1. Prof. Recep AKDAĞ Morocco, March 2015

2. HEALTH COVERAGE: COMPREHENSIVE STRATEGY Implementation in Unison Equity Sustainability Social Determinants 2

3. Social Security Institution Service Providers Individuals Government Premiums & Co-payments State Contribution & Deficit Financing Paymen t Invoice Health care MoH Hospitals University Hospitals Private Hospitals Pharmacies IMPLEMENTATION: UNIVERSAL HEALTH INSURANCE SYSTEM 3 Emergency Transport Primary Health Care

4. 4 UniversalCovers everyone with exceptions* ComprehensiveAll needed care Contribution basedBismarckian model CompulsoryEnforced by law Authoritative bodySocial Security Institution Members of Parliament, Members of Constitutional Court Persons who receive health care services abroad Members of foundation funds Prisoners and detainees Privates * IMPLEMENTATION: CHARACTERISTICS OF UNIVERSAL HEALTH INSURANCE Health care services are provided by their institutions

5. Health Insurance Coverage Number Holders of Compulsory Insurance19.874.529 Pensioners10.925.023 Dependents33.028.458 Subsidized persons9.049.208 Persons subject to means testing (non-working group) 3.607.839 Other Public Coverage out of UHI 1.210.847 Total Population in Turkey77.695.904 Health Insurance Coverage Number Holders of Compulsory Insurance19.874.529 Pensioners10.925.023 Subsidized persons9.049.208 Persons subject to means testing (non-working group) 3.607.839 Dependents33.028.458 Total Population of Turkey77.695.904 IMPLEMENTATION: UNIVERSAL HEALTH INSURANCE STATISTICS 5

6. “ Without adequate public funding and government stewardship, health insurance mechanisms pose a threat rather than an opportunity to the objectives of equity and universal access to health care.” Health Insurance in low-income countries, Joint NGO Briefing Paper, May 2008 IMPLEMENTATION: IMPORTANCE OF PUBLIC FUNDING 6

7. Purpose To determine who will and how much premium will be paid? Result Premium Amount, if paid, Is determined Service is rendered to the poor. Method Average income of the household divided to the number of the family member. Income bracket is set. WHAT IS A MEANS TEST ?

8. Social Solidarity and Welfare Foundation (SSWF) Social Solidarity and Welfare Foundation (SSWF) (2) Income Test Evaluation - Welfare Data Sys. - Household Eval. - Grading Evaluation - Welfare Data Sys. - Household Eval. - Grading (3) Per Capita Income SSWF Board of Trustees SSWF Board of Trustees (4) Decision for Income Bracket SSI (6) Provision HEALTH FACILITY (7) Health care service (1) Application Premium amount if paid, notified Payment Made MEANS TESTING FLOW CHART

9. Who is covered by the means test? 1. Citizens whose premiums are fully paid by the government: Citizens whose per capita income in the household are less than 1/3 of the set monthly minimum subsistence wage. 2. Citizens who pay their premiums themselves: Individuals who are not covered by Universal Health Insurance, but still have income and whose per capita income in the household are more than 1/3 of minimum subsistence wage. WHO IS COVERED BY THE MEANS TEST?

10. INCOME CODE PER CAPITA INCOME INCOME BRACKETS (USD) PREMIUM STATUS I0 If it is less than 1/3 of the monthly gross minimum subsistence wage 0 – 160 Premium paid by government I1 If it is more than 1/3 of the monthly gross minimum subsistence wage 160.00 – over Premium paid by the individual PREMIUM PAYMENT BRACKETS

11. “Individuals can go to appeal with a written petition, within 15 days of the premium payment notification approved by the local welfare foundation”. A final decision is made within 15 days of the submission of the petition. APPEAL FOR MEANS TESTING DECISION

12. Other than the changes occured on the per capita income, individual can not request for renewal of their testing within 6 months Means Test can be renewed also in the case of status changes such as Death, Birth, Marriage, Divorce, etc... Individuals can go to appeal within 15 days of the means testing result notification made to them by the local welfare foundation. A Final Decision is made within 15 days of the submission of the written appeal. If a member of the household move to another location the record on the Residence Registration System(RRS) will be taken into account. As per the decision of the SSI and SSWF a renewal can be requested due to a report, appeal, income change, rule revision etc.. If an appeal is not made within the duration set by the law, the mean testing decision will be final. MEANS TESTING RENEWAL REQUEST

13. Number of the Individuals whose premium paid by the government OTHER 1,959,307 I0 7.600.925 NUMBER OF THE INDIVIDUALS

14. IMPLEMENTATION: BENEFIT PACKAGE EXCLUSIONS Any kind of health care services for aesthetic purposes Health care services not permitted or licensed by MoH Some of new treatment modalities Chronic sickness of foreign country citizens presenting with the diseases prior to their qualification for public health insurance 14

15. 15 Pharmaceuticals: 10%-20% for outpatient prescription, no co-payment for drugs that cure chronic diseases, no co-payment for inpatient prescription 5-12 TL for each outpatient visits at hospitals (public- private) No co-payment – chronic illnesses and occupational diseases – emergency transport including air ambulance – inpatient services 15 IMPLEMENTATION: CO-SHARING

16. 16 Private hospitals carry the right to ask patients for additional charges up to 90% of the prices listed on the Health Enforcement Notification (2012) Additional fee varies between 50% and 90% based on the class of private hospitals Exemptions for emergency treatment, intensive care and high-cost treatments IMPLEMENTATION: EXTRA CHARGES IN PRIVATE HOSPITALS