Lessons from Turkey’s achievements in universal health coverage

With political will, Turkey achieved universal health coverage in a decade, improving life expectancy, maternal mortality and citizen satisfaction

By Recep Akdağ, deputy minister of health, Turkey

In February 2013, I received a letter from Julio Frenk, who was the dean of Harvard T.H. Chan School of Public Health. At that time, my duties as the minister of health of Turkey since 2002 had just ended. Turkey’s Health Transformation Programme, which we carried out during that period, had achieved great success.

In an article in The Lancet, Rifat Atun and his colleagues put this achievement into words: “After 30 years of slow progress, since 2003 Turkey has been able to design and implement wide-ranging health system reforms to achieve universal health coverage that substantially reduced inequities in health financing, health service access, and outcomes”.

Julio’s letter included an invitation to lead an eight-week seminar for post-graduate students, in addition to my existing responsibilities for the Ministerial Leadership in Health programme at Harvard University. I gladly accepted the invitation and decided to present a section from the movie John Q in my first seminar.

This movie is about the story of a father who, for financial reasons, was not able to get treatment for his son who needed a heart transplant. John Q makes us realise the profundity of the concept of health for all or, in more recent terms, universal health coverage. I would like to highlight that, with its focus on humanity and equity, providing universal health coverage is much more than just having health insurance.

We achieved universal health coverage in Turkey in 10 years, not only by increasing the insurance coverage to 99% but also by ensuring quick access to high-quality services without financial hardship.

Through the HTP, citizen satisfaction rates increased from 39% to 75%, life expectancy at birth improved from 72 to 78 years, the maternal mortality ratio was reduced from 64 to 14 per 100,000 births, and households with catastrophic health expenditure decreased from 81 to 14 per 10,000 households.

To maintain these figures, we spend only $500 per capita in a year, out of which $400 comes from public funding.
Nevertheless, the stagnation in these indicators from the end of the HTP until 2019 implies that we need a second phase of transformation in Turkey. I strongly believe that it is necessary to simultaneously focus on the final goals of a health system (namely health status, satisfaction, financial protection and sustainability) and the regenerative logic of the policy cycle.

The importance of political will for equity

John Q has a happy ending. However, in most regions of the world, including many rich countries – such as the subject of the movie, the United States – patients do not always end up in such happy scenarios.

There are hundreds of millions of people who cannot access their most basic healthcare needs, which I believe is a fundamental human right. Unfortunately, catastrophic and impoverishing healthcare expenditures are ruining families around the world.

So, what should we do? Of course, there are numerous technical solutions to the problem, such as establishing single-payer insurance with an equitable benefit package, restructuring primary care, strengthening health literacy and promotion, switching to pay-for-performance, employing public-private partnership models, and other measures. These kinds of solutions were embedded in the health reforms of Turkey.

We also implemented more politically difficult interventions, such as ending dual practice. In most countries, policy makers ignore or hesitate to solve this problem. However, dual practice not only makes patients suffer, but also significantly reduces the efficiency of public healthcare facilities. Another politically difficult action we took was to challenge the laissez-faire approach to providing health care and regulate the role of the private sector. It is crucial to have a balanced allocation of human resources between public and private healthcare sectors, and a strong public capacity, in order to procure services from the private sector without causing harmful consequences.

Whether easy or difficult to implement, healthcare reforms always require political support from both the public and head of state. I suggest a two-pronged approach to obtain these types of support: harvesting the low-hanging fruit to gain power for more time-consuming reform initiatives. On the other hand, to convince ministers of finance, we should be very patient and always use the relevant literature to establish legitimacy. Furthermore, the role of international organisations, such as the World Health Organization, is invaluable for the ability to empower actors of transformation.

I would like to conclude with a request from the politicians of rich countries: let us unite in helping the poor countries. Turkey has fulfilled this duty with utmost sincerity for many years, including its charitable work for asylum seekers that made Turkey the most charitable country in the world in terms of official development aid as a percentage of its gross domestic product in 2017.

All of us can do it. Let us make universal health coverage more than just a dream.