Sabahattin AYDIN MD, PhD

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The Success and Challenges in Strengthening
Health System Performance through Eliminating
Disparities in Health Services Turkey Perspective

• Sabahattin AYDIN MD, PhD
• Dept. Undersecretary of MoH

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Health service is a field of constant
development in which periodic requirements and
strategies may vary. Keeping this aspest in
mind, we need to focus many issues and challenges
in health service delivery and purchasing
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Before the reform agenda

• the main problems of our health system included
  fragmentation
• Public health care providers were ownd by
  different institutions.
• Existence of multiple public health insurance
  institutions with different status.
• lack of unity in implementation,
• Problems which citizens used to suffer in the
  services because of different status.

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common challenges

• we can also mention about other challenges such
  as
• lack of capacity of service providers in terms of
  technical, personnel and infrastructure,
• long patient queues, waiting periods,
• low salaries for physicians and other health
  personnel working in public sector,
• due to low salary policies the increased number
  of private practices,
• lack of an efficient and effective recording
  system

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Reform agenda of HTP

• Main driving force
• the political authorities ensured their full
  support and made valuable contributions
• significant steps have been taken addressing the
  strengthening of health services.

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Reform agenda of HTPp4p

• Health personel motivation was achieved by
  supplementary payment implementation .
• An unique model was designed to measure
  individual performance of physicians
• Institutional evaluation of the health providers
  in terms of quality criteria effected the P4P

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Reform agenda of HTPp4p

• This implementation has resulted in increases in
  productivity, advancement in technical and
  physical structure of the hospitals.
• The personnel of the institution have become more
  appertaining to their institutions.
• Promoted the modernization of MoH hospitals
• Helped harmonisation of public hospitals under
  the authority of MoH.

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Reform agenda of HTPPPP

• Hospitals were allowed to outsource many
  facilities which induced competetive improvement
• The controlled share of private sector in service
  delivery is increased.
• Investments by PPP /PFI are on the way (?)

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Reform agenda of HTPUHI

• Disparities in service use by the citizens who
  are covered by different health insurances were
  aimed to be minimized.
• As a first step, outpatient treatment and drug
  expenses of the green-card holders are covered by
  the State (insurance for the poor)
• Benefits packet of workers was increased (SSK)
• Universal Health Insurance Coverage Act was
  adopted.
• Legislative process for harmonisation and
  universal coveredge was completed.

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Reform agenda of HTPUHI

• Social Security Institution, being the main
  authority of UHI, has gained a significant power
  as the sole purchaser which helped to minimise
  inequalities.
• Through full implementation of universal coverage
  in 2009 and 2010, disparitiesand inequalities
  will be almost eliminated.

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Reform agenda of HTPFM

• Pilot implementation of family medicine has been
  started in 2005
• At the mean time FM cevered 22 province with
  almost 15 million citicens (1/5 of population)
• The main idea is to strengthen the primary
  healthcare services and ensure their efficiency.

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Reform agenda of HTPHR

• Strict human resource policy was adopted
• Obligatory service for doctors was rearranged
  promoting to work in rural
• A new ... system with higher salary in the rural
  area was lounched
• Health personel movement within the country was
  made available according to planning based on
  need.
• The ratio of doctor intensity between the highest
  and lowest changed from 1/14 to 1/4

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Reform agenda of HTPHIS

• FM implementation was based on electronic
  recording and central evaluation of the data.
• Hospital information systems were established,
  which enables precise and effective recording
  systems in terms of procedures and statistical
  data
• Hence, the errors and defects in the recording
  system are avoided and this has contributed to
  the strengthening of financial structures of
  hospitals.
• Online electronic controll system by SSI is
  implemented that prevented inequalities in
  invoice producing.
• More reliable data became available to help
  policy making

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Reform agenda of HTPPhr. Pricing Policy

• In 2004, transparency is ensured in pricing
  system based on reference pricing.
• This induced generic competition which caused
  considerably decrease in the prices
• Significant alleviation in its burden on public
  finance helped to eliminate in equalities to
  access to medicines in different social groups.

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• Despite all political will, support and
  commitment, there is always a risk of resistance
  and obstacles in front of the reforms and
  programme processes.

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Resistance to reforms

• Harmonisation of hospitals drows resistance from
  different social groups
• Integration of different social security
  institutions with different visions under one
  roof and establishing a solid new insurance
  mechanism is a hard process.
• You have to deal with and overcome the monetary
  burden of improvement and development.
• The policymakers face the risk of conflicts
  within different institutions within or outside
  the government
• Convincing the Finance Ministries is the most
  important task

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Other challenges

• We are all aware of the shortage in qualified
  health personnel all around the world.
• This shortage makes it more difficult during
  implementation process.
• Therefore, the health personnel can suffer from
  time to time because of heavy burdens and
  workloads.
• Trained and qualified personel easily shifts to
  private sector where they can earn more

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Outcomes

• Neonatal mortality rate (x/1000)
• Maternal mortality rate (x/100.000)

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• The vaccination ratios (x/100)
• The number of measles cases

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• Likewise, the prevalence of infectious diseases
  also decreased.
• The number of malaria cases
• The number of the typhoid fever cases

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• In addition, several campaigns have been
  initiated to decrease the prevalence of chronic
  diseases
• These include healthy nutrition programme,
• Cardio-vascular diseases control programme,
• Physical activity programme,
• Tobacco Control Act, and etc.

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• The ratio of out-of pocket expenditure is
  recorded

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• After the implementation, the percentage of
  benefiting from primary healthcare services shows
  an increasing trend in areas where family
  medicine is implemented.
• About 60 admits to primary healthcare services
  are recorded.

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• Last but not least, access to health services is
  increased
• Consequently the satisfaction of the citizens is
  increased (x/100)
• life expectancy is increased.

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THANK YOU