1. Healthcare Reforms and Pharmaceuticals Lessons from Turkey Prof. Dr. Mehtap Tatar Hacettepe University Faculty of Economics and Administrative Sciences Department of Health Care Management

2. Agenda O General health care reforms O Impact of reforms O Reforms in pharmaceutical policies

3. Health Transformation Program 2003 - O Purchaser-provider split O Family practitioner scheme O General health insurance O Hospitals with administrative and financial autonomy

4. Extension of private hospital use 2003 Performance based payment 2004 Pilot family practitioner scheme 2005 Extension of Green Card Benefits Transfer of SSK hospitals 2008 Coverage of population under 18 2010 Extension of family practitioner scheme 2011 Full time and university performance based system Introduction of GHI Health campuses Major reform initiatives Use of private pharmacies by SSK

5. Impact of the program O Improved access O Increased share of private providers O Increased satisfaction with the system O Increased health expenditures

6. Improved access O Before reforms, among those who felt health care need: 13% did nothing 19% used self treatment 30% used self prescribed medicine (National Health Accounts Household Survey, 2003)

7. Outpatient visit per person per year MoH

8. Increasing share of private providers Number of outpatient visits to private hospitals MoH

9. Increased satisfaction (%) MoH

10. Increased health expenditures Health Expenditure/GDP (%)

11. Pharmaceuticals

12. Pricing of pharmaceuticals O External reference pricing O cheapest of France, Greece, Italy, Portugal, Spain O Public price O Public discount on retail price (currently 41% for originals) O Internal reference pricing O Cheapest + 10%

13. External reference pricing 2004 VAT to 8% 2005 Pozitive list Internal reference pricing cheapest+ 30% 2006 20% co- payment for Green Card Internal reference pricing cheapest + 22% 2007 Reimbursement commission 2009 Generic price 66% of the original Major pharmaceutical regulations

14. 2010 Internal reference pricing cheapest + 15% Global budget 2010:14,6 billion TL 2011: 15,6 billion TL 2012: 16,7 billion TL 2010 32,5% public discount for originals New GMP regulations 2010 3D Barcode system introduced 2011-????? Major pharmaceutical regulations

15. Total pharmaceutical expenditure (billion TL) www.aifd.org.tr Performance based payment system Transfer of SSK Hospitals Increased use of private hospitals Extension of Green Card benefits Coverage of population under 18 Family Practitioners Health campuses Autonomous hospitals

16. Issues on the agenda O Health Technology Assessment O Further discounts O Rational drug use O Restrictions on prescriptions

17. Thank you mtatar@hacettepe.edu.tr

18. 2010 Internal reference pricing cheapest + 15% Global Budget Billion TL 2010: 14.6 2011: 15.6 2012: 16.7 2010 32,5%discount for originals New GMP regulations 2010 3D Barcode system introduced 2011 - ??? Major pharmaceutical regulations

19. Reorganization of the MoH 2.11.2011 O Turkish Medicines and Medical Devices Agency O Market regulation O Marketing approval O Pricing (pharmacoeconomic analysis for pricing)

20. Health Implementation Guideline 5.11.2011 O Changes in public discounts O Originals without generics 41% O Originals with generics 28% O Generics 28% O Internal reference pricing cheapest + 10%

21. Points to consider O Impact analysis of reforms is crucial? O What are the drivers for increasing expenditures O Isolated emphasis on spending or utilization alone can be problematic O What is the limit for discounts? O Who will be most affected by discounts?

22. Thank you! mtatar@hacettepe.edu.tr