Turkey’s former minister of health explains how he is working to pass on his experience and knowledge to the next generation of health policy makers around the world, and discusses the current areas of focus for the Turkish healthcare system.
Could you tell us a bit about how have you spent your time since you left your post as minister of health?
I left office in 2013, and about a month later I was invited to work with the Harvard School of Public Health by my dear friend and the school’s Dean, Julio Frenk. Of course, I accepted this invitation and taught a special course for masters and doctoral students in the autumn of 2013. Harvard was also conducting a special program “Ministerial Leadership in Health” that is still continuing today, and I was selected as a member of the program’s advisory board and resource group. It is a unique program, one that brings together at least 10 to 15 ministers of health from around the world each June, along with the faculty from the Harvard School of Public Health, Kennedy School of Government, assorted academics, and five to eight experienced former ministers of health to act as mentors.
During the same period of time, I also started doing some consultancy work for the WHO and the World Bank, and was invited to give several speeches and participate in discussions on healthcare transformations, universal healthcare, and other health policy related issues. I enjoy this kind of work very much, as I have the opportunity to share my experiences with other people and countries that can benefit from it, and at the same time I continue to learn day by day. I truly believe that learning is a lifelong process, and that we should all strive to learn what we can from each other, and from our experiences.
What do you think was the key to success of your health transformation program?
I oversaw the health transformation in Turkey from 2002 to 2012 on behalf of my party, the Justice and Development party, who made possible some very substantial reforms. At the time we took office in 2002, a long period of coalition had caused politics to stagnate. Turkey was not in a good position with regards to the economy, various social issues, and of course the public health system. The entire country was waiting and hoping for change, and the expectations for this change to happen were very high.
This was both an advantage and disadvantage for us; we were able to gain strong political commitment and public support , which were essential for reforms of the magnitude that were required, but if we had failed it would have been a disaster for the country. Fortunately, we were able to achieve real progress through our efforts, and together the changes that were made transformed the healthcare system in Turkey to the extent that it is now being used as a model for many developing countries.
As a bottom line, I can say that the key success of our transformation program is to have functioning and sustainable universal health coverage in Turkey.
In your capacity as an outside consultant, what is your current advice regarding the Turkish healthcare system?
We achieved a great transformation of the healthcare system in Turkey in a short period of time, and its success has been studied and reported upon extensively, with articles published in the Lancet and several WHO and World Bank publications since 2013. However, there is still much room for improvement, and there are always new expectations and perceptions, emerging problems, and changing resources. Therefore regulators and government should constantly adapt the system to address the new challenges, and in doing so the most important priority is assuring sustainability and stability of core services and capabilities, while evolving to address changing circumstances.
The current defining circumstance in Turkey is that we have limited number of human resources in healthcare, and have the lowest number of doctors per capita in Europe. Following the health reforms the number of medical visits per year by the average Turkish person has increased from below three to over eight visits per year, due to easy access to healthcare, and in some cases healthcare services are being overused. One of the ways that we can directly work against this is by improving health literacy through education.
Promoting healthy lifestyles should be the first priority of our system to fight against the increasing burden of non-communicable disease as the most basic form of preventative medicine. Turkey has already made extensive progress with regards to tobacco control, having accomplished all of the WHO’s MPOWER measures which have had a significant impact on tobacco use thus far. However, we have another public issue which is obesity and inactivity. Turkish people are getting more obese and less active, in part due to urban migration, and we are becoming one of the most obese populations in the world. While we have made the necessary plans and preparations to prevent obesity, there is a lot more we could be doing on this issue.
Another unrelated issue has been created by one of the biggest assets of our healthcare system, which is the very strong single payer national health insurance system. By restructuring and merging the public health insurance system into a single national entity, we were able to cover more than 98 percent of the country’s population, and we have established one of the most powerful public institutions, namely Social Security Institution (SGK). Unfortunately, Turkish civil society is quite weak and we do not have strong NGOs or advocacy groups, to protect citizens’ rights when confronting the health insurance system. This is not an issue as long as the national health insurance committees make the necessary and correct decisions for the public, but in the case that they err, the public will not be able to challenge them on mistakes, as they should. Therefore, I feel that the government should make it a priority to help strengthen patient advocacy groups and civil society, to check and balance the power of the social security institution.
What should the role of the government be in terms of regulation vs. intervention?
It is a tough question, and depends on the country in question. In general, many academics and politicians have theoretical preconceptions, such as the belief that purchasing and provision should be split, or that the ministry of health should be distanced from operations and take on a stewardship role. Promoting decentralization is also very popular, in terms of giving facilities and regions more autonomy.
In my opinion, you need to find a good balance; too much of any one thing will cause issues, be it chaos or inflexibility. Turkey has found a good balance; we have a strong centralized ministry of health, that provides the majority of primary and emergency healthcare services, yet we also have a healthy and growing private hospital system. Ideally, individual public facilities should be given delegated management responsibilities and be funded and assessed objectively based on their performance so that some degree of competition is insured between facilities, and with the private sector itself. These are the keys to achieving quality while controlling costs, and it has allowed Turkey to achieve the excellent benchmark in healthcare that is now fueling health tourism from across the region.
The political power and strength of the ministry of health is essential for maintaining purchasing power and stability, and flexibility and efficiency can be achieved through delegation and private sector procurement. If you look at Chile for example, where the GDP per capita and many health indicators are similar to Turkey’s, they are having a real problem in healthcare because the private system is very strong relative to the public system, and the government is unable to implement meaningful reforms because it is hardly possible to merge or restructure the systems. As such, they have a high cost high quality private system and a lower quality inefficient public system, and are facing significant obstacles in their efforts to create a high quality efficient cost national system.
For innovation, how can the government support innovation while the focus remains on prices?
We discussed these issues a lot with the industry during my term as well, and I know that there are currently some very heated debates. I believe that having almost 80 million people in Turkey, having a well functioning, sustainable health insurance system for all the people is the most important priority. Our aim is to sustain the access to services, and all drugs, new drugs, particularly in accordance with evidence based drug use. At the same time, our strong social health insurance system has very strong purchasing power to make good bargains, and we have had to put some pricing rules in place to keep healthcare expenditures within responsible limits. That said, the situation has changed since the system was introduced, and the government understands that the status quo is not sustainable.
Regarding how we can make encourage pharmaceutical R&D activities in Turkey, I believe that they key is for companies to be incentivized by the basic science infrastructure, academic research, and talent. The ministry of science and technology is working to increase Turkey’s capabilities in these areas, and there is a wide array of financial incentives to attract investment from multinationals. However, we already have a healthy global clinical trial industry with a wide array of international pharmaceutical companies conducting clinical studies in Turkey, and our national health system makes patient recruitment is very straight forward.
How important is it for a domestic Turkish pharmaceutical industry to survive and prosper for this to be achieved?
Our domestic industry, especially in terms of generic production, is excellent. They have excellent GMP standards and features in their facilities, and produce very high quality generic products. If the government introduces the right incentives to the local industry, perhaps we can stimulate meaningful investment in R&D as well.
However, as I said before, the current reimbursement prices are not sustainable for many companies, and this is understood. It is necessary to make a sincere dialogue between the industry and government, however the industry needs to resist the temptation to focus on their profits; a new “win-win” solution must be found, it will soon be time for all of the relevant stakeholders to begin discussing and negotiating such a solution.