PROF. DR. MEHTAP TATAR HACETTEPE UNIVERSITY FACULTY OF ECONOMICS AND ADMINISTRATIVE SCIENCES
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“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
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“ 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 . Agenda. Meaning of PHC and integrated PHC - PowerPoint PPT Presentation
Transcript of PROF. DR. MEHTAP TATAR HACETTEPE UNIVERSITY FACULTY OF ECONOMICS AND ADMINISTRATIVE SCIENCES
“INTEGRATION: THE STORY FROM HEALTH ECONOMICS AND HEALTH
POLICY PERSPECTIVE WITH EXAMPLES FROM TURKEY AND EUROPE”
PROF. DR. MEHTAP TATAR
HACETTEPE UNIVERSITYFACULTY OF ECONOMICS AND ADMINISTRATIVE SCIENCESDEPARTMENT OF HEALTHCARE MANAGEMENT
Agenda• Meaning of PHC and integrated PHC• PHC in Turkey• Impact of the Health Transformation Program• Concluding remarks
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
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.
Thank you for putting me back on the track!
Definition of PHC
Comprehensive Definition Narrow 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
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
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
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
PHC in Turkey
Definition of PHC- Turkey 1990s
Comprehensive Definition Narrow 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
Health Transformation Program2003 -
• Purchaser-provider split• Family practitioner scheme• General health insurance• Performance based payment• Hospitals with administrative and financial autonomy
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
Community Health Center
Family Health Center
Health Group PresidencyHealth CenterMaternal and Child Health CenterTuberculosis Control CenterInstitutional PhysicianHealth houseSSK DispensarySSK Health Station
Pre- reform Post- reform
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
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.
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
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%
10th Anniversary - Impact of the program
Per capita visits to a physician
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.01.1
1.3
1.3
1.7
1.9
2.2
2.5
2.8
2.7
3.3
2.0
2.1
2.4
3.0
3.4
3.9
4.2
4.5
4.6
4.9
3.2
3.4
3.8
4.7
5.3
6.1
6.7
7.3
7.3
8.2
Primary Healthcare Secondary and Tertiary HealthcarePer capita visits
MoH, 2013
Referrals from the PHC facilities (%)
2002 2003 2004 2005 2006 2007 2008 2009 2010 20110.0
5.0
10.0
15.0
20.0
25.0
22.0
18.2
13.2
10.2
6.4
2.41.3 1.0 0.4 0.7
Immunization coverage- Turkey (%)2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
DaPT1 82 76 86 87 92 98 97 97 98 98
DaPT2 80 71 85 84 89 96 96 96 98 98
DaPT3 78 68 85 84 90 96 96 96 97 97
BCG 77 76 79 88 88 94 96 96 97 97
HBV3 72 68 77 80 82 96 92 94 96 96
MMR 82 75 81 84 98 96 97 97 97 98
CPV3 - - - - - - - 97 95 96
Antenatal Care Coverage (Minimum one visit) %
Mideastern Anatolia
Southeastern Anatolia
Northwestern Anatolia
Turkey
Eastern Blacksea
Central Anatolia
Mediterrean
Western Blacksea
Western Anatolia
İstanbul
Western Marmara
Aegean
Eastern Marmara
0 20 40 60 80 100 120
49
56
49
70
74
69
74
72
75
79
80
76
79
85
85
87
95
96
98
98
99
99
99
99
99
99
2011 2002
Pregnant, infant, child and puerperant follow-up activities
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Average no of follow-ups per
pregnant1.7 1.8 2.2 2.4 2.7 3.1 3.3 3.6 4.2 4.3
Average no of follow-ups per
infant3.4 3.3 4.3 4.8 5.2 6.0 6.4 6.8 7.1 8.1
Average no of follow-ups per
child1.0 1.0 1.3 1.5 1.5 1.6 1.6 1.6 1.6 2.0
Average no of follow-ups per
puerperant0.7 0.7 0.8 0.9 1.0 1.1 1.2 1.4 1.5 2.0
Overall satisfaction with healthcare services
2003
2004
2005
2006
2007
2008
2009
2010
2011
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
39.3
19.9
19.1
18.0
15.3
16.7
16.7
13.8
12.0
23.2
33.2
25.6
29.7
18.3
19.9
19.3
13.1
12.2
39.5
46.9
55.3
52.3
66.5
63.4
65.1
73.1
75.9
Moderately satisfied Unsatisfied Satisfied
MoH, 2013
Satisfaction from PHC services (EUROPEP study) (%)
Health Center Family Health Center65
70
75
80
85
90
95
75
90
20112008
Infant Mortality Rate Under Five Mortality Rate
Maternal Mortality RateMoH, 2013
Number of general practitioners per 100 000 population
İstanbul
Southeastern Anatolia
Western Anatolia
Eastern Marmara
Turkey
Mediterranean
Mideastern Anatolia
Aegean
Western Marmara
Central Anatolia
Northeastern Anatolia
Western Blacksea
Eastern Blacksea
35
33
48
47
47
49
43
57
49
59
41
58
51
42
49
53
53
53
54
56
58
58
59
60
63
64
2011 2002
Population per actively working family physician 2011
Central Anatolia
Western Blacksea
Aegean
Northeastern Anatolia
Eastern Blacksea
Mediterranean
Eastern Marmara
Western Marmara
Turkey
Mideastern Anatolia
Western Anatolia
Southeastern Anatolia
İstanbul
3,507
3,511
3,525
3,529
3,570
3,663
3,677
3,686
3,696
3,744
3,818
3,848
3,883
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
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?
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
Are we ready for a paradigm shift?
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
Thank you……[email protected]
