“INTEGRATION: THE STORY FROM
HEALTH ECONOMICS AND HEALTH
POLICY PERSPECTIVE WITH EXAMPLES
FROM TURKEY AND EUROPE”
PROF. DR. MEHTAP TATAR
HACETTEPE UNIVERSITY
FACULTY OF ECONOMICS AND ADMINISTRATIVE SCIENCES
DEPARTMENT OF HEALTHCARE MANAGEMENT
Agenda
• Meaning of PHC and integrated PHC
• PHC in Turkey
• Impact of the Health Transformation Program
• Concluding remarks
My career journey with PHC!
• Title of my Ph.D. thesis from University of Nottingham
• Health for All by the year 2000 and Primary Health Care:
The Turkish Case (1993)
• First comprehensive analysis of the Turkish health policies from PHC
perspective
• First study using qualitative research techniques in the field
• First work emphasizing and differentiating between comprehensive
and selective PHC with its implications in the Turkish health care
system
Turkish Journals
• Tatar, M. ‘Decentralisation and Health Reforms: Theoretical
•
•
•
•
•
Analysis of the New Structural Model of the Turkish Health
System’. Amme İdaresi, 26(4), 1993.
Tatar, M., ‘Theoretical Analysis of Primary Health Care
Definitions and Applications), Toplum ve Hekim, 9(60), 1994.
Tatar, M. ‘Theoretical Analysis of Primary Health Care
Definitions and Applications: Misunderstanding or Confusion?’,
Toplum ve Hekim, 9(62), 1994.
Tatar, M., ‘Primary Health Care: A Political and Ideological
Approach’, Toplum ve Hekim, 10(67), 1995.
Tatar, M., ‘The Sine Qua Non of Primary Health Care
Approach: Community Participation’, Toplum ve Hekim,
10(67), 1995.
Tatar, M., ‘Polio Vaccination Campaign: Are Campaigns a
Solution or Menace to Health Problems’, Toplum ve Hekim,
11(71), 1996.
Thank you for putting me back on the track!
Definition of PHC
Comprehensive Definition
Narrow Definition
A philosophy and an
approach to improve the
health status of people
Essential health
services provided at the
first level of contact
Community participation,
decentralization,
intersectoral action
General practitioner as
the gatekeeper
Primary Health Care
• Comprehensive Primary Health Care
• Selective Primary Health Care
• Integrated Primary Health Care
One stop delivery model in which an individual or family visits
its local primary care unit or general practitioner as the first
point of encounter within the health care system. The PHC
provider (gatekeeper) either treats the patient or refers to a
specialist
Primary Care (Starfield 1991)
Those services
• addressing the most common problems by providing a
mix of preventive, curative and rehabilitative services
• integrating care when more than one health problem
exists
• dealing with the context of illness
• organizing and rationalizing the deployment of basic and
specialized resources
The magic word: Gatekeeping!
• A mechanism for
• Rationing services
• Control of the use of specialist, hospital or other expensive services, to
reduce or restrict health care costs
• Improving or maintaining quality of care
• Coordinating the whole packages of care that is received by a patient,
which could improve continuity
COST
QUALITY
Cutting cost at the expense of the patient?
In theory an organizational mechanism to promote integration
PHC in Turkey
Definition of PHC- Turkey 1990s
Comprehensive Definition
Narrow Definition
A philosophy and an
approach to improving the
health status of people
Essential health
services provided at the
first level of contact
Community participation,
decentralization,
intersectoral actiom
General practitioner as
the gatekeeper
Health Transformation Program
2003 • Purchaser-provider split
• Family practitioner scheme
• General health insurance
• Performance based payment
• Hospitals with administrative and
financial autonomy
Pilot family
practitioner
scheme
2003
Extension of
the family
practitioner
scheme
Transfer of
SSK
hospitals
Extension of
use of
private
facilities
2004
Performance
based
payment
Use of
private
pharmacies
by SSK
2005
Extension of
Green Card
Benefits
Introduction
of GHI
2008
Coverage of
population
under 18
Major reform initiatives
Health
campuses
2010
2011
Full time and
university
performance
based
system
Pre- reform
Health Group Presidency
Health Center
Maternal and Child Health Center
Tuberculosis Control Center
Institutional Physician
Health house
SSK Dispensary
SSK Health Station
Post- reform
Community Health Center
Family Health Center
Family Practitioner Scheme
• Family practitioners sign a contract with the MoH
• Funded from the MoH budget
• Primary Health Care is free
• Each family medicine unit is responsible for the health
and well-being of an assigned group of patients and for
coordinating patient care across the health system
• Capitation based payment system:,
• higher coefficient for certain categories of the population such as
registered pregnant women (adjustment factor of 3), prisoners
(adjustment factor of 2.25), children under 4 years and elderly over
65 years (adjustment factor of 1.6).
• Lump sum money for administrative expenses
Family practitioner performance based
payment system
• Two performance levers.
• salary deduction system
contracted providers risk up to 20 percent of their base payment if
their family medicine unit fails to meet coverage targets of at least 98
percent key MCH indicators.
• administrative system
‘warning points’ for failure to meet governance, service delivery or
quality standards specified in a set of 35 indicators. If a provider
accumulates 100 or more warning points over a contract period his
or her contract can be terminated.
Salary deduction system
• Includes eight indicators in one performance domain
• Immunization coverage rate of registered children for each target
vaccination (BCG, DPT3, Pol3, measles, HepB3, Hib3, each
assessed separately)
• Registered pregnant women with a minimum of 4 antenatal care
visits according to schedule
• Follow-up visits of registered babies & children
Salary deduction system
• A deduction of 2% if the monthly coverage rate is 97% to
•
•
•
•
98%
A deduction of 4% if the monthly coverage rate is 95% to
96%
A deduction of 6% if the monthly coverage rate is 90% to
94%
A deduction of 8% if the monthly coverage rate is 85% to
89%, and
A deduction of 10% if the monthly coverage rate is lower
than 85%
10th Anniversary - Impact of the program
Per capita visits to a physician
2011
3.3 4.9
8.2
2010
2.7 4.6
7.3
2009
2.8 4.5
7.3
2008
2.5 4.2
2007
6.7
2.2 3.9
2006
6.1
1.9 3.4
2005
5.3
1.7 3.0
2004
1.3 2.4
2003
1.3 2.1
2002 1.1 2.0
0.0
4.7
3.8
3.4
3.2
5.0
Primary Healthcare
MoH, 2013
10.0
Secondary and Tertiary Healthcare
15.0
Per capita visits
20.0
Referrals from the PHC facilities (%)
25.0
22.0
20.0
18.2
15.0
13.2
10.2
10.0
6.4
5.0
2.4
1.3
1.0
0.4
0.0
2002
2003
2004
2005
2006
2007
2008
2009
2010
0.7
2011
Immunization coverage- Turkey (%)
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
DaPT1
82
76
86
87
92
98
97
97
98
98
DaPT2
80
71
85
84
89
96
96
96
98
98
DaPT3
78
68
85
84
90
96
96
96
97
97
BCG
77
76
79
88
88
94
96
96
97
97
HBV3
72
68
77
80
82
96
92
94
96
96
MMR
82
75
81
84
98
96
97
97
97
98
CPV3
-
-
-
-
-
-
-
97
95
96
Antenatal Care Coverage (Minimum one visit) %
2011
2002
Eastern Marmara
99
79
Aegean
99
76
Western Marmara
99
80
İstanbul
99
79
Western Anatolia
99
75
Western Blacksea
99
72
Mediterrean
98
74
Central Anatolia
98
69
Eastern Blacksea
96
74
Turkey
95
70
Northwestern Anatolia
87
49
Southeastern Anatolia
85
56
Mideastern Anatolia
85
49
0
20
40
60
80
100
120
Pregnant, infant, child and puerperant follow-up
activities
2002
2003
2004
2005
2006
2007
2008
2009
2010
201
1
Average no of
follow-ups per
pregnant
1.7
1.8
2.2
2.4
2.7
3.1
3.3
3.6
4.2
4.3
Average no of
follow-ups per
infant
3.4
3.3
4.3
4.8
5.2
6.0
6.4
6.8
7.1
8.1
Average no of
follow-ups per
child
1.0
1.0
1.3
1.5
1.5
1.6
1.6
1.6
1.6
2.0
Average no of
follow-ups per
puerperant
0.7
0.7
0.8
0.9
1.0
1.1
1.2
1.4
1.5
2.0
Overall satisfaction with healthcare services
2011
12.0
2010
12.2
13.8
75.9
13.1
73.1
2009
16.7
19.3
65.1
2008
16.7
19.9
63.4
2007
15.3
2006
18.3
18.0
2005
29.7
19.1
2004
66.5
19.9
2003
52.3
25.6
55.3
33.2
39.3
0%
20%
40%
Moderately satisfied
MoH, 2013
46.9
23.2
39.5
60%
Unsatisfied
80%
Satisfied
100%
Satisfaction from PHC services
(EUROPEP study) (%)
95
90
90
85
80
75
70
75
2008
2011
65
Health Center
Family Health Center
Infant Mortality Rate
MoH, 2013
Under Five Mortality Rate
Maternal Mortality Rate
Number of general practitioners per 100 000
population
2011
2002
Eastern Blacksea
64
51
Western Blacksea
Northeastern Anatolia
58
60
41
59
59
58
Central Anatolia
Western Marmara
49
58
57
56
Aegean
Mideastern Anatolia
43
Mediterranean
49
Turkey
47
Eastern Marmara
47
Western Anatolia
Southeastern Anatolia
İstanbul
48
49
33
35
42
54
53
53
53
63
Population per actively working family physician
2011
İstanbul
3,883
Southeastern Anatolia
3,848
Western Anatolia
3,818
Mideastern Anatolia
3,744
Turkey
3,696
Western Marmara
3,686
Eastern Marmara
3,677
Mediterranean
3,663
Eastern Blacksea
3,570
Northeastern Anatolia
3,529
Aegean
3,525
Western Blacksea
3,511
Central Anatolia
3,507
Health promotion programs of the MoH
• Obesity Control Program
• Diabetes Control Program
• Tobacco Control Program
• Cardiovascular Diseases Prevention and Control Program
• Global Alliance Against Chronic Respiratory Disease
• Mental Health Control Program
• Home Healthcare Program
Integrated health care system?
• No gatekeeping
• We don’t know the cost of this
• We don’t know the quality impact
• No connection with secondary or tertiary
care
• Continuity of care is left to the family
practitioner
• Disease management role?
Challenges for integrated health care
• Shortage of physicians and other health
professionals
• Potential decrease in number of patients for
hospitals
• Paradigm shift in organization and provision of
health care services
Are we ready for a paradigm shift?
European perspective vs Turkish
• More developed PHC philosophy and
organization
• More awareness about the impact on cost and
quality
• More opportunities for coordination and
integration
• Requirements for cultural change
Thank you……
mtatar@hacettepe.edu.tr