DEVELOPMENT OF PUBLIC HEALTH RESEARCH COUNTRY PROFILE REPORT TURKEY

1

• DEVELOPMENT OF
• PUBLIC HEALTH RESEARCHCOUNTRY PROFILE REPORT
  TURKEY
• Professor Hikmet PEKCAN MD, MPH
• Turkish Public Health Association
• Ankara/Turkey
• 2006
• hikmetp_at_hacetepe.edu.tr

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TURKEY
3
GENERAL INFORMATION  

• Foundation (date) October 29, 1923
• System of Government Republic
• Capital Ankara
• Surface Area 780 576 km2
•  

4

• Government
•  
• Turkey is a republic with a unicameral parliament
  of 550 members.
• The Head of State is President Ahmet Necdet
  Sezer.
• Justice and Development Party was elected in
  November 3, 2002
• The new cabinet headed by Prime Minister Recep
  Tayyip ERDOGAN.
•  

5
Demographic Indicators

• Total Population- 1997 (estimate - million) 62.8
  
• 2000 (census -
  million) 67.8
• Rural 35
• Urban 65
• 2005 (estimate
  million) 72.3
• Natural population growth rate ()(2005) 1.26
• Age distribution () 2005
• 
  0-14 years 28.4
• 
  15-64 years 65.7
• gt65
  years 5.9

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POPULATION PYRAMID TURKEY, 2000
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Gross National Product (GNP) per capita

• In 1998
• 3160 (World Bank Atlas Method)
• 6594 (Purchasing power parity method)
• In 2003
• 3390 (real growth rate 5.9 )
• In 2004
• 4112 (real growth rate 10 increased by 21.4
  )
• In 2005
• 4128 (increased by 5 )
• Real GDP according to purchasing power parity
• per capita (2004) 7213

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Economic Indicators

• Total health expenditure
• In consolidate budget (2000) 63.0
• In GNP (2000) 6.6

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Vital Statistics

• Crude birth rate (per 1000 live births) (1998)
  23.4
• Number of live births, per 1000 population(2002)
  21.3
• Annual intercensal increase (1990-97)
  15.1
• Total fertility rate (2003) 2.2
• Urban 2.1
• Rural 2.7
• West 1.9
• East 3.7
• Life expectancy at birth for both sexes (years)
  70.8
• 
  Male 66.9
• 
  Female 71.5

10
Mortality Rates

• Infant mortality rate (per 1000 live
  births-2003) 29
• Urban 23
• Rural 39
• West 22
• East 41
• Under-five mortality rate(per 1000 live births)
  37
• Maternal mortality rate (per 100 000 live
• births) (1998) 49
• Crude mortality rate (per 1000 live
  births-2000) 6.7

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Vaccinations

• Children 12-23 months fully immunized 54.2
• BCG 88
• DPT1 89
• DPT2 76
• DPT3 64
• Polio1 95
• Polio2 83
• Polio3 69
• Measles71

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• Acute poliomyelitis incidence (per 100 000) 0.0
• Tuberculosis incidence (per 100 000 all
  forms-2004) 32.0
• Syphilis incidence (per 100 000-2002) 4 496
  cases reported between 1990-2002
  4.9
• AIDS incidence per 100 000-2004) 551 cases
  reported between 1985 and 2004 0.8

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• Human development index (HDI-2002)
• Ranks 88 in 2003 HDR 0.75
• Percent of regular daily smoking adults (2000)
  65.0
• Pure alcohol consumption per litre per person per
  year (1996) 0.9
• Average enrgy per person per day (1999-2001)
  3360 kcal

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Public Health Structure in Turkey

• Placement of Public Healthin the National Health
  Policy
• (main public health law/legislation).

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The Constitution of The Republic of Turkey

• Article 5.- The fundamental aims and duties of
  the State are to safeguard the independence and
  integrity of the Turkish Nation, the
  indivisibility of the country, the Republic and
  democracy to ensure the welfare, peace, and
  happiness of the individual and society to
  strive for the removal of political, social and
  economic obstacles which restrict the fundamental
  rights and freedoms of the individual in a manner
  incompatible with the principles of justice and
  of the social State governed by the rule of law
  and to provide the conditions required for the
  development of the individuals material and
  spiritual existence.

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The Constitution of The Republic of Turkey

• Article 10.- All individuals are equal without
  any discrimination before the law, irrespective
  of language, race, color, sex, political opinion,
  philosophical belief, religion and sect, or any
  such considerations. No privilege shall be
  granted to any individual, family, group or
  class. State organs and administrative
  authorities shall act in compliance with the
  principle of equality before the law in all their
  proceedings.

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The Constitution of The Republic of Turkey

• Article 12.- Everyone possesses inherent
  fundamental rights and freedoms which are
  inviolable and inalienable. The fundamental
  rights and freedoms also comprise the duties and
  responsibilities of the individual to the
  society, his/her family, and other individuals.

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The Constitution of The Republic of Turkey

• Article 13.- Fundamental rights and freedoms may
  be restricted by law, in conformity with the
  letter and spirit of the Constitution, with the
  aim of safeguarding the indivisible integrity of
  the State with its territory and nation, national
  sovereignty, the Republic, national security,
  public order, general peace, the public interest,
  public morals and public health, and also for
  specific reasons set forth in the relevant
  Articles of the Constitution. General and
  specific grounds for restrictions of fundamental
  rights and freedoms shall not conflict with the
  requirements of the democratic order of society
  and shall not be imposed for any purpose other
  than those for which they are prescribed. The
  general grounds for restriction set forth in this
  article shall apply for all fundamental rights
  and freedoms.

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The Constitution of The Republic of Turkey

• Article 17.- Everyone has the right to life and
  the right to protect and develop his material and
  spiritual entity.
• The physical integrity of the individual shall
  not be violated except under medical necessity
  and in cases prescribed by law and shall not be
  subjected to scientific or medical experiments
  without his/her consent.
• No one shall be subjected to torture or
  ill-treatment no one shall be subjected to
  penalties or treatment incompatible with human
  dignity..

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The Constitution of The Republic of Turkey

• Article 19.- Everyone has the right to liberty
  and security of person.
• of measures taken in conformity with the
  relevant legal provision for the treatment,
  education or correction in institutions of a
  person of unsound mind, an alcoholic or drug
  addict or vagrant or a person spreading
  contagious diseases, when such persons constitute
  a danger to the public

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The Constitution of The Republic of Turkey

• Article 41.- The family is the foundation of
  Turkish society. The State shall take the
  necessary measures and establish the necessary
  organization to ensure the peace and welfare of
  the family, especially the protection of the
  mother and children and for family planning
  education and application.

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The Constitution of The Republic of Turkey

• Article 56.- Everyone has the right to live in a
  healthy, balanced environment. It is the duty of
  the State and citizens to improve the natural
  environment, and to prevent environmental
  pollution. 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 health and social assistance
  institutions, in both the public and private
  sectors. In order to establish widespread health
  services general health insurance may be
  introduced bay law.

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EQUITY FOR HEALTH CARE
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Fertility, birth interval, use of contraceptive
methods and induced abortion by residence Turkey
Demographic and Health Survey- 2003
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Antenatal care, place of delivery and assistance
during delivery by residence, Turkey Demographic
and Health Survey 2003
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Turkey
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CAUSES OF MATERNAL MORTALITY

• Haemorrhage
• Toxemia
• Infections

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General Directorate of Mother and Child
Health/Family Planning
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Major causes of mortality (under 5 years)

• Birth trauma and other perinatal
  causes 48.4
• Acute respiratory infections 12.3
• Coronary hearth diseases 7.4
• Meningococcal infections 6.7
• Diarrheal diseases 6.0
• Others 19.3

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Nutritional status of children by residence,
Turkey Demographic and Health Survey 2003
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25 known
75 known
total hypertension cases
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Education level according to residence Turkey
Demographic and Health Survey 2003
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Percent distribution of some housing
characteristics, according to residence, Turkey
Demographic and Health Survey 2003
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Number of Hospitals, Beds and Beds For 10.000
Population by Regions, Turkey 2003
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Health centers with no physician and health
houses with no midwife (2003)
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   The structure of public health management and
services (national, regional local)

• The Ministry of Health is the officially
  responsible from developing and implementing
  health policies in Turkey. The Ministry provides
  the primary care of charge at the health centers
  and health houses throughout the country.
  Secondary and tertiary curative services are paid
  by the individuals out of pocket or through
  insurance organizations. Besides the Ministry of
  Health, the Social Insurance Organization,
  universities, armed forces, some other public
  organizations and private sector provide health
  services.

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Health Centers/Health House

• Health centers serve a population of 5000-10000
  in rural and 10000-50000 in urban areas.
• Health care teams in health centers are composed
  of staff like general practitioners, dentists,
  nurses, midwives, sanitarians and other relevant
  personnel.
• In each health house, which is the most
  peripheral units of the health care network, a
  midwife serves.

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Administrative Units

• The main administrative units in Turkey are
  provinces (81 provinces).
• Provincial governors (Vali) represent each
  ministry, including health, in their province.
• Provincial health directors on behalf of
  provincial governors direct health services.
• Provinces are further divided into districts and
  districts are divided into villages.
• In the country, there are 81 provinces, 849
  districts and 36 699 villages.

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Municipalities

• Municipalities are founded in the localities with
  more than a population of 2000.
• Their main responsibility regarding health is
  environmental health services such as safe water,
  waste disposal and food control.

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 The current main issues of public health

• Strategic/ long-term objectives in public
  health until 2020
• Turkey has National Health Policy 21 which has
  main objective
• to improve health statistics of Turkey,
• to increase life expectancy,
• to improve quality of life and
• To eliminate the differences of health levels
  between regions and social groups.

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For the achievement of these main goals, long
term objectives are

• to control, eliminate and eradicate important
  infectious diseases in Turkey
• to increase the quality of life by reducing the
  frequency of important non-infectious diseases
  such as disability, disability for work and
  early death.
• to reduce deaths and injuries caused by
  accidents, violence and disasters and provide
  continuity .

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• to provide healthy start and continuity to the
  life to newborns, babies and preschool children.
• to reduce health problems related to sexual life
  at least 50 .
• to decrease the use of addictive substances such
  as tobacco, alcohol, volatile, and psychoactive
  drugs to minimum level.
• to decrease the factors effecting health in
  negative way like malnutrition and inadequate
  physical activity to minimum level.

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• to increase the health quality of youth, elderly
  and handicapped persons and to provide more
  active role in society.
• to improve psycho-social goodness statue of
  society and provide special care for mentally ill
  patients.
• to provide more health living conditions at home,
  school, at work and every place we live.
• to provide reachable, acceptable and usable
  qualified health service to society, to enlarge
  health network via eliminating social and
  regional differences, and to reach
  sustainability.

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Current Priorities and Immediate Objectives of
Public Health

•  To achieve our long term objectives, our current
  and immediate objectives are
• to provide basic health education to society,
• to eliminate extreme poverty and starvation,
• to improve maternity and child health,
• to decrease child mortality rate,
• to struggle with AIDS/HIV, malaria and other
  diseases,

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• to maintain sustainability of environmental and
  natural resources,
• to improve global collaboration for development,
• to encourage gender equality and to improve
  social role of women in society,
• eradication of infectious diseases.

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Public health research as a strategic issue
within the national policy on science and
research,

• Total research and development expenditures on
  health is 10 of total research and development
  expenditures in Turkey.
• On health issues research and development (RD)
  studies are done by universities, public and
  commercial sector.

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• Main topics of RD studies are biotechnology and
  genetic researches.
• The other studies are diagnosis and treatment of
  cancer and circulatory diseases, eradication of
  infectious and parasitic diseases (epidemiology,
  microbiology), pharmacology, maternal and child
  health, family planning, environmental protection
  methods, surgical and clinical techniques and
  their equipment improvement, artificial tissue
  and organ development, natural organ and tissue
  transplantation.

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• Although RD studies on health are recommended
  and supported in Turkish development plans and
  annual investment programs, RD studies on health
  are not enough.

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Organization of public health research
(institutional structure for planning, priority
setting, funding, implementation, communication)

• On health issues research and development
  studies are done by the following associations
  and institutions

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• Ministry of Health (MoH)
• MoH is the main public health policy maker of
  Turkey.
• Organized and serves in basis of public health
  approach and health priorities of the country.
• Serve as a main health provider of the Turkish
  Republic.
• According to its role MoH conducted important
  public health researches to determine the health
  problems, service needs or to evaluate the
  success of interventions.
• Population and Health Research, 2003 and National
  Health Burden Study were the latest and most
  important population based public health studies.
  
• MoH conducts an intervention to prevent iron
  deficiency, vitamin D deficiency among Turkish
  children in 2005. Projects can be funded by
  partners or only by the economical sources of
  MoH.
• Programmes such as prevention of iodine
  deficiency disorders, prevention and promotion of
  breastfeeding, baby-friendly hospitals etc are
  also on progress.

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• Refik Saydam Hygiene Center Presidency School of
  Public Health (RSHCPSPH)
• RSHCPSPH is the branch of MoH and serves as a
  research center.
• This institution has been conducted number of
  studies in collaboration with national and
  international partners.
• Health revision project studies are conducted by
  RSHCPSPH.

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• Medical faculties
• The number of Medical Faculties are more than
  forty in Turkey.
• Public health departments of medical faculties
  conduct public health researches in collaboration
  with national and international partners and
  supporters.
• WHO, UNICEF, UNDP etc are the international
  partners of medical faculties.
• Collaborating centers of WHO serves as focal
  research points in medical faculties too.

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• Hospitals
• Hospitals are organized to serve secondary and
  tertiary health services in Turkey.
• They conduct blood and blood products circulation
  system project and emergency department
  organization networks projects in Turkey.

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• Hospital Management High School(HMHS)
• HMHS was one of the main partners of Health
  Burden Study of Turkey.

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• Voluntary organizations (associations, societies
  and foundations)
• In previous two decades the number of voluntary
  organizations has been increased.
• These organizations are in communication with
  international donors.
• They conduct number of studies related with
  health problems of Turkey.
• European Union Reproductive Health Program formed
  a new platform for voluntary organizations to
  conduct public health researches on reproductive
  health.

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• Pharmacy Companies
• National Disability Study of Turkey and Hepatitis
  B Prevalence Study were conducted by pharmacy
  companies in Turkey.

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• Research Institutions
• TUBITAK (The Scientific and Technical Research
  Council of Turkey)
• In these associations and institutions, medical
  faculties, Ministry of Health, hospitals, TUBITAK
  and Refik Saydam Hygiene Center Presidency School
  of Public Health are the most active ones.

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•  TUBITAK
• Generally supports researches of academic
  institutions.
• One of the latest public health research
  supported by TUBITAK is A Study in Provincial
  Center of Van to Determine the Socio-demographic
  Characteristics, Life Quality and Health Status
  of the Urban Population

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• Funding of the studies are
• provided by State Planning of Organization (DPT)
  and Turkish Treasury via internal and external
  sources.
• Today in Turkey on health issues after hospitals
  and medical faculties, research center is Refik
  Saydam Hygiene Center Presidency School of Public
  Health.

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• There was no center for RD studies and for
  coordination of studies on.
• RD studies on health were held separately and
  uncoordinated so that more than one institute can
  work on same topic at the same time and this
  cause loss of time and money.
• The reasons for these are there is no
  administrative structure and not using the
  available arrangements.
• To handle with this situation, it decided to
  centralize in one center at Refik Saydam Hygiene
  Center Presidency School of Public Health. The
  administrative and institutional structure and
  studies are still under construction for this
  School of Public Health.

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Main areas of public health research during last
two-three years or current planning period.

• Turkish Population and Health Research
• Research of Determination of Maternal Deaths and
  Causes
• National Health Financial Records Research
• National Disease Burden and Cost Efficiency
  Research
• Work Load Indicators in Personnel Need
  Methodology
• Improvement of Management Capacity Study

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  Collaboration with international projects

• International Reproduction Health Education
  Center (UN Population Fund)
• Computer Based Management and Support Systems
  Project (UNOPS)
• United Nations Population Fund Third Countries
  Program (2001-2005)
• Projects by Ministry of Health under UN
• Third Countries Program Developing Strategy for
  Adolescent Reproduction Health
• Information and Service Requirements
• Strengthen Management of Reproduction
• Health, etc.

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• On International Family Health Visual Auditory
  Program (With JICA- Japanese International
  Cooperation Agency)
• Integrated Management of Childhood Illness
  Program (IMCI) with WHO
• Strengthening of Family Planning Education,
  Family Planning and Consultancy Programs after
  Delivery and Abortion, Contraceptive Logistics
  and Management Information System Improvement
  Project (USAID)

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• Healthy Cities Project (WHO)
• European Network of Health Promoting Schools (WHO
  Regional Office for Europe, Council of Europe,
  European Commission)

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• The role of EU public health networks for
  supporting new developments in public health
  research evaluation and recommendations.
• Cancer Scanning and Education Centers Project is
  supported by EU MEDA Program.
• There are also project with MATRA Program of EU.
  

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Key Health Challenges

• Periodical provision of reliable public health
• indicators
• Maternal and Child Health
• Non-communicable diseases (mainly CVDs and
  cancer)
• Communicable diseases (mainly vaccine
  preventable)
• Health care reforms, including health policy
  development
•  Prevention of road and domestic accidents

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Sources

• State Statistics Institution web site
  www.die.gov.tr
• MoH- Turkey Health Report (February 2004)
• 2005 Annual Programme of 8th Five Year
  Development Plan
• MoH, UNFPA, HUIPS Hospital Research 1997
• HUIPS (2004) Turkey Demographic and Health
  Survey
• 2005 Annual Programme of 8th Five Year
  Development Plan
• WHO Report 2004 Geneva. (WHO/HTM/TB/2004.331)
• www.saglik.gov.tr
• MoH www.saglik.gov.tr
• http//hdr.undp.org/statistics/data/cty/cty_f_TUR.
  html
• http//hdr.undp.org/statistics/data/cty/cty_f_TUR.
  html