Prof. Dr. Sabahattin Aydın, Rector of Medipol University, chairman of the Executive Council of TUSAP Healthcare Platform, former executive board member of the World Health Organization (WHO), former deputy undersecretary (2003-2010) at the Ministry of Health of Turkey, and one of the most respected healthcare leaders in Turkey, provides insights into the historical Health Transformation Program that his team designed and implemented from 2003 onwards, while discussing the critical success factors that rendered possible to overhaul Turkey’s health system and usher in universal health coverage in the country.
As deputy undersecretary of the Ministry of Health, you led the Health Transformation Program (HTP), which introduced major changes to the Turkish health system’s functions of stewardship and organization, financing, resource management, and service delivery to achieve universal health coverage. Could you give us an overview of the Turkish health system and its evolution prior to the implementation of the HTP?
The Turkish Ministry of Health and Social Affairs was established in 1920, a short time after the inauguration of the Turkish Grand National Assembly and three years before the creation of the Republic of Turkey. The newly created Ministry had a special focus on public health, which marked a true disruption with the healthcare approach in force during the Ottoman Empire.
In the 1940s, another significant transformation fostered the centralization of the Turkish health system and Turkey’s Ministry of Health hitherto became the largest healthcare provider in the country. In the 1960s, the Ministry put an emphasis on the development of the primary care network across the country. Turkey eventually embraced a market economy model in the early 1980s, this structural shift also trickled down to the health system: market dynamics started shaping the healthcare sector and the private healthcare industry swiftly began thriving, while we noticed a rapid surge in the number of pharmaceuticals and healthcare technologies available in Turkey. Nevertheless, these market dynamics mainly occurred at the secondary and hospital care levels, while primary care development was still mainly driven by the public sector. The latter developed itself at a slower pace over the years, while being evenly distributed across the country, with a clear lack of capacity in large urban areas, such as Istanbul.
In 2003, I was appointed as Undersecretary of the Minister of Health, whereas I was a clinician with an academic background rather than a bureaucrat. Although I had no experience in public health management prior to joining the Ministry, my academic career as a chief physician at the Yüzüncü Yıl University Hospital provided me with a wealth of on-the-ground experience. When the AK Party entered into power in 2003 after a steep economic crisis, Recep Tayyip Erdoğan [who was serving as Prime Minister at the time – Ed.] established the comprehensive overhaul of the health sector as a priority. This vision translated into the Health Transformation Program (HTP), which was designed and implemented by the team lead by Recep Akdağ, the Health Minister. As the deputy undersecretary and the member of this dedicated team, I was in charge of the monitoring of the implementation of HTP until 2010.
The HTP undoubtedly marked a key development in the Turkish health system, as it led to the rapid expansion of health insurance coverage and access to healthcare services for all Turkish people, especially the poorest population groups. What do you identify as the key success factors that enabled the successful transformation of the health system through the HTP?
First of all, one must keep in mind that Turkey’s healthcare basis, which we further developed through the HTP, was already relatively robust – we clearly did not build a health system from scratch. Turkey had accumulated more than 75 years of experience in health management, and some aspects of our country’s healthcare ecosystem were satisfactory. For example, existing primary care centers displayed a good level of expertise, while – at the secondary care level – almost the entire population was covered – albeit through a variety of social security institutions and benefit regimes for public servants, private workers, independent professions, underprivileged populations, etc.
A first success factor I would however highlight is that we aimed from day 1 to harmonize health benefits for the entire population, and not only for the people that already had existing health coverage.
Political stability also emerged as a crucial enabler of health reforms: for example, when we started designing the HTP, we found out that its full benefits would materialize in the 2030s! In this context, one easily understands why it is typically hard for politicians to invest political capital into bold, health related programs, whose results will not appear before the next election cycle. Turkey’s political stability since 2003 has provided us with the time, continuity, and consistency to successfully implement the HTP.
In a similar fashion, I see political leadership as another crucial success factor that rendered the HTP possible – both at the level of the Ministry of Health and at the head of state. Although intense conversations at times occurred between the Ministry of Health, other Ministries, and the cabinet of the head of state, then-Prime Minister Erdoğan always supported us. Although health expenses soared as a result of increasing health coverage, we never felt any pressure from the head of state to put a spell on increasing expenses or deviate from our initial plans. In the meantime, one should recall that Turkey’s public finances were under close scrutiny in the early 2000s, as the country was still benefitting from an IMF bailout program [which was initiated before Erdoğan acceded to power in 2003]. Despite this difficult context, the HTP was always favored in terms of resources allocation.
Was the HTP the first attempt of a recent Turkish government to reform the country’s health system? If not, how do you explain your team succeeded where others had failed beforehand?
The HTP did not mark the first time that a Turkish government aimed at implementing structural reforms in the health sector; however, previous reform attempts failed because of the internal and external resistance they faced. Resistance is typical to any attempt of reform, and even more so when it comes to any country’s healthcare or welfare system. Resistance to reform typically stems out from the workers of the sector, but also from parts of the population itself; although considered reforms aim to improve the healthcare paradigm in the long term, the population typically focuses it attention on the short-term evolution of its rights and benefits – or what it perceives as such.
To overcome the expected resistance of the population, we first and foremost put a special emphasis on the reform planning and agenda, in order to enable a controlled, incremental overhaul of the country’s health system. In the meantime, we paid attention to not exclusively focus on long-term improvements, which the population and patients would not feel before decades, and looked at introducing quick improvements into the system, even if the latter did not exactly fall within the main objectives of the HTP. Through these quick, short terms improvements, we ensured that both workers and the people did not massively reject the HTP and the team heading its implementation.
To give you an idea, our first reform was to improve the package benefits of underprivileged people, which contributed to build up support among a large share of the Turkish population. In the meantime, the introduction of a reference pricing system for pharmaceuticals tied to a fixed exchange rate allowed us to control medicines spending while significantly increasing access, which allowed us to gain public and political support and move forward the core of the HTP – although medicine spending only accounts for a small share of total healthcare expenditures. Another example relates to the hospital sector: we transferred Turkey’s public hospitals under the responsibility of the Ministry and rapidly optimized health services delivery in the sector – an aspect that patients can easily feel but that was not fundamentally included in the core of the HTP.
In the meantime, my team displayed during many years a level of dedication and commitment that was absolutely sky high. At that time, the AK party was a very young party, and most of its members were new to the exercise of power; there was nonetheless a strong desire to deliver on our promises, which translated into our team members working day and night for the advancement of the HTP. Designing and implementing the HTP was more than a mere professional assignment – we truly were on a mission.
In 2018, very few emerging countries have managed to establish a universal healthcare system, even more so in the early 2000s. Where did you look for inspiration when designing the HTP?
I could perhaps single out the Taiwanese model as an example [which was implemented in 1995 – Ed.], but – overall – we evaluated and studied the health systems of more than 30 countries, while myself and the then-Minister of Health Recep Akdag visited in person many of these countries, from Finland to Cuba or France. We also organized many high-level workshops where experts from both developed and developing countries shared their insights. We gained significant learning from these interactions, but it was truly impossible to copy-paste a given model to the reality of the Turkish ecosystem. More than transposing or adapting a single or a hybrid model from abroad, we took into consideration the insights of other countries but concentrated our efforts on leveraging the heritage of our past and both the strengths and areas for improvement in the existing model.
In 2003, Turkey’s population was still very young; as a matter of fact, in 2017, 50 percent of the Turkish population was still under the age of 31. However, the elderly population is growing two times faster than the rest of the population. Given this looming and rapid epidemiological shift, does Turkey need a new HTP?
In a similar manner as in other countries around the world, our aging population and the increasing healthcare needs it entails stands out as the main challenge ahead of us. There is no new, comprehensive healthcare transformation program being considered at the moment, but the Ministry of Health is envisioning significant reforms, in which elderly care as well as non-communicable diseases management would be targeted in priority.
The HTP truly emerged as an inclusive call towards all healthcare stakeholders and investors in the country to come together and shift Turkey’s healthcare paradigm. The HTP gathered together all healthcare resources available in the country – in an effective way – without making any distinction between the public and the private sectors nor between domestic and foreign institutions and nurtured the development of a sound and intertwined relationship between the private and the public sector. Although there is still an open dialogue going on between these stakeholders, both the relationship in itself and the external context has changed over the past years. As a consequence, I personally believe that this relationship must be updated and further refined, according to the evolving needs of the country.
You are currently the Chairman of the executive council of Turkey’s Health Platform TUSAP, which brings together the heads of leading public and private health organizations and entities as well as trade associations across the country’s healthcare continuum. What is your approach to foster a productive conversation among such a variety of stakeholders – ranging from the government to academia without forgetting the healthcare, pharma and medical devices industries?
First of all, I have been appointed to this position because I somewhat seat at an equal distance from all these stakeholders and from all parts of the healthcare chain – I have no personal interest in helping one stakeholder or one part of the healthcare system over another.
When it comes to stakeholder management, I always prioritize and focus on the bigger picture and aim at including all stakeholders’ inputs, so the decision making process is not altered by a lack of perspective, which would prevent us from integrating valuable insights and solutions. This holistic approach has actually proven itself extremely valuable when we had to make difficult choices on very technical topics during the implementation of the HTP. In the same manner, I always strive to ensure our approach is not limited to the health system or to the scope of action of the Ministry of Health by integrating stakeholders from the education and scientific systems, which both play a crucial role in the procurement of healthcare products and services.
On a personal basis, I always consider my interlocutor as a stakeholder of the healthcare ecosystem, regardless of the size or prestige of the institution or organization he heads, and treat all stakeholders in an absolutely equal manner.
Last but not least, maintaining an utmost level of ethics stands as the only way to gain the respect of such a large variety of stakeholders. In a similar fashion, I have never sought or gained any personal advantage during my time at the Ministry of Health, and none of the decisions I made brought me any kind of perks – my decision-making process was exclusively driven by the perspective of making the HTP successful and ensuring the largest number of Turkish patients could benefit from its completion.
Any final message for our international readers?
If one truly wants to have an impact on people’s and patients’ lives, he has to turn this noble objective into an overarching, life-defining mission, where money and other material contingencies are secondary and personal sacrifices will most likely be required. In the meantime, I again emphasize the importance of political leadership to complete such structural, long-term reforms. However, whether it is at the executive or political level, the main driver remains the same: the unalterable commitment and ambition to improve people’s lives – and this is exactly what happened in Turkey with the HTP.
Patient centricity may have become a platitude in today’s healthcare sector, but this nonetheless stands as the only way to design, lead, implement, and make comprehensive healthcare reform successful. The person in charge of such a critical mission, will have to take critical decisions along the way – the only way to overcome all hurdles and rally the people to this noble cause is to truly and fully put the patients at the core of your endeavor.