Primary Health Care in TurkeyA Brief History and Current Situation

Dr. Ruşen TopallıKocaeli University Medical SchoolDepartment of Family Medicine

Türkiye Aile Hekimleri Uzmanlık DerneğiTurkish Association of Family Physicians

Content

Brief history of health care services in TurkeyBrief history of family medicine in TurkeyCurrent health care system (in theory & in practice)Ongoing changes in health care

Late Ottoman Period

1827 First modern medical school1871 Memleket Tabibi (Country physicians): First primary care tasks...1914 General Health Directorate under Ministry of Internal Affairs

Independence War Period

May 1920: Ministry of Health (Minister: Dr. Adnan Adıvar)

October 1923: Republic of Turkey

Republic of Turkey (1923)

12,000,000 populationAnd 554 physicians...

Early Republic Period

Dr. Refik Saydam (1st Minister of Health 1923 - 1937)Priority given to preventive services...Country doctors of Ottoman Empire became government doctors of the new republic...Hospital services were seen as a duty of local authorities

Government Doctors

Many tasks (104 articles) ... Environmental healthForensic tasksInfectious diseases surveillanceOccupational and school healthAdministrative tasksFree health care of the poor... etc...

Vertical Organizations

Specific institutions for specific diseases. Such as:TrachomaMalariaSyphilisTuberculosis

1937 – 1949 Period

Plan for broadening of health care services to small towns and villages...Health centres for every 20,000 population...Integration of preventive and curative health services...Separate health service organization for workers (SSK)

Specialization in General Medicine

1947, general health specialists for health centresProbably the first recognition of a primary care specialty in the worldAbandoned in 1955 and general health specialists were given the right to continue in another specialty...

1950 – 1960 Period

Priority given to hospital medicine...Local hospitals became units of the Ministry of Health (MoH). New hospitals opened by MoH.

After 1960:Socialization of Health Services

Act# 224 (May 1961)Prof. Dr. Nusret FişekPrimary care based health services17 years before Alma-Ata

Socialization of Health Services

1 Sağlık Ocağı (the main primary care unit) for each 5-10,000 populationTeamwork: Physician, nurse, midwife, environmental health technician etc.Integrated preventive and curative health care services...

However...

All the tasks of the old government doctor transferred to Sağlık Ocağı doctor...Including environmental health issues, forensic duties...

From 1960 to present...

Socialization broadened to all country...Number of Sağlık Ocağı’s approached to 6000 (1 SO for 11,500 citizens).15,000 physicians work at Sağlık Ocağı’s (1 SO physician for 4,500 citizens) Every citizen is registered to a Sağlık Ocağı (whether he/she knows or not)...

Socialization of Health Services(A success story or not?)

“Socialization, that is succesfully practiced from 1963 to 1965, became unsuccesful after 1966.”

Prof.Dr. Nusret Fişek

Why not?

Lack of financial supportAbundance of tasksLack of personnel motivationLack of lab./imaging facilitiesLoss of trustworthinessInadequately educated personnel (esp. physicians)

Vertical Organizations

Still alive... Overlapping tasks with Sağlık OcağıMaternal & Child Health & Family Planning Centres (AÇSAP)Ambulatory Tuberculosis Units (VSD)Disease State Management (Hypertension, Diabetes, ...)

From 1990’s to present day...

An initiative from the government...Called HEALTH REFORM A new primary care system promoted called: “family medicine system”Caused confusion about family medicine“a discipline” or “a system”

From 1990’s to present day...

Family medicine system is percepted as privatization in health care...Most parties at the left wing of political spectrum are against this system, on the other end, central and right wing parties all include “family medicine” in their programmes...

The specialty of family medicine

And family physicians tried to explain:Family medicine is not a system, it is a medical specialty and discipline...And family physicians are the main primary care physician workforce of any health system...

What about the specialty of FM?

Is it a success story or not?

Specialization in Family Medicine

1983 Regulation basis completed...1985 Training began in 9 teaching hospitalsA 3-year-all-hospital-rotation programme(9 months internal disease, 9 months paediatrics, 8 months obstetrics & gynaecology, 6 months general surgery and 4 months psychiatry)

TAHUD

Turkish Association of Family Physiciansestablished in 1990

Some milestones...

Departments in Universities (1993)1st National Congress of Family Medicine (İstanbul, 1993)Branches of TAHUD (İstanbul 1993, İzmir 1995, Ankara 1998, Bursa 2000)

Some milestones...

1st attendance to WONCA-Europe Meeting (1995)Turkish Journal of Family Practice (1997)Decision to join WONCA (1998)

Today...

1200 family physicians distributed to 90% of the country32 academic departments out of 48 medical schools29 residency training programmes5 national congresses (6th Bursa 2004)Member of WONCA

While these are happening...

Turkish Medical Association (one of those who equalize “family medicine” and “privatization of health services”) made repeated attempts to end family medicine, to close departments at the universities, etc...

Institute of General Practice

Turkish Medical Association established an Intitute with a small number of practitioners in 1998. Their aim is to make “General Practice” recognized as a separate discipline and to educate GPs... They sometimes define GP different from FP (GP is community oriented while FP focuses on the individual)

Turkey today (physician workforce)

68,000,000 population95,000 physicians45,000 specialists (including 1200 FPs)15,000 trainees in various specialties35,000 practitioners (w/o vocational training after completion of medical school)

(25,000 medical students...)

Current status of primary care...

Patient Sağlık Ocağı Hospital

Is that so simple?

Certainly not...

To understand the (complexity of) health care services, one should first try to understand social security system of Turkey...

Who pays for health services?

SSK (workers) 45%Bağ-kur (self-employed) 15%State employees 10%Emekli Sandığı (retired state employees) 4%Yeşilkart (no-insurance & poor) 15%Private insurance 1%Self paying or none 10%

SSKSSK Hospital

SSK ACC

SSK Teaching Hospital

University Hospital

Private Hospital

Sağlık Ocağı

MoH Hospital

Bağ-Kur

MoH Teaching Hospital

State Employee Ins. HC

RetiredYeşilkart

Turkish health care sytem (simplified version)

What changes ahead? (Plans of the Current Ministry of Health)

(not so much different from previous plans)All social security plans will be united in a single “general health insurance”Personal “family doctors” for every individual rather than territory based primary care Family physicians and practitioners will be recruited as “family doctors”

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