1.  Nur Onvural, Ph.D. School of Business, Pfeiffer University Arif Varhan, MHA, Inspector, Social Security Institution

2. http://www.pfeiffer.edu/2 Presenter Disclosure Nur Onvural (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3.  Ensuring that all people can use healthcare services they need o equity in access to health services o quality of health services is good enough to improve the health of those receiving services o financial-risk protection Sources: -- Universal coverage is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma ‑ Ata declaration in 1978. -- WHO: Health Systems Financing – The Path to Universal Health Coverage, 2010 http://www.pfeiffer.edu/3 Moving toward health coverage

4.  There were five social health insurance programs in Turkey prior to Universal Health Coverage 1. Social Insurances Agency (SSK) for blue collar workers (est. in 1945) 2. Social health insurance for retired civil servants (est. in 1949) 3. Social health insurance for active civil servants 4. Social health insurance for self-employed (Bag-Kur) (est. in 1971) 5. Green card for indigent (est. in 1992) for inpatient care only  Inequitable benefit packages  Inadequate access to healthcare providers  In 2003 o 67.2% of the population was covered by health insurance o Satisfaction with health care services was at 39.5% o Low levels of health expenditures at 5.3% of GDP http://www.pfeiffer.edu/4 Sources; Aran et all, Atun, OECD

5.  Strengthen governance, financing and delivery of the health system o including human resources, physical structures, and information systems  Expand health insurance to all citizens o Widen the green card coverage and extend its benefits to include outpatient and drugs for low-income groups  Increase access to healthcare providers o Increase access to hospital care, the number of public health institutions and health care professionals o Develop primary care in the framework of family medicine (particularly for maternal and child health) – focus on a patient-centered health system o Enhance benefits for pharmaceuticals  Improve public health  Increase the public health expenditures Sources: Turkish Ministry of Health, Turkey’s Health Transformation Program, OECD and WHO, 2012 http://www.pfeiffer.edu/5

6.  The Social Security Institution (SSI) o Established in 2006 as a public entity o Administration of universal health insurance (UHI) as well as social security services, and pension payments  Universal Health Insurance o The five existing diverse social insurance programs with inequitable benefit packages were unified under the SSI from 2008 to 2012 In 2008 – Social insurance agency, retired and self employed group In 2010 -- Active In 2012 – Green Card o Eligibility and coverage were revised and extended o Benefit packages were equalized  Access to Hospitals o All public hospitals are administered by the Ministry of Health Hospitals belonging to the Social Insurance Agency were integrated with the Ministry of Health hospitals in 2005 o Reimbursement of hospitals are disbursed by the SSI, Ministry of Health, and the Ministry of Finance http://www.pfeiffer.edu/6 Sources: SSI, OECD 2008

7. http://www.pfeiffer.edu/7 Population Enterprises Patients Retired Green card Active Bag-Kur for Self employed Social Insurance (SSK) MoH Hospitals Family Medicine Other Private Hospitals Pharmacies University Hospitals NGO Other Ministry of Finance Treasury State Assist. Fund for children Ministry of Health SSI Compulsory contributions Government contributions Fee for service capitation Private insurance Healthcare services Out of pocket payments Fee for service Premiums Source: OECD & World Bank, 2008 Salaries Line item budget capitation Government Providers

8.  Service Delivery  Coverage of population by health insurance -- effective, safe, quality care to those who need it with minimum waste  Demand for health care services and supply of health care providers  Health Information  Collection, analysis, disseminations and use of reliable and timely information on health determinants, health system performance and health status  Health Financing  Adequate funds for health; protection from catastrophic expenses; incentives for providers to be efficient  Leadership and Governance  Strategic policy framework; effective oversight; regulation and accountability http://www.pfeiffer.edu/8 Source: WHO: Everybody Business: Strengthening health systems to improve health outcomes, 2007

9. http://www.pfeiffer.edu/9 % coverage by Universal Health Insurance Health Insurance coverage was extended from 67.2% in 2003 to 82% in 2013 Number of Hospital Visits by Years and Sectors Number of total hospital visits have increased by 205% in 2013 compared to 2002 Source: The Ministry of Health Stat Year Book 2013

10. http://www.pfeiffer.edu/10 When comparing 2013 numbers to 2002 numbers: There is an overall 31% increase in the total number of hospitals yet MoH hospitals increased by 10%, University hospitals by 38% whereas private hospitals increased by 103% in 2013 Source: The Ministry of Health Stat Year Book 2013

11.  MEDULA -- A nation-wide integrated health information system (Hospital, Optic, Pharmacy, Medical Devices) between the SSI and health care providers for  Electronic claims – unified claims management system  Electronic medical records (such as treatments, diagnoses, insurance information of patients, demographics, prescriptions, and test results)  Storage and display of the MRI and CT reports to prevent duplications  Electronic prescriptions –utilization management  Reimbursements – single payer  Business intelligence support systems for analytical processing, data mining, process mining, predictive and prescription analytics  Document Management System to provide the continuation of standardized, fast and effective services http://www.pfeiffer.edu/11

12.  Revenues of Universal Health Insurance o Compulsory contributions or mandatory premium collections through payroll deductions at 12.5% of earnings (5% from employees and 7.5% from employers) o State contributions from the General Budget Revenues -- the Ministry of Finance and the Ministry of Health  Out of pocket payments for Universal Health Insurance o Contribution Payments by patients deducted from payrolls Set by the SSI btw 10-20% of patients’ earnings o Additional Fees paid directly to private hospitals and/or private health care organizations http://www.pfeiffer.edu/12

13. http://www.pfeiffer.edu/13 Source: SSI, Monthly basic indicators, January 2015 Deficits of about 10% over the course of the health transformation program The data includes all expenditures of the SSI

14. http://www.pfeiffer.edu/14 Source: TurkStat, Health Expenditure Statistics, OECD Health Data 2014, OECD Health Data 2015. The Ministry of Health Stat Year Book 2013 The health expenditure percentages are still behind the other OECD countries (at 8.9% in 2013) Per capita expenditures(2013) in Turkey are at $941 whereas the OECD countries are at $3453 Total health expenditures as a percentage of GDP in Turkey

15.  The SSI is an $60B organization responsible for pension payments and universal health insurance  Effective oversight and management, regulation, accountability are handled through the following directorates o Directorate General of Universal Health Insurance Responsible for the implementation of the Universal Health Insurance policies. o Directorate General of Insurance Premiums Collection of premiums via provincial directorates o Directorate General of Service Provisions Responsible for the continuous service provisions of the SSI Information services in order to increase the efficiency of Institution’s activities. o Presidency of Guidance and Inspection Assessments on frauds, misuse, overuse, and/or abuse of health services with hospitals, medical device companies, and pharmacists and In charge of interrogations and investigations with all stakeholders holding contractual relationships with the SSI. http://www.pfeiffer.edu/15 Source: The Social Security Institution retrieved from http://www.sgk.gov.tr/wps/portal/enhttp://www.sgk.gov.tr/wps/portal/en

16.  Service Delivery o Significant increases in the percentage of covered individuals o High utilization of healthcare services as determined by the number of hospital visits and the number of hospitals o Extensiveness of benefits and the future affordability of Universal Health Insurance  Health Information System o Data analysis for cost effectiveness studies to develop innovative reimbursement models and health outcomes  Health Finance o Premium collections and health care expenditures for Universal Health Insurance o Innovative models to control increases in health care expenses  Leadership and Governance o Efficient and productive usage of resources in the administration of the SSI o Improvements in work processes http://www.pfeiffer.edu/16

17.  Organizational structure and work flow between the MoH and the SSI to be better aligned  Health expenditures are still below the other OECD countries  Health management information system (HMIS) to allow sharing of data and statistics btw the MoH and the SSI  The SSI has to become the effective purchasing agent by focusing on health economic analysis to improve its cost effectiveness  Provider satisfaction issues to be addressed o Compulsory choice between public and private sector o Increased supervision and accountability for Pay for Performance (P4P) o Patient empowerment and provider’s role  Quality of care can be further enhanced by o The development and use of evidence-based clinical guidelines and protocols o Collection of data on the outcome of treatment in the hospital sector  More effective treatments to reduce the burden of non-communicable diseases  Incentives for patients to utilize primary care rather than hospitals http://www.pfeiffer.edu/17 Source: WHO Successful Health System Reforms: The case of Turkey –May 2012

18.  Nur M. Onvural, Ph.D. | Associate Professor of Economics and Finance School of Business and Division of Applied Health Sciences, Pfeiffer University 2880 Slater Road Suite 100| Morrisville, NC| 27560 Main: 919.238.2400 | Direct: 919.238.2404 | Cell: 919.616.4308 | Fax: 919.238.2401 http://www.pfeiffer.eduhttp://www.pfeiffer.edu | Nur.Onvural@pfeiffer.eduNur.Onvural@pfeiffer.edu  Arif Varhan, MHA | Inspector The Social Security Institution of the Turkish Republic Simon Bolivar Cad. No: 23 06610 Cankaya, Ankara TURKEY Cell: +90 507 066 3969 http://www.sgk.gov.trhttp://www.sgk.gov.tr | arifvarhan@gmail.comarifvarhan@gmail.com http://www.pfeiffer.edu/18

19.  Akdağ, R. Turkey Health Transformation Program Evaluation Report, 2003-2010. Ankara: Ministry of Health, 2011.  Aran M, Hentschel J. Protection in good and bad times? The Turkish Green Card Health Program. World Bank Policy Research Working Paper No. 6178. Washington, DC: The World Bank, 2012.  Atun R., Aydın S., Chakraborty S., Sumer S., Aran M., Gürol I., Nazlıoğlu S., Özgülcü Şenay, Aydogan U., Ayar B., Dilmen U., Akdağ R. (2013). “Universal health coverage in Turkey: enhancement of equity”. Lancet; 382: 65–99  Ministry of Health, Health Statistics Yearbook 2013 retrieved from http://ekutuphane.tusak.gov.tr/kitap.php?id=239&k=health_statistics_yearbook__ 2013 http://ekutuphane.tusak.gov.tr/kitap.php?id=239&k=health_statistics_yearbook__ 2013  OECD & The World Bank. (2008). “OECD Reviews of Health Systems: Turkey.” Retrieved from http://www.oecd-ilibrary.org/social-issues-migration-health/oecd- reviews-of-health-systems-turkey-2008_9789264051096-enhttp://www.oecd-ilibrary.org/social-issues-migration-health/oecd- reviews-of-health-systems-turkey-2008_9789264051096-en  Republic of Turkey-Ministry of Health (MoH).(n.d.). Turkey Health Transformation Program. Retrieved from http://www.saglik.gov.tr/EN/belge/2-125/turkey-health- transformation-program.htmlhttp://www.saglik.gov.tr/EN/belge/2-125/turkey-health- transformation-program.html  Republic of Turkey-Social Security Institution (SSI). (n.d.). History of Social Security in Turkey. Retrieved from http://www.sgk.gov.tr/wps/portal/en/english/history/http://www.sgk.gov.tr/wps/portal/en/english/history/ http://www.pfeiffer.edu/19

20.  Social Security Institution. (2012). SSI Statistical Yearbook - 2012. Retrieved from: http://www.sgk.gov.tr/wps/portal/en/english/statistics_new/statistical_yearbook http://www.sgk.gov.tr/wps/portal/en/english/statistics_new/statistical_yearbook  Social Security Institution. (n.d). The History of Social Security Implementations in Turkey. Retrieved from http://www.sgk.gov.tr/wps/portal/en/english/history_yenihttp://www.sgk.gov.tr/wps/portal/en/english/history_yeni  Social Security Institution (Jan 2015) Monthly Basic Indicators  Turkish Statistical Institute. Life satisfaction survey [in Turkish], 2011. Retrieved from http://www.tuik.gov.tr/Kitap.do?metod=KitapDetay&KT_ID=11&KITAP_ID=15 http://www.tuik.gov.tr/Kitap.do?metod=KitapDetay&KT_ID=11&KITAP_ID=15  Turkish Statistical Institute Web Site retrieved from http://www.turkstat.gov.tr/UstMenu.do?metod=temelist http://www.turkstat.gov.tr/UstMenu.do?metod=temelist  World Health Organization, (2013(, Turkey promotes universal health coverage -- Retrieved from http://www.euro.who.int/en/health-topics/Health-systems/health- systems-financing/news/news/2013/06/turkey-promotes-universal-health-coveragehttp://www.euro.who.int/en/health-topics/Health-systems/health- systems-financing/news/news/2013/06/turkey-promotes-universal-health-coverage  World Health Organization. (2012). “Successful Health System Reforms: The Case of Turkey.” Retrieved from http://disab.saglik.gov.tr/yonetim/Uploads/files/kitaplar/Successful%20Health%20 System%20Reforms-The%20Case%20of%20Turkey.pdf http://disab.saglik.gov.tr/yonetim/Uploads/files/kitaplar/Successful%20Health%20 System%20Reforms-The%20Case%20of%20Turkey.pdf http://www.pfeiffer.edu/20