General Health Insurance Financing of Health Services in Turkey and Restructuring of the Ministry of

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• General Health Insurance Financing of Health
  Services in Turkey and Restructuring of the
  Ministry of Health
• 1 April 2006
• Istanbul, Turkey

Dr. Rifat A. Atun WHO Consultant Director,
Centre for Health Management Imperial College
London
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Health Systems Strengthening

• Key to achieving our goals
• Improved level and distribution of health
• Fair financing with financial risk protection
• User satisfaction

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Effective Stewardship

• Informed by evidence key to strengthening health
  systems

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Progress to dateRemarkable achievementscatalyse
d by strong political leadership a strong
technical team
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Not reinventing the wheelevidence informed
policy devleopment
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Stewardship and Organizational Arrangements

• Structural changes
• Integration of SSK hospitals into MOH provider
  network
• Restructuring the MoH
• Restructuring of MoLSS
• Structured pluralism
• Net result Purchaser-provider separation
• Enhanced accessibility
• Improved efficiency
• Purchaser moving to the driving seat
• User at centre of decision making

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Financing

• Move to a Universal Health Insurance Scheme
• Cost-sharing
• Performance related pay revolving fund
• Net result
• Equity enhancing access and accessibility
• Improved efficiency harmonization
• Improved quality better standards
• Transparency

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Service delivery

• Family Medicine Centred Primary Health Care
• Citizen centred health care delivery model
• Improved efficiency referral-counterreferral
  system improving
• Increased user satisfaction
• Quality accreditation

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Resource generation and utilization

• Structured pluralism
• Engage the private sector
• Develop capacity
• Re-established Hifzisihha
• Training of doctors and health staff, especially
  those working at PHC level
• Motivational initiatives
• Incentives
• Contracts

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So what are the remaining challenges?
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Inefficiencies in health systems

• I once asked a worker at a crematorium who had
  a curiously contented look on his face, what he
  found so satisfying about his work. He replied
  that what fascinated him was the way in which so
  much went in and so little came out.
• I thought of advising him to get a job in the
  NHS....
• Archie Cochrane

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Total Health Expenditure as a of GDP
Source OECD Health Data
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Life expectancy at birth and health spending per
capita, 2003
Source OECD Health Data
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Need to look ahead, or.
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1. Strengthening the Stewardship Role

• Expand role and articulate strategy to inform
  function and structure

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Mexico Example

• System Development
• Policy Development
• Strategic Planning
• Intersectoral collaboration
• Social Mobilization
• Formulating standards
• Defining priorities and articulating these in
  service packages

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Mexico Example

• 2. Coordination of the health system
• Capacity
• Use of high technology
• 3. Financial design
• Not purchasing or payments
• 4. Regulation
• Sanitary public health
• Health care services accreditation,
  certification, licencing
• 5. Consumer protection
• MOH becomes the champion of the citizen

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2. Decentralization
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Letting go
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Prepare the ground for

• Local governance
• Autonomous hospitals

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Decentralisation v.s. Integration
Decentralisation Low
Desired direction of reforms
Integration Low
Integration High
Necessary shift in direction of reforms
Direction of reforms
Decentralisation High
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3. Further strengthen the role of the GHIS as a
strategic purchaser
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Strategic purchasing

• Commissioning
• Contracting
• Instruments that focus on quality, outcome and
  efficiency and
• Contestability
• Structured pluralism
• Responsive providers

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Balancing incentives with organizational targets
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4. Accelerate structural shiftsInformed by needs
and supply side capability embedded in strategic
planning process
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Strategic positioning of providers the era of
close to client service delivery
Highly differentiated services
Tertiary University Hospitals
District General Hospitals
Wide geographic coverage
Local coverage
Primary Community Care
Less differentiated services
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Cross cutting investments
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1. Joined up governance

• Co-operation

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1. Joined up governance

• Joined up needs assessment
• Joined up priority setting
• Joined up strategic planning

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2. Joined up monitoring and evaluation
Data
Information
Knowledge
Policy action
Establishing sustainable ME function
Generate local evidence
Evidence informed decisions
Analytic capacity
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Data Transformation Cycle
Health Monitoring
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3. Invest in human resources

• Develop key skills and competences for
• Stewardship
• Strategic purchasing
• Effective provision
• Developing informed users

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Empower and enable

• Releasing from the hands of bureaucracy

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4. Communication

• Robust and sustained communication
• Social mobilization
• 360 Advocacy

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If not now when?If not us
WHO?
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Girne - Cyprus