Economic Research Forum (ERF)

Universal primary care lowers mortality: evidence from Turkey

345
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

Fair competition is needed to empower women economically in the Arab world

The participation rates of women in the labour market in Arab countries are the lowest in the world. This column argues that remedying the under-representation of women in the labour force is a social and economic imperative for the region. There are three dimensions for action to realise the potential of Arab women: amending laws and regulations; instilling fair competition in markets; and promoting the digital economy.

Recession without impact: why Lebanese elites delay reform

The survival of Lebanon’s political elites is highly dependent on the wellbeing of the economy. Why then do they delay necessary reform to avoid crisis? This column examines the role of politically connected firms in delaying much-needed economic stabilisation policies.

Competition laws: a key role for economic growth in MENA

Competition policy lacks the attention it deserves in the countries of the Middle East and North Africa (MENA), a region characterised by monopolies and lack of market contestability. As this column explains, there are many questions about the extent of anti-competitive barriers facing new market entrants in the region. What’s more, MENA’s weak overall performance on competition is likely to be hindering economic growth and the path towards structural transformation.

The future of Egypt’s population: opportunities and challenges

Egypt’s potential labour supply depends on the growth and changing composition of its working-age population. This column reports the latest data on labour supply and fertility rates, concluding that the country has a window of opportunity with reduced demographic pressures to try to address longstanding structural challenges for the labour market.

Formidable challenges facing the Middle East require a sea change in economic policies

Weakening global growth, endemic conflicts and increased tensions within the Middle East and North Africa (MENA) – as well as emerging challenges such as climate change and rapid demographic shifts – are likely to have an adverse impact on the region’s economic, social and political stability in the coming years. This column outlines the policy responses that are needed to avert disaster.

Domestic demand and competition: a new development paradigm for MENA

A lack of competition in domestic and regional markets is holding back development in the Middle East and North Africa. This column argues that the region and the international community must ensure that barriers to market entry and exit are eliminated, and that independent regulatory bodies at the national and regional levels help to promote domestic demand as the main engine for sustainable and inclusive growth.

Effects of urbanisation on productivity and wages: evidence from Turkey

Are the substantial productivity gains associated with larger cities in developed countries similar for developing countries? This column provides evidence on urbanised economies in the non-Western world by focusing on Turkey, a country that has experienced fast urbanisation and a high rate of growth of the urban population.

How import dependence could lead to corruption in MENA

Export-led development strategies have had little success in MENA countries; what’s more, instruments of earlier import-substitution strategies – such as state-owned enterprises, high tariffs and subsidies – have survived. As this column explains, these legacies have created crony-capitalist industries that have limited the level of competition in many sectors of the economy and furthered the region’s dependence on imports.

Gender discrimination in small business lending: evidence from Turkey

Discrimination in access to financial services can prevent women from exploiting their entrepreneurial potential. This column reports on a ‘lab-in-the-field’ experiment to test for the presence of gender discrimination in small business lending in Turkey.

Social security for young workers in Arab countries

Social security coverage of young workers in Arab countries is low – in part because many are employed in informal jobs; and in part because they do not see the value of the system. This column reports survey evidence on young workers’ attitudes towards participation in both social security and politics. It also explores policy reforms that might make access to social security universal for young workers.