Identifying key factors underlying the improved ability of the Social Security Institution of

Turkey in providing Universal Health InsuranceAPHA – November 3, 2015

Nur Onvural, Ph.D. School of Business, Pfeiffer UniversityArif Varhan, MHA, Inspector, Social Security Institution

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Mandatory Disclosure Slide

http://www.pfeiffer.edu/

Presenter DisclosureNur Onvural

(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

No relationships to disclose

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Three dimensions to consider when moving toward Universal

Health Coverage Ensuring that all people

can use healthcare services they needo equity in access to

health serviceso quality of health

services is good enough to improve the health of those receiving services

o financial-risk protection

Sources:-- Universal coverage is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma‑Ata declaration in 1978. -- WHO: Health Systems Financing – The Path to Universal Health Coverage, 2010

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Moving toward health coverage

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Turkish Health System before Universal Health Coverage

There were five social health insurance programs in Turkey prior to Universal Health Coverage1. Social Insurances Agency (SSK) for blue collar workers (est. in

1945)2. Social health insurance for retired civil servants (est. in 1949)3. Social health insurance for active civil servants4. Social health insurance for self-employed (Bag-Kur) (est. in 1971)5. Green card for indigent (est. in 1992) for inpatient care only

Inequitable benefit packages Inadequate access to healthcare providers In 2003

o 67.2% of the population was covered by health insuranceo Satisfaction with health care services was at 39.5% o Low levels of health expenditures at 5.3% of GDP

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Sources; Aran et all, Atun, OECD

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Highlights of the Health Transformation Program (2002 -2012)

to enhance the Turkish Health System

Strengthen governance, financing and delivery of the health systemo including human resources, physical structures, and information systems

Expand health insurance to all citizenso Widen the green card coverage and extend its benefits to include

outpatient and drugs for low-income groups Increase access to healthcare providers

o Increase access to hospital care, the number of public health institutions and health care professionals

o Develop primary care in the framework of family medicine (particularly for maternal and child health) – focus on a patient-centered health system

o Enhance benefits for pharmaceuticals Improve public health Increase the public health expenditures

Sources: Turkish Ministry of Health, Turkey’s Health Transformation Program, OECD and WHO, 2012

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The establishment of the Social Security Institution and its role

with Universal Health Insurance The Social Security Institution (SSI)

o Established in 2006 as a public entityo Administration of universal health insurance (UHI) as well as social security

services, and pension payments Universal Health Insurance

o The five existing diverse social insurance programs with inequitable benefit packages were unified under the SSI from 2008 to 2012

• In 2008 – Social insurance agency, retired and self employed group• In 2010 -- Active• In 2012 – Green Card

o Eligibility and coverage were revised and extended o Benefit packages were equalized

Access to Hospitalso All public hospitals are administered by the Ministry of Health

• Hospitals belonging to the Social Insurance Agency were integrated with the Ministry of Health hospitals in 2005

o Reimbursement of hospitals are disbursed by the SSI, Ministry of Health, and the Ministry of Finance

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Sources: SSI, OECD 2008

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Turkish Health System after Universal Health Insurance

http://www.pfeiffer.edu/

PopulationEnterprises

Patients

Retired

Green card

Active

Bag-Kur for Self

employed

Social Insurance

(SSK)

MoHHospital

s

Family Medicin

e

Other

Private Hospitals

Pharmacies

University

Hospitals

NGO

Other

Ministry of Finance

TreasuryState Assist.

Fund for children

Ministry of Health

SSICompulsory contributions

Government contributions

Fee for servicecapitation

Private insurance

Healthcare services

Out of pocket payments

Fee for service

Premiums

Source: OECD & World Bank, 2008

SalariesLine item budget

capitation

Government

Providers

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The key factors applicable to the SSI to enhance the health system in

providing Universal Health Insurance Service Delivery

Coverage of population by health insurance -- effective, safe, quality care to those who need it with minimum waste

Demand for health care services and supply of health care providers

Health Information Collection, analysis, disseminations and use of reliable and timely

information on health determinants, health system performance and health status

Health Financing Adequate funds for health; protection from catastrophic expenses;

incentives for providers to be efficient

Leadership and Governance Strategic policy framework; effective oversight; regulation and

accountability

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Source: WHO: Everybody Business: Strengthening health systems to improve health outcomes, 2007

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Percent Coverage by Universal Health Insurance and

Utilization of Healthcare Services

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Years 2010 2011 2012 2013Population 73,722,988 74,724,269 75,627,384 76,667,864Universal Health Cov. 61,506,194 64,088,819 62,899,043 62,806,374

83% 86% 83% 82%

% coverage by Universal Health Insurance

Health Insurance coverage was extended from 67.2% in 2003 to 82% in 2013

Number of Hospital Visits by Years and Sectors

2002 2009 2010 2011 2012 2013Ministry of Health 109,793,128

228,279,139

235,172,924 254,342,943 260,974,401 277,485,135

University 8,823,36119,364,86

520,098,75

4 24,437,107 27,080,436 29,985,697

Private 5,697,17047,618,18

647,712,54

0 59,060,486 66,582,098 71,341,411

Total 124,313,659295,262,1

90302,984,2

18 337,840,536 354,636,935 378,812,243

Number of Hospital Visits by Years and Sectors

Number of total hospital visits have increased by 205% in 2013 compared to 2002

Source: The Ministry of Health Stat Year Book 2013

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Healthcare Providers after moving to Universal

Health Insurance

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0 200 400 600 800 1000 1200 1400 1600

854

832

840

843

834

774

69

65

65

62

59

50

550

541

503

489

450

271

44

45

45

45

46

61

Number of hospitals by years and sectors

MoH University Private Other

Years

2002

2009

2010

2011

2012

2013

When comparing 2013 numbers to 2002 numbers:There is an overall 31% increase in the total number of hospitals yet MoH hospitals increasedby 10%, University hospitals by 38% whereas private hospitals increased by 103% in 2013

Source: The Ministry of Health Stat Year Book 2013

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SSI and Health Management Information System

MEDULA -- A nation-wide integrated health information system (Hospital, Optic, Pharmacy, Medical Devices) between the SSI and health care providers for Electronic claims – unified claims management system Electronic medical records (such as treatments, diagnoses, insurance

information of patients, demographics, prescriptions, and test results)

Storage and display of the MRI and CT reports to prevent duplications Electronic prescriptions –utilization management Reimbursements – single payer

Business intelligence support systems for analytical processing, data mining, process mining, predictive and prescription analytics

Document Management System to provide the continuation of standardized, fast and effective services

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SSI and Financing of Universal Health Insurance Revenues of Universal Health Insurance

o Compulsory contributions or mandatory premium collections through payroll deductions at 12.5% of earnings (5% from employees and 7.5% from employers)

o State contributions from the General Budget Revenues -- the Ministry of Finance and the Ministry of Health

Out of pocket payments for Universal Health Insuranceo Contribution Payments by patients deducted from payrolls

• Set by the SSI btw 10-20% of patients’ earningso Additional Fees paid directly to private hospitals and/or

private health care organizations

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Revenues and Expenditures of the SSI

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Source: SSI, Monthly basic indicators, January 2015

Deficits of about 10% over the course of the health transformation program

The data includes all expenditures of the SSI

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Total Health Expenditures in Turkey

over the course of the health transformation program

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2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

% 5.4 5.3 5.4 5.4 5.8 6.0 6.1 6.1 5.6 5.3 5.2 5.4

Source: TurkStat, Health Expenditure Statistics, OECD Health Data 2014, OECD Health Data 2015.The Ministry of Health Stat Year Book 2013

The health expenditure percentages are still behind the other OECD countries (at 8.9% in 2013)

Per capita expenditures(2013) in Turkey are at $941 whereas the OECD countries are at $3453

Total health expenditures as a percentage of GDP in Turkey

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Leadership and Governance: SSI and Universal Health Insurance

The SSI is an $60B organization responsible for pension payments and universal health insurance

Effective oversight and management, regulation, accountability are handled through the following directorates o Directorate General of Universal Health Insurance

• Responsible for the implementation of the Universal Health Insurance policies. o Directorate General of Insurance Premiums

• Collection of premiums via provincial directorateso Directorate General of Service Provisions

• Responsible for the continuous service provisions of the SSI• Information services in order to increase the efficiency of Institution’s activities.

o Presidency of Guidance and Inspection• Assessments on frauds, misuse, overuse, and/or abuse of health services with

hospitals, medical device companies, and pharmacists and • In charge of interrogations and investigations with all stakeholders holding

contractual relationships with the SSI.

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Source: The Social Security Institution retrieved from http://www.sgk.gov.tr/wps/portal/en

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Conclusions and Future Work

Service Deliveryo Significant increases in the percentage of covered individualso High utilization of healthcare services as determined by the number of

hospital visits and the number of hospitalso Extensiveness of benefits and the future affordability of Universal Health

Insurance Health Information System

o Data analysis for cost effectiveness studies to develop innovative reimbursement models and health outcomes

Health Financeo Premium collections and health care expenditures for Universal Health

Insuranceo Innovative models to control increases in health care expenses

Leadership and Governanceo Efficient and productive usage of resources in the administration of the SSIo Improvements in work processes

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Lessons Learned from the WHO Report

Successful Health System Reforms: The Case of Turkey Organizational structure and work flow between the MoH and the SSI to

be better aligned Health expenditures are still below the other OECD countries Health management information system (HMIS) to allow sharing of data

and statistics btw the MoH and the SSI The SSI has to become the effective purchasing agent by focusing on

health economic analysis to improve its cost effectiveness Provider satisfaction issues to be addressed

o Compulsory choice between public and private sectoro Increased supervision and accountability for Pay for Performance (P4P)o Patient empowerment and provider’s role

Quality of care can be further enhanced by o The development and use of evidence-based clinical guidelines and protocolso Collection of data on the outcome of treatment in the hospital sector

More effective treatments to reduce the burden of non-communicable diseases

Incentives for patients to utilize primary care rather than hospitals

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Source: WHO Successful Health System Reforms: The case of Turkey –May 2012

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Questions? Nur M. Onvural, Ph.D. | Associate Professor of Economics

and FinanceSchool of Business and Division of Applied Health Sciences, Pfeiffer University

2880 Slater Road Suite 100| Morrisville, NC| 27560Main: 919.238.2400 | Direct: 919.238.2404 | Cell: 919.616.4308 | Fax: 919.238.2401http://www.pfeiffer.edu | Nur.Onvural@pfeiffer.edu

Arif Varhan, MHA | Inspector

The Social Security Institution of the Turkish RepublicSimon Bolivar Cad. No: 23 06610 Cankaya, Ankara TURKEYCell: +90 507 066 3969http://www.sgk.gov.tr | arifvarhan@gmail.com

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References Akdağ, R. Turkey Health Transformation Program Evaluation Report, 2003-2010.

Ankara: Ministry of Health, 2011. Aran M, Hentschel J. Protection in good and bad times? The Turkish Green Card

Health Program. World Bank Policy Research Working Paper No. 6178. Washington, DC: The World Bank, 2012.

Atun R., Aydın S., Chakraborty S., Sumer S., Aran M., Gürol I., Nazlıoğlu S., Özgülcü Şenay, Aydogan U., Ayar B., Dilmen U., Akdağ R. (2013). “Universal health coverage in Turkey: enhancement of equity”. Lancet; 382: 65–99

Ministry of Health, Health Statistics Yearbook 2013 retrieved from http://ekutuphane.tusak.gov.tr/kitap.php?id=239&k=health_statistics_yearbook__2013

OECD & The World Bank. (2008). “OECD Reviews of Health Systems: Turkey.” Retrieved from http://www.oecd-ilibrary.org/social-issues-migration-health/oecd-reviews-of-health-systems-turkey-2008_9789264051096-en

Republic of Turkey-Ministry of Health (MoH).(n.d.). Turkey Health Transformation Program. Retrieved from http://www.saglik.gov.tr/EN/belge/2-125/turkey-health-transformation-program.html

Republic of Turkey-Social Security Institution (SSI). (n.d.). History of Social Security in Turkey. Retrieved from http://www.sgk.gov.tr/wps/portal/en/english/history/

http://www.pfeiffer.edu/

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References Cont’d Social Security Institution. (2012). SSI Statistical Yearbook - 2012. Retrieved

from: http://www.sgk.gov.tr/wps/portal/en/english/statistics_new/statistical_yearbook

Social Security Institution. (n.d). The History of Social Security Implementations in Turkey. Retrieved from http://www.sgk.gov.tr/wps/portal/en/english/history_yeni

Social Security Institution (Jan 2015) Monthly Basic Indicators Turkish Statistical Institute. Life satisfaction survey [in Turkish], 2011. Retrieved

from http://www.tuik.gov.tr/Kitap.do?metod=KitapDetay&KT_ID=11&KITAP_ID=15

Turkish Statistical Institute Web Site retrieved from http://www.turkstat.gov.tr/UstMenu.do?metod=temelist

World Health Organization, (2013(, Turkey promotes universal health coverage -- Retrieved from http://www.euro.who.int/en/health-topics/Health-systems/health-systems-financing/news/news/2013/06/turkey-promotes-universal-health-coverage

World Health Organization. (2012). “Successful Health System Reforms: The Case of Turkey.” Retrieved from http://disab.saglik.gov.tr/yonetim/Uploads/files/kitaplar/Successful%20Health%20System%20Reforms-The%20Case%20of%20Turkey.pdf http://www.pfeiffer.edu/