Economic Research Forum (ERF)

Universal primary care lowers mortality: evidence from Turkey

848
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

Happiness in the Arab world: should we be concerned?

Several Arab countries have low rankings in the latest comparative assessment of average happiness across the world. But as this column explains, the average is not a reliable summary statistic when applied to ordinal data. The evidence from more robust analysis of socio-economic inequality in happiness suggests that policy-makers should be less concerned about happiness indicators than the core development objective of more equitable social conditions for citizens.

It’s too early to tell what happened to the Arab Spring

Did the Arab Spring fail? This column presents a view the consensus view from ERF’s recent annual conference in Morocco: careful analysis of the fundamental drivers of democratic transitions suggests that it’s too early to tell.

Arab regional cooperation in a fragmenting world

As globalisation stalls, regionalisation has emerged as an alternative. This column argues that Arab countries need to face the new realities and move decisively towards greater mutual cooperation. A regional integration agenda that also supports domestic reforms could be an important source of growth, jobs and stability.

Reformed foreign ownership rules in UAE: the impact on business entry

In an effort to stimulate economic growth and diversify the economy, the government of the United Arab Emirates has recently implemented regulatory reform that allows 100% foreign ownership of companies operating in the country. This column examines the implications of the reform for entry of new firms in Dubai, using unique data on new business licences in the emirate.

Self-employment in MENA: the role of religiosity and personal values

How important are individual’s values and beliefs in influencing the likelihood that they will embrace the responsibilities, risks and entrepreneurial challenge of self-employment? This column presents evidence from 12 countries in the Middle East and North African region on the roles of people’s religiosity and sense of personal agency in their labour market choices.

Gender differences in business record-keeping and planning in Iraq

Only one in every ten informal businesses in Iraq is led by a woman. Yet as research summarised in this column reveals, those businesses are more likely to set budgets and sales targets, and to keep business records. This may be evidence of the role of social exclusion in motivating greater reliance on the formal bureaucratic system.

Conflict and debt in the Middle East and North Africa

With the global economy is in its third year of deceleration amid declining inflation and oil prices, the Middle East and North Africa grew by just 1.9% in 2023, with a forecast for growth in 2024 at 2.7%. In addition to heightened uncertainty brought on by the conflict centred in Gaza, many countries in the region are also grappling with pre-existing vulnerabilities, including rising debt levels. This column summarises a new report that unpacks the nature of debt in MENA – and explains the critical importance of keeping rising debt stocks in check.

Making aid-for-trade more effective in the MENA region

Aid-for-trade represents an important opportunity for developing countries to enhance their trade capacities. But the positive effect of aid-for-trade on exports can hinge on the quality of institutions in recipient countries. According to research reported in this column, in the Middle East and North Africa, it is specific aid types – such as aid to support trade policy reform and aid to enhance productive capacities – that matter most for exports.

Sanctions and carbon emissions in Iran

How are Iran’s energy use and emissions of carbon dioxide affected by the imposition of economic sanctions? This column summarises new research that analyses a range of different scenarios and which takes account of multiple economic, social and environmental dimensions, notably what happens to growth and energy intensity, and whether sanctions are lifted.

Can a free trade area in services boost trade within the Arab region?

With trade in goods among Arab countries remaining modest, trade in services could play the pivotal role of an engine of growth in economic integration within the region, as well greater participation in global value chains. This column outlines progress to date and what needs to be done to make a success of AFTAS, the Arab free trade area in services.




LinkedIn