Turkey’s successful overhaul of its healthcare system to include universal coverage and improved services is receiving international plaudits. Once a primarily public system plagued with long lines, inadequate training, and heavy bureaucracy, Turkey has created a hybrid public/private system that many around the world now emulate. Since 2003, Turkey has improved insurance coverage of the poorest from 2.4 million people in 2003, to 10.2 million in 2011. Health service access has also improved for women and children.
Former health minister Recep Akdağ, who oversaw the changes, speaks here with Solutions about these reforms, the future of health care in Turkey, his recommendations for President Obama, and the importance of “keeping it simple.”
A trained physician, Akdağ studied at the Faculty of Medicine in Ataturk University and Kings College in London. He later became a professor at Ataturk University and served in the administration, before being elected for Parliament and appointed the national Minister of Health in 2002. He served at this a post until January of 2013.
Can you describe the state of the healthcare system before these reforms, and what triggered introducing the system?
The reforms started in 2002. Before then, the situation in Turkey was not good, economically, socially, or politically. We had a coup in 1997—not a real military coup, but the military nonetheless pushed the government to leave its position and then took power. So the situation was very bad. At the same time, surveys showed people were desperate for change: The financial institutions were bad. Health care coverage was very bad. On paper, all insured people had coverage, but this was just on paper. Almost all specialists had private offices and also positions in public hospitals. Public hospitals were crowded and ineffective. If you needed to get a service from a hospital, you had to go to a private office and pay extra. That caused catastrophic expenditures. There was no emergency transport for rural areas, and even in the towns you had to pay money if you needed an ambulance. The poor had rights to take services as inpatients, but they had to pay for prescriptions, which was financially very hard.
Turkey is surrounded by instability—in Syria, Iraq, Egypt, and Lebanon. What role does political stability play in a nation’s ability to enact health care reform?
The role political stability played was very important. Before 2002, before the Justice and Development Party took office, and before the coup, the government was weak; it was unstable. But in 2002, the Justice and Development Party won the majority with 34 percent of the total vote. We took office as a single party, and established a strong government. In 2007, the second election for our new party, we increased our percentage of the popular vote to 47, and in the third election, our vote increased to 50 percent.
Over the last 10 years, Turkey has benefited greatly from political stability and a strong government; this helped with all of the recent reforms, including health reform. There is instability in Iraq and Syria, but those situations don’t affect us. National stability allowed us to make reforms, and as we made more reforms, the trust of the people increased. We eventually felt that we could make reform across the whole system of government.
In the early years of any transformation, if you have enough support and trust from the public, then you can continue on. Without that trust, it is very difficult, especially in health, because there are a number of strong stakeholders in this sector. You have to be fast to make important changes.
Regarding providing health care, is there a deeper argument about the role of public systems versus private systems in Turkey?
Not really. In my country, the people generally believe that health is a fundamental human right. So [nongovernmental organizations] and other groups stand behind the public system. Before our term, we had a strong public system but it didn’t work well. We had a private health sector in our country, as well, but less than 2 percent of the population has private health insurance. We created a single-payer system for everybody, including poor people. We are all under one roof. All insurance systems are under one roof and we have one strong single-payer system. Now 98 percent of our population is under this umbrella. The benefit package is the same for all the people.
We created equity in health care. If you are rich, you can go to a private hospital and receive private service. At the same time we strengthened providers on the public side. So now we have strong public health care facilities in our country. When you need to go to a hospital or specialist but you have a low income, then you can go to any public hospital. If you are of the middle class, you can choose public or private, and the system will pay for you up to a cap, and you will have to pay the difference. So the system works very well. We protect all the citizens.
There is one more important point: if you need an emergency service, and have a problem like cancer or heart disease, the private hospital will not charge you—the public system pays for you. And all the transportation, like ambulances—even airlift ambulances, which we have now in Turkey—is free. And all preventable care is also free of charge.
What’s Turkey’s opinion of President Obama’s nationalized health care plan, popularly known as “Obamacare”?
The system is totally different in the United States. It is based on private health insurance, and private hospitals on the provider side. So the system in the U.S. is generally based on the private market. You have Medicare and Medicaid payments by the government, but still the private sector has more power in the market. And your system in the U.S. is very complex. When I taught a class at Harvard, I asked them: What does your health insurance cover? For example, if you need a heart transplant, will it pay? Almost none of them knew the details of their coverage. When some students brought me their papers, I felt I needed an accountant to understand.
This is a problem. Health insurance should be as simple as possible. You never know what you will have coverage for in the U.S. Turkey has a public finance system, and the system treats everyone equally, so you know what you’re getting.
The nature of disease is changing in Turkey, from infectious disease to chronic illness, such as high blood pressure, diabetes, and cancer. How has the Turkish health system responded?
You’re absolutely right. The infant and under-five mortality rates have decreased, as have maternal health issues. Communicable disease and preventable disease rates have dropped and vaccination rates have improved.
We’ve now initiated health-promotion programs. It’s very important to create a healthy lifestyle for the community, mainly to prevent heart disease and strokes, which are often related to weight, inactivity, smoking, and drinking alcohol. We created promotional programs and we have so far been very successful, especially in our tobacco control program. We are the first country in the world, according to the World Health Organization, to achieve all the recommended initiatives regarding tobacco: we increased taxes for cigarettes, banned advertising, banned indoor cigarette smoking, banned sales of cigarettes to children under 18, and we put warning signs and pictures on the packages. This has been very successful. We used to have a saying: “smoking like a Turk.” That is changing now. We changed the percentage of the population that smokes from 33 percent to 26 percent in five years, and the smoking rate continues to decrease. We also created a program for obesity, but this is more difficult because everyone likes to eat, and Turkey has excellent cuisine.
How will the Turkish system keep costs down, especially given aging population by the end of the century?
Our population is aging, but not too fast. We hired McKinsey to make forecasts for 2023: what will be our health expenditures then? We saw that, okay, our health expenditures will continue to increase, but not too much. Our health expenditure in Turkey today is $600 per capita per year. If you correct it according to purchasing power, it comes up to $950 per capita per year. That’s enough to provide all emergency transport free of charge, as well as preventative care, care for pregnant women, and good technology and doctors for everybody.
In the U.S., the average health expenditure is more than $8,000 per capita per year, so it’s a huge difference. Unfortunately, it’s also increasing in the U.S.