Transcript Health Transformation Program in Turkey Towards Universal Health Coverage Prof. Recep AKDAĞ Morocco, March 2015 Prof.

Health Transformation Program
in Turkey
Towards Universal Health Coverage
Prof. Recep AKDAĞ
Morocco, March 2015
Prof. Recep Akdag
Former Health Minister
1
PRESENTATION FLOW
• Ethical Approach
• Final Goals
• Context & Diagnosis
• Health Policy
• Implementation
• Access & Efficiency
• Monitoring & Evaluation
• Sustainability
2
2
ETHICAL APPROACH: HEALTH AS A RIGHT
Ethical Principles for the HTP
• Human beings come first
• Health is one of the most important, and fundamental
human right
3
ETHICAL APPROACH: UNIVERSAL HEALTH COVERAGE (UHC)
“Universal Health Coverage (UHC) is defined as
access for all to appropriate, promotive, preventive,
curative and rehabilitative health care at an
affordable cost in case of need.” *
* WHO
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UNIVERSAL HEALTH COVERAGE IN TURKEY:
ENHANCEMENT OF EQUITY
6 July, 2013
“…after 30 years of slow progress, since 2003 Turkey
has been able to design and implement wide-ranging
health system reforms to achieve universal health
coverage that substantially reduced inequalities in
health financing, health service access, and
outcomes.”
5
FINAL (PERFORMANCE) GOALS
• Health Status (HS)
• Public Satisfaction (PS)
• Financial Protection (FP)
• Sustainability (S)
6
HS: LIFE EXPECTANCY AT BIRTH
In 1998, WHO estimated life expectancy in Turkey to
reach 75 years in 2025
(WHO Estimation, 1998)
We achieved a life expectancy of 75 years in 2009
(World Health Statistics, 2011)
7
HS: LIFE EXPECTANCY AT BIRTH
Number of Years Gained (2000-2011)
Life Expectancy 2011
79
80
75
3
OECD
OECD
3
Turkey
Turkey
5
WHO European
WHO European
RegionRegion
77
4
Upper-Middle
Income
Countries
Upper-Middle
Income
Countries
74
World
71
90
UpperLevel
Income Level
Countries
Upper Income
Countries
60
30
3
World
0
3
0
References: OECD Health Data 2013, World Bank World Development Indicators
8
2.5
5
HS: MATERNAL MORTALITY RATIO (PER 100.000 LIVE BIRTHS)
Change (2000-2010)
Maternal Mortality Ratio, 2010
14
Upper Income Level
-7.7
15.5
Turkey
20
WHO European Region
31.0
Upper-Middle Income
30.3
53
210
76.9
34.4
World
200
100
-10
0
Reference: WHO World Health Statistics, 2013
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20
50
80
HS: INFANT MORTALITY RATE ( PER 1.000 BIRTHS )
Change (2000-2011)
Infant Mortality Rate, 2011
OECD
4.1
Upper Income Level
5.0
28.6
Turkey
7.7
76.7
WHO European Region
11.0
38.9
Upper-Middle Income
16.0
40.7
World
37.0
40
41.8
20
27.5
0
0
Reference: OECD Health Data, 2013
WHO World Health Statistics, 2013
10
40
80
PS: SATISFACTION FROM PUBLIC SERVICES
Reference: TURKSTAT, 2012
11
Patient Satisfaction (%)
PS: PATIENT SATISFACTION AND PER CAPITA HEALTH EXPENDITURES
Referance: OECD Health Dara, EU Social Climate Report 2011,
Turkish Statistical Institute, Life Satisfaction Survey 2011
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FP: CATASTROPHIC & IMPOVERISHING HEALTH EXPENDITURES
%
Catastrophic Health Expenditures
2002 2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
0,75
0,84
0,64
0,59
0,68
0,36
0,48
0,37
0,17
0,14
0,43 0,25
0,28
0,23
0,34
0,19
0,17
0,22
0,15
0,15
0,07
Proportion of households
with catastrophic health 0,81
expenditures
Incidence of household
impoverishment due to
health expenditures
Reference: TURKSTAT
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HEALTH POLICY CYCLE
Health Policy Cycle
POLITICS
Getting Health Reform Right: M. Roberts et al, 2004 (quoted with modification).
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HEALTH POLICY: CONTEXT & RECEPTIVITY TO CHANGE
• CURRENT STATUS
• RECEPTIVITY
Openness
Responsiveness
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HEALTH POLICY: TRANSFORMATIONAL CHANGE
LEADERSHIP APPROACH
Technical
Adaptive
Authorities apply current
know-how
The people with the
problem learn new ways
“Leadership on the line “ : Heifetz & Linsky , 2002
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HEALTH POLICY: COMMITMENT
A Fundamental Shift in Turkish Political
Culture
Putting the government at the service of its citizens
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HEALTH POLICY: HOW TO OBTAIN PUBLIC SUPPORT ?
• Sincere and honest intention & approach
• Public will feel your intention and respond
accordingly
• Lesson to Learn: Public support is the most
important tool for any government which wants to
take a reform initiative in democracies.
18
HEALTH POLICY: ACCOUNTABILITY
Accountability to Whom?
• To yourself
• Ethical standpoint
• Set Goals
• Public (Major Stakeholder)
• Others
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HEALTH POLICY: INITIAL POSITION MAP FOR STAKEHOLDERS
SUPPORT
OPPOSITION
Prime
Minister
Cabinet
Medical
Labor
Unions
Minister of
Health
Ministry of
Health
Opposition
parties
Supreme
Court
The Public
Media/NGO
s
Council of
State
SSI (former)
Parliament/
Ruling party
Health
Personnel
Private
Clinics
University
Hospitals
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HEALTH POLICY: TEAM WORK
Team Formation
Political Decision
Transformational
Leadership
Teamwork
Minister
A Team
Policy
Development
TEAM A
Minister
Delivery
TEAM B
Public
NGOs
Delivery
Team
Field
Coordinators Field Managers
Monitoring/Evaluation
Health Staff
Education Pool:
Learning Organization
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HEALTH POLICY: WHAT I KEEP IN MY POCKET!
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HEALTH POLICY: FRAMEWORK OF THE HEALTH SYSTEM, 2002
*
*
FINANCE
SERVICE PROVISION
Goverment
Budget (MoF)
MoH
Subsidy scheme for
The Poor
Self Employees’
insurance
*
Public Workers’
insurance
*
Retired Public
Workers’ insurance
*
PHC
Emergency
Transport
Public
Hospitals
**
Private Hospitals
CITIZENS
Premiums
/ Co-pays
Full
Cost
Physicians’
Private
Offices
Weak
Regulation
Pharmacies
Blue Collar
Workers’ insurance
(SIO)
SIO hospitals,
facilities
Public University
Hospitals
(Managed by
Council of
Higher Edu)
* Coverage packages were different
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** Very limited services provided by private hospitals were paid by public insurance
HEALTH POLICY: TWO-PRONGED APPROACH
Year 1
URGENT ACTION PLAN
STRATEGIC PLANNING AND ACTION PLAN
November 2002
3 months
CONTINUOUS EVALUATION WITH A TIMETABLE
Kyrgyzstan, September 2014
Prof. Recep Akdag
Former Health Minister
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HEALTH POLICY: NO HOSTAGES IN THE HOSPITALS!
First day in the
office
28.11.2002
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HEALTH POLICY: COMPREHENSIVE STRATEGY
Social Determinants
Implementation in Unison
Equity
Sustainability
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HEALTH POLICY: FRAMEWORK OF THE HEALTH SYSTEM, 2012
FINANCE
SERVICE PROVISION
General Government
Budget (MoF)
MoH
PHC
Social Security
İnstution (SSI)
Emergency
Transport
Public
hospitals
Private Hospitals
Regulation
Premiums
And
Co-pays
CITIZENS
Private Physician
Offices
Pharmacies
Public University
Hospitals
27
(Managed by Council of Higher Education)
6
IMPLEMENTATION: UNIVERSAL HEALTH INSURANCE SYSTEM
State Contribution & Deficit Financing
Government
Social Security Institution
Invoice
Payment
Individuals
MoH Hospitals
University Hospitals
Private Hospitals
Independent Pharmacies
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Contracted
Health Service Providers
IMPLEMENTATION: PUBLIC EXPECTATIONS
• Patient Rights
• Financial Protection
• Access to Services
– Emergency Transport and Care
– Primary Heathcare
– Secondary & Tertiary Care
– Rehabilitative & Palliative Care
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IMPLEMENTATION: DISTRIBUTION OF HEALTHCARE SERVICES
MOH
Emergency Transport
Primary Health Care
University
Hospitals
Hospital Care
Private
Pharmacy
30
IMPLEMENTATION: PATIENT RIGHTS
Barrier
Intervention
• Lack of effective
mechanisms for
patient rights
• Regulations for patient rights
• Patient rights units in all public
hospitals
• 720.000 application in 8 years, 83%
resolved on site
• 7/24 Hotline for patient needs
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IMPLEMENTATION: IMPORTANCE OF PUBLIC FUNDING
“ Without adequate public funding and government
stewardship, health insurance mechanisms pose a
threat rather than an opportunity to the objectives
of equity and universal access to health care.”
Health Insurance in low-income countries, Joint
NGO Briefing Paper, May 2008
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IMPLEMENTATION: CHARACTERISTICS OF
UNIVERSAL HEALTH INSURANCE
Universal
Covers everyone with exceptions*
Comprehensive
All needed care
Contribution based
Bismarckian model
Compulsory
Enforced by law
Authoritative body
Social Security Institution
* Health care services are provided by their institutions
•Members of Parliament,
•Members of Constitutional Court
•Persons who receive health care services abroad
•Members of foundation funds
•Prisoners and detainees
• Privates
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IMPLEMENTATION: UNIVERSAL HEALTH INSURANCE STATISTICS
Health Insurance Coverage
Number
Holders of Compulsory Insurance
19.874.529
Pensioners
10.925.023
Dependents
33.028.458
Subsidized persons
9.049.208
Persons subject to means testing
(non-working group)
3.607.839
Other Public Coverage out of UHI
1.210.847
Total Population
77.695.904
34
IMPLEMENTATION: BENEFIT PACKAGE EXCLUSIONS
• Any kind of health care services for aesthetic purposes
• Health care services not permitted or licensed by MoH
• Some of new treatment modalities
• Chronic sickness of foreign country citizens presenting with the
diseases prior to their qualification for public health insurance
35
IMPLEMENTATION: CONTRIBUTIONS
• Premium Rate: (12.5%)
Liable
Rate
Employee
5%
Employer
7,5%
Self-Employed
12,5%
Individuals subject to only UHI
MoF Contribution
12%
Match ¼ of
Premiums collected
annually
• The premiums of the most vulnerable groups such as
individuals with lack of financial self-support, children under
the age of 18, heimatlos and refugees are paid by the
government.
36
IMPLEMENTATION: CO-SHARING
• Pharmaceuticals: 10%-20% for outpatient prescription, no copayment for drugs that cure chronic diseases, no co-payment for
inpatient prescription
• Orthesis and Prosthesis: 10%-20% (cap of 75% of gross minimum
wage), no co-payment if vital importance
• 5-12 TL for each outpatient visits at hospitals (public- private)
• No co-payment
– chronic illnesses and occupational diseases
– emergency transport including air ambulance
– inpatient services
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37
IMPLEMENTATION: EXTRA CHARGES IN PRIVATE HOSPITALS
• Private hospitals carry the right to ask patients for
additional charges up to 90% of the prices listed on the
Health Enforcement Notification(2012)
• Exemptions for emergency treatment, intensive care and
high-cost treatments
• Additional fee varies between 50% and 90% based on the
class of private hospitals
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IMPLEMENTATION: EMERGENCY TRANSPORT
Barrier
Intervention
• Insufficient workforce
and vehicles for
emergency services
• Free service
for all cases
• Access time
Urban: 0-10 min. : 94%
Rural: 0-30 min. : 96%
• 350.000 cases
/ year 2002
• 3.230.000 cases
/ year 2012
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IMPLEMENTATION: PRIMARY HEALTHCARE
Barrier
• Inadequate primary care
health services
Intervention
2005
Establishment of Family Medicine
To cover all the individuals free of charge:
•Citizens’ right to choose their physicians
•More than 21.000 family physicians
•More than 7.000 service points
•Extra payment to encourage working in
disadvantaged areas
•Negative & positive incentives
40
2010
IMPLEMENTATION: PRIMARY HEALTHCARE
Barrier
• Inadequate preventive
health services
Intervention
• Improved mobile health services and
mobile pharmacy implementation in rural
• “Guest mother” project for pregnant
women
• Cancer screenings (Special centers)
• Neonatal screenings
• Micronutrients support
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IMPLEMENTATION: PRIMARY HEALTHCARE
Barrier
• Inadequate preventive
health services
Intervention
• Comprehensive and widespread
immunization program
Immunization
2002
2012
78
97
(7 antigens)
(13 antigens)
Immunization Rate for Turkey (%)
Routine Vaccines
of Childhood
42
IMPLEMENTATION: HEALTH PROMOTION
Barrier
• Inadequate health
promotion
Intervention
• Health promotion
• Tobacco: Comprehensive approach (MPOWER)
• The leader in the world for fighting
against tobacco*
• Obesity and inactivity ?
*WHO Report on the Global Tobacco Epidemic, 2013
http://apps.who.int/iris/bitstream/10665/85380/1/9789241505871_eng.pdf
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IMPLEMENTATION: HOSPITAL SERVICES
Barrier
Intervention
• Inefficient
hospital
services
• All public hospitals were combined by
MoH with increased autonomy.
• Separate consultation room for each
physician
Central patient
appointment system
44
Home care services
“you are not alone at home…”
EFFICIENCY: HUMAN RESOURCES ALLOCATION
Addressing human resources
inequity in distribution
•
Obligatory service (300-500 days)
•
Contract based recruitment
•
Performance based payment (P4P)
•
No more dual practice
•
New relocation rules
•
Increased seats in medical schools
•
Central human resources planning
45
EFFICIENCY: HUMAN RESOURCES
Barrier
Intervention
• Low productivity of health
workforce
• Increased productivity
Number of visits to physician
/ person / year
46
EFFICIENCY: STRENGTHENED PUBLIC SERVICES
Barrier
Intervention
• Weak
infrastructure
• Increased full service rooms in
hospitals
47
EFFICIENCY: STRENGTHENED PUBLIC SERVICES
Barrier
Intervention
• Weak infrastructure
500
448
450
400
350
310
• Investment in
medical
equipment and
technology
300
250
200
150
• Service
procurement
121
100
50
18
0
2002
2012
Computed Tomography
2002
2012
MRI
48
• Outsourcing
EFFICIENCY: STRENGTHENED PUBLIC SERVICES
Increased number of medical
equipment
Increased expenditures for
Investments (by 2012 prices,
million TL)
500
23,107
448
450
400
350
310
4.3 fold
300
250
200
150
121
100
50
18
0
2002
2012
(CT Scan)
2002
2012
MRI Scan
49
EFFICIENCY: PUBLIC & PRIVATE BALANCE
“Laissez-Faire” ?
50
EFFICIENCY: PUBLIC & PRIVATE BALANCE
Service volume
• Consider country
resources as a whole
Public
care
facilities
▫ Keep public-private health
care balance
• Ensure regulatory
effectiveness
84%
Low & middle income
Private
care
facilities
16%
Upper-middle &
high income
Middle income
51
EFFICIENCY: HANDLING BUDGET GAP
Decreased health needs
- Promotion of healthy life styles
- Adequate prevention
- Increased health literacy
Budget Gap




Increased budget
Increased effectiveness
Cost containment
- Cutting services?
- Cutting purchasing prices?
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Drug Reference System
Service Procurement
Performance Based Payment
Full-time Policy
EFFICIENCY: CHANGE IN PUBLIC PHARMACEUTICAL EXPENDITURE (%)
%153
1994-2002
1994-2002
1994-2002
2002-2012
Rate of increase in number of pillboxes
2002-2011
2002-2012
Rate of increase in pharmaceuticals expenditure
Public Pharmaceuticals Expenditure
(2012 Prices - million TL)
Number of Pillboxes (million)
1994
2002
2012
1994
2002
2012
539
699
1.769
6.244
14.624
14.484
53
EFFICIENCY: PUBLIC HEALTH EXPENDITURES BY SERVICE PROVIDER (USD)
18,000
17,732
16,000
14,000
12,000
10,000
8,081
8,000
6,000
4,000
4,116
3,616
3,417
2,000
616
0
3,581
970
823
386
2002
2003
2004
2005
2006
2007
2008
2009
2010
Ministry of Health
University Hospitals
Private Hospitals And Health Institutions
Pharmaceutical Expenditures
Other Health Expenditures
54
2011
2012
EFFICIENCY: SERVICE PROCUREMENT
Radiologic imaging prices (as of 2011 prices in Turkish Lira)
55
EFFICIENCY: PERFORMANCE BASED PAYMENT (P4P)
56
EFFICIENCY: WHY DID WE ADOPT A FULL-TIME POLICY?
Dual
Working
Full-Time
Working
Citizen
Hospital
Citizen
Hospital
Victim
Inefficiency
Access
Equity
High Quality
Efficiency
High Quality
57
MONITORING AND EVALUTION
• Evaluation meetings with ‘Field Coordinators’, governors, mayors
and community managers
• Face to face informal
conversations
• Meetings with:
-
Public
Health staff
Political party members
Professional associations
345 site visits in 81 provinces (2002-2011)
58
MONITORING AND EVALUTION
Presence on the Ground
After family medicine system was set up, there was
a push for a referral system :
• Referral program piloted in 4 provinces
• On the ground evaluation: Minister’s disguise
59
MONITORING AND EVALUTION
• Statistical Surveys (conducted periodically by the
Turkish Statistical Institute, Universities and MOH)
• Surveys from international organizations
(OECD, WHO, World Bank, UNICEF)
• Media feedback
60
S: TOTAL HEALTH EXPENDITURES IN RELATION TO GDP (USD)
References: Social Security Institution, Ministry of Finance
61
S: PUBLIC HEALTH EXPENDITURES IN RELATION TO GDP (USD)
40,000
900,000
800,397
800,000
35,000
34,332
30,000
700,000
600,000
25,000
500,000
20,000
400,000
15,000
300,000
232,745
10,000
200,000
9,004
5,000
100,000
0
0
2002
2003
2004
2005
2006
2007
2008
2009
Public Expenditure on Health
2002
Public
Expenditure on
Health
GDP
2005
2012
GDP
2011
2012
33.670
33.763
34.332
232.745 304.595 393.563 483.992 529.932 647.846 735.190 615.746 732.357
777.283
800.397
4,3%
4,3%
Share of Public
Health Expend. in 3,9%
GDP
2004
2011
2010
9.004
2003
2010
2006
2007
2008
2009
11.990 15.604 17.939 21.082 26.651 31.644 30.914
3,9%
4,0%
3,7%
4,0%
62
4,1%
4,3%
5,0%
4,6%
S: PUBLIC VS PRIVATE HEALTH EXPENDITURES
50
Health Expenditures (Billion USD)
42,6 billion $
8%
40
15%
Other Private
30
Out-of-Pocket
Public
20
12,5 billion $
10%
10
20%
77%
71%
0
2002
2012
63
S: TRENDS IN NON-INTEREST PUBLIC EXPENDITURES
AND PUBLIC HEALTH EXPENDITURES
References: Social Security Institution, Ministry of Finance
64
S: SUSTAINABILITY MET?
• Health service needs mostly met
• Economic growth continuing
• Pharmaceutical prices under control
• Service procurement become widespread
• New hospital investments by PPP initiated
• Preventive health strenghtened
• Health promotion started
• Clinical quality studies started
65
S: RISKS
• Poor protection of individual rights against the system
• Failing to adapt to new conditions
• Low health literacy
• Unhealthy lifestyle
Obesity & Inactivity
Success can make
you blind.
Tobacco
Alcohol
66
2002 – 2012
HEALTH TRANSFORMATION PROGRAM IN TURKEY (HTP)
WHO, Successful Health System
Reforms: The Case of Turkey
“It is possible to achieve major improvements in
health system performance in a relatively short
period of time under the right conditions.”
May, 2012
67