qotd: Turkey’s phenomenal success with socialized medicine

National Bureau of Economic Research
August 2015
NBER Working Paper 21510
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

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

***

OECD
OECD Reviews of Health Care Quality: Turkey 2014
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-turkey-2013-9789264202054-en.htm

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Comment by Don McCanne

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.