Health System in Turkey: Reforms, Transformation and Challenges

Abstract:

This paper analyses the Turkish health system in the backdrop of the Health Transformation Program (HTP) implemented in the early 2000s. The objective of this analysis is to draw lessons for health system strengthening aimed at access and equity in health services, financial protection and improved health outcomes for lower and upper middle income countries aspiring to achieve universal health coverage (UHC). The paper traces the trajectory of health system reform in Turkey, from 2003 to 2019, and analyses the contextual factors that drove the reform process.

Prior to HTP, the Turkish health system experienced challenges ranging from fragmentation in health financing and provisioning, gaps in the availability of health workforce and infrastructure, and a lack of accountability in service provision. These led to high out of pocket expenditure on health, inequities in access and health outcome, and consequently patient dissatisfaction. HTP took several measures including the integration of five insurance schemes, separation of purchasing from provisioning, constitution of health as a legal right, expansion of the autonomy of public hospitals, strengthening primary care, and the implementation of universal health insurance scheme.

These reform interventions contributed to reducing regional disparity in health care access, outcome, and financing, with increased patient satisfaction.  The inequity in maternal and child health outcomes witnessed considerable improvement, along with an increase in the coverage of preventive services. The reform led to increase in health insurance coverage from 70 percent in 2002 to 99 percent in 2019. Out of pocket expenditure (percentage of total health expenditure) reduced from 19.8 percent in 2002 to 16 percent in 2020. Despite these achievements, gaps remain in the form of continuing secondary care focus, rising disease burden due to non communicable disease, and catastrophic expenditures. This paper attempts to understand the key policy instruments that contributed to these positive shifts and the context within which they were successful.