Economic Research Forum (ERF)

Universal primary care lowers mortality: evidence from Turkey

1002
In 2005, Turkey extended basic healthcare services to its entire population under a free-of-charge, centrally administered system. This column reports research showing that the programme was successful in lowering mortality rates across provinces, particularly for the most vulnerable. The findings provide compelling evidence in support of providing accessible healthcare services to all citizens.

In a nutshell

Turkey’s Family Medicine Program, first introduced in 2005, led to reductions in the country’s mortality rates, particularly among the most vulnerable populations – infants and the elderly.

The Program also contributed towards an equalisation of disparities in mortality rates across provinces.

Extending healthcare services to all citizens is critical to achieving universal coverage and improving public health.

The goal of universal health coverage is for all citizens to obtain adequate and basic health services without fear of financial hardship from unaffordable out-of-pocket payments. A question for any country with this ambition is how to establish a healthcare delivery system that can achieve and maintain universal coverage of health services. Countries living up to this challenge have usually taken two main approaches.

In the first group are countries that have taken a predominantly demand-side approach through mechanisms such as health insurance, user fees on the basis of ability-to-pay, and conditional cash transfers. In the second group are countries that have opted for mainly supply-side schemes through extending government-financed public provision of healthcare services, or creating incentive mechanisms that financially motivate providers to expand their coverage.

A notable example of a supply-side healthcare intervention is Turkey’s Family Medicine Program (FMP), which has extended basic healthcare services to the entire Turkish population under a free-of-charge and single-payer system that is fully financed and administered by the central government.

The programme was first initiated as a pilot in 2005 in the province of Düzce, and gradually expanded to cover the entire Turkish population living in all 81 provinces by the end of 2010. Currently, the FMP provides healthcare services to all Turkish citizens, and employs over 21,000 family physicians – all public employees – in roughly 6,768 and 971 family and community health centres, respectively.

There is evidence crediting the FMP with increased patient satisfaction and use of healthcare services, but there has not been a rigorous evaluation of the programme’s impact on measures of health outcomes. This is despite the scope and the scale of the Turkish programme, which makes it arguably one of the most ambitious and comprehensive efforts ever implemented in a developing country with the goal of achieving universal health coverage.

The signature feature of the Turkish FMP is the assignment of every citizen to a ‘family physician’, who constitutes the central and first point of contact for patients. Every Turkish citizen is required to register with a particular family physician who is in charge of providing a wide range of healthcare services at neighbourhood clinics that operate on a walk-in basis.

Through the FMP, essential and primary healthcare services are treated through the family health services located within the communities. For conditions that are more complicated or require specialists, patients are referred to hospitals. Therefore, the FMP also helps to reduce the pressure and the waiting time for more serious and complicated conditions at the hospitals, which in turn might improve health at a lower cost.

Changes in mortality can be attributed to the fact that the FMP has dramatically improved the quality and access to primary care in terms of preventive, curative, and rehabilitative services, especially for pregnant women, new mothers, infants, children, and the elderly, whose healthcare needs are the major focus of the FMP.

The FMP has essentially established a socialised medicine programme for basic healthcare services, as the services are provided free-of-charge by state-employed family physicians. This is in sharp contrast with most other interventions, especially those with demand-side incentives, which primarily focus on the impact of reducing out-of-pocket healthcare expenses.

In our research, a comprehensive evaluation of the impact of the FMP, we analyse data for the period 2001-14, making use of the fact that the FMP rolled out gradually across Turkish provinces and over time in order to identify the programme’s effect on age-specific mortality rates in Turkey.

Our analysis indicates that the FMP has led to reductions in mortality rates. But the benefits associated with the FMP appear to be the strongest among the most vulnerable populations – infant and the elderly for mortality rates.

Furthermore, our results indicate that the programme resulted in a more rapid reduction in mortality in provinces with a higher baseline mortality rate. This implies that the FMP might have also contributed towards an equalisation of disparities in mortality rates across provinces.

Overall, our analysis provides compelling evidence in support of the view that extending healthcare services to all citizens is critical to achieving universal coverage and improving public health.

Further reading

Cesur, Resul, Pinar Güneş, Erdal Tekin and Aydogan Ulker (2017) ‘The Value of Socialized Medicine: The Impact of Universal Primary Healthcare Provision on Mortality Rates in Turkey’, Journal of Public Economics.

A longer version of this summary is available at VoxEU.

Most read

Trust in Lebanon’s public institutions: a challenge for the new leadership

Lebanon’s new leadership confronts daunting economic challenges amid geopolitical tensions across the wider region. As this column explains, understanding what has happened over the past decade to citizens’ trust in key public institutions – parliament, the government and the armed forces – will be a crucial part of the policy response.

Climate change: a growing threat to sustainable development in Tunisia

Tunisia’s vulnerability to extreme weather events is intensifying, placing immense pressure on vital sectors such as agriculture, energy and water resources, exacerbating inequalities and hindering social progress. This column explores the economic impacts of climate change on the country, its implications for achieving the sustainable development goals, and the urgent need for adaptive strategies and policy interventions.

Small businesses in the Great Lockdown: lessons for crisis management

Understanding big economic shocks like Covid-19 and how firms respond to them is crucial for mitigating their negative effects and accelerating the post-crisis recovery. This column reports evidence on how small and medium-sized enterprises in Tunisia’s formal business sector adapted to the pandemic and the lockdown – and draws policy lessons for when the next crisis hits.

Assessing Jordan’s progress on the sustainable development goals

Global, regional and national assessments of countries’ progress towards reaching the sustainable development goals do not always tell the same story. This column examines the case of Jordan, which is among the world’s leaders in statistical performance on the SDGs.

The threat of cybercrime in MENA economies

The MENA region’s increasing access to digital information and internet usage has led to an explosion in e-commerce and widespread interest in cryptocurrencies. At the same time, cybercrime, which includes hacking, malware, online fraud and harassment, has spread across digital networks. This column outlines the challenges.

Qatarisation: playing the long game on workforce nationalisation

As national populations across the Gulf have grown and hydrocarbon reserves declined, most Gulf countries have sought to move to a more sustainable economic model underpinned by raising the share of citizens in the productive private sector. But, as this column explains, Qatar differs from its neighbours in several important ways that could render aggressive workforce nationalization policies counterproductive. In terms of such policies, the country should chart its own path.

Economic consequences of the 2003 Bam earthquake in Iran

Over the decades, Iran has faced numerous devastating natural disasters, including the deadly 2003 Bam earthquake. This column reports evidence on the unexpected economic boost in Bam County and its neighbours after the disaster – the result of a variety of factors, including national and international aid, political mobilisation and the region’s cultural significance. Using data on the intensity of night-time lights in a geographical area, the research reveals how disaster recovery may lead to a surprising economic rebound.

Macroeconomic policy-making for sustainable development in Egypt

In recent years, economic policy in Egypt has been focused primarily on macroeconomic stabilisation to curb inflation, to reduce the fiscal deficit and the current account deficit, and to increase GDP growth. As this column explains, this has come at the expense of the country’s progress on the Sustainable Development Goals, which is rather modest compared with other economies in the region or at the same income level. Sustainable development needs to be more integrated with the conception and implementation of fiscal and monetary policies.

Education and health in Tunisia: is human capital at risk?

Tunisia has made significant strides in enhancing the skills, knowledge and health of its population, all cornerstones of economic growth and social progress. This column examines the state of the country’s education and healthcare systems, identifying structural weaknesses that could jeopardise human capital and, by extension, progress towards achieving the sustainable development goals.

Qatar’s pursuit of government excellence: promises and pitfalls

As Qatar seeks to make the transition from a hydrocarbon-based economy to a diversified, knowledge-based economy, ‘government excellence’ has been identified as a key strategic objective. This column reports what government effectiveness means in terms of delivery of public services, digitalisation of services, and control of corruption – and outlines the progress made to date on these development priorities and what the country needs to do to meet its targets.