Primary Care in Turkey

By Hakan Yaman, MD, MS
Professor of Family Medicine
Department of Family Medicine,
Faculty of Medicine, University of Akdeniz, Turkey

  
Primary care in Turkey was established first time by the law "Socialization of Health Services" No: 224 in 1961 and provided preventive and curative basic medical services by state-owned health centers. Services were provided by a medical team (i.e. GP without resident training in family practice-medical practitioners, nurses, midwives, health technicians, environmental technicians, medical secretaries, drivers etc.). Their main duty were providing mainly preventive services in the community. They served to a population of 5000-10000 people and served mainly rural areas. Most people lived in rural areas in the sixties and they were more in need for clean water, sanitation and other public health measures. Daily medical services were also provided in these centers and a network of secondary care and tertiary care facilities were available, where patients could be referred to by the medical practitioners.
Before the law enforcement in Turkey mainly hospitals were in charge of medical services provision. A very well established vertical arranged preventive services system showed success in the fight against Tuberculosis, Malaria, Trachoma and other common infections in community. This vertical arrangement of preventive services have been kept until now.

After the millennium, with the endorsement of the "Pilot Law of Family Practice Implementation" in 2004, family practice services were separated from the public health services. Medical practitioners received a 7 day instruction on the new system and on the principles of family practice (appropriate to EURACT Educational Agenda) and began with a new working contract to serve as family doctors in their new offices. New incentives like better salaries, focus on patient care, new working title etc. created a shift to these new "Family Health Centers". Public health services are provided by the established Community Health Centers, which serve for a population of 100000 or for each county.
By December 2010 in 81 province of Turkey 6330 family health centers and 986 community health centers serve with 20183 family doctors and at least the same number of family health professionals for the whole population of Turkey (approx.73 million).
Family doctors have a patient list of approx. 3400 people and provide preventive and curative services. Immunization of different risk groups (especially childhood), screening pregnant women and newborns, home visits are a part of daily routine. With 100 year celebration of the foundation of the Turkish Republic in 2023 an increase in the number of family doctors to 43.600 and specialists of family medicine to 15000 is planned. It is estimated that this will lower the patient list to 2000.
Even the "The Transition of Health Project" of the Turkish Ministry of Health created discussion among medical profession and medical colleges, family doctors working in this working environment seem to be satisfied with these conditions. The outcome of certain health indicators also showed improvement. The live expectancy increased to 73.7 (female=71.5 and male=76.1) in 2009. Infant mortality rate decreased to 9.9 per thousand in 2010 and maternal mortality to 19.4 per 100000. Immunisation rate exceeded 95% in children and free MMR, combined five vaccine (in addition to tetanus, diphteria and pertusis; Hemophilus Influenza Type B and inactive polio vaccines have been added) and in 2008 conjugated pneumonia vaccine have been added to the official vaccination schedule.

"The Transition of Health Project" made elementary changes in primary care in Turkey. The shift of medical human sources to family practice created shortage of doctors and health professionals in the community health centers and emergency services (either in hospitals of emergency services).

The family doctors are doing an excellent job in primary care and the satisfaction level of patients of these services increased to 83%. But the "gatekeeper" function has not been introduced yet. The family doctors are still in need in professional training to provide better primary care services for chronic conditions and elderly patients. The Ministry of Health is piloting in different provinces a distance learning certification program, which will last one year. And professional societies are preparing Continuing Professional Development opportunities to support the family doctors. These efforts and the support of the already existing family practice vocational scheme will certainly contribute to increase the quality of primary care in Turkey.

The implementation of e-Health in the medical system in Turkey has increased the accountability and transparency in health system. All family health centers are using electronic patient records (over 60% use the software provided free by the ministry of health) and so provide health authorities and insurances with the necessary service information. This also diminishes the time burden of formal procedures. Hopefully the ICPC-2R coding system will be implemented in the future.
Most family health centers are supported by central medical laboratory units during daily clinical routine and results can be retrieved from an automated system by internet. This enhances the quality of laboratory results and diminishes the burden of patients.
In the near future certain areas like health promotion (i.e. smoking cessation, exercise prescription, diet advice etc.), service for special risk groups (i.e. implementation of elderly friendly primary health care toolkit and rehabilitation, home visits, supervision of home care etc.), provision of special services (i.e. family-oriented primary care, narrative-based primary care etc.) need to be emphasized. Special training (i.e. diabetes education, respiratory disease education, counseling, office management etc.) to health professionals working in family and community health centers are needed. From a patients perspective the self-care stage need to be addressed by the primary care team. By attaining these measures an increase in satisfaction of patients, an improvement in the quality of health and a decrease of health expenditure might be expected.

References

1. Gunes ED, Yaman H. Transition to Family Practice in Turkey. Journal of Continuing Education in the Health Professions 2008; 28(2): 106-112.
 
2. Yaman H, Akdeniz M, Howe J. [GeroFam Concept: a Proposal of Solution for the Coming Demographic Change]. GeroFam. 2010; 1(1): 1-14. Turkish. doi:10.5490/gerofam.2010.1.1.2 . Available at: 
http://www.scopemed.org/?iid=2010-1-1.000&&jid=19
 
3. Akdeniz M, Ungan M, Yaman H. [The Development of Family Medicine as a Discipline in Turkey]. GeroFam. 2010; 1(1): 29-40. Turkish. doi:10.5490/gerofam.2010.1.1.4. Available at: http://www.scopemed.org/?iid=2010-1-1.000&&jid=19
 
4. Heyrman,J. ed. , EURACT Educational Agenda, European Academy of Teachers in General Practice EURACT, Leuven.

5. Akdag, R. ed. [The Turkish Transition of Health Program-Progression Report, September 2010]. Turkish Ministry of Health. Publ. No: 807. 2010. Turkish.

6. Ekinci H. [The Implementation Family Practice in Turkey-Current State]. Presentation at the Antalya Family Practice Evaluation Meeting of the Ministry of Health. December 22th-24th, 2010. Antalya, Turkey.