Lessons from Turkey: How Bahrain is looking to improve its healthcare

Turkey initiated its Health Transformation Program (HTP) in 2003. Prior to the HTP, its health service delivery was fragmented and relied heavily on the higher cost of hospital care. Primary care was inadequate and trained health workers in short supply and distributed inequitably. Overall, the health sector was underfinanced and governance in it was weak. In time, though, the HTP de-fragmented financing and service delivery, and expanded coverage to nearly the entire population.

Today, Turkey is often cited as a success story: it has improved its health outcomes, achieving health-related millennium development goals well before the 2015 deadline. The number of women dying from pregnancy-related causes more than halved since 1990 to about 20 per 100,000 live births in 2013. The number of infants dying before their first birthday dropped from 55.7 in 1990 to 16.5 per 1,000 live births in 2012.

So, what policy lessons can Turkey’s experience offer Bahrain?

1. The sequencing of health reforms can improve the political impact of the process. From early on, Turkish policy makers acknowledged the political challenges of changing the health sector. Initially, they focused on introducing simple, cost-effective, and highly visible reforms to garner public support. For instance, one of the first reforms was to ban the practice of holding patients in health facilities until their medical bills were paid (2002). This was instrumental to paving the way for larger-scale reforms. Key institutional changes were likewise introduced in carefully planned phases. The time taken gave policy makers the flexibility they needed to assess the reforms and introduce incremental adjustments.
2. The pace of reforms can make or break the process. The rapid implementation of reform is another important aspect of Turkey’s experience. Policy makers set ambitious timelines and monitored progress on the ground closely. This doesn’t mean reforms were rushed. Health service delivery in the public sector was undermined by physicians spending a significant amount of time working in the private sector too (dual practice). Turkey used a gradual approach to tackle this: physicians’ salaries were increased and linked to their performance in hospitals (2003). It was only after a good number of them had voluntarily transitioned from dual practice that the practice was banned in 2010.
3. The macroeconomic and fiscal environment matters. The Turkish economy underwent a decade of rapid economic growth from 2003 to 2013. Coupled with prioritizing health in public spending, this has led to increased funding. Today, Turkey allocates 6.3 percent of its income to health compared to 5.3 per cent in 2003. This has helped finance the expansion of its Green Card Program, a non-contributory insurance scheme for the poor.
4. The consolidation of various entitlement programs helps reduce inefficiencies in health financing. Turkey consolidated five separate health insurance schemes with varying benefits’ packages and contribution rates into one Social Security Institution (SSI). It was done in stages: three insurance schemes—Sosyal Sigortalar Kurumu (SSK) (for formal sector employees), Bag-Kur (for the self-employed), and Emekli Sandigi (for retired civil servants)—were integrated in 2006; a civil servants program was transferred to the SSI in 2010; and finally the Green Card Program became a part of the SSI system in 2012, unifying all entitlements. Benefit packages were harmonized and health premiums (contributions) were linked to income.
5. Health financing reforms should be accompanied by changes in health service delivery. To end fragmentation and duplication in public sector service delivery, the SSK hospital network was integrated into the Ministry of Health’s system in 2005. The family medicine program was piloted (2005) and rolled out nationwide (2010).
6. Primary health care reforms pay off. Today, more than 20,000 family physicians provide primary and preventive care services free of charge. Family physicians receive higher salaries if they care for pregnant women and for children, and for serving in remote or less developed areas. Although there is still not enough public health care to cater for everyone, the primary health care reforms have been well received by the public.

The study tours the World Bank organized for Bahraini officials to Turkey and to Estonia provided Bahrain important lessons on how best to put new health policies in place as Bahrain embarks on its own reform of social health insurance, provider payment systems, and provider autonomy. What resonated with us—as well as the Bahraini delegation—the most, was the ‘patient-centeredness’ of the new Estonian and Turkish systems. The strong emphasis on health as a right was the cornerstone of reform.