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Turkey. The learning from these activities then formed the basis of the HTP. Learning from other
experiences also influenced the sequencing of reforms in order to build and sustain political buy-in
and support and make reforms more sustainable. To that effect, the MoH proceeded in three steps: (1)
focus on “quick fixes” of the most important issues which would yield visible results important to
patients as well as the general population; (2) then implement systematic reforms in order to improve
performance; and (3) focus on long-term issues such as the structure of the ministry in order to match
new roles and responsibilities (WHO, 2012). Frequent field visits by a multi-disciplinary field
coordination team (FCT) that frequently included health directors from different provinces helped
communicating and overcoming challenges as well as building capacity and acceptance for the
reforms. Other measures for ensure buy-in and accountability were the establishment of formal and
informal feedback mechanisms such as regular monitoring reports and a telephone hotline for
patients, as well as passing responsibilities for following up on patient complaints directly onto Deputy
Provincial Health Directors and Deputy Hospital Directors (Ibid.).
The HTP’s structural changes, financing reforms, expansion of infrastructure and human resources,
achieved substantial improvements in health coverage and outcomes such as maternal and child
health and communicable diseases. However, a number of challenges and opportunities will need to
be addressed in order to make UHC long-term fiscally sustainable and improve the quality of the
services and health outcomes.
Ongoing and future challenges
One particular area in need of improvements is the quality of diagnostic and curative care, in hospitals
specifically (WHO, 2012). Furthermore, the epidemiological transition raises the need to strengthen
primary health-care system further (Atun et al., 2013; OECD, 2014; Giovanis and Ozdamar, 2017).
Priorities here are an increase in the number of family physicians and nurses, the continued skills
development of health staff, and improvements in physical and technical resources within primary
health care. Community-based prevention and screening programmes for breast and cervical cancer;
chronic illnesses and physical, nutritional, and metabolic risk factors need to be expanded (Atun et al.,
2013; WHO, 2012).
In terms of fiscal sustainability, it has been argued that Turkey’s health reforms took place during times
of economic growth, which facilitated expenditure increases and service expansion. However, due to
combination of factors – such as the large share of informal workers which results in less revenue
available for health spending,14 the aging population and epidemiological transition, and increased
public expectations and demands on the health system have “started to create burden on the
maintenance of the healthcare system sustainability” (Giovanis and Ozdamar, 2017, p. 12). Associated
expectations on rising out of pocket expenditure then raise concerns about the sustainability of the
health coverage. Informal payments – offered by patients as well as demanded by provider against
policies – have also been reported to discourage uptake of the health services (Ibid.). The family
medicine programme could play a role here: responsible for primary care, clinical guidelines
particularly for the prevention of long-term conditions can help reduce prevalence rates and
associated costs to patients and the health system.
Another area for progress is the need for monitoring and improvement initiatives related to the quality
of care, and the need to collect and report quality measures more regularly and widely specifically, as
identified by OECD’s review of the health care quality in 2014. In 2015, 80–90 information and
communications technology [ICT] companies provided health information systems to hospitals and
family medicine facilities across Turkey; and the General Directorate for Health Information Systems
of the MoH ran more than 20 central systems to obtain and harmonize different sets of demographics,
clinical, and administrative data (World Bank, 2015).
14 In 2013, 22 per cent of employed workers were estimated to have been active in the informal economy and around 20 per cent did
not pay any income tax (Giovanis and Ozdamar, 2017).