Changes in primary care provision in Turkey: A comparison of 1993 and 2012
Introduction
The health care reforms that have taken place in Turkey over the last decade, were inspired by the evidence that stronger primary care contributes to better performance of health care systems overall [1], [2], [3], [4]. Prior to these reforms, primary health care services in Turkey were organized in accord with the 1961 Law on the Socialization of Health Services. According to this law primary care services were provided by health centers (HCs), staffed by teams consisting of a doctor, a nurse, a midwife, and an environmental health technician and an administrator in larger centers (5). Primary care doctors (PCDs) working in HCs were called as “general practitioners” (GPs). In Turkey the term GP refers to a primary care doctor who is a medical graduate with no formal vocational training in general practice/primary care or any other medical specialty. Salary based payments were the main source of income for these primary care doctors. Turkish GPs working in any given HC were collectively responsible for the service provision to a geographically predefined area with a population of 5000–10,000. All running costs of these centers were provided by Ministry of Health (MoH).
To establish a stronger primary care system, in 2003 the Turkish government introduced the “Health Transformation Program” (HTP). This reform program was implemented between 2003–2010 to close the quality gap between the healthcare system in Turkey, and those in Europe and other Organisation for Economic Co-operation and Development (OECD) countries [6]. Introduction of family doctor (FD) scheme for primary care services; introduction of general health insurance (all existing insurance schemes gathered under one umbrella), and financial and executive independence of public hospitals were the major initiatives of the HTP [7]. The FD scheme first introduced as a pilot program in 2003 and was then extended to cover the whole country at the end of 2010. It was the core tenet of HTP with a view to strengthen the primary care service in the country, by fully replacing the former HCs. Since the number of medical graduates who completed a three-year postgraduate vocational training in family medicine (family medicine specialists) was limited, those primary care doctors who were formerly called “GPs” were re-designated as “FDs” after completing a 10 days orientation course [8]. With the introduction of new structure, the FDs are paid on a capitation basis with incentives for selected preventive services. In general, the income of FDs has increased significantly (more than two folds). The HCs which are now called “Family Health Centers” (FHC) are consisted of a core team of a FD and a nurse or a midwife. After the implementation of the HTP, the responsibility of running the FHC has given to the FD, a major change which was aligned with the major aim of HTP: evolving the function of MoH from an administrator to a planner and supervisor.
Along with these changes the MoH started to employ FDs as contracted independent professionals, whereas in old structure they were government employees, no different than any other civil servant with permanent positions. However, the main service areas of FHC remained similar to the former HCs to a great extent with an exception of community based services such as environmental health and school health that are provided by public health units (named as Community Health Centers (CHC) after the reforms). One of the significant changes that the reforms brought was that each FD were initially given pre-assigned patient list (per maximum of 4000 patients per FD) to work with; however, the patients were free to change their FDs if they wished. Facilities for the FHC were improved compared to former HCs including computerization enabling electronic record keeping [5], [6], [7], [8].
Despite all structural and procedural reforms within primary care, and the increase in health expenditure, a recent study has found that the structure and delivery process of primary care in Turkey was not as strong compared to most countries in Europe [9], [10]. The lack of manpower in primary care, both quantitatively and qualitatively (47 FD per 100.000 population in 2013, with less than 10% of them having completed a postgraduate vocational training), the high number of patients per FD (the average number of patients per FD was 3621 in 2013) and the disproportionately low number of primary care encounters among total outpatient clinical activity per year (less than 40%) have been reported as the areas for improvement [11], [12]. In the absence of a compulsory referral chain from primary care to specialist settings, patients can enter into the healthcare system at whatever point they prefer. This disjointed healthcare provision, along with the increased workload (between 2002 and 2012 annual per capita PCD visits increased approximately by three fold whereas total number of PCDs increased only around 35%) of FDs has resulted in significant inefficiencies at the primary care level [8], [12]. Various studies evaluating the Turkish healthcare during the last decade have been focused mainly on the provider or user views about the new organization of the primary care services [5], [13], [14], [15], [16], [17]. However, an evaluation that explored the changes within primary care over time has been lacking.
This is the first study, which aims to give a detailed insight into the changes that have taken place in the Turkish primary care, and compare the service profiles of PCDs in 1993 and 2012. However, assessment of the HTP implementation process is out of scope of this study. This study rather focuses on the changes in the primary care service provision based on selected aspects such as PCDs being the first contact of care, the involvement of PCDs in various services, and the knowledge exchange and collaboration with other health professionals. This study will aim to explore as to whether the breadth of the service profile of PCDs has expanded.
Section snippets
Materials and methods
Data, based on the cross sectional questionnaire-based surveys among PCDs have been derived from the 1993 European GP Task Profile study and the 2012 Quality and Costs of Primary Care in Europe (QUALICOPC) study. Both of these studies were multinational, and included 28 European countries.
In 1993, the study sample included a random sample of PCDs in 10 preselected provinces out of all 74 provinces in Turkey. In total, 199 doctors responded (response rate: 50%). In this sample doctors working in
Characteristics of PCDs
The percentage of female participants of the 1993 (34.2%) study slightly differs from the sample in 2012 (30.4%); although not statistically significant (p > 0.05). The participants from 1993 were relatively younger than the participants from 2012 (30.6 ± 4.5 vs 44.0 ± 6.4; p < 0.001). The settings in which the PCDs worked are summarized in Table 1. Compared to 1993, in 2012 a larger percentage of participants were FDs with a vocational training (10% vs 0.5%). In both years, doctors working in urban
Discussion
The results of this first comparative study provide an opportunity to describe the change in the provision of primary care services during the previous two decades in Turkey. Overall, our results demonstrate that the service profile of PCDs appears to have improved according to their own reporting. Major findings could be summarized as follows: FDs’ reported higher involvement in chronic diseases, first contact care, antenatal and child health care during the last two decades whereas some
Conflict of interest
Authors declare no conflict of interest related to this paper and funding of this research has been clarified in the section below.
Funding
The QUALICOPC (Quality and Costs of Primary Care in Europe) study has been co-funded by the European Commission under the Seventh Framework Programme (FP7/2007-2013; grant agreement 242141). The 1993 GP Task Profile Study was funded from the EC BIOMED 1 programme (contract no. BMH1-CT92-1636).
Acknowledgements
The authors thank their partners in the QUALICOPC project for their role throughout the study and their coordination of the data collection. Moreover, the authors would like to thank N. Çakmak for his role in the data collection in 1993, to Peter Whetton for editing the English language of the manuscript and to Abdullah Demirkol for his final critical reading.
References (35)
- et al.
Strengthening weak primary care systems: steps towards stronger primary care in selected western and eastern European countries
Health Policy
(2013) Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012
Gaceta Sanitaria
(2012)- et al.
Universal health coverage in Turkey: enhancement of equity
Lancet
(2013) - et al.
Political, cultural and economic foundations of primary care in Europe
Social Science & Medicine
(2013) - et al.
Europe’s strong primary care systems are linked to better population health but also to higher health spending
Health Affairs
(2013) - et al.
The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998
Health Services Research
(2003) Turkey Health Transformation Program. Evaluation Report 2003–2010
(2011)- et al.
Health care reform in Turkey: a dynamic path in the wake of political consensus
Eurohealth
(2006) - et al.
Turkey Health system review
Health Systems in Transition
(2011) The importance of measuring and improving the strength of primary care in Europe: results of an international comparative study
Turkish Journal of Family Practice
(2013)
Strength of primary care in Turkey
Turkish Journal of Family Practice
Health statistics yearbook Turkey 2013
Family medicine model in Turkey: a qualitative assessment from the perspectives of primary care workers
BMC Family Practice
A snapshot of the organization and provision of primary care in Turkey
BMC Health Services Research
The influence of a market-oriented primary care reform on family physicians’ working conditions: a qualitative study in Turkey
European Journal of General Practice
Assessing the structural and functional properties of family physician services by using the PCAS (Primary Care Assessment Survey: Primary Care Evaluation Scale)
Turkish Journal of Public Health Scale
Patient Satisfaction With Prımary Health Care Services
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