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  1. Primary Health Care in TurkeyA Brief History and Current Situation Yrd. Doç. Dr. Memet IŞIKAtatürk University Medical SchoolDepartment of Family Medicine Modified from the presentation of Assistant Prof. Ruşen Topallı - Kocaeli University Medical SchoolDepartment of FM

  2. Objectives • At the end of this lecture, the participants will be able to; • Discuss the brief history of health care services in Turkey • Discuss the brief history of family medicine in Turkey • Discuss the former health care system of Turkey • Discuss ongoing changes in health care

  3. Late Ottoman Period • 1827 First modern Medical School (I. Mahmut Tıphane-i Amire (14 Mart Tıp Bayramı) • 1871 Memleket Tabibi (Country physicians): First primary care tasks... • 1914 General Health Directorate under Ministry of Internal Affairs

  4. Independence War Period • May 1920: Ministry of Health (Minister of First Turkish Grand National Assemly: Dr. Adnan Adıvar) • October 1923: Republic of Turkey

  5. Republic of Turkey (1923) • 12,000,000 population • And 554 physicians...

  6. Early Republic Period • Dr. Refik Saydam (1st Minister of Health 1923 - 1937) • Priority given to preventive services... • Country doctors of Ottoman Empire became government doctors of the new republic... • Hospital services were seen as a duty of local authorities

  7. Government Doctors • Many tasks (104 articles) ... • Environmental health • Forensic tasks • Infectious diseases surveillance • Occupational and school health • Administrative tasks • Free health care of the poor... etc...

  8. Vertical Organizations Specific institutions for specific diseases. Such as: • Trachoma • Malaria • Syphilis • Tuberculosis

  9. 1937 – 1949 Period • Plan for broadening of health care services to small towns and villages... • Health centres for every 20,000 population... • Integration of preventive and curative health services... • Separate health service organization for workers (SSK)

  10. Specialization in General Medicine • 1947, general health specialists for health centres • Probably the first recognition of a primary care specialty in the world • Abandoned in 1955 and general health specialists were given the right to continue in another specialty...

  11. 1950 – 1960 Period • Priority given to hospital medicine... • Local hospitals became units of the Ministry of Health (MoH). • New hospitals opened by MoH.

  12. After 1960:Socialization of Health Services • Act# 224 (May 1961)Prof. Dr. Nusret Fişek • Primary care based health services • 17 years before Alma-Ata

  13. Socialization of Health Services • 1 Sağlık Ocağı (the main primary care unit) for each 5-10,000 population • Teamwork: Physician, nurse, midwife, environmental health technician etc. • Integrated preventive and curative health care services...

  14. However... • All the tasks of the old government doctor transferred to Sağlık Ocağı doctor... • Including environmental health issues, forensic duties...

  15. From 1960 to present... • Socialization broadened to all country... • Number of Sağlık Ocağı’s approached to 6000 (1 SO for 11,500 citizens). • 15,000 physicians work at Sağlık Ocağı’s (1 SO physician for 4,500 citizens) • Every citizen is registered to a Sağlık Ocağı (whether he/she knows or not)...

  16. Socialization of Health Services(A success story or not?) “Socialization, that is succesfully practiced from 1963 to 1965, became unsuccesful after 1966.” Prof.Dr. Nusret Fişek

  17. Why not? • Lack of financial support • Abundance of tasks • Lack of personnel motivation • Lack of lab./imaging facilities • Loss of trustworthiness • Inadequately educated personnel (esp. physicians)

  18. From 1990’s to present day... • An initiative from the government... • Called HEALTH TRANSITION PROJECT • A new primary care system promoted called: “family medicine model” • Caused confusion about family medicine“a discipline” or “a system”

  19. From 1990’s to present day... • Family medicine model is percepted as privatization in health care... • Most parties at the left wing of political spectrum are against this system, on the other end, central and right wing parties all include “family medicine” in their programmes...

  20. The specialty of family medicine And family physicians tried to explain: • Family medicine is not a system, it is a medical specialty and discipline... • And family physicians are the main primary care physician workforce of any health system...

  21. Specialization in Family Medicine • 1983 Regulation basis completed... • 1985 Training began in 9 teaching hospitals • A 3-year-all-hospital-rotation programme • Internal medicine 4 months, Obst-Gyn. 4 months, pediatrics 5 months, psychiatry 2 months, Chest dis. 1 months, cardiology 1 months, general surgery 1 months http://kurullar.saglik.gov.tr/kurullar/tuk/TUK%20Karar%2082.pdf

  22. TAHUD • Turkish Association of Family Physiciansestablished in 1990

  23. Some milestones... • Departments in Universities (1993) • 1st National Congress of Family Medicine (İstanbul, 1993) • Branches of TAHUD (İstanbul 1993, İzmir 1995, Ankara 1998, Bursa 2000)

  24. Some milestones... • 1st attendance to WONCA-Europe Meeting (1995) • Turkish Journal of Family Practice (1997) • Decision to join WONCA (1998)

  25. Today... • 2000 family physicians distributed to 90% of the country • 45 academic departments out of 70 medical schools • 8 national congresses (9thwill be 31 Sept-3 October 2010 Antalya) • Member of Wonca

  26. While these are happening... • Turkish Medical Association (one of those who equalize “family medicine” and “privatization of health services”) made repeated attempts to end family medicine, to close departments at the universities, etc...

  27. Turkey today (physician workforce) • 72,500,000 population • 95,000 physicians • 45,000 specialists (including 2000 FPs) • 15,000 trainees in various specialties • 35,000 practitioners (w/o vocational training after completion of medical school) • (25,000 medical students...)

  28. Current status of primary care... Hospital Sağlık Ocağı (ASM) Patient Is that so simple?

  29. Certainly not... • To understand the (complexity of) health care services, one should first try to understand social security system of Turkey...

  30. Who pays for health services? • SSK (workers) 45% • Bağ-kur (self-employed) 15% • State employees 10% • Emekli Sandığı (retired state employees) 4% • Yeşilkart (no-insurance & poor) 15% • Private insurance 1% • Self paying or none 10%

  31. SSK Hospital SSK Teaching Hospital SSK SSK ACC University Hospital Bağ-Kur Sağlık Ocağı Private Hospital State Employee MoH Hospital Ins. HC MoH Teaching Hospital Yeşilkart Retired Former Turkish health care sytem (simplified version)

  32. TSM:Toplum Sağlığı Merkezi SGK: Sosyal Güven Kurumu University Hospital ASM: Aile Sağlığı Merkezi Private Hospital State Employee MoH Hospital Private Ins. MoH Teaching Hospital Yeşilkart Retired New Turkish health care sytem

  33. The Health Transition Project • All social security plans are united in a single “general health insurance” • Personal “family physicians” for every individual rather than territory based primary care • Family physicians and practitioners are recruited as “family physicians” • Payment system become salary + per capita

  34. Thanks for joining... Ref: Dr. Ruşen TopallıKocaeli University Medical SchoolDepartment of Family Medicine