Primary Health Care in Turkey A Brief History and Current Situation Dr. Ruşen Topallı Kocaeli University Medical School Department of Family Medicine Türkiye Aile Hekimleri Uzmanlık Derneği Turkish Association of Family Physicians

Content Brief history of health care services in Turkey Brief history of family medicine in Turkey Current health care system (in theory & in practice) Ongoing changes in health care

Late Ottoman Period 1827 First modern medical school 1871 Memleket Tabibi (Country physicians): First primary care tasks 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 population And 554 physicians...

Early Republic Period Dr. Refik Saydam (1st Minister of Health ) 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 health Forensic tasks Infectious diseases surveillance Occupational and school health Administrative tasks Free health care of the poor... etc...

Vertical Organizations Specific institutions for specific diseases. Such as: Trachoma Malaria Syphilis Tuberculosis

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 centres Probably the first recognition of a primary care specialty in the world Abandoned 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 Fişek Primary care based health services 17 years before Alma-Ata

Socialization of Health Services 1 Sağlık Ocağı (the main primary care unit) for each 5-10,000 population Teamwork: 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 support Abundance of tasks Lack of personnel motivation Lack of lab./imaging facilities Loss of trustworthiness Inadequately educated personnel (esp. physicians)

Vertical Organizations Still alive... Overlapping tasks with Sağlık Ocağı Maternal & 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 Training began in 9 teaching hospitals A 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 Physicians established in 1990

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

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

Today family physicians distributed to 90% of the country 32 academic departments out of 48 medical schools 29 residency training programmes 5 national congresses (6 th 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 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 population 95,000 physicians 45,000 specialists (including 1200 FPs) 15,000 trainees in various specialties 35,000 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%

SSK SSK Hospital SSK ACC SSK Teaching Hospital University Hospital Private Hospital Sağlık Ocağı MoH Hospital Bağ-Kur MoH Teaching Hospital State Employee Ins. HC Retired Yeşilkart 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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