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Turkey’s phenomenal success with socialized medicine

The Value of Socialized Medicine: The Impact of Universal Primary Healthcare Provision on Birth and Mortality Rates in Turkey

By Resul Cesur, Pınar Mine Güneş, Erdal Tekin, and Aydogan Ulker
NBER Working Paper 21510, National Bureau of Economic Research, August 2015

Abstract

This paper examines the impact of universal, free, and easily accessible primary healthcare on population health as measured by age-specific birth and mortality rates, focusing on a nationwide socialized medicine program implemented in Turkey. The Family Medicine Program (FMP), launched in 2005, assigns each Turkish citizen to a specific state-employed family physician, who offers a wide range of primary healthcare services that are free-of-charge. Furthermore, these services are provided at family health centers, which operate on a walk-in basis and are located within the neighborhoods in close proximity to the patients. To identify the causal impact of the FMP, we exploit the variation in its introduction across provinces and over time. Our estimates indicate that the FMP caused large declines in mortality rates across all age groups with more pronounced impacts among infants and the elderly, and a moderate reduction in the birth rates, primarily among teenagers. Furthermore, the results are suggestive that the program has also contributed towards equalization in the mortality disparities across provinces. Our findings highlight the importance of a nationwide supply-side intervention on improving public health.

From the Introduction

An  increasing number of countries are devising reforms aimed at improving public health and reducing disparities in the delivery of and access to basic healthcare services. Many countries have taken a primarily demand-side approach to extending health coverage, through mechanisms such as health insurance, user-fees on the basis of ability-to-pay, and conditional cash transfers. There are also countries that have opted for mainly supply-side schemes by extending government financed public provision of healthcare services or creating incentive mechanisms that financially motivate providers to expand their coverage.

The emerging consensus from the strand of the literature that focuses on the demand-side healthcare financing reforms is that extending health insurance coverage improves both access and utilization, at least among the targeted groups. However, the evidence on the degree to which these interventions limit out of pocket expenditures for services and improve health outcomes is mixed and inconclusive.4 The relatively few studies that have focused on supply-side reforms, on the other hand, find that increased availability of free or heavily subsidized healthcare improves both access and health outcomes.

In this paper, we study the impact of a supply-side healthcare intervention implemented in Turkey on measures of mortality and birth rates. The Family Medicine Program – called FMP hereafter – introduced in 2005, has extended basic healthcare services to the entire Turkish population under a free-of-charge and single-payer system that is fully financed and administered by the central government. The key operational feature of the FMP is the assignment of each Turkish citizen to a specific family physician, who offers a wide range of basic healthcare services at easily accessible walk- in clinics called the Family Health Centers.

The Turkish reform has essentially established a socialized medicine program for basic healthcare services since the services are provided free-of-charge by state-employed family physicians. This is in sharp contrast with most other interventions, especially those concerning demand-side incentives, which primarily focus on the impact of reducing out-of-pocket healthcare expenses. Additionally, there is a growing conviction among the leading global health organizations, policymakers and practitioners about the importance of achieving universal health coverage, i.e., ensuring basic and affordable healthcare services to whole citizens irrespective of their ability to pay.

Our results indicate that the FMP led to considerable health benefits. In particular, we find that the FMP caused a large and statistically significant decline in overall mortality rate with more pronounced and long-lasting effects among infants and the elderly. We also find that the FMP reduced the birth rates, especially among teenagers.

From the Conclusions

Over the past decade, the Turkish healthcare system has undergone a major transformation marked by significant investments in infrastructure, education of healthcare personnel, modernization of patient tracking and payment systems, and most importantly, the launching of the Family Medicine Program (FMP). With the introduction of the FMP in 2005, Turkey has essentially established a socialized healthcare system for primary healthcare services, under which every Turkish citizen is ensured a comprehensive package of healthcare service that is free-of-charge irrespective of the citizen’s ability to pay. This paper provides the first comprehensive analysis of the impact of the FMP on the outcomes of age-specific birth and mortality rates using province level data between 2001 and 2013. 

Our results indicate that the FMP has caused reductions in both mortality and birth rates. The benefits associated with the FMP appear to be the strongest among the most vulnerable populations, i.e., the infants and the elderly for the mortality rate, and the teenagers for the birth rate. Furthermore, the results indicate that the program resulted in a more rapid reduction in mortality in provinces with a higher baseline mortality rate. This implies that the FMP might have also contributed towards an equalization of the mortality disparities across provinces.

A handful of recent studies highlight the importance of supply-side reforms in improving public health and reducing disparities in health outcomes in countries like Brazil and Thailand. The current study builds upon this growing strand of literature by documenting evidence on the effectiveness of a nationwide supply-side intervention from Turkey, which emphasizes direct service provision and effective government oversight. The findings in this paper provide further compelling evidence in favor of the view that extending healthcare services to all citizens is critical to achieving universal coverage and improving public health.

The signature feature of the Turkish FMP is the assignment of every citizen to a new category of “family physicians,” who are the central and first point of contact for patients. Every Turkish citizen is required to register with a particular family physician, who is in charge of providing a wide range of healthcare services at neighborhood clinics that operate on a walk-in basis.

http://www.nber.org/papers/w21510

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OECD Reviews of Health Care Quality: Turkey 2014

OECD, November 25, 2014

From the Executive Summary

Over the past decade, Turkey has implemented remarkable health-care reforms, achieving universal coverage in 2003, and dramatically expanding access to care for the population. Accompanied by significant investment in the hospital sector and the establishment of a family physician system, the Health Transformation Programme (HTP) has delivered a high level of activity in the health system. The reforms benefited from ambitious leadership and a clear set of priorities (focused on expanding health insurance and improving access and, in the clinical domain, on maternal and child health). An evaluation culture built in from the beginning and a willingness to open up the reform process to external scrutiny were also fundamental elements. Centralisation and rationalisation of the health system’s governance was critical in achieving recent health-care successes.

http://www.oecd.org/publications/oecd-reviews-of-health-care-quality-tur...

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Comment:

By Don McCanne, MD

Turkey’s phenomenal success in health care reform is largely due to the establishment of the supply-side Family Medicine Program - a socialized health care system for primary health care services. Maybe we in the United States should be thinking beyond a single payer social insurance program. A single payer socialized medicine program built on a primary care infrastructure offers many advantages that may never be realized if we stop short with mere insurance reform. Just a thought.