Identifying key factors underlying the improved ability of the Social Security Institution of Turkey in providing Universal Health - Nur Onvural, Ph.D. School of Business, Pfeiffer University Arif Varhan, MHA, Inspector, Social Security Institution

1.  
Nur Onvural, Ph.D. School of Business, Pfeiffer University
Arif Varhan, MHA, Inspector, Social Security Institution

2. http://www.pfeiffer.edu/ 2
Presenter Disclosure
Nur Onvural
(1) The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose

3.  Ensuring that all
people can use
healthcare services
they need
o equity in access to
health services
o 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

4.  There were five social health insurance programs in Turkey
prior to Universal Health Coverage
1. 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 servants
4. 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 insurance
o Satisfaction with health care services was at 39.5%
o Low levels of health expenditures at 5.3% of GDP
http://www.pfeiffer.edu/ 4
Sources; Aran et all, Atun, OECD

5.  Strengthen governance, financing and delivery of the health system
o including human resources, physical structures, and information
systems
 Expand health insurance to all citizens
o 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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6.  The Social Security Institution (SSI)
o Established in 2006 as a public entity
o 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 Hospitals
o 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
http://www.pfeiffer.edu/ 6
Sources: SSI, OECD 2008

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Population
Enterprises
Patients
Retired
Green
card
Active
Bag-Kur for
Self
employed
Social
Insurance
(SSK)
MoH
Hospitals
Family
Medicine
Other
Private
Hospitals
Pharmacie
s
Universit
y
Hospitals
NGO
Other
Ministry of Finance
Treasury
State Assist.
Fund for
children
Ministry of
Health
SSI
Compulsory contributions
Government contributions
Fee for service
capitation
Private insurance
Healthcare services
Out of pocket payments
Fee for service
Premiums
Source: OECD & World Bank, 2008
Government
Providers

8.  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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Years 2010 2011 2012 2013
Population 73,722,988 74,724,269 75,627,384 76,667,864
Universal 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 2013
Ministry of Health 109,793,128 228,279,139 235,172,924 254,342,943 260,974,401 277,485,135
University 8,823,361 19,364,865 20,098,754 24,437,107 27,080,436 29,985,697
Private 5,697,170 47,618,186 47,712,540 59,060,486 66,582,098 71,341,411
Total 124,313,659 295,262,190 302,984,218 337,840,536 354,636,935 378,812,243
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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854
832
840
843
834
774
69
65
65
62
59
50
550
541
503
489
450
271
44
45
45
45
46
61
0 200 400 600 800 1000 1200 1400 1600
Years
Number of hospitals by years and sectors
MoH University Private Other
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 increased
by 10%, University hospitals by 38% whereas private hospitals increased by 103% in 2013
Source: The Ministry of Health Stat Year Book 2013

11.  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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12.  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 Insurance
o Contribution Payments by patients deducted from payrolls
• Set by the SSI btw 10-20% of patients’ earnings
o Additional Fees paid directly to private hospitals and/or private
health care organizations
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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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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

15.  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 directorates
o 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

16.  Service Delivery
o Significant increases in the percentage of covered individuals
o High utilization of healthcare services as determined by the number of
hospital visits and the number of hospitals
o 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 Finance
o Premium collections and health care expenditures for Universal Health
Insurance
o Innovative models to control increases in health care expenses
 Leadership and Governance
o Efficient and productive usage of resources in the administration of the
SSI
o Improvements in work processes
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17.  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 sector
o 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 protocols
o 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

18.  Nur M. Onvural, Ph.D. | Associate Professor of Economics and
Finance
School of Business and Division of Applied Health Sciences, Pfeiffer
University
2880 Slater Road Suite 100| Morrisville, NC| 27560
Main: 919.238.2400 | Direct: 919.238.2404 | Cell: 919.616.4308 |
Fax: 919.238.2401
http://www.pfeiffer.edu | Nur.Onvural@pfeiffer.edu
 Arif Varhan, MHA | Inspector
The Social Security Institution of the Turkish Republic
Simon Bolivar Cad. No: 23 06610 Cankaya, Ankara TURKEY
Cell: +90 507 066 3969
http://www.sgk.gov.tr | arifvarhan@gmail.com
http://www.pfeiffer.edu/ 18

19.  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/ 19

20.  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%2
0System%20Reforms-The%20Case%20of%20Turkey.pdf
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