTS. All reimbursement institutions began to perform their pharmaceutical payments by checking them over the system. In addition to these, hospitals were also included in the scope of the Tracing system because they are one of the places where pharmaceuticals pass through and the products which entered the hospitals began to be traced. As from 1 January 2011, the second phase of the Pharmaceutical Tracing System will be activated and at this stage, pharmaceutical warehouses will be ensured to be included in the tracing system. Planned Legislation Within the framework of the objective specified in the Strategic Plan of our Ministry covering the years of as to clarify the stewardship, arrangement, planning and supervising roles of the ministry by the end of 2011, within the scope of the restructuring of the Ministry of Health, the following preparations have been continuing; The Organization Law of the Ministry of Health, Medical Occupations Law, Basic Health Law, Public Hospital Unions Law. 130

131 TOWARDS NEW HORIZONS OECD Reviews of Health Systems, Turkey Page, 124: Health system reform is a perpetual process. At this early stage in its implementation, Turkey appears to be one of the few middleincome countries to be implementing a big bang reform effectively. The HTP represents both an important improvement in Turkey s social welfare system and a good practice example for other countries struggling with the same issues. 131

132 v Health Transformation Program in Turkey September

133 TOWARDS NEW HORIZONS Last Word All was different yesterday, And all will be better tomorrow 133

134 134 Health Transformation Program in Turkey September 2010

135 REFERENCES References 1. Türkiye Cumhuriyeti Anayasası, Sayılı Sağlık Hizmetlerinin Sosyalleştirilmesi Hakkında Kanun Gerekçe Metni, Sayılı Sağlık Hizmetlerinin Sosyalleştirilmesi Hakkında Kanun Metni, Aile Hekimliği Türkiye Modeli. Sağlık Bakanlığı, Ankara, Aydın S. Hayata Yüksekten Bakabilmek, Medipolitan Eğitim ve Sağlık Vakfı Yayınları İstanbul, Çetin E. İstanbul da yaşayan çocuk ve adolesanlarda anemi prevalansının araştırılması (Tez), İstanbul Üniversitesi Tıp Fakültesi, Demir eksikliği araştırması, Sağlık Bakanlığı Hacettepe Üniversitesi, 2008, Ankara 8. Demirel H Arası Sağlık Politikaları ve Sağlıkta Planlama, Medipolitan Eğitim ve Sağlık Vakfı Yayınları İstanbul, Dünya Sağlık Örgütü. 21. Yüzyılda Herkese Sağlık. WHO: Copenhagen: WHO Publications; Evliyaoğlu N, Altıntaş D, Atıcı A. Anne sütü, inek sütü, formül mama ile beslenenlerde demir durumu, Türkiye Klinikleri Pediatri Dergisi Fişek N. Halk Sağlığına Giriş, Hacettepe Üniversitesi Yayını, Genel Sağlık Sigortası ve Sağlık Bakanlığının Değişen Rolü, Sağlık Bakanlığı, Ankara, Gökçay G, Kılıç A. Çocuklarda demir eksikliği anemisinin epidemiyolojisi, Çocuk Sağlığı ve Hastalıkları Dergisi, Herkese Sağlık, Türkiye nin Hedef ve Stratejileri-Sağlık 21. Sağlık Bakanlığı Yayınları, Improving Health Systems: The Contribution of Family Medicine. WONCA; Lozoff B, Andraca I, Castillo M, Smith B. Behavioral and developmental effecs of preventing iron-deficiency anemia in healthy full-term infants. Pediatrics, OECD Health Data, OECD Publications, ÖSYM Yıllıkları 19. Özkan B ve ark. Prevalance of vitamin deficiency rickets in the eastern part of Turkey, Eur J Pediatr, Özsarı S.H. Cumhuriyet Dönemi Sağlık Politikaları ve Sağlıkta Yeniden Yapılanma, Türkiye Sorunlarına Çözüm Konferansı-II Cumhuriyet in Kazanımları Ekim 1998 Ankara, Ankara Üniversitesi Basımevi, Ankara, Roberts M.J, Hsiao W. Getting Health Reform Right, Sağlık 2003, Sağlık Bakanlığı Faaliyet Raporu, Sağlık Bakanlığı, Ankara, Sağlık 2004, Sağlık Bakanlığı Faaliyet Raporu, Sağlık Bakanlığı, Ankara, Sağlık 2005, Sağlık Bakanlığı Faaliyet Raporu, Sağlık Bakanlığı, Ankara, Sağlık 2006, Sağlık Bakanlığı Faaliyet Raporu, Sağlık Bakanlığı, Ankara, Sağlıkta Dönüşüm Programı, Sağlık Bakanlığı, Ankara, Sağlıkta e-dönüşüm, Sağlık Bakanlığı, Ankara Sağlıkta Performans Yönetimi ve Performansa Göre Ödeme Sistemi. Sağlık Bakanlığı, Ankara Türkiye Cumhuriyeti Dokuzuncu Kalkınma Planı , DPT, Ankara, Ulusal Sağlık Hesapları, Yalçın SS, Yurdakök K, Açıkgöz D, Özmert E. Short-term developmental outcome of iron prophylaxis in infants. Pediart Int, Sağlık Bakanlığı Stratejik Plan , Sağlık Bakanlığı, Ankara, Türkiye Sağlıkta Dönüşüm Programı ve Temel Sağlık Hizmetleri, Kasım , Sağlık Bakanlığı, Ankara, İlerleme Raporu, Türkiye Sağlıkta Dönüşüm Programı, Ağustos 2008, Sağlık Bakanlığı, Ankara, Türkiye'de Sağlık Eğitimi ve Sağlık İnsangücü Durum Raporu, Haziran 2010, YÖK, Ankara, Türkiye Cumhuriyeti Sağlık Bakanlığı, Sağlık İstatistikleri Yıllığı 2008, Sağlık Bakanlığı, Ankara, Yataklı Tedavi Kurumları İstatistik Yıllığı 1996, Sağlık Bakanlığı, Ankara, Yataklı Tedavi Kurumları İstatistik Yıllığı 1997, Sağlık Bakanlığı, Ankara, Sağlık İstatistikleri 1996, Sağlık Bakanlığı, Ankara, Sağlık İstatistikleri 1997, Sağlık Bakanlığı, Ankara,

136 Health Transformation Program in Turkey September Sosyal Sigortalar Kurumu 1996 yılı İstatistik Yıllığı, Sosyal Sigortalar Kurumu Genel Müdürlüğü, Ankara, Sosyal Sigortalar Kurumu 1997 yılı İstatistik Yıllığı, Sosyal Sigortalar Kurumu Genel Müdürlüğü, Ankara, Türkiye'de Anne ve Çocukların Durum Analizi1996, UNICEF-Sağlık Bakanlığı, Ankara, OECD Sağlık Sistemi İncelemeleri TÜRKİYE, OECD-Dünya Bankası, Making Reform Happen, Lessons from OECD Countries, OECD, The European Health Report 2009, Health and Health Systems, WHO, Türkiye'de Verem Savaşı 2010 Raporu, Sağlık Bakanlığı, Ankara, 2010 Web Sources Hükümet Programı Hükümet Programı Hükümet Programı, 5. Acil Eylem Planı, 6. Dünya Sağlık Örgütü web sayfası 7. Kamu Yönetimi Temel Kanunu Tasarısı, 8. Kamu Hastane Birlikleri Kanunu Tasarısı, 136

137 CHAPTER 5 ANNEXES

138 138 Health Transformation Program in Turkey September 2010

139 ANNEXES a) Strategic plan STRATEGIC GOALS ULTIMATE GOAL To increase and improve the health status of our people STRATEGIC GOAL 1 To protect the society from the health risks, STRATEGIC GOAL 2 To ensure provision of required health services in a quality and safe way, STRATEGIC GOAL 3 To supervise equity, to ensure responsiveness to needs and expectations while focusing on human oriented approach in healthcare services. 139

140 Health Transformation Program in Turkey September 2010 Strategic objectives and strategies for objectives STRATEGIC GOAL 1 To protect the society from health risks OBJECTIVE 1.1. To ensure all people get access to health promotion and healthy living programs. OBJECTIVE 1.2. To improve maternal, child, and adolescent health and to reduce maternal mortality rate below 10 per hundred thousand and infant mortality rate below 10 per thousand by the end of OBJECTIVE 1.3. To continue improving emergency healthcare services and disaster health management against emergencies, disasters and threats and to keep these ready to meet needs in timely, effective, and efficient manner. OBJECTIVE 1.4. To reduce the prevalence of communicable diseases and to reduce the deaths attributable to these diseases. OBJECTIVE 1.5. To reduce the prevalence of non-communicable diseases and the deaths attributable to these diseases. OBJECTIVE 1.6. To increase the rate of non-smokers among the population above the age of 15 above 80% by the end of 2014, to implement the alcohol control program, and to reduce addictive substance use. OBJECTIVE 1.7. To support for increasing the ratio of population living in a healthy and safe physical environment. OBJECTIVE 1.8. To ensure access of all employees to occupational health services, to reduce the levels of mortality and disability due to occupational diseases. 140

141 ANNEXES STRATEGIC GOAL 2 To ensure provision of required healthcare services in a quality and safe way. OBJECTIVE 2.1. To continue improving hospital services in administrative, structural and functional ways, to increase the service standards and efficiency. OBJECTIVE 2.2. To increase the quality of diagnosis, curative and rehabilitation services, to ensure the provision of these services within principles of accessibility, efficacy, efficiency, measurability and equity. OBJECTIVE 2.3. To clarify the stewardship, regulatory, planning and supervisory role of The Ministry by the end of 2011 in the scope of restructuring of The Ministry of Health. OBJECTIVE 2.4. To complete the Organization of Community and Region-based Health Services by the end of 2014 and to make the regions sufficient health zones inside. OBJECTIVE 2.5. To support the R&D and scientific publications in the scope improving healthcare services. OBJECTIVE 2.6. To improve pharmaceuticals and medical device services and to sustain safe, accessible, and quality provision. OBJECTIVE 2.7. To complete, operate, and improve Turkey Health Information System/e-health which will ensure access to effective information in the process of decision making and service provision. OBJECTIVE 2.8. To make sectors accountable for the impact of their policies and actions on health, to improve multi-sector health accountability policy. OBJECTIVE 2.9. To continue cooperation with other nations and international organization in the area of health, to make Turkey a center of attraction in its regions and to increase the capacity of transborder health services provision. 141

142 Health Transformation Program in Turkey September 2010 STRATEGIC GOAL 3 By focusing on human oriented approach in healthcare services, to supervise equity, to ensure responsiveness to needs and expectations. OBJECTIVE 3.1. Taking human oriented approach as basis in healthcare service provision, to give priority to the people in special need because of physical, mental, social or economic conditions. OBJECTIVE 3.2. To disseminate family medicine practice nationwide by the end of 2010 for the purpose of increasing the quality and provider and patient satisfaction rate from the primary level healthcare services and generating human oriented service. OBJECTIVE 3.3. To respond to the expectations of the patients and relatives as well as medical necessities during health service processes, to increase the level of satisfaction. OBJECTIVE 3.4. To ensure protection for the people from financial risks when accessing to health services. 142

143 ANNEXES b) Public hospital unions Within the scope of the Administratively and financially autonomous health managements component of the Health Transformation Program, the Draft Law on the Pilot Implementation of Public Hospital Unions has been discussed by the Commission on Health, Family, Labor and Social Affairs of the TGNA. The draft is on the agenda of the plenary committee of the TGNA. Through this draft, hospital administrations will be able to act more independently and flexible in using their resources and capacity and evaluating the economic conditions. Autonomous administrative units will also gain responsibility along with their competency and they will be directed in order to plan their resources, personnel investments, management costs, budget and objectives taking into consideration the strategic work load of the area for which they are responsible. Such a responsible autonomy is thought to result in wise management of resources, efficiency and careful budget use. As a result of the clarification of the principle of Local administration through the draft, the significance and importance of inspection increases as well. The understanding of administration and the differences under the scope of inspection correspondingly have been included via preparation of annual performance programs in accordance with the objective, policy, strategic plan and legislation determined by The Ministry. A citizen based, result and objective focused understanding of administration inclined to determine objective rather than problem solution directed towards the future rather than the past has been adopted. Accordingly, an understanding of inspection based on objectives and performance indicators and functioning of the system has gained importance rather than the classical understanding of inspection based on the past and the individuals. The Ministry, purified from its routine burdens through such steps, will be able to save more time for its actual duties such as strategic thinking, improving future oriented designs, developing missions and visions, shaping basic aim, policy and priorities, establishing measurable success indicators, and improving human resources. At this step the transformation in the understanding of administration will be reflected and restructuring of The Ministry will be completed. By this draft law it is aimed that public health services will be provided in a more participatory, effective, efficient, fast, quality and in a more sensitive manner in order to meet the demand and expectations of citizens. 143

144 Health Transformation Program in Turkey September 2010 THE DRAFT LAW ON PUBLIC HOSPITAL UNIONS Aim and Scope ARTICLE 1- (1) The aim of this law is to determine the relevant principles on the establishment and operations of public hospital unions in pilot provinces to be determined by the Council of Ministers in order to ensure that secondary and tertiary health services are provided in participatory, equal, quality, easily accessible way and appropriate for the needs and expectations of the society, through efficient and effective use of resources. Definitions: ARTICLES 2- (1) For the implementation of this law, the meanings of the definitions are as follows; a) The Ministry: The Ministry of Health, b) Union: The legal person established from the hospitals or hospital groups under the scope of this law, c) Front-line personnel: The staff of the General Secretary, who has completed higher education, employed as to carry out office services, ç) Hospital: The secondary and tertiary level healthcare institutions linked to the Ministry under the scope of the union, d) Secondary level healthcare institution: Healthcare institutions with high technical equipments, with or without beds, where specialized physicians provide service and which could be established to provide service according to the type of disease, age or gender, e) Specialist personnel: The personnel assigned for positions requiring a special knowledge, experience or specialty in the fields determined by the Ministry in the units of general secretariat apart from hospital administration as contracted personnel with the title of specialist placed in the attached Schedule (I), f ) Tertiary level healthcare institution: The healthcare institution where health and training services are provided in major and minor branches, Establishment of the Union and Coordination ARTICLE 3- (1) The secondary and tertiary healthcare institutions, in accordance with the results of the evaluation to be applied within the framework of first paragraph of the 5 th Article, could be transformed into a union with a statute which is equal to the relevant institution of the Ministry with a legal and real personality through the proposal of the Ministry and the decision of the Council of Ministers. The unions are subject to the provisions in the private law besides the issues arranged under the scope of this law. More than one union may be established in the same province on the condition that the size of the service provided is taken into consideration. Once the provisions of this law start to be implemented in a specific province, all the hospitals in the said province are covered in the scope of the union. This provision is applied only if all the unions are established in a province where more than one union is to be established. (2) The Ministry may establish coordination departments for the unions by gathering together more 144

145 ANNEXES than one in order to plan healthcare services and investments jointly and to improve cooperation. The principles and procedures of operation shall be determined by the Ministry. The coordination department shall submit the evaluation report and its proposals to the Ministry. The Ministry shall evaluate these reports in accordance with the objective, policy and the strategic plan determined and shall transform them into a regional plan and forward to the unions. The unions shall be obliged to obey these plans. Bodies of the Union ARTICLE 4- (1) The bodies of the union include the executive board, general secretariat and hospital administrations. (2) The executive board is the highest decision making authority of the union and it consists of the following members: a) Two members one of whom shall have bachelor s degree, master s degree or PhD in any field of law to be determined by provincial general assembly and the other shall be a chartered accountant, freelance accountant or person from banking and finance sector. b) A member to be determined by the governor. c) A member who has medical training, a member from health sector, a member among provincial health directors or deputies, and a member among the member of chamber of trade and commerce or where the chambers are established separately, among the members of the chamber of trade, who is experienced in investment and management. (3) In addition to the general specifications described in the Article 48 of the Law on Civil Servants No 657 Dated: , the members of the Executive Board shall have minimum bachelors degree and except for the representative of the provincial health directorate, the members of the Executive board shall have at minimum 5 years experience in the public or private sector. (4) The owners, share holders or responsible managers of the pharmacies and private health institutions and establishments nation wide or the people whose spouses or blood and bylaw relatives of the second degree are the owners, share holders or responsible managers of the pharmacies and private health institutions and establishments in the province where the union exists, cannot be member of the executive board. The members of the executive board, nationwide, and their spouses and above mentioned relatives, in the said province, shall not establish commercial relationships with the health institutions and establishments linked to the Ministry and the Unions. The members, even if they have quitted their position, shall not use the knowledge they acquired during their duty for themselves or for others interests or disadvantage. (5) The office principles and procedures of the executive board shall be determined by the Ministry. The secretariat services of the executive board shall be executed by the general secretariat. (6) Competent authorities shall notify their members within one month as of the communiqué of the Provincial Health Directorate on the formation of the executive board. Where there is no notified member within this period, the Ministry fulfills the positions itself. The executive board shall elect a president and a deputy by an absolute majority during the first meeting. Should the president and the deputy not elected with the majority votes on that elections, the candidates who receive the majority of the 145

146 Health Transformation Program in Turkey September 2010 votes on the third meeting following the day of the second meeting shall be deemed as president and the deputy. If none of the candidates could be elected on the third elections, the president and the deputy are assigned among the members by the Ministry. The members who do not participate meetings three times in a row or who do not participate meetings five times in a year without a valid excuse lose membership with the decision of the board; the ones who lost membership eligibility or the ones who are thought not to be acquiring eligibility criteria are excluded from membership automatically. The period of membership shall be three years. If any membership is finalized in any way, the remaining period will be completed by members to be assigned in the same way. A member may be elected for the executive board maximum for three terms. If they resign, they shall not be re-elected for two years. Membership for the executive board is not an impediment for the actual duties of members. (7) The executive board meets ordinarily at least twice a month. The president may call a meeting for any urgency. The executive board meets with minimum 5 members and decides with four members. Abstention is not allowed. The agenda of the board shall be prepared by the president. Members may propose items to the agenda with the approval of the president or by the absolute majority of the total number of the members. Other issues apart from these shall not be discussed. The discussions are entered into minutes or recorded with audio devices. The decisions taken shall be signed by the president and the participating members. Universities, occupational organizations, syndicates, non-governmental organizations, representatives, general secretaries, experts or other relevant persons from the occupational unions of nurses and midwives may be invited by the decision of the executive board to the meetings yet shall not have the right to vote. (8) The head and the members of the executive board participating in the meetings are paid monthly a peace salary of which amount is determined annually by the decision of Supreme Planning Council for the president and members of the executive boards in the state economic enterprises. The members of the executive board shall be paid full amount of the peace payment on the years they take office. At the end of that year, the amount is paid 10% more in A class unions; 10% less in C class unions; 15% less in D class unions; 20% less in E class unions; 20% more in unions which complete two years in their A class. A bonus is paid to the members who increase the class of their unions on the amount of last paid peace payment for once. For the members assigned from other establishments are paid allowances in accordance with the provisions of the Law on allowances dated and No: Executive Board membership does not require having insurance in accordance with Law No on Social Security and Universal Health Insurance dated 31/5/2006 and the peace payments to be made to the president and members of the board shall not be included in the income counted in the insurance premium. (9) The general secretariat is the implementation body of the union. The representative of the union is the general secretary. Departments of medical services, administrative services and financial services are established under the general secretariat. (10) The hospitals linked to the union are administered by a hospital manager. The office of chief physician, administrative and financial affairs and health care services directorates are established under the hospital manager. Considering the size of the hospitals and with the approval of the executive board, the number of the departments may be increased up to four in and delegation of duty is determined. 146

147 ANNEXES (11) On condition that the norms and the standards defined by the Ministry is not violated, assistant chief physicians and assistant administrators are assigned in accordance with the number identified by the executive board. Classification of Hospitals ARTICLE 5- (1) Hospitals are evaluated in accordance with the methods and principles to be defined by the Ministry on the issues such as patient and staff satisfaction, service infrastructure, organization, quality and efficiency. The evaluation may be carried out through public and private evaluation institutions. Hospitals are graded over 100 according to the results of the evaluation and evaluation is renewed for a period not less than six months and more than 1 year. When hospitals are classified these grades are taken into consideration. Hospitals are classified into five groups as (A), (B), (C), (D) and (E) in accordance with their grades. On the condition that there is not any (E) grade hospitals in the service area that will be turned into a union, the hospitals with a grade of (C) or a higher degree may be turned into a union. According to the results of the evaluation, where the union; a) lowers to the (E) grade, b) lowers to the two levels below compared to the previous classification, c) lowers to the one level below compared to the previous classification, stays in the same lower level in the second evaluation and fails to rise to the higher level in the third evaluation, ç) fails to rise to the level (C) or a higher level in the assigned period in order to remove shortcomings when it lowers to the level (D), d) for the unions taken over in Class (E) and (D), if the one in class (D) fails to rise to Class (C) in the third evaluation; the one in class (E) fails to rise to class (D) in the second and Class (C) in the third evaluation, e) where one of the hospitals within the union lowers to class (E) and fails to rise to class (D) or higher in the subsequent evaluation; the current executive board is annulled and another board is established as soon as possible. Until the new board is established the former executive board continues to be in charge or a provisional executive board is established. Duty, Authorization and responsibilities of the Executive Board ARTICLE 6- (1) The duties of the executive board are as follows: a) To prepare the annual performance program determined in accordance with the objective, policy, strategic plan defined by the Ministry and the legislation, b) With the aim of executing the services in the union region in a more effective, easy-to-access and efficient way; 1) To prepare proposals for the Ministry in order to establish, close, join or alter hospitals and units through evaluation of current capacities, 2) To plan emergency health services, intensive care units and dialysis units at the regional level, 3) To take decisions in provision, hiring and efficient dispersion of high tech medical devices of high cost, 147

148 Health Transformation Program in Turkey September ) To improve precautions for uninterrupted service provision, 5) To define new investment needs and to take decisions in maintenance and modification, 6) To plan personnel and to take decisions in order to define principles on personnel movements, 7) To take decisions on similar issues. c) To decide on the budget, balance sheet, annual financial tables, activity reports and investment proposals of the union, ç) To decide directly on abdicating from rights and claims, settling down disputes through negotiation or arbitration, applying or not applying for peace, admission, abdication or legal procedures for execution prosecutors in accordance with the lines defined in the central budget law; for higher amounts to decide in accordance with the approval of the Ministry, d) To purchase or rent immovables, to sell any kind of immovable of the union in accordance with the principles defined by the Ministry; establishing limited tangible rights on the unneeded immovables registered on the union or lease them, or transfer them to the Ministry of Finance for sale; to operate in accordance with the assignment objective along with the constructions and facilities assigned for the Treasury and the union, to operate, ensure operation of or to rent non-medical areas, e) To define expenditures limits and duty and authority dispersion in accordance with the tendering legislation, f ) To take decisions on using cash properties of the union in accordance with the Law No and date 28/3/2002 on Regulation of Public Financing and Debt Management, g) to decide to procure healthcare, legal, and consultancy services when needed, ğ) To plan on the job training for union personnel, h) To regulate procedures on the operation of the union, ı) To ensure that services are carried out in accordance with the legislation, strategic plan and the performance program and to take precautions to improve personnel satisfaction, effectiveness and efficiency and quality standards, i) In the framework of norm position principles and standards, to decide on the creation, cancellation and modification of the positions, within the limitations of positions in the attached tables of Decree Law No. 190 and date 14/12/1983 on General Staff and Procedures. The duties of the general secretary ARTICLE 7- (1) The duties of the general secretary are as follows: a) To administer the union in accordance with the objective, policy and strategies determined by the Ministry, the decisions of the executive board and the performance program, b) To inspect the activities and the procedures of the union, to evaluate its administration system, to monitor its effectiveness of functioning and of management processes and to ensure that management quality and efficiency are improved, c) to represent the union against legal and real persons and the forensic and administrative authorities, to provide necessary explanations and information for the public, 148

149 ANNEXES ç) to ensure coordination between hospitals and cooperation with other institutions and establishments, d) To submit the budget and investment proposals of the union to the executive board and to carry out the issues such as tendering and service procurement in accordance with the decisions of the executive board, e) To carry out studies in order to render that the services based on material and human power within the union are provided in the most possible efficient and effective way and to submit these studies for the approval of the executive board; to execute processes for personnel assignment, appointment and other procedures in accordance with the decisions of the union; to plan scientific studies through training activities, to execute these studies in cooperation and to inspect them. f ) To ensure that information processing systems are established and the statistical data with regard to the union are tracked, to combine the financial tables of the union and to prepare proposals for the executive board on the precautions to be taken, g) To ensure that services with regard to patient rights, patient and personnel satisfaction and social need of patients are improved and ethical principles for medical and public officers are applied, ğ) To plan and inspect medical services, health care services, social services and support services, h) To execute accounting services and to accrue the union incomes within the scope of the relevant legislation, to follow up and collect the incomes and claims and to execute expenditure procedures, ı) To carry out other duties of the union, (2) On condition that the decisions taken by the executive board are not violated, the general secretary may, when necessary, hand over some of the duties to sub-unit administrators through determination of the limits in a written way. However this devolution does not remove the responsibility of the devolving party. (3) The hospital manager has the duty, authority and responsibility defined for the general secretariat on the hospital basis and is responsible against the general secretary for the execution of all the services efficiently and in accordance with the legislation. The quality, status and the rights of the contracted personnel ARTICLE 8- (1) The general conditions specified in Article 48 of the Law No. 657 are required for the personnel to be employed for the positions identified in the table (1). (2) The General Secretary, administrative and financial service heads, hospital manager, managers and deputy managers should be graduated from health sciences, health administration, law, public administration, economics, management, accounting or finance, industrial engineering, sociology, or psychology departments including departments of medicine, dentistry, or pharmacy of four year higher education institutions or equivalent foreign institutions or should have masters or PhD degree on the above mentioned areas; managers of technical units should be graduated from the departments of civil engineering, mechanical engineering, electric-electronic, biomedicine or computer engineering departments; and shall have 5 years of working experience in public or private sector in the said fields. (3) The president of the medical services shall be a physician or specialist having the title of associate professor or professor in the field of medicine or shall be a physician with a master s or a doctorate s 149

150 Health Transformation Program in Turkey September 2010 degree in the field of medicine or with a master s or doctorate s degree in the field of law, public administration, and health management; the head doctor of the training and research hospitals shall be a specialist having a master s or a doctorate s degree; other head doctors at other hospitals shall be specialist physicians, physician with PhD in the field of medicine, or a physician with a master s or doctorate s degree in the field of law, management, public administration, and health management; the head doctors of the hospitals having less than 100 beds shall be physician; the head doctor of the dental hospitals shall have been trained in the field of dentistry; the assistants should have been trained in the field of medicine, dentistry or pharmacy or shall be a graduate of health sciences on the condition that he/she has a masters degree. (4) The personnel to be assigned as an expert in the general secretariat shall have minimum fouryear university education and have minimum 5 years experience in the public of private sector; the experts and bureau staff recruited directly shall have received minimum 70 point from the Public Personnel Selection Examination. The distribution and procedures and principles on the employment of the experts and office staff are determined by the Ministry. (5) Contracted personnel are assigned for the positions defined in the attached table (I). Individual performance criteria and objectives which have been developed considering the organizational objectives and performance evaluation criteria are described in the contract annex. The executive board president signs a contract with the general secretary directly upon the board decision and on the proposal of the general secretary with the presidents and the hospital managers. The General Secretary signs contract with the head doctors and directors upon the proposal of the hospital manager. The experts and bureau staff are contracted by the general secretary. Hospital manager signs contract with the deputy head doctors upon the proposal of the head doctor and with the deputy managers upon the proposal of related manager. The contract periods can not exceed three years. At the end of three years the contracts may be renewed. Depending on the developments in performance objectives in the contract annex, the contract with the general secretary may be terminated directly before the end of contract period, and the contract of the other personnel may be terminated by the executive board upon the proposal of the general secretary. At the end of the two months as of the date the general secretary or the new executive board take office, all the contracts of the contracted personnel assigned for the positions defined in the attached table (1) terminate ex mero motu. After one month as of the date the new hospital administrator takes office, the contracts of the head doctors, managers and deputy head doctors terminate ex mero motu; after one month as of the date the new head doctors and managers take office, the contracts of the deputies terminate ex mero motu. Such personnel may be contracted once more. When the contracts of the personnel employed directly in such positions defined in the attached table (1) terminate due to any reason, they break off their relations with the union. Direct recruitment is not a vested right for being transferred into a government position or any other personnel recruitment method. (6) The ones who acquire the appropriate qualifications among the personnel employed as civil servants in public establishments and institutions may be contracted for the positions defined in the attached table (1) of their own accord and on the approval of their institution. Such personnel are deemed to be on unpaid leave. These personnel continue to be subject to indent (c) of the first paragraph in Article 4 of the Law No. 5510, taking into consideration their position for which they are assumed to do unpaid leave. Their services in such positions are evaluated as vested right salary and grade. The personnel whose contract has been terminated due to any reason applies to previous institutions of employment in one month and is assigned to the previous position; if that is not possible, that person is assigned to a position suitable for his grade. 150

151 ANNEXES (7) The contracted personnel who are not included in the scope of paragraph six of this article are considered to be within the scope of indent (a) of the first paragraph of Article 4 in the Law No in terms of social security. Financial Rights and Responsibilities of the Contracted Personnel ARTICLE 9- (1) The monthly salary of the contracted personnel defined in the attached table (1) can not exceed the two-fold for the general secretary, one and a half-fold for the presidents, hospital manager, head doctor, and deputy head doctor; one-fold for the managers and experts; 0.75 fold for the deputy directors; and half-fold for the bureau staff of the maximum payment rate determined in accordance with the indent (B) of the Article 4 of the Law No: 657. The union may pay bonuses for the personnel within this scope from the incomes obtained through the contribution of the personnel. Taking the service provision conditions and criteria determined by the ministry the rate and the methods and procedures of such payment are determined by The Ministry with the approval of the Ministry of Finance, based on the title, position, working conditions and period, contribution, and performance of the personnel. The amount of the extra payment in a month from the incomes obtained through the contribution of the personnel can not exceed the threefold for the general secretary and the presidents; three and a half fold for the head doctor; two and a half fold for the deputy head doctor, one and a quarter fold for the manager and experts; and 0,75 fold for the deputy directors; and half fold for the bureau staff of the maximum payment rate determined in accordance with the indent (B) of the Article 4 of the Law No: 657. Maximum additional payment for the medical services president and the hospital manager, if the manager is a specialist physician, may be applied as three and a half fold. (2) The payment for the contracted personnel shall be conducted at the beginning of the month following the work. No other payments than the items stated above shall be made to the contracted personnel and no provisions shall be added to the contracts to this effect. (3) The contracted personnel shall not involve in another income producing work; may not work in another facility on monthly payment, with wage or as contracted, shall not carry on the art or profession privately, shall not involve in the activities that are forbidden for the civil servants by the Law no (4) The weekly working hours for the contracted personnel are the same for the precedent civil servants. (5) The provisions for the contracted personnel in the indent (b) in Article 4 of the Law no. 657 shall be in effect for the vacations and end of job compensations of the contracted personnel. No unemployment benefit insurance is paid for the said personnel. Transfer of the Personnel within the Ministry to the Unions, Use of the Positions, and Additional Payment ARTICLE 10- (1) The union employs contracted personnel subject to the staff titles defined in the attached table (I) and subject to Law No. 657, Law No 4924 and date 10/7/2003 on Employment of Contracted Health Personnel in Locations Where the Provision of Employees is Difficult, and the Law on Amending Some Laws and Decree Laws. (2) The norm staff principles and standards of the unions are jointly defined by The Ministry, 151

152 Health Transformation Program in Turkey September 2010 Ministry of Finance and State Personnel Presidency. In the framework of these principles and standards, the unions define their norm staff. In accordance with the norm staff principles and standards, appointments shall not be made to the vacant positions for the services carried out by contracted personnel. (3) The Ministry s staff and positions at the hospitals in the scope of the unions are defined by units, class, title, and grades. These staff and positions are transferred into the union with the Cabinet Decision regulating union transformation and are deemed to be excluded from the parts of the table attached to the Decree Law No. 190, related to the Ministry. The transferred personnel shall continue their existing status as of the date of transfer. (4) Direct assignments to the union positions, placements in contracted health personnel positions, or assignment or shifting from one union to another or to the other units of the Ministry or from the Ministry units to the unions shall be subject for the related legislation and the general provisions. For the purpose of ensuring balanced distribution of the health personnel nationwide, The Ministry shall have the planning and placement authority for the appointments and transfers to the staff and contracted health personnel positions of the unions. Related principles and procedures are defined through regulations to be issued by the Ministry. (5) The personnel who are assigned within the Ministry units may be assigned to the hospitals within the scope of the unions by the Ministry upon the demand from the Executive Board and their will. The financial and social rights as well as monthly salaries of such personnel shall be covered by the unions. (6) Additional payment from the union income obtained through the contribution of the personnel might be done to the union personnel (except for the workers and the personnel defined in attached table (I). The payment rate, principles and methods shall be determined by the Ministry upon the approval of the Ministry of Finance, taking into consideration the personnel s title, duty, working conditions and duration, service contribution, performance as well as the processes such as examination, anesthesia, invasive processes and working in risky specialty departments and also considering the service presentation requirements and criteria that are determined by the Ministry. The amount of the monthly payment to the personnel from the union s income which is provided through the contribution of the personnel shall not exceed 800 per cent of the total of monthly payment (including the additional indicator), additional payment and any indemnities (excluding position, representation and foreign language compensation) for the professors and associate professors who are appointed to specialist doctor positions as well as clinical chiefs and deputy chiefs; this limit is 700 percent for specialist doctors, specialist dentist, and the specialists in branches determined in medical specialty legislation in accordance with legislative provisions; 500 percent for general practitioners and dentists; 250 percent for pharmacists; and 150 percent for the other personnel. 150 per cent rate may be applied as 200 per cent to the personnel working in the services requiring special care such as intensive care, delivery room, newborn, infant, burn, dialysis, operating room, infection, mental health, organ and tissue transplantation, and emergency services and etc. Except for shift services, additional payments are made to in return of their income generating work outside the working hours, except fir shift services. This amount shall not exceed 30 percent of the amounts defined herewith in this paragraph for the doctors, dentists and the specialist according to medical specialty legislation and 20 percent for the other personnel. The amount of the additional payment for the contracted personnel shall be determined based on the 152

153 ANNEXES precedent personnel with the same title and working duration in the same unit and this additional payment shall on no account exceed the maximum level of the payment to a precedent personnel. In accordance with Paragraph 1 in Article 9 and this paragraph, the total monthly payment to the personnel shall not exceed 40% of the gross product collected through the contribution of the personnel. The provisions in additional Article 3 of the Decree Law No. 375 and date 30/6/1989 on the individuals paid according to Article 5 of Law No 209 and date 4/1/1961 on Revolving Fund to the MoH Healthcare Organizations and Rehabilitation Facilities applies for those who benefit from additional payments anticipated herewith in this paragraph. (7) An additional payment from the union income is made regardless of any contribution to clinical chiefs and deputy chiefs who receive additional payment in accordance with this article, (including additional indicator) on an amount of 410 percent of the highest government official salary; this amount if 335 percent for specialist according to medical specialty legislation and specialist dentists; 180 percent for general practitioner and dentists. Provisions on monthly salaries apply for the right to this payment and getting paid. Monthly additional payment amount in the scope of this paragraph is deducted from additional payment to be made for the same month in the scope of paragraph six. Where the additional payment to be made in accordance with this paragraph is higher than the payment to be made in the scope of paragraph six, the difference shall not be taken back. Those who receive payment in the scope of this paragraph shall not be paid according to the additional Article 3 of the Decree Law. Inspection of the Unions ARTICLE 11- (1) The Unions are subject to the inspection of the Court of Accounts. Administrative and technical auditing of the unions shall be conducted by the Ministry, financial procedures and activities shall be audited by The Ministry and Ministry of Finance. According to the results of auditing; a) In case the unions hinder their duties and services significantly and this situation threats public health or in case the executive board can not meet three times in a row or can not make a decision, the Ministry may revoke the board and establish a temporary board. b) In case fraud is determined in union procedures, the related members of the board shall be dismissed by the Ministry and new assignments shall be made through the same method of member selection. The Ministry may demand from the board to revoke of the contracts of the personnel within the attached schedule (1) who are deemed to be in relation with the fraud if this demand is not fulfilled within the appropriate period of time, the board shall be dismissed and new board shall be established by the Ministry. c) The new executive board is formed in maximum 4 months in accordance with the principles and procedures in Article 4. Temporary board continues to act until the establishment of the new board. ç) The members of the executive board who are dismissed within the scope of the evaluation made in accordance with Paragraph 1 in Article 5 of this Law or the provisions of this paragraph may not be present in the first executive board to be established. The Capital, Income, and Expenditure of the Union ARTICLE 12- (1) The capital of the union shall consist of transferred capital, income deficit at the end of accounting period, aid and donation, and the aid from the allocations included in the 153

154 Health Transformation Program in Turkey September 2010 budget of the Ministry for this purpose. The transferred capital is the paid capital displayed within the transferred budget of the hospitals which are transformed into unions. The process related with the increasing of the union capital shall be executed by the Executive Board. (2) The income of the union shall be as follows: a) Collection of income in return for health services such as examination, diagnosis, treatment, laboratory testing, procedure, home care, clinical hotel, patient transfer, and similar healthcare services from the real and corporate persons. b) Collection of income in return for the first substance, supplies, manufactured vaccine, IV, prosthesis, etc. c) Collection of income in return for producing medicine, human blood and blood components as well as the other substances which are procured or produced. ç) Income from the sell of any immovable of the union; income from establishment of limited tangible rights on or leasing of the immovables registered on the union which are not needed in terms of the service carried out, together with the buildings and facilities on them; income from operating the immovables belonging to the Treasury and allocated to the union in line with the allocation purpose together with the buildings and facilities on them; operating, ensure operation, and leasing the non-medical areas; income from the sell, on current market value, of immovables registered on the union, which were transferred by the board to the Ministry of Finance and which are registered on the Treasury at the land registry office, on its own initiative. d) Collection of income in return for the courses, seminars, training, research, publishing, calibration, and consultancy services on health. e) Donations and aids. f ) Government aids in order to tackle with the differences of financial rights of the personnel, investment allocations and regional development differences. g) Other income. (3) The expenditures of the union shall be as follows: a) Payments made to the members of the Executive Board, and any payments and monthly payments to be made (in accordance with the legislation) to the union personnel. b) Purchasing and leasing of any kind of medical, surgical and laboratory equipments, supplies and devices; purchase of consumables and furniture. c) Providing maintenance, repair, and construction, medical and technical installations and landscaping. ç) Procurement of health services, consultancy and legal services when required. d) Purchasing of movables and immovables, establishing limited tangible rights on the required immovables, leasing them and covering any kind of expenditure on them. e) Purchasing or leasing ambulance, hearse and service vehicle or providing them through service procurement as well as their insurance and other expenditures. 154

155 ANNEXES f ) Expenditures made for the transition of the priced products to the free market or other organizations. g) Expenditures made for Research and Development, for experimental purposes, purchasing of kits and equipments, animal breeding and facilitating from their products, growing, maintaining and selling the needed agricultural harvest. ğ) Expenditures made for the preventive medicine, fighting with disasters and outbreaks, etc. h) Payments made to the foreign assistants who are in specialty training (the payment shall not exceed the amount to be found through multiplying indicator number (15.000) by the monthly coefficient of civil servants). ı) Expenditures for service procurement for laboratory, chemical analysis, imaging, etc. and use of equipment in return for kit. i) Service procurement expenditures in accordance with the legislation. j) The other expenditures required by the union activities. The Budget and Accounting of the Unions and Other Financial Provisions ARTICLE 13- (1) The budget of the union is prepared by the general secretary as of each accounting period. The budget is implemented after adjudicated by the executive board. A copy of the budget is sent to The Ministry and Ministry of Finance. (2) The budget and accounting proceedings of the unions are carried out according to the regulation issued by the Ministry of Finance getting comments from The Ministry. (3) The goods and services which are useful to be purchased centrally may be purchased collectively by the Ministry or by the union authorized by the Ministry, on the condition that these good and services are paid by each union s own budget and with the decision of the board. The principles and procedures on this paragraph is defined by the Ministry. (4) The unions and Ministry of Health healthcare institutions may transfer the goods and fixtures that they do not use or need to each other without cost or on a cost to be determined, on the condition that these goods and fixtures were purchased through the revolving fund resources. The unions may give goods to each other through gratuitous loan agreement. (5) The Unions may initiate commitments into upcoming years from the union resources for the procurement of continuous goods and services and renting or obtaining high cost medical devices through procurement of. (6) The executive board is authorized to transfer resources without remuneration or as a debt from financially prosperous unions to the financially inadequate unions. (7) All monthly salaries, financial rights, and social rights of the union personnel are covered from union budget. (8) The unions transfer 5 percent of amount collected from the monthly gross proceeds to the revolving fund account of the Ministry in order to cover the needs of the unions without sufficient income and to carry out the objectives defined in Paragraph 6 in Article 5 of the Law no The 155

156 Health Transformation Program in Turkey September 2010 Ministry has the authority to increase this ratio to 10 percent according to the financial situation of the unions. The Ministry is also authorized for the transfer of the total amount or a part of it directly to the related health directorate revolving fund account for the same purpose. (9) The properties of the unions are equivalent to state properties, cannot be confiscated. (10) The papers of the unions are free from stamp duty and proceedings of the unions are free from duties. (11) The people commissioned and authorized with acquiring and using financial and fiscal resources of the unions are responsible for acquisition, utilization, accounting, and reporting of the resources in an effective, efficient, and lawful manner and responsible for taking any necessary measures to prevent misuse of the resources. (12) Provisions in Law numbered 6245 and dated 10/2/1954 on per diems, law numbered 237 and dated 5/1/1961 on Vehicles, State Tender Law numbered 2886 and dated 8/9/1983 and Public Procurement Law Numbered 4734 and dated 4/1/2002 apply for the unions. (13) In accordance with indent (k) in Article 18 of the Law numbered 2828 and dated 24/5/1983 on Social Services and Child Protection Agency and in accordance with provisional Article 1 of the Law numbered 5234 and dated 17/9/2004 on Amending Some Laws and Decree Laws, no cuts shall be made from the income of the unions. (14) Among the immovables which were transferred to the Ministry of Finance to be sold, those not sold within two years are transferred to the union and registered in the land registry office onto the Union on its own initiative. (15) The Ministry is authorized to make necessary arrangements and correct the doubts that can arise during the implementation of this law. Revoked and Amended Provisions ARTICLE 14- (1) Articles 5, 6, 7 and 8 and Paragraph (a) in Article 9 of the Law dated 7/5/1987 and numbered 3359 has ben revoked. (2) Public hospital unions phrase has been added into indent (a) of Paragraph 1 in Article 4 of the Law No. 197 and dated 18/2/1963 on Tax on Motor Vehicles. The phrase will come after Social Security Organization phrase. (3) The first sentence of additional Article 9 of the Law No and date 7/5/1987 has been amended as Healthcare agencies and institutions under Ministry of Health and public hospital unions as well as related units at the universities may be used together in the framework of mutual cooperation. (4) Paragraph 1 in Additional Article 3 of the Law No and date 31/5/2006 on Social Insurance and Universal Health Insurance has been amended as: Among those who receive additional payments in accordance with Article 5 of Law No. 209 and date 4/1/1961 on the Revolving Fund to be Provided for the MoH Healthcare Organizations and Rehabilitation Facilities and Article 10 of Law on Public Hospitals Unions (except for those who receive additional payment in the scope of Paragraph 6 of Article 5 in Law No. 209 and those assigned or appointed in The Ministry or Public Hospital Unions by proxy) and at the same time 156

157 ANNEXES who are insured in the scope of indent (c) of Paragraph 1 in Article 4 of the said law; physicians and specialist according to the medical specialty legislation are subject to additional insurance premium that is limited with disability, old age, and death insurance on the amount paid to them in accordance with additional Article 3 of the Law No. 209 and Article 10 of the Law on Public Hospital Unions, provided for they pay the insurance premium including the employer contribution themselves. However, the amount of income to be subject to additional insurance premium shall not exceed the difference between maximum income limit taken as a basis for insurance premium defined in first paragraph of Article 82 and the total income amount taken as a basis for insurance premium to be determined according to Paragraph 3 in Article 80 for those who would enjoy this right. PROVISIONAL ARTICLE 1- (1) Chief physician, deputy head doctor, manager, deputy manager and head nurse positions within the health agencies which are decided to be transformed into unions shall be revoked by the execution date of the Decree Law on the transformation and shall be considered as dismissed from the related part of the schedule (1) attached to the Decree Law no (2) The personnel who work as a chief physician, deputy chief physician, manager, deputy manager or a chief nurse for the health agencies that are transformed into unions in accordance with this Law, shall be dismissed on the date the personnel defined in attached table (I) take office. These personnel shall be assigned to positions appropriate for their vested rights in at most three months and they may be assigned to required works until that time. Until the date of their assignment, these personnel shall continue receiving their previous financial rights such as monthly payments, additional indicators and any compensation payments (except for the payments for the second duty, assignee duty and revolving fund). Where the new net amount of the contract payment, bonus payment, monthly payment, additional indicator payment, any raises and compensation payments (except for the payments in accordance with Paragraph 6 in Article 5) are less than the net total amount of the monthly payments, additional indicator payments, any raises, compensation payments and other financial rights that the said personnel received in the last month of their previous position (except for the shift payment, the payments for the second duty, assignee duty and revolving fund), the difference shall be paid as a compensation payment (without being cut) until the difference is corrected. Where there are personnel transferred to The Ministry within the health units that are transformed into unions in accordance with the Law dated 6/1/2005 and numbered 5283, the amounts that are determined in accordance with Article 5 of the said Law within the transfer date shall be taken into account for the difference compensation payments. The duties of the personnel who are acting instead of head doctor, deputy head doctor, hospital manager, deputy manager and head nurse as a second duty or through assignment terminate ex mero motu when the actual personnel defined in attached table (I) start to work again. (3) The needed personnel from the personnel who conduct the accounting works within the hospitals that are transformed into unions and the personnel who are within the permanent staff of the Ministry of Finance may continue their duty upon the request of the executive board and the approval of the Ministry of Finance. The duration of this duty shall not exceed 5 years starting from the date of the transformation. The personnel continuing their duties within this scope shall get benefit from the payment that is stated in Paragraph 6 in Article 10 with the same principles and methods. 157

158 Health Transformation Program in Turkey September 2010 (4) Any movables and vehicles of the hospitals that are transformed into unions shall be transferred to the unions in accordance with the methods and principles to be established jointly by the Ministry of Finance and Ministry of Health. The immovables belonging to the Treasury and that are allocated to the hospitals that are transformed into unions shall be considered as allocated to the unions with the buildings and facilities on them. (5) The current assets, liabilities and equities within the balance sheet made up by the date of the transformation of the hospital revolving fund enterprises and the Higher Specialty Hospital into unions within the scope of this Law shall be considered as transferred to the union without any other procedures. (6) The contracts, law suits and execution proceedings shall be conducted by the standing of the unions. All the rights, authority, liabilities, claims and debts shall be transferred to the unions. (7) The provisions of the Article 5 of the Law no (which shall be abolished with this Law) shall continue to be executed on the Higher Specialty Hospital until it is transformed into a union within the scope of this Law. (8) The amount from the revolving fund income that is determined by the Ministry by associating its year with the investment program shall be continued to be allocated to the accounting units in relation with the unions in order to be used for the completion of the building constructions of the hospitals that are transferred into health unions. (9) The monthly payments, base monthly payments, seniority payments, family aids, raises and compensation payments paid to the personnel whose monthly payments and other payments are made from the Ministry s budget before the allocation within the group of personnel holding the positions allocated for the unions (in accordance with the Paragraph 3 in Article 10 of this Law) shall be covered by the Ministry s budget beginning from the month of transformation for 5 years. (10) The placements for appointments and transfers shall be carried out in accordance with applicable legislation until the regulation in Paragraph 4 in Article 10 is issued. (11) Until the unions define their norm staff, the establishment and cancellation of the staff and vacant position changes are carried out by the Council of Ministers upon the proposal of The Ministry and approval of the Ministry of Finance and State Personnel Presidency. (12) Where the number of staff and positions transferred to the unions in the framework of this law are above the number of norm staff to be determined, the surplus staff are deemed to be cancelled if they become vacant for any reason. (13) Budget and accounting proceedings are carried out according to the legislation on enterprises with revolving fund until the regulation in Paragraph 2 in Article 13 is laid down. Entry into Force ARTICLE 15- (1) This law shall enter into force on the day of its publication. Execution ARTICLE 16- (1) The provisions of this Law shall be executed by the Council of Ministers. 158

159 ANNEXES TITLES AND NUMBER OF POSITIONS FOR THE CONTRACTED PERSONNEL Title and Number of the Positions GENERAL SECRETARIAT 90 HEAD OF MEDICAL SERVICES 90 HEAD OF ADMINISTRATIVE SERVICES 90 HEAD OF FINANCIAL SERVICES 90 EXPERT HOSPITAL MANAGER 500 HEAD DOCTOR 500 MANAGER DEPUTY HEAD DOCTOR DEPUTY MANAGER OFFICE STAFF 450 TOTAL

160 160 Health Transformation Program in Turkey September 2010