Country and population

Turkey is a south-eastern European country of 72.56 million inhabitants in a territory of 785 347 km² (mean density of 94 hab./km²) (TurkStat, 2009). It is divided into 7 regions and 81 provinces. The annual population growth rate was 1.45% between 2008 and 2009. Total fertility rate is 2.16 children per woman (Hacettepe University Institute of Population Studies, 2008). Currently, 67.0% of Turkish people are aged 15–64, 7.0% are over 65 years and 49.7% are women. The density is very variable between provinces, ranging from 11 in Tunceli to 2486 hab./km² in Istanbul (TurkStat, 2009).

Development and economy

Turkey is a parliamentary representative democracy. Since its foundation as a republic in 1923, Turkey has developed a strong tradition of secularism (Çarkoglu, 2004). The President of the Republic is the head of state and has a largely ceremonial role. Executive power is exercised by the Prime Minister and the Council of Ministers which make up the government, while legislative power is vested in the unicameral parliament, the Grand National Assembly of Turkey.

Turkey has the world’s 15th largest GDP (PPP) and 17th largest nominal GDP (World Bank, 2009). The country is a founding member of the OECD and the G20 major economies. The GDP per capita was PPP$ 12 476 in 2009 (IMF, 2010). Turkey ranked 83rd on the Human Development Index with 0.679 and was listed among the countries of high human development (UNDP, 2010). The unemployment rate is quite high: 14% of the active population in 2009 (TurkStat, 2009).

Concerning education, 47.9% of the population has at least eight years of school education, but 3.62% of males and 14.65% of females are considered as illiterate (TurkStat, 2009).

Population’s health

Life expectancy at birth in Turkey is 75.8 years for women, 71.5 years for men (TurkStat, 2009). The infant mortality decreased significantly in the previous years and reached 17 deaths for 1,000 living births in 2008 (Hacettepe University Institute of Population Studies, 2008). However, there is a large discrepancy between the provinces regarding all health indicators. Main causes of hospital deaths in 2008 were cardiovascular diseases (34.3%) cancer (15.3%), respiratory diseases (11.4%) and diseases of nervous system (5.5%). According to gender, cardiovascular diseases are the first cause of hospital deaths for females (37.1%) and second for males (32.1%) whereas cancer is the first cause of hospital deaths for males (17.7%) and second for females (12.1%) (Ministry of Health, 2010). According to the 2004 Burden of Disease Report, perinatal causes and cardiovascular diseases, respiratory system diseases, cancer, osteoarthritis and psychological disorders defined as chronic diseases constitute the disease burden for the population in Turkey (Ministry of Health & RSHMB, 2004).

Characteristics of the health care system

Table A30.1 shows some basic figures about the Turkish health care system. Starting from 1961, with the adaptation of the Law No. 224 on Socialization of Health Services, the main structure of the health system consisted of health posts, health centres (per population of 5000–10 000), mother and child health and family planning centres at primary care level; and province and district hospitals at secondary care level. The basic approach of socialization consisted of multidimensional/ integrated services delivery (Ministry of Health, 2009). In the following decades, several pitfalls and inefficiencies, such as regional inequalities in health status, high uninsured population (one-third), variability of services between insurance funds and lack of gatekeeping forced the authorities to plan health care reforms since 1980. As a result the Turkish health care system has undergone a serious transformation process during the last decade. It was not surprising that this transformation process showed many similarities with the general actual tendency in other parts of the world, especially recent health care reforms in less developed countries in Europe. Starting in 2003, the Ministry of Health of Turkey launched a World Bank supported health care reform, entitled the “Health Transformation Programme”. The aim of this programme was to organize, finance and deliver health services in line with the principles of equity, efficiency and effectiveness. The programme included three major initiatives:

Table A30.1

Development of health care resources and utilization.

• introduction of a general health insurance scheme by gathering the health funds under one umbrella;
• strengthening of public health care and the introduction of a family practitioner scheme;
• enabling hospitals to have financial and administrative autonomy (Tatar & Kanavos, 2006).

At the end of 2010, the family practitioner scheme will have been introduced in all provinces of Turkey. The annual budget allocated for primary care has doubled from TL (Turkish liras) 2 billion (€0.9 billion) to nearly TL 4 billion (€1.8 billion) in 2009 (Ministry of Health, 2009). Although these developments are quite promising, there are still some challenges to deal with. First of all, the available number of physicians who have specialized in family practice remains far from adequate to serve the entire population (Tatar & Kanavos, 2006). In 2008, Turkey has 1.4 physicians and 1.3 nurses per 1000 people (Ministry of Health, 2009). Another challenge is the gatekeeper role of primary care. Currently, in practice, no referral system is utilized (Ministry of Health, 2009).

2.1. Primary care governance

Even though primary care was acknowledged as important for many years, its first major legislative basis was introduced through the 1961 Law on the Nationalization of Health Care Delivery. However, it took until 2003, before family medicine began to be introduced as a primary care model responding to the changing health needs of the entire population with a promise of long-term government support.

The government’s vision of current and future primary care has been published in several laws, policy strategies and other formal statements. They include a number of stipulations concerning primary care such as: the disciplines responsible for the provision of primary care; responsibilities and tasks of family doctors, nurses and other primary care disciplines; educational requirements for family doctors; minimum norms for the availability of family doctors in a population; minimum norms for the availability of primary care facilities in rural areas; requirements on keeping medical records in primary care; requirements on monitoring the performance of primary care. Specific primary care policy targets (including date of achievement) are nonexistent in the published policy documents.

The Ministry of Health is the major provider of primary and secondary health care and the only provider of preventive health services in Turkey. Primary health care has its own department (called the General Directorate of Primary Health Care) at national level and is financed through a (nationally set) budget within the Ministry of Health since 1963 (Kringos et al., 2008; Ministry of Health, 2009). About 75% of primary care facilities are under the responsibility of the Ministry of Health. About 25% are managed by universities, the Turkish army and private providers. At the central level, the Ministry of Health is responsible for Turkey’s health policy and health services. The General Directorate of Primary Health Care in the Ministry is in charge of the strategic and operational management of health centres (newly called family health centres) and community health centres. Provincial health directorates manage the health services at the provincial level. Staff in each of the 81 provincial health directorates are appointed by the Ministry of Health, with the approval of the provincial governor. The directorates make technical decisions concerning the scope and volume of health services and, furthermore, have responsibility for matters of personnel and estate management. Health care units at the provincial level mainly consist of: family health centres, community health centres, mother and child health and family planning centres (with the Health Transformation Programme, they are reduced in number, embedded in community health centres, and their function is more organizational and educational than to do with service provision), tuberculosis dispensaries, and hospitals. At the end of 2010, the total number of family health centres is 6330 and community health centres is 986 nationwide. A total of 20 183 family doctor positions exist in these centres.

In the past, the relationship between the central and provincial levels has been characterized by poor communication and lack of coordination, which has resulted in more regional diversity in the provision of health services than might be expected from the centralized structure of the health care system. However, it appears there is no longer so much variation between provinces in primary care policy or specific priorities. There are now uniform standards of implementation and provinces pay attention to them, although Istanbul, with its population of more than 10 million and neglected primary care services over many years, seems to be a big challenge. Other differences still exist between provinces; for instance, in the prevalence of family doctors and in the payment system for primary care physicians. However, these differences are not the result of diversity in provincial health policy but are related to the phased introduction of family medicine. There are no regional differences in terms of tasks and responsibilities for family doctors, coverage (such as co-payments for patients) or norms for the target population per family doctor. Therefore, despite some decentralization actions, the role of the Ministry of Health in primary care is still strong. Organizations of (medical) professionals and organizations representing patients or consumers and other non-governmental organizations are involved in the policy-making process with the Ministry of Health on an ad hoc basis (Kringos et al., 2008; Savas, Karahan & Saka 2002).

Current laws and official policy statements include minimum norms for the availability of family doctors in the population and minimum norms for the availability of primary care facilities in rural areas, but do not stipulate anything about distributing primary care providers (except for underdeveloped areas) and facilities more evenly. Primary care physicians are geographically very unevenly distributed in Turkey.

Quality improvement mechanisms are being implemented gradually in primary care. Internal practice checks and practice inspections by health authorities and external clinical audits are applied infrequently. Obligatory periodic tests of professional knowledge and skills of primary care providers are not used.

The Ministry of Health is responsible for the certification of primary care physicians. To be certified as a family doctor, candidates are currently required to complete a retraining course, which has been developed by the relevant medical university departments in collaboration with the Association of Family Physicians. At present, there is no periodical recertification scheme for primary care, so as yet there are no criteria for recertification, such as minimum amounts of continuing medical education activities or having practised as family doctor for a certain period of time. Currently, no medical specialization is needed to work as a family doctor, although approximately 10% of active primary care physicians are family physicians who had vocational training. Similarly, for nurses, no special primary care training is needed. No deadline for obligatory vocational training in primary care has been declared by the authorities; consensus is emerging on introduction of obligatory vocational training starting in the year 2017. There are regulations for primary care facilities concerning minimum standards for the design of premises, equipment and hygiene.

The Ministry of Health coordinates the development and implementation of clinical guidelines for primary care. The approach seems to be hierarchical. Topics are determined by the Ministry, which assigns medical specialists to draft the guidelines. Efforts are being made to involve GPs and family doctors into this process. The prepared guidelines are subsequently distributed by the Ministry to all health centres (Kringos et al., 2008).

Basic patient rights, including informed consent, patient access to own medical files, confidential use of medical records and availability of patient complaint procedures, were formalized in the 1998 statute of patient rights (Kringos et al., 2008).

2.2. Economic conditions of primary care

The annual budget allocated for primary care was nearly TL 4 billion (€1.8 billion) in 2009 (Ministry of Health, 2009). Out of total expenditure on health, 2.3% was spent on prevention and public health in 2000 (OECD, 2009).

In 2007, 29% of Turkish respondents to a Eurobarometer survey rated family medicine care as not very affordable (European Commission, 2007).

Although formally primary care services are free of charge, a declaration from the Ministry of Finance dated September 2009 regulated out-of-pocket payments for outpatient clinics. According to this declaration patients had to pay TL 2 (€0.92) for each visit of family physician. They pay this at the pharmacy when they get their medicine. This situation was brought to court and the State Council decided to stop implementing this in April 2010. Now family medicine visits seem to be free of charge, but the government may find an another way to ask for contributions at any time (State Council Division 10, 2010). In 2008, 14.4% of males and 10.9% of females have no health insurance coverage (TurkStat, 2010).

In 2007, most primary care providers were state-employed. A WHO-NIVEL study performed in 2007 among family doctors in two Turkish provinces (Bolu province, n = 37; Eskisehir, n = 41) showed that almost all family doctors (90%) were salaried. In addition, capitation elements of payment (including additional bonuses for working in disadvantaged areas and also limited performance payment for predefined preventive services) were reported by 59% of the family doctors in Bolu and 35% in Eskisehir (Kringos et al., 2008). Since the end of 2010 all family doctors working in primary care are self-employed with contracts to health authority (Kringos et al., 2008). The average monthly income of a family doctor (with five years’ experience) is €2250. Fig. A30.1 shows how this income relates to the annual income of other medical professionals. Recently (30 December 2010) a Directory of contract and payment regulations for primary care professionals was published. According to this directory, the income of a family doctor will be affected positively if he/she has finished vocational training, performs high percentages of preventive services (vaccination, antenatal care, etc.), is working in a family health centre with a high quality rank, has more pregnant, elderly or child patients and is working in an underdeveloped area (Ministry of Health, 2011).

Fig. A30.1

How does the average income of mid-career health professionals relate to that of a mid-career GP?

2.3. Primary care workforce development

There is no obligatory referral system at the moment, which means patients can go to any health unit, and any health professional at any time. Primary care is therefore delivered by family doctors, in addition to all types of medical specialists. Out of all active physicians, 13.8% are working in primary care (as a GP or family doctor) in 2007 (Kringos et al., 2008). Fig. A30.2 shows a steady increase in the supply of GPs over the past years. A slower upward trend is shown for the other medical professions.

Fig. A30.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period.

The average age of family doctors is 39 years (in 2007). The WHO-NIVEL study performed in 2007 among family doctors in two Turkish provinces showed that 41% of the family doctors are younger than 35 years, 38% are aged 35–45 years, and 21% older than 45 years of age (Kringos et al., 2008).

In a normal week a family doctor works an average of 51.2 hours (Kringos et al., 2008). The official minimum working hours of family doctors is 40 hours. Additional hours worked are on a voluntary basis. In May 2010, the Ministry of Health issued a directory about the practice of family medicine, explaining the responsibilities of health professionals in primary care. A law about family medicine implementation has not been proposed for discussion yet. However, there is ongoing work on it, which might be put before Members of Parliament in winter 2011, or otherwise postponed until the elections in June 2011.

The family medicine specialization in primary care is increasingly being seen as a career. In the past, being a (non-specialized) GP used to be the first step towards becoming a secondary medical specialist. Now, family medicine is more appreciated as a full specialty in its own right. The capacity for specialization in family medicine amounts to about 500 places per year (which is about 11% of the total number of places for specialization). About 80% of family medicine university places are occupied. Up to 2007, about 300 family doctors have completed the postgraduate training each year.

Family medicine departments have been established in three-quarters of the medical universities (currently 40 out of the total of 54). They are involved in education as well as scientific research. Most of the postgraduate training programmes in family medicine last three years. In all universities, part of the residency programme in family medicine is spent in primary care practice; the duration varies between six months and one year (Kringos et al., 2008). The curriculum for vocational training for family medicine has been revised very recently and the obligatory primary care period was set at 18 months for all residents.

The national professional organization of family physician specialists is TAHUD (Türkiye Aile Hekimleri Uzmanlık Derneği), which was established in 1990. TAHUD’s activities include: defence and advocacy of its members’ material interests, professional development, education and scientific activities. It publishes a four-monthly journal for its members. Provincial associations of family doctors have also been set up in seven provinces. There are also independent associations for family doctors, mostly family doctors without vocational training, in several provinces. Some of them give membership to specialist family physicians as well. With the participation of all these provincial associations the Turkish Federation of Family Doctors’ Associations was established in 2008.

3.1. Access to primary care services

Over recent years, there has been a systematic increase in the availability of family doctors working in primary care. However, compared to the overall number of physicians, there are still severe shortages of physicians and nurses in primary care. Besides, there are geographical differences in the availability of family doctors. The difference between the provinces with the highest and lowest density of family doctors is 34 per 100 000 population (in 2007) (Ministry of Health, 2010). Shortages (of physicians and nurses in primary care, gynaecologists, cardiologists, surgeons, dentists, pharmacists and hospital nurses) seem to be more severe in the eastern provinces than in the west. There is no up-to-date register of primary care professionals which is actively used for human resources planning. This could be one of the measures needed to overcome these shortages (Kringos et al., 2008).

In some rural areas there is a lack of availability of medicines due to a shortage of pharmacies. The Ministry of Health is planning to introduce mobile pharmacy services for these areas, like the existing mobile primary health care services in rural areas.

In 2007, only 60% of the Turkish respondents to a Eurobarometer survey reported being satisfied with access to primary care in general (European Commission, 2007). In another satisfaction study coordinated by Hıfzısıhha School of Public health, the provincial health directorates implemented the Europep among 34 472 patients, who received primary health care services in 81 provinces in June 2010. Pertaining to the views about the health care facility last visited, patient satisfaction was found to be 82.8% in the provinces under the family medicine implementation, 80.1% in the provinces without the family medicine implementation and 81.2 % in all provinces in general (Dağdeviren & Akturk, 2004).

Appointment systems are generally not used in primary care (see Fig. A30.3). Nor are e-mail consultations or a practice web site generally used. Family doctors do frequently perform telephone consultations, and sometimes offer special clinical sessions (for example for diabetic patients) (Kringos et al., 2008).

Fig. A30.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres.

Family doctors can define their own working hours as long as they work a minimum of 40 hours per week. The WHO-NIVEL study performed in 2007 showed that 38% of the responding family doctors said they did not make any home visits. Among patients (n = 1492) there was quite strong reservation as to whether the family doctor would make a home visit at the request of the patient. Only one-third (33%) thought this would happen; almost half (45%) did not know whether they would get a home visit; 22% of the patients were convinced their family doctor wouldn’t make any home visits (Kringos et al., 2008).

The model of providing primary care services in the evenings and during the weekend differs according to geographical region. However, the most commonly used model for after-hours care is practice-based services, in which family doctors within one practice or organized in a group of practices look after their patients on out-of-hours schedules. Hospital emergency departments also occasionally provide primary care services after office hours (Kringos et al., 2008) Continuity of primary care services

Most family doctors use a patient list system, with an average list size of 3687 patients. Of the patients in the WHO-NIVEL study (Kringos et al., 2008), 77.8% reported visiting their usual provider for their common health problems. Patients are free to choose their health centre and provider. However results from the 2007 WHO-NIVEL study showed that the policy on choice principles is either not very well defined or not well communicated to patients, as they were mostly not aware of these principles. Fig. A30.4 shows that patients were least satisfied with regard to their trust in their family doctor. They were however satisfied with the average consultation duration of 11 minutes and other aspects of the quality of their relation with their family doctor.

Fig. A30.4

Patient satisfaction with aspects of care provision.

The same study showed that only 42.3% of the family doctors (n = 78) kept clinical records for all patient contacts routinely. Concerning the quality and confidentiality of medical records, the only requirement is that records must be kept electronically. All family doctors have a computer at their disposal in their office, which is mostly used for keeping medical records and searching for expert information on the internet. Only a minority of family doctors can easily generate lists of patients by diagnosis or health risk with their current medical record system. Routinely, all family doctors are asked to send their health statistics to regional health authorities for developing health politics for future.

Patients have direct access to any medical care provider for their health care problems. Family doctors occasionally use referral letters when they refer a patient to a medical specialist. They also only occasionally receive information within 24 hours about contacts that patients have had with out-of-hours services. There is no standardized system of communication between family doctors and medical specialists. Specialists only rarely communicate back to a family doctor after an episode of treatment (Kringos et al., 2008).

3.2. Coordination of primary care services

Teams of three or more family doctors are the dominant organizational model of practice (see Fig. A30.5). Family doctors sometimes also work with disciplines other than doctors in their family medicine centre. Out of family doctors, 76.6% work in their centre with practice nurses; 54.5% work with midwives/birth assistants; 15.6% work with community/home care nurses; 7.8% work with dentists; 1.3% work with pharmacists.

Fig. A30.5

Shared practice.

Family doctors have regular face-to-face meetings (at least once per month) with other family doctors, practice nurses, and less so with midwife/birth assistants, pharmacists and social workers. It is very common for family doctors to work with a re-trained practice nurse who provides several services, including maternal care services, immunizations, or health promotion and education services.

There is very little communication and cooperation between family doctors and medical specialists. For example family doctors rarely ask advice from medical specialists, and specialists rarely provide clinical lessons for family doctors or offer joint consultations (Kringos et al., 2008).

3.3. Comprehensiveness of primary care services

Family doctors are the main providers of primary care. Primary care is provided in family health centres by one or more family doctors, depending on the size of the centre. Family doctors have a strong position as doctor of first contact for women and children (see Table A30.2). However, they are not the obvious entry point for nonmedical problems. The involvement of family doctors in the treatment of diseases could be improved, if compared to colleagues in western Europe. However, compared to the situation in Turkey 15 years ago, the position is much better now. Family doctors are moderately involved in the provision of preventive care and care for specific patient groups. There are also few links with the community in which primary care is provided.

Table A30.2

GPs’ involvement in delivery of various primary care services.

4.1. Quality of primary care

There is currently (2010) no official data available on the quality of primary care.

4.2. Efficiency of primary care

Very little official information is available on the efficiency of primary care.

Of all family doctor–patient contacts, 3.6% are home visits. Patients on average have 7.6 visits to a family doctor each year. An average consultation takes 11 minutes (Kringos et al., 2008).