Continuity and organization of healthcare were a key focus in the Seljuk-Ottoman medical tradition. This organizational approach was strengthened after the foundation of the Republic. Yet, a more western-oriented approach was taken in the organization of the whole government and services. Parallel to the trends worldwide, there occurred changes in basic preferences in health policies.Health Policies in the 1920-1923 Period
Following the foundation of the Grand National Assembly of Turkey, the Ministry of Health was established on 3 May 1920 by the Law no. 3. The first Minister of Health was Dr. Adnan Adıvar. The main goal of this initial period was to heal the wounds of the war and to build the legislation rather than developing a regular registration system.Health Policies in the 1923-1946 Period
After the Republic was proclaimed, Dr. Refik Saydam held the ministerial office until 1937. Dr. Saydam significantly contributed to the design and development of healthcare services in Turkey. In 1923, healthcare services were delivered at governmental and municipal facilities, quarantine offices and health posts by 554 physicians, 69 pharmacists, 4 nurses, 560 health officers and 136 midwives. The country had 86 hospitals and 6.437 patient beds back then.
During this period;
- The Law on Practice of Medicine and Medical Sciences no. 1219 (1928), and
- The Law on Public Hygiene no.1593 (1930) were adopted. These two and similar other laws are still in effect.
The health policies during the tenure of Refik Saydam had four main pillars:
1- Plan, design and implement healthcare centrally,
2- Organize preventive care at central level and curative care at local administrations,
3- Raise the appeal of medical faculties to citizens to increase the number of health workers and enforce mandatory service for medical faculty graduates,
4- Launch programs to fight against communicable diseases like malaria, syphilis, trachoma and leprosy.
Under these pillars;
- Healthcare services were based on the "single-purpose care in broad geography - vertical organization" model.
- Legislation was developed to promote preventive care. Local administrations were encouraged to open hospitals. The objective was to have a government physician in every district.
- Starting from densely populated settlements, diagnostic and treatment offices were opened in 150 district centers in 1924 and 20 more in 1936. The salaries of physicians providing preventive care were raised and they were forbidden to engage in private practice.
- Comprehensive Numune (model) hospitals were opened in Ankara, Diyarbakır, Erzurum, and Sivas to be followed by Haydarpaşa Numune Hospital in İstanbul in 1936. An important purpose of these hospitals were to function as model facilities in their respective provinces. Later, the Numune hospitals opened in Trabzon and Adana increased the total number to 7.Health Policies in the 1946-1960 Period
The "First 10-Year National Health Plan", the first written health plan of the Republic, was adopted at the Supreme Health Council in 1946. The plan was announced by the Minister of Health Dr. Behçet Uz on 12 December 1946. However, Dr. Uz had to leave office before the plan was enacted.
It took nearly one and a half year for the National Health Plan to become a draft bill. It was approved by the Council of Ministers and at four different Parliamentary committees thanks to the efforts of Dr. Uz who was appointed Minister once again in the Hasan Saka government (10.8.1947/10.6.1948). However, the bill was not enacted because of the change of government again.
Although the National Health Plan and the National Health Program were not entirely implemented in the form of a law, the two documents deeply influenced the healthcare organization around the country.
The basic approach was to centralize inpatient facilities that had been controlled by local administrations.
The Plan aimed to expand healthcare to rural areas by establishing a 10-bed health center for every 40 villages. The care design of these facilities consisted of delivering preventive and curative services together. By design, each facility included two physicians, one health officer, one midwife, one visiting nurse and a village midwife and a health officer for every 10 villages. The number of the health centers was 8 in 1945, 22 in 1950, 181 in 1955 and 283 in 1960.
The Maternal and Child Health Section was established at the Ministry of Health in 1952. A Maternal and Child Health Development Center was established in Ankara in 1953 with assistance from UNICEF and World Health Organization.
In this period, pro-natalist policies were adopted due to high rate of child and infection related mortalities. Therefore, Turkey continued to increase the number of health centers, maternity facilities and infection prevention centers and strengthened its corps of health professionals.
The average life-expectancy at birth was 43.6 years in 1950–1955, 52.1 years in 1960–1965 and 57.9 years in 1970–1975 period.
Minister of Health Dr. Behçet Uz announced the "National Health Program and Health Bank Studies" on 8 December 1954. Following on the First 10-Year National Health Plan, the Program provided the building blocks of healthcare planning and organization in Turkey.
The National Health Plan split the country into seven health regions (i.e. Ankara, Balıkesir, Erzurum, Diyarbakır, İzmir, Samsun and Seyhan). The National Health Program, on the other hand, divided the country into 16 health regions (i.e. Ankara, Antalya, Bursa, Diyarbakır, Elazığ, Erzurum, Eskişehir, İstanbul, İzmir, Konya, Sakarya, Samsun, Seyhan, Sivas, Trabzon and Van).
After İstanbul and Ankara universities, the medical faculty of Ege University started admitting students in 1955 in order to strengthen the health workforce. The number of physicians, nurses and midwives rose from 3.020, 721 and 1285 in 1950 to 8.214, 1658 and 1.285 in 1960, respectively.
The increase was more than 100% in 10 years in all three professional groups.
The number of hospitals and beds were also increased significantly. More pediatric, maternal and tuberculosis prevention hospitals were opened.
The Ministry of Health had 118 healthcare facilities with 14.581 beds in 1950 and 442 facilities with 32.398 beds in 1960. The number of beds per 100.000 citizens rose from 9 in 1950 to 16.6 in 1960.
All these efforts improved the health outcomes of the population.
TB related deaths declined considerably in this period. TB mortality rate in provincial and district centers fell from 150 in 1946 to 52 per 100.000 in 1960.
The same was true for infant mortality rate. The infant mortality rate decreased from 233 per 1000 in 1950 to 176/1000 in 1960.
Both the National Health Plan and the National Health Program were aimed to provide health insurance to citizens for a fee, cover the treatment costs of the uninsured poor from a special administration budget, set up a health bank to finance healthcare costs, control production of drugs, serums and vaccines and create industries to produce milk and baby formulas.
For this purpose, the Biological Control Laboratory and a vaccination station were established at Refik Saydam Public Hygiene Center in 1947. The production of intradermal BCG started in the same year. The production of pertussis vaccines started in 1948.
The Workers' Insurance Administration (Social Insurance Institution) was created in 1946. Health facilities and hospitals for insured workers were opened after 1952.
In this period, legislation was developed for civil society organizations and various medical professions such as:
Law on Turkish Medical Association (1953/6023)
Law on Pharmacists and Pharmacies (1953/6197)
Nursing Law (1954/6283)
Law on the Union of Turkish Pharmacists (1956/6643)Health Policies in the 1960-1980 Period
The Law on the Socialization of Health Services no. 224 was enacted in 1961. Socialization in health was launched in 1963 and expanded to the whole country in 1983. Health posts, health centers and district and provincial hospitals were opened countrywide to provide extensive, continuous, integrated and staged healthcare.
The Population Planning Law no. 554 was adopted in 1965. This was a shift from a pro-natalist to an anti-natalist policy.
The “single-purpose care in broad geography" approach was dropped for the sake of "multipurpose care in limited geography".
The General health Insurance bill drafted in 1967 did not find its way to the Council of Ministers.
The Second 5-Year Development Plan reintroduced the idea of creating the General Health Insurance in 1969.
The bill for the General Health Insurance was referred to the Parliament in 1971 but it was not enacted.
The bill was resubmitted to the Parliament in 1974 but no deliberations were opened.
In 1978, the Law on Full-Time Practice of Health Professionals was adopted and public physicians were banned from opening concurrent private clinics. The law was abolished in 1980 by the Law on Compensation and Working Principles of Health Professionals and the ban on opening private clinics were lifted.Health Policies in the 1980-2002 Period
The 1982 Constitution provides that citizens have social security rights and that the state shall be responsible for ensuring that these rights are exercised. According to Article 60 of the Constitution, everyone has the right to social security and the state shall take necessary measures and establish the organization for the provision of social security. In addition, Article 56 of the Constitution is as follows: "To ensure that everyone leads their lives in conditions of physical and mental health and to secure cooperation in terms of human and material resources through economy and increased productivity, the state shall regulate central planning and functioning of the health services. The state shall fulfill this task by utilizing and supervising the health and social assistance institutions, in both the public and private sectors".
The same article includes a provision to the effect that "General Health Insurance may be established".
Under the third chapter of Social and Economic Rights and Duties, Article 41 reads: "The family is the foundation of the Turkish society. The state shall take the necessary measures and establish the necessary organization to ensure the peace and welfare of the family, especially where the protection of the mother and children is involved".
In 1983, the second law on family planning services no. 2827 which was adopted in 1983 in line with the aforementioned Article of the Constitution expanded the scope and boundaries of family planning services.
The term "family planning" (mentioned as population planning due to the title of the law) in the Law 2827 referred to "individuals' being able to have as many children as they want and whenever they want".
Article of 3 the Law reads: "... For this purpose, the Ministry of Health and Social Assistance shall be authorized to establish a dedicated organization, obtain or manufacture or outsource provision of contraceptive drugs, provide citizens in need with such drugs for free or on a rate cheaper than the production cost or take measures to that effect". Articles 4 and 5 of the Law allow for male and female sterilization and termination of pregnancy up to week 10.
The Basic Law on Health Services was adopted in 1987. However, the law was not fully enforced as the implementing regulations were not published and a number of articles were canceled by the Constitutional Court.
In 1990, the State Planning Organization prepared the "Healthcare Sector Master Planning Study" together with the Ministry of Health. This basic plan on the healthcare sector marked the beginning of a process of addressing health reforms.
The preparatory theoretical efforts for the health reforms gained momentum with the First and Second National Health Congress held in 1992 and 1993. The Law 3816 of 1992 introduced the green card for poor citizens without social security. This allowed low-income people to be covered by health insurance although the care package was limited.
In 1993, the Ministry of Health developed the "National Health Policy" which consisted of five main components including support, environmental health, healthcare delivery and goals for healthy Turkey.
In 1998, the General Health Insurance was submitted to the Parliament by the Council of Ministers as the "Bill on Personal Health Insurance System and Health Insurance Administration" but the bill was not enacted.
In 2000, a bill entitled the Health Fund was sent to the ministries for their views, though without any outcome.
The main components of the Health Reform efforts in 1990s were as follows:
1- Create General Health Insurance by merging all social security institutions,
2- Introduce family practice for primary care,
3- Grant autonomy to hospitals,
4- Reorganize the Ministry of Health to become a planning and coordinating body with a special focus on preventive healthcare.
Clearly, this was a period when major theoretical work was done but without noteworthy chances for implementation.Health Policies after 2003: Turkey Health Transformation Program
Following the elections of 3 November 2002, the 58th Government announced its Urgent Action Plan on 16 November 2002. The Action Plan included the following targets under the title "Health for All":
1- Reorganize the administration and functions of the Ministry of Health,
2- Cover all citizens under universal health insurance,
3- Merge all health facilities under a single body,
4- Grant administrative and financial autonomy to hospitals,
5- Introduce family medicine,
6- Attach special focus on maternal and child health,
7- Expand preventive care,
8- Promote private sector investment in healthcare,
9- Delegate powers to lower levels in all public institutions,
10- Address shortage of health professionals in priority development regions, and
11- Launch e-transformation in health.
Following the announcement of the Urgent Action Plan, the Health Transformation Program was developed and announced in early 2013 by the Ministry of Health. The Health Transformation Program included targeted reforms under 8 themes:
1- Ministry of Health as the planner and supervisor,
2- Universal health insurance gathering everyone under a single roof,
3- An extensive, accessible and friendly healthcare system,
a) Strengthened primary care and family medicine,
b) Effective, tiered referral chain,
c) Health facilities with administrative and financial autonomy,
4- Highly motivated health workforce equipped with knowledge and skills,
5- Education, training and scientific institutions to support the system,
6- Quality and accreditation for quality and effective health services,
7- Institutional organization in rational drug and supply management,
8- Access to effective information at decision making process: Health information system.
The health system underwent major changes in the 2003-2008 period. The Program was developed and launched in early 2003 based on the earlier experiences including socialization and subsequent health reform efforts.
The program was built after a diligent review of steps taken in the field of health and projects implemented by the Ministry since the foundation of the Republic with a view to embracing the positive legacy of the past.
After a few years into implementation, the changes in policy brought about by the Health Transformation Program (HTP) were widely discussed and the practical outcomes of change(s) were welcomed by both providers and users.
Complaints disappeared one after another and the focus gradually shifted from long waiting lists and accessibility issues to patient satisfaction and patient safety.
Patients stranded in hospitals for failing to pay the bills became a thing of the past as the main concern was the provision of social insurance and Universal Health Insurance. After addressing the emergency transportation issues, demands were now focused on qualified intensive care unit beds in sufficient numbers.
Satisfactory immunization achieved, new vaccines were constantly added to the vaccination schedule.
The economic concerns of health professionals were gradually addressed.
The committed steps taken in health reflected positively on the public and private sector and rich and poor citizens alike.
The 60th Government of 2007 added three more themes to HTP in the light of the experience and achievements of the past five years:
1- Health promotion and healthy lifestyle programs for a better future,
2- Mobilizing stakeholders and multi-dimensional health responsibility for intersectoral collaboration,
3- Cross-border health services which will further Turkey's position internationally.