1. “INTEGRATION: THE STORY FROM HEALTH ECONOMICS AND HEALTH POLICY PERSPECTIVE WITH EXAMPLES FROM TURKEY AND EUROPE” PROF. DR. MEHTAP TATAR HACETTEPE UNIVERSITY FACULTY OF ECONOMICS AND ADMINISTRATIVE SCIENCES DEPARTMENT OF HEALTHCARE MANAGEMENT

2. Agenda Meaning of PHC and integrated PHC PHC in Turkey Impact of the Health Transformation Program Concluding remarks

3. My career journey with PHC! Title of my Ph.D. thesis from University of Nottingham Health for All by the year 2000 and Primary Health Care: The Turkish Case (1993) First comprehensive analysis of the Turkish health policies from PHC perspective First study using qualitative research techniques in the field First work emphasizing and differentiating between comprehensive and selective PHC with its implications in the Turkish health care system

5. Turkish Journals Tatar, M. ‘Decentralisation and Health Reforms: Theoretical Analysis of the New Structural Model of the Turkish Health System’. Amme İdaresi, 26(4), 1993. Tatar, M., ‘Theoretical Analysis of Primary Health Care Definitions and Applications), Toplum ve Hekim, 9(60), 1994. Tatar, M. ‘Theoretical Analysis of Primary Health Care Definitions and Applications: Misunderstanding or Confusion?’, Toplum ve Hekim, 9(62), 1994. Tatar, M., ‘Primary Health Care: A Political and Ideological Approach’, Toplum ve Hekim, 10(67), 1995. Tatar, M., ‘The Sine Qua Non of Primary Health Care Approach: Community Participation’, Toplum ve Hekim, 10(67), 1995. Tatar, M., ‘Polio Vaccination Campaign: Are Campaigns a Solution or Menace to Health Problems’, Toplum ve Hekim, 11(71), 1996.

6. Thank you for putting me back on the track!

8. Definition of PHC Comprehensive DefinitionNarrow Definition Essential health services provided at the first level of contact General practitioner as the gatekeeper A philosophy and an approach to improve the health status of people Community participation, decentralization, intersectoral action

9. Primary Health Care Comprehensive Primary Health Care Selective Primary Health Care Integrated Primary Health Care One stop delivery model in which an individual or family visits its local primary care unit or general practitioner as the first point of encounter within the health care system. The PHC provider (gatekeeper) either treats the patient or refers to a specialist

10. Primary Care (Starfield 1991) Those services addressing the most common problems by providing a mix of preventive, curative and rehabilitative services integrating care when more than one health problem exists dealing with the context of illness organizing and rationalizing the deployment of basic and specialized resources

11. The magic word: Gatekeeping! A mechanism for Rationing services Control of the use of specialist, hospital or other expensive services, to reduce or restrict health care costs Improving or maintaining quality of care Coordinating the whole packages of care that is received by a patient, which could improve continuity Cutting cost at the expense of the patient? In theory an organizational mechanism to promote integration COST QUALITY

12. PHC in Turkey

13. Definition of PHC- Turkey 1990s Comprehensive DefinitionNarrow Definition Essential health services provided at the first level of contact General practitioner as the gatekeeper A philosophy and an approach to improving the health status of people Community participation, decentralization, intersectoral actiom

14. Health Transformation Program 2003 - Purchaser-provider split Family practitioner scheme General health insurance Performance based payment Hospitals with administrative and financial autonomy

15. Extension of use of private facilities 2003 Performance based payment 2004 Pilot family practitioner scheme 2005 Extension of Green Card Benefits Transfer of SSK hospitals 2008 Coverage of population under 18 2010 Extension of the family practitioner scheme 2011 Full time and university performance based system Introduction of GHI Health campuses Major reform initiatives Use of private pharmacies by SSK

16. Community Health Center Family Health Center Health Group Presidency Health Center Maternal and Child Health Center Tuberculosis Control Center Institutional Physician Health house SSK Dispensary SSK Health Station Pre- reformPost- reform

17. Family Practitioner Scheme Family practitioners sign a contract with the MoH Funded from the MoH budget Primary Health Care is free Each family medicine unit is responsible for the health and well-being of an assigned group of patients and for coordinating patient care across the health system Capitation based payment system:, higher coefficient for certain categories of the population such as registered pregnant women (adjustment factor of 3), prisoners (adjustment factor of 2.25), children under 4 years and elderly over 65 years (adjustment factor of 1.6). Lump sum money for administrative expenses

18. Family practitioner performance based payment system Two performance levers. salary deduction system contracted providers risk up to 20 percent of their base payment if their family medicine unit fails to meet coverage targets of at least 98 percent key MCH indicators. administrative system ‘warning points’ for failure to meet governance, service delivery or quality standards specified in a set of 35 indicators. If a provider accumulates 100 or more warning points over a contract period his or her contract can be terminated.

19. Salary deduction system Includes eight indicators in one performance domain Immunization coverage rate of registered children for each target vaccination (BCG, DPT3, Pol3, measles, HepB3, Hib3, each assessed separately) Registered pregnant women with a minimum of 4 antenatal care visits according to schedule Follow-up visits of registered babies & children

20. Salary deduction system A deduction of 2% if the monthly coverage rate is 97% to 98% A deduction of 4% if the monthly coverage rate is 95% to 96% A deduction of 6% if the monthly coverage rate is 90% to 94% A deduction of 8% if the monthly coverage rate is 85% to 89%, and A deduction of 10% if the monthly coverage rate is lower than 85%

22. 10 th Anniversary - Impact of the program

23. Per capita visits to a physician MoH, 2013

24. Referrals from the PHC facilities (%)

25. Immunization coverage- Turkey (%) 2002200320042005200620072008200920102011 DaPT182768687929897 98 DaPT2807185848996 98 DaPT3786885849096 97 BCG77767988 9496 97 HBV3726877808296929496 MMR82758184989697 98 CPV3-------979596

26. Antenatal Care Coverage (Minimum one visit) %

27. Pregnant, infant, child and puerperant follow-up activities 200220032004200520062007200820092010 201 1 Average no of follow-ups per pregnant 1.71.82.22.42.73.13.33.64.24.3 Average no of follow-ups per infant 3.43.34.34.85.26.06.46.87.18.1 Average no of follow-ups per child 1.0 1.31.5 1.6 2.0 Average no of follow-ups per puerperant 0.7 0.80.91.01.11.21.41.52.0

28. Overall satisfaction with healthcare services MoH, 2013

29. Satisfaction from PHC services (EUROPEP study) (%) 2008

30. Infant Mortality RateUnder Five Mortality Rate Maternal Mortality Rate MoH, 2013

31. Number of general practitioners per 100 000 population

32. Population per actively working family physician 2011

33. Health promotion programs of the MoH Obesity Control Program Diabetes Control Program Tobacco Control Program Cardiovascular Diseases Prevention and Control Program Global Alliance Against Chronic Respiratory Disease Mental Health Control Program Home Healthcare Program

34. Integrated health care system? No gatekeeping We don’t know the cost of this We don’t know the quality impact No connection with secondary or tertiary care Continuity of care is left to the family practitioner Disease management role?

35. Challenges for integrated health care Shortage of physicians and other health professionals Potential decrease in number of patients for hospitals Paradigm shift in organization and provision of health care services

36. Are we ready for a paradigm shift?

37. European perspective vs Turkish More developed PHC philosophy and organization More awareness about the impact on cost and quality More opportunities for coordination and integration Requirements for cultural change

38. Thank you…… mtatar@hacettepe.edu.tr