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Healthcare financing reform in Turkey: context and salient features

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Journal of European Social Policy
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Healthcare financing reform in Turkey: context and salient features

Hasan Hüseyin Yildirim and Türkan Yildirim
Journal of European Social Policy 2011 21: 178
DOI: 10.1177/0958928710395045

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 European Briefing

Healthcare financing reform in Turkey:

context and salient features
Hasan Hüseyin Yıldırım*
Department of Health Care Management, Faculty of Economics and
Administrative Sciences, Hacettepe University, Ankara, Turkey
Türkan Yıldırım
Department of Health Services Management, Faculty of Health Sciences,
Ankara University, Ankara, Turkey

Abstract
The health field is characterised by high uncertainties which can lead to large expenditures. One way
to manage these uncertainties is to develop collectively-financed health care systems. Some countries
create this collective financing through general taxes, whereas others rely on premiums set up through
compulsory social health insurance. Turkey, a middle-income country, has historically used several
mechanisms to extend health care to its population. However, inadequate financing and poor service
quality have plagued this health care system.
Recently, a transition from a system of multiple insurance schemes that cover only about two-thirds
of the population to a single-payer system aiming to achieve universal coverage has been under way to
overcome problems in the fragmented health financing system and ensure universal coverage. With the
enactment of the General Health Insurance Scheme Law in 2006, the Turkish health care system has
embarked on one of its most radical and far-reaching reforms since the socialization attempt of the 1960s.
This paper focuses on the health care financing reform in Turkey, concentrating on its salient
features in terms of financing functions and policies and explores the main differences between the
old and new systems. The care and coverage aspects are also dealt with. Our results suggest that if
well implemented, the GHIS reform can be a powerful engine for achieving universal coverage and
enhancing equity and solidarity in the Turkish health care system. However, to reach this end, a
transition process is required, as the success of the GHIS will depend on its ability to manage chal-
lenges during the implementation process.

Keywords general health insurance scheme, health policy, healthcare financing reform, health
transformation programme, Turkey

Introduction countries that has sought to extend healthcare

coverage to the whole of its population via a col-
In recent years Turkey has attracted international lectively financed healthcare system. The Turkish
interest as one of a small group of middle-income

*Author to whom correspondence should be sent: Hasan Hüseyin Yıldırım, Department of Health Care Management,
Faculty of Economics and Administrative Sciences, Hacettepe University, Beytepe Campus, 06800 Ankara, Turkey.
[email: hhy@hacettepe.edu.tr]

2011. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav Journal of European Social Policy,

© The Author(s), 2009.
0958-9287; Vol. 21(2):
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 Healthcare financing reform in Turkey
reform story is essentially one of the transformation of
a fragmented system comprising a multiplicity of het-
erogeneous insurance schemes, covering about two-
thirds of the population, into a single-payer system
aiming to achieve universal coverage. In the last few
decades Turkey has adopted several mechanisms with
widely differing benefits, regulations and contribution
levels, as well as separate institutions to extend cover-
age progressively to its population. Multiple schemes,
however, brought organizational fragmentation and
significant disparities in quality and access to services.
To address these problems, there has been a long and
at times sluggish process of reform attempts aiming to
institute a new health financing institution and intro-
duce universal health insurance (Müderrisoğlu et al.,
1998). Fundamental reform was delayed mainly
because of political and governance problems.
However, the logjam was broken in 2002 with the
election of a government commanding a large major-
ity and with a clear intention to realize reform of the
healthcare system. A major health transformation
programme (HTP) (Sağlık Bakanlığı, 2003) was
announced in 2003 and enacted in the following
years. The centrepieces of the reformed system were
the General Health Insurance Scheme (GHIS), a single
system combining all existing schemes under one
umbrella, and the Social Security Institution, a single-
payer insurance agency founded in 2006.
In essence the GHIS and the Social Security
Institution create a new structure in which a single
purchasing agency finances healthcare for the whole
population via a single social health insurance fund.
This system is based on social insurance contribu-
tions and the redistributive effect of general taxation.
It is intended to provide the Turkish population with
access to a wide range of health services and to
ensure unity, equity and efficiency in the delivery of
these services (Resmi Gazete, 2006a,b, 2008).
This paper aims to provide a concise but adequate
account of the recent healthcare financing reform in
Turkey with emphasis on its salient features and to
show how the reformed system represents a radical
change in terms of financing functions and policies. To
this end the main differences between the old and new
systems and the background of the reform of both the
financing and related overall aspects of the healthcare
system will be explored and the GHIS will be analysed.
Our primary focus on the financing dimension of
the healthcare system reform rather than the deliv-
ery and organization of care, although these are
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179
dealt with as well, reflects the importance of the new
purchaser/provider organization of Turkish health-
care in shaping the overall system. The GHIS played
a determining role in the final reform design and the
coordination of health and social security policies.
Financing mechanisms and sources often play a very
powerful role in shaping the other functions and
policies of a healthcare system and the positioning
of its actors. Financing arrangements determine the
structure of interests and incentives and are likely to
influence the culture and ethos of the professional
workforce. Consequently healthcare systems around
the world are frequently classified according to the
ways in which they are financed. The reformed
Turkish healthcare system constitutes a case that
confirms the prominence of the financing dimension
in the characterization of the system, justifying also
our focus on this dimension.
In order to be able to characterize the Turkish
healthcare financing system systematically and thus
ensure its international and historical comparability
for future research and analyses, the study employs
the widely used ‘functional approach’ (Kutzin, 2001,
2008; Thomson et al., 2008; World Health Organi­
zation, 2000; World Health Organization Regional
Office for Europe, 2006). This framework analyses
financing systems in terms of three important func-
tions that must be performed by any system if it is to
work effectively: revenue collection, revenue pooling
and purchasing. The functional approach also identi-
fies at least four key aspects of policy: healthcare
expenditures, coverage, benefits and cost sharing.
Advocates of the approach suggest that: ‘The way in
which each of these functions and policies is carried
out or applied can have a significant bearing on
policy goals such as financial protection, equity, effi-
ciency and sustainability’ (Thomson et al., 2008).
In the sections that follow, we first provide a brief
overview of the Turkish healthcare system and then
discuss the financing system. We analyse the financ-
ing functions and policies of the Turkish healthcare
financing system first in the pre-HTP period prior to
2003 and then as they operate in the current GHIS
system. Finally, our main conclusions are presented.
The Turkish healthcare system: A brief
overview
Turkey is a parliamentary, representative democracy
situated in both Europe and Asia, and is divided into
Journal of European Social Policy 2011 21(2)
180 Yıldırım and Yıldırım

Table 1 Socioeconomic indicators of Turkey and the European Union-27

Turkey European Union-27

Indicators 2000 2008 2008

Population 67,420,000 71,517,104 495,455,424
Population growth (annual %) 1.7 1.4 0.10
Urban population (%) 65.76 67.35 74.085
Per capita gross domestic product (€) 3,608 6,3167 24,2567
Real gross domestic product growth (annual %) 6.8 4.9 0.8
Annual average rate of inflation (%) 49.2 10.06 3.04
Employment rate (%) 48.8 49.5 70.5
Unemployment rate (%) 6.5 11.0 7.22
Labour force participation rate (% among 15–64-year-olds) 51.13 51.07 72.07,a
Total fertility rate 2.27 2.168 1.548
Life expectancy 68.86 71.66 79.066
Infant mortality rate 36 284 5.214
Maternal mortality rate (per 100,000 live births) 28.55 19.42 5.96
Total health expenditure as a % of gross domestic product 4.9 5.75 8.925
Per capita health spending (€) 397 4005 1,6705
Public sector health expenditure as a % of total health 62.9 71.45 75.545
expenditures
Private expenditures on health as a % of total health 37.1 19.95 17.185
expenditure
Literacy rate (%) in the population aged >15 85 88.77 98.727
United Nations Development Programme Human 0.742 0.7986 0.9156
Development Index
Physicians (per 100,000) 126.25 154.277 321.627
Nurses (per 100,000) 236.92 269.186 745.476
General practitioners (per 100,000) 69.79 74.846 96.686
Sources: EUROSTAT (2010), Organisation for Economic Co-operation and Development (2008, 2009), Türkiye
.
Istatistik Kurumu (2010a,b), World Health Organisation (2010), World Bank (2009).
Notes: aEuropean Union-15; superscripts refer to the last digit of the year for which data are incorporated; for example,
5
means 2005 data.

81 provinces that are further subdivided into 923
administrative districts. The country has a popula-
tion of 72.5 million people and an average annual
population growth rate of 1.45 percent. According
to the 2009 census, 75.5 percent. of the population
lives in urban centres (Türkiye IIstatistik Kurumu,
2010a). Turkey has been a candidate for member-
ship to the European Union since 1999 and has
carried out accession talks since 2005. It has a
dynamic and open market economy, with a gross
domestic product reaching €6316 per person in
2008. The recent classification of the World Bank
includes Turkey in the upper-middle-income country
group (World Bank, 2009). Turkey has made con-
siderable progress in improving socioeconomic indi-
cators such as mortality, morbidity, life expectancy
and income. However, it still lags far behind
European Union-27 averages (see Table 1).
Many actors are involved in the process of health
policy development in Turkey. The state fulfils its
general responsibilities for planning, coordination
and finance. The development of health system
institutions is mainly undertaken by the Ministry of
Health, military institutions, parliamentarian com-
missions, the Ministry of Labour and Social Security,
the Ministry of Finance, the Council of Higher
Education, the State Planning Organization, the
Social Security Institution, and other relevant organ-
izations and institutions (Savas et al., 2002). In
addition, professional organizations such as the

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 Healthcare financing reform in Turkey
Turkish Medical Association, chambers of doctors
and other non-governmental organizations (particu-
larly in recent years) all figure in the policy-making
process. Furthermore, international organizations
such as the World Health Organization, World
Bank, Organisation for Economic Co-operation and
Development, and International Monetary Fund are
or have been involved in different ways; the
European Union is related above all through the
process of accession negotiations.
The Turkish healthcare system has undergone a
tremendous change since 2003 with the purpose of
organizing, providing financing for and delivering
health services in an effective, productive and equi-
table way under the HTP (Sağlık Bakanlığı, 2003).
Before the launch of the HTP in 2003, the supply
side of the Turkish healthcare system was a mix of
private and public sector institutions and had a four-
tiered health delivery system: the Ministry of Health,
Social Insurance Organization, university hospitals
and the private sector. However, publicly owned
hospitals (including Social Insurance Organization
hospitals) not operated by universities or the mili-
tary were transferred to the Ministry of Health in
February 2005 under the HTP. The supposed reason
for this action was to ensure uniformity among
public health service providers in terms of the
quality of services, but a hidden motivation in the
matter was to smooth the process of transferring the
hospitals to the local governments within the frame-
work of public administration reforms. As a result
of this unification, healthcare provision can cur-
rently be described as tripartite: the Ministry of
Health, university hospitals and the private sector.
The Ministry of Health runs large-scale health facil-
ities (for example, village clinics, units, centres,
outpatient clinics and hospitals) and is the main pro-
vider of primary and secondary healthcare services
and the only provider of preventive health services.
The university hospitals, by definition, should
provide tertiary healthcare, but in practice they
provide health services at all levels. The private
health sector provides health services through hospi-
tals, clinics and polyclinics, doctors’ offices, phar-
macies, laboratories, and the production of medical
instruments and medications (World Bank/State
Institute of Statistics, 2005).
A family physician model (Resmi Gazete, 2004)
has also been in operation since 2004 under the
HTP, with the aim of creating a strong preventive
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181
and primary healthcare system (Organization of
Economic Co-operation and Development /World
Bank, 2008). This model is currently being imple-
mented in 40 of Turkey’s 81 provinces and there are
plans to extend the model to all 81 provinces by the
end of 2010.
As it is the focal point of this paper, the financing
dimension of the Turkish healthcare system is dis-
cussed below in a separate section dividing the
history of the system into two periods based on the
launch of the HTP in 2003.
Healthcare financing in Turkey
Healthcare financing in Turkey prior to the
HTP in 2003
Prior to 2003, a number of health insurance funds
operated with widely differing benefits, regulations
and contribution levels. The Active Civil Servant
Scheme, established in 1965, was financed through
allocations from the government budget to institu-
tions employing active civil servants. The Green
Card Scheme, which was created in 1992 as a social
assistance mechanism to cover poor people earning
less than one-third of the minimum wage, was
financed from the Ministry of Health budget. Before
the Green Card law, health expenditures of poor
people had been covered by the Fund for the
Encouragement of Social Cooperation and
Solidarity. The Green Card law indicates that for
those who do not qualify for the Green Card and
cannot yet afford health services, the clauses of the
law on the Fund for the Encouragement of Social
Cooperation and Solidarity will be applied (Günal,
2008). The Government Employees Retirement
Fund, established in 1949, was financed by contri-
butions from active civil servants to cover retired
civil servants and their families. The Social Insurance
Organization, founded in 1964, covered the largest
segment of the population – blue- and white-collar
workers in the public and private sectors and their
dependents – and was financed by premiums based
on payroll wages. The Social Insurance Agency of
Merchants, Artisans and Self-Employed was estab-
lished in 1971 and since 1987 has offered health
benefits covering the self-employed financed by
revenues from the self-employed. In addition to
these main programmes, some of the institutions
(for example, banks, insurance companies and
Journal of European Social Policy 2011 21(2)
 Table 2 Features of health financing in Turkey before and after reform 182
After health financing
Features Before health financing reform reform
Schemes Social Insurance The Social Insurance The Government Active Civil Green Card Scheme General Health Insurance
Organization Agency of Employees Servant Established in 1992 Scheme
Established in Merchants, Artisans Retirement Fund Services Established in 2006
1964 and Self-Employed Established in 1949 Established in
Established in 1971 1965
(offering health
benefits since 1987)
General Multiple, mixed and fragmented system Single insurer;
characteristics Non-standard contributions, benefits, coverage, access and utilization standard contributions,
In addition to the main schemes, there were also other schemes such as private health insurance and benefits, coverage, access

Journal of European Social Policy 2011 21(2)

private funds and utilization (in theory)
Those who could not pay for health services and were not able to get a Green Card could obtain state-
financed health care under the Law on the Encouragement of Social Cooperation and Solidarity
Out-of-pocket payments in the form of direct payments, user charges, and informal payments were
practiced widely
For the Social Insurance Organization, the Social Insurance Agency form Merchants, Artisans and Self-
Employed, and the Government Employees Retirement Fund, general budget transfers compensated for
fiscal deficits when there was a gap between revenues and expenditures
Affiliation Attached to the Attached to the Attached to the Attached to Attached to the Attached to the Ministry
and Ministry of Ministry of Labour Ministry of Finance the Ministry Ministry of Finance of Labour and Social
accountability Labour and Social and Social Security until May 2006, of Finance through the Ministry Security through the
Security until May until May 2006, transferred to the through their of Health, will be Social Security Institution
Yıldırım and Yıldırım

2006, transferred transferred to the Social Security institutions transferred to the

to the Social Social Security Institution until 2010, Social Security
Security Institution transferred to Institution by the end

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Institution the Social of 2010
Security
Institution in
January 2010
Who was/is Private sector Merchants, artisans Retired civil servants Active civil People who had no Turkish citizens, refugees,
insured? employees and and the self- and their dependents servants and social security foreigners residing in
blue-collar public employed their regarding health care Turkey for more than 1
workers, seasonal dependents and whose income year
agricultural amounted to less
workers and their than one-third of the
dependents net minimum wage

(Continued)
 Table 2 (Continued)
After health financing
Features Before health financing reform reform
Coverage (% 49.49 23.43 13.03 15.2 Aiming at universal
of population) 67.2 and 84.5 coverage (100%, in
(2003) theory)
Basic benefits Pre-paid short- All outpatient and Diagnosis and Diagnosis and Inpatient and (1) Primary care,
term medical and inpatient diagnosis treatment treatment ambulatory care, rehabilitation, preventive
maternal benefits, and treatment. pharmaceuticals. services; (2) ambulatory
employment- Insurees were To qualify for a and inpatient care; (3)
related accident required to pay Green Card, an maternal benefits as well
and occupational health insurance individual should not as in vitro fertilization
disease benefits; premiums for at be covered by any treatment; (4) partial
long-term benefits least 8 months and social security system general oral and dental
for old age, have no record of and must have a care; (5) blood and blood
disability and default of health monthly income of products, bone marrow,
survivor pensions; insurance and long- less than one-third of vaccination, medicine,
did not provide or term insurance the minimum wage medical devices and
pay for preventive premiums (excluding taxes and equipment
services social security
premiums)
Contribution Employees (5% of 20% premiums 20% of the Benefits were General budget 12.5% of a person’s gross
rate salary), employers collected from deduction of the financed by (100%) income, and employee
(6%), state beneficiaries. The Government general tax (5%), and employer
subsidized (8.5% scheme worked on a Employees revenues; no (7.5%) salary deductions.
employer share reimbursement Retirement Fund premiums The rate for people who
5% employee system (State share as were assessed are only dependent on
Healthcare financing reform in Turkey

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share) employer), 16% of for active civil GHIS is 12% of their
the deduction of the servants while earnings. The
Government they were contribution of the state
Employees covered will be 3% of insured
Retirement Fund directly earnings as the basis for
(participant share); through their premiums
funded through the employers
contributions of the
active civil servants
and their employers
(general budget
revenues)

Journal of European Social Policy 2011 21(2)

183
 Table 2 (Continued)
184

After health financing

Features Before health financing reform reform
User charges 20% – 10% 20% 10–50% Co-payment: 2–15 Turkis
Lira (€1.0336–7.7519, on
June 3 2010);
co-insurance: 10%–20%;
1–100% private sector
hospitals (for details see
Table 3)
Risk-pooling Internalized Internalized Internalized Budget Budget allocation Internalized, Social
and allocation allocation Security Institution

Journal of European Social Policy 2011 21(2)

among funds
The role of tax Subsidization Subsidization Subsidization Subsidization Full State contribution to the
financing GHI; covering non-paying
sections of the
population; funding
public health activities,
medical education and
research
Purchasing Mainly from its Contracting from Contracting from Contracting From public Contracting from public
own hospitals public and private public and private from public providers and private providers
until 2005, and providers providers and private
Yıldırım and Yıldırım

then contracting providers

from public and
private providers

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Payment Case payment; Case payment; Fee- Case payment; Fee- Case payment; Case payment; Fee- Capitation for General
mechanisms Fee-for-services for-services for-services Fee-for- for-services Practitioners; lump sum
services fees; global budgeting;
fee-for-services; case
payment; performance
based payment;
Diagnostic Related
Groups

Sources: Authors’ own construction based on Devlet Planlama Teşkilatı (2004, 2006), Resmi Gazete (2006a, 2006b, 2008) and Organisation for Economic
Co-operation and Development/World Bank (2008)
 Healthcare financing reform in Turkey
corporations) had funds to cover the health expen-
ditures of their employees. With the exception of the
Green Card Scheme, all other social health insur-
ance schemes were employment-related and health
benefits were, broadly speaking, tied to employment
status. Table 2 compares the main characteristics of
all of these schemes.
Expenditures
Before launching the HTP, Turkey spent €397 per
person on healthcare and total health expendi-
tures were 4.9 percent of gross domestic product.
Public spending on health accounted for 62.9
percent of total health expenditures, with private
expenditures accounting for 37.1 percent (see
Table 1).
Coverage and benefits
Before the GHIS was established under the HTP,
health insurance coverage estimates for the Turkish
population varied widely, from 67.2 percent to 84.5
percent. In one case, an estimate of 101.15 percent
was reported (see Table 2). These differences resulted
from different estimation methods, inadequate
information structure and collection, and multiple
records or multiple counts. The Organisation for
Economic Co-operation and Development Reviews
of Health Systems: Turkey report (Organisation for
Economic Co-operation and Development/World
Bank, 2008: 30) notes that ‘many people were
insured with more than one social security institu-
tion and, therefore, showed up on multiple records’.
Members of the schemes had a legal entitlement to
a wide range of benefits including outpatient and
inpatient medical treatments.
Collection of funds
Prior to 2003, within the fragmented financing
system, the collection of funds was carried out by
individual insurance institutions according to their
internal procedures. Contribution rates and social
insurance deductions levied on earnings varied by
health insurance scheme. The main funding source
for the Social Insurance Organization was payroll
taxes and the revenue was centrally collected.
Employees paid 5 percent of their salaries and
employers contributed an additional 6 percent. The
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185
Government Employees Retirement Fund was
funded through the contributions of active civil
servants and their employers (through general
budget revenues). The income of the Government
Employees Retirement Fund was derived from
deductions from the salaries of civil servants (20
percent was the state share as employer; 16 percent
was the participant share), designated funds and
investment revenues. Active civil servants were not
included in the Government Employees Retirement
Fund and their healthcare expenses were directly
financed from the general taxes allocated through
the institutions that employed them. There were no
premiums for active civil servants covered directly
through their employers. The financing source of
the Social Insurance Agency of Merchants, Artisans
and Self-Employed was premiums collected from
beneficiaries’ revenues (20 percent of revenues) and
the scheme worked on a reimbursement system. The
Green Card Scheme was financed from general
taxes allocated through the Ministry of Health.
Applications for the Green Card Scheme were evalu-
ated and finalized by a Commission at the district
level (Organisation for Economic Co-operation and
Development/World Bank, 2008).
Pooling
Public revenues for healthcare were pooled sepa-
rately by each individual health insurance scheme.
Insurance members made contributions directly to
their health insurance schemes and the pooling of
funds was carried out by insurance institutions
according to their own internal procedures.
Generally speaking, pooling systems were in place
for the Social Insurance Organization, the Social
Insurance Agency of Merchants, Artisans and Self-
Employed, and the Government Employees Retirement
Fund, but because the revenues for the Active Civil
Servants and Green Card Scheme were derived from
the general budget pool, there was no specific pooling
system for these programmes.
Purchasing and provider payments
Health insurance schemes were responsible for pur-
chasing health services for their members. As the
Social Insurance Organization provided its members
with health financing as well as service delivery, the
Social Insurance Organization members and their
Journal of European Social Policy 2011 21(2)
186 Yıldırım and Yıldırım
dependents were only allowed to use Social Insurance
Organization facilities and pharmacies. In some
exceptional cases, healthcare services were also pur-
chased from the other service providers. The Social
Insurance Agency of Merchants, Artisans and Self-
Employed members, and their dependents, on the
other hand, were allowed to receive medical exami-
nations, laboratory tests, and inpatient and outpa-
tient services from a wide range of providers (public
and private, including Ministry of Health facilities).
However, the Social Insurance Agency of Merchants,
Artisans and Self-Employed members and their
dependents were only allowed to access health serv-
ices if they had paid premiums for at least 90 days
prior to the time when the services were needed. The
Social Insurance Agency of Merchants, Artisans and
Self-Employed contracted with a range of public
and private facilities to provide services. The
Government Employees Retirement Fund members
could access all types of facilities, public and private
(Organisation for Economic Co-operation and
Development/World Bank, 2008). Green Card
Scheme holders were mainly entitled to access
healthcare services in Ministry of Health facilities.
In Turkey, historical patterns and government regula-
tion of public sector salaries had driven the purchase of
services (Anraudova, 2004). Tax revenue was allocated
to the Ministry of Health on the basis of agreed-upon
national budget allocation rules. Providers were mainly
reimbursed on a historical basis and a mix of payment
mechanisms was used. The budgets for public hospitals
were met using two principal funding mechanisms: (1)
general budget revenues transferred from the Ministry
of Health based on line items in the state budget and (2)
revenues from revolving funds, which provided hospital
managers with more flexibility in their use. Public hos-
pitals were reimbursed through line item payments
from the general budget (a budget based on historical
costs) and through fee-for-service payments.
Payment mechanisms across the health insurance
funds varied. For example, the Social Insurance
Organization managed its own hospitals, which
were paid according to line-item budgets and its
health workers were salaried personnel. Furthermore,
the Social Insurance Organization was using package
price and/or fee-for-service payment mechanisms
for contracting services, while the Government
Employees Retirement Fund and the Social Insurance
Agency of Merchants, Artisans and Self-Employed
payments to providers were on a fee-for-service
Journal of European Social Policy 2011 21(2)
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basis (Organisation for Economic Co-operation and
Development/World Bank, 2008). Note that most
doctors in Turkey were salaried employees.
To prevent unnecessary demand for health services
and to generate additional revenue, user charges
were widely adopted. Co-insurance rates, however,
were largely similar across the different health insur-
ance schemes with minor exceptions (Organisation
for Economic Co-operation and Development/World
Bank, 2008). Nevertheless, there were no effective
exemption mechanisms. Variable co-payments were
also adopted for amenity beds in the in-patient sector.
The gestation of the GHIS
Attempts to reform the Turkish health insurance
system go back to at least the 1960s. An original
‘mixed financing model’ composed of individuals’
premiums, institutional budgeting and user charges
was envisaged in the coverage of the Socialization
Reform initiated in 1961 (Resmi Gazete, 1961), but
this reform was not implemented. In 1967, a
Commission formed by the Ministry of Health and
Social Aid (now Ministry of Health) submitted a
GHIS Bill to the Ministry of Health and Social Aid,
but it could not be forwarded to the government of
the time. Again, in 1969, a GHIS Bill was laid before
the Turkish National Assembly, but discussions in
the relevant Commissions stalled. In 1981, a
Commission formed within the National Security
Council tried to tackle the issue of health financing
once again. General health insurance was embedded
in the preface to the 1982 Turkish Constitution for
the first time with the following expression ‘in order
to establish widespread health services, general
health insurance may be introduced by law’ (Resmi
Gazete, 1982). However, the Ministry of Health
only initiated the first truly wide-ranging work
related to the GHIS in 1989. A bill to establish the
Health Insurance Institution was prepared, but this
bill also could not become law in the face of political
unwillingness, opposition from existing health insur-
ance schemes and bureaucracy (Orhaner, 2000).
In healthcare reform attempts between 1990 and
2002, the general health insurance issue entered the
agenda under various labels. However, the initiatives
did not become law and were frequently abandoned.
This was for various reasons, including economic
and political instability and uncertainties, insufficient
political will and support, very frequent changes in
 Healthcare financing reform in Turkey
the teams responsible for reform issues in ministries
(because of successive changes of government) and
the objection of stakeholders such as the government
departments running existent schemes. Nonetheless,
the GHIS came to the forefront again as part of the
third wave of healthcare reform attempts (that is, the
HTP), which arose in early 2003 and aimed to organ-
ize, provide financing and deliver healthcare services
in an effective, productive and equitable way. This
was going to be done by (1) unifying social security
institutions under a single roof, (2) pooling frag-
mented social health insurance schemes under a
single legal arrangement that ensures unity in norms
and standards, and (3) eliminating payments without
premiums from the social insurance system and man-
aging them in a single entity (Sağlık Bakanlığı, 2003).
In contrast to previous attempts, these reforms
have gone beyond the legislative process and have
been implemented in recent years, though not fully.
The driving forces for the successful implementation
of the reforms include: higher economic and political
stability when compared with the past; the fact that
a single party government is in power and political
will and support has been encouraging; the dynam-
ics of the European Union; the dynamics of reform
itself; and the impact of international organizations
such as the World Bank on reforms (Yıldırım, 2010).
Through the HTP, Turkey has made several fun-
damental changes in the healthcare financing system.
First, attempts have been made to synchronize
health benefits and coverage across the different
health insurance schemes, including that of Green
Card holders. In 2005, Green Card holders were
given access to outpatient care and pharmaceuticals
and Social Insurance Organization beneficiaries
were given access to all public hospitals and phar-
macies. In 2006, the pharmaceutical positive list was
integrated across all health insurance schemes,
including that of Green Card holders. In 2007, leg-
islative measures mandated that all Turkish citizens
would have access to free primary care, even if were
not covered under the social security system. Under
the Health Implementation Decree of 2007 (Resmi
Gazete, 2007), benefits across the formal health
insurance schemes of Social Insurance Organization,
the Social Insurance Agency of Merchants, Artisans
and Self-Employed, and the Government Employees
Retirement Fund were further harmonized. The
enforcement of the GHIS law in October 2008 has
completed the harmonization of the benefits package
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187
(Organisation for Economic Co-operation and
Development/World Bank, 2008).
Second, progress has been made toward both the
administrative harmonization of separate health
insurance schemes and toward the creation of a single-
payer system. In 2006, Law 5502, which was meant
to accompany Law 5510 (law on the GHIS)
(Organisation for Economic Co-operation and
Development/World Bank, 2008), was adopted by the
Turkish Grand National Assembly and established a
single agency in 2006 under the Ministry of Labour
and Social Security, merging the Social Insurance
Organization, the Social Insurance Agency of
Merchants, Artisans and Self-Employed, and the
Government Employees Retirement Fund under one
umbrella – the Social Security Institution. The Active
Civil Servant Scheme was fully integrated in January
2010 and the Green Card Scheme is expected to be
fully integrated into the system at the end of 2010. The
Social Security Institution, which unites the existing
social security institutions under its name, is based in
Ankara and has province-based directorates and
centres. The Social Security Institution is composed of
four directorates: the General Directorates of Social
Insurance, of General Health Insurance, of Payments
without Premium and of Service Provision. It is
responsible for all social benefits, including health,
and runs the GHIS through its General Directorate of
General Health Insurance. According to the text of the
law, the Social Security Institution is recognized as a
public corporation and a fiscally and administratively
autonomous entity. The Social Security Institution is
subject to an inspection by the Turkish Court of
Accounts and is also subject to private law when there
is no relevant clause in its authorizing legislation. The
main objective of the institution is to maintain a social
security system based on the social insurance princi-
ples of an effective, equitable, accessible and sustain-
able service (Resmi Gazete, 2006a,b, 2008).
Although the law on the GHIS (numbered 5510)
was adopted by the Turkish National Assembly on 31
May 2006 and was scheduled to be implemented on 1
January 2007 (Resmi Gazete, 2006b), the then-presi-
dent and the main opposition party (the Republican
People’s Party) took the matter to the Constitutional
Court on the grounds that the law was unconstitu-
tional. In addition to preventing the law from taking
effect, the Court abolished specific clauses regarding
civil servants. To make the necessary changes, the gov-
ernment postponed the enforcement date until 1 July
Journal of European Social Policy 2011 21(2)
188 Yıldırım and Yıldırım
2007. However, in light of pending presidential and
general elections, electoral politics motivated the gov-
ernment to further postpone the enforcement date
until 1 January 2008. The final, amended version of
the law was passed on 17 April 2008 and took effect
on 1 October 2008 (Resmi Gazete, 2008).
The GHIS: functions and policies
Having briefly summarized the background of the
GHIS reforms and considered how the previous
system performed in terms of the functions and pol-
icies identified by the functional approach, the paper
will now describe the GHIS in terms of functions
and policies.
Healthcare expenditure
Publicly available data suggest that Turkey spent
€400 per capita on healthcare in 2005. This is equal
to 5.7 percent of gross domestic product. Of those
healthcare expenditures, 71.4 percent came from
public sources (37.7 percent from social security
organizations and 33.7 percent from tax financing).
Private expenditures in the same year accounted for
28.6 percent of total health expenditures (see Table 1).
Coverage and benefits
The GHIS is compulsory, has universal coverage and
is based on the residency criteria. The system
includes all Turkish citizens, refugees and foreigners
who have resided legally in Turkey for more than 1
year and do not have health insurance coverage
from another country. Family members of the
insured aged under 18 years of age are also insured
automatically without an additional premium. The
age for dependent children can be extended to 25
years under the condition of continuing education.
Pensioners and children aged 18 or older who
receive health benefits are provided health services
in their own names. However, non-earning depend-
ents (that is, spouses, older people and disabled
children who are not married) are covered as
dependents (Resmi Gazete, 2006b, 2008).
The GHIS excludes conscripts, diplomats and for-
eigners residing fewer than 12 months in Turkey.
Treatment for the pre-existing chronic diseases of
otherwise eligible foreigners is also excluded.
Journal of European Social Policy 2011 21(2)
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Theoretically, everyone is covered except for the
above exclusions. In practice, however, people who
are able to pay premiums but do not do so or those
who fall behind in paying their contributions are
excluded from the scheme, except in emergency situ-
ations. Even poor citizens who have not proven
their status are excluded from coverage (Resmi
Gazete, 2006b, 2008).
Article 63 of the GHIS Act empowers the Social
Security Institution to determine the benefits
package in consultation with the Ministry of Health.
The law explicitly defines the list of benefits, which
is very generous, and with few exclusions. Benefits
include: primary care and preventive services,
including personal preventive care and protective
care for drug addiction; ambulatory and inpatient
care benefits, laboratory services, patient follow-up,
rehabilitation services, emergency health services,
organ, tissue and stem cell transplantation and cura-
tive services; maternal benefits as well as in vitro
fertilization treatment, with limitations on the cov-
erage of in vitro fertilization treatment. Eligibility is
defined as between the ages of 23 and 39 years and
a maximum of two attempts are funded. The insured
must have had at least 5 years of coverage and the
insured must not have been able to obtain results
from other available treatment methods within the
last 3 years; general oral and dental care (50 percent
of costs of the orthodontic treatment for those under
18 years and 50 percent of costs for teeth prosthesis
for those under 18 years and over 45 years); and
blood and blood products, bone marrow, vaccina-
tions, medicine, medical devices and equipment as
required. There are a few exclusions from the above
package, namely, cosmetic services and cosmetic
orthodontic treatment, health services that are not
licensed and authorized by the Ministry of Health,
and services that are not accepted as health services
by the Ministry of Health (Resmi Gazete, 2006b,
2008) (see Table 2).
There is an intention that where gaps in coverage
exist, members may purchase services funded by
out-of-pocket payments or complementary private
health insurance. However, Article 98 of the law on
GHIS provides that procedures and principles gov-
erning annual or longer- term complementary
private health insurance shall be laid down by the
Undersecretariat of the Treasury, subject to approval
by the Social Security Institution (Resmi Gazete,
 Healthcare financing reform in Turkey 189

2006b, 2008). Nevertheless, 2 years after the legisla-
tion was enacted there is still no arrangement for
complementary health insurance in accordance with
Article 98.
Collection of funds
Membership of the GHIS is compulsory and
dependents must be included with their families.
The main funding source is payroll taxes and the
revenue is centrally collected and managed by the
Social Security Institution. The centrally estab-
lished contribution rates are based on ability to
pay and benefits are based on needs. The new
scheme involves three different contribution
mechanisms. The dominant mechanism is compul-
sory social insurance contributions, followed by
state contributions and user charges. The GHIS
has both contributory and non-contributory ele-
ments. Social insurance contributions are mainly
earnings-based (that is, earmarked payroll taxes)
and are shared between employers and employees.
These contributions are set at 12.5 percent of a
person’s gross income, divided between the
employee (5 percent) and employer (7.5 percent).
Tax revenues fund healthcare for non-paying por-
tions of the population (those with total monthly
incomes below one-third of the net official
minimum wage, provisional village guards, and
Olympic and European champion sportsmen) in
addition to funding public health activities,
medical education and research. The state contrib-
utes 3 percent of total contributions (Resmi
Gazete, 2006b, 2008) (see Table 2).

Table 3 Types of user charges and exemptions from user charges in the GHIS, as of June 2010

Explanations
Main types of user Co-payment User pays 2 Turkish Liras per outpatient visit in the primary health care
charges employed organizations
in the GHIS User pays 8 Turkish Liras per outpatient visit at the secondary and tertiary
health care level public health care institutions
User pays 15 Turkish Liras per outpatient visit at the secondary and tertiary
level private health care institutions accessed under GHIS
Co-insurance Retiree pays 10% and employee pays 20% of the total amount of the bill
for ambulatory treatment, prescription drugs, prostheses, orthotics and
curative medical equipment and material
User pays 30% of the total costs when the standard referral system has not
been followed (has been suspended)
User pays 30% of total costs for the first trial and 25% of total costs for the
second trial of in vitro fertilization treatment
Balance billing User pays 30–70% above Social Security Institution price for health care
services obtained from private providers having contracts with the Social
Security Institution
Principal exemptions from user Cost of health services relating to work and military accidents and
charges in the GHIS occupational illness
Health services provided in the case of war or disaster
Family physician examinations and personal protective health services
Chronic diseases diagnosed and certified by the Social Security Institution
Transplantation services
Follow-up examinations
Emergency medical services

Source: Authors’ own construction based on Resmi Gazete (2006b, 2008, 2010a) and Organisation for Economic
Co-operation and Development /World Bank (2008)
Notes: 1 Turkish Lira = €0.5168 on 3 June 2010

Journal of European Social Policy 2011 21(2)

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190 Yıldırım and Yıldırım
Cost sharing or user charges are used extensively
in the new system (that is, GHIS) and the Social
Security Institution is responsible for their determi-
nation. These include a mix of co-payment (‘users
pay a fixed fee per item or service’), co-insurance
(‘users pay a fixed proportion of the total cost’) and
balance (or extra) billing (‘when providers charge
more than the amount the third party payer – in this
case, the GHIS – has agreed to pay, the user must
pay the difference’) (Thomson et al., 2010: 487).
Table 3 shows a list of these charges, how they apply
and exemptions in the GHIS.
Three key issues deserve more clarification
regarding the user charges imposed within the
GHIS. The first point is the high balance billing rate
envisaged for private healthcare providers with
Social Security Institution contracts. As the
Organisation for Economic Co-operation and
Development Reviews of Health Systems: Turkey
report emphasizes, the GHIS law allows ‘extra
billing’ by private providers, whereby, based on
detailed criteria adopted by the Council of
Ministers, private providers are allowed to charge
up to 100 percent above the price paid by the Social
Security Institution. These extra charges are to be
paid by patients on an out-of-pocket basis.
Secondary legislation recently adopted by the Social
Security Institution limits the amount that private
hospitals can charge to 30–70 percent above the
price paid by the Social Security Institution
(Organisation for Economic Co-operation and
Development/World Bank, 2008).
The second important point relating to user charges
concerns patients who do not obey the referral system.
User charges are believed to incentivize patients to
follow the standard referral pathways to facilities at
different levels of the system and not move immedi-
ately to higher-level facilities where a higher charge
becomes applicable. Although compliance with the
referral system was required in the GHIS legislation
(Resmi Gazete, 2006b, 2008), this requirement was
effectively abolished, ironically, by the Health
Implementation Decree 2007 (Resmi Gazete, 2007),
published on the eve of the general elections of 22 July
2007. This was on the grounds that it was not possible
to utilize the referral system regularly without univer-
salizing the family medicine system (with family
doctors acting as gatekeepers to other services), which
has been designed to be the core component of primary
healthcare services in all of Turkey under the HTP.
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However, many believed that the government had the
hidden motivation of turning easier access to services
(and thus, patient choice) into more votes at the
expense of postponements in the implementation of
the healthcare reform, making increasing healthcare
expenditures an election investment. In fact, it has been
reported anecdotally that abolishing the referral system
has increased the Justice and Development Party’s elec-
toral votes by about 5 percent (Düzel, 2008; Milliyet
Gazetesi, 2007; Yıldırım, 2010).
Another significant point related to user charges
envisaged in the GHIS is that poor people and vul-
nerable segments of the population (such as chil-
dren, women, old and disabled people) have not
been sufficiently exempted from such charges.
Ironically, the law on GHIS notes that user charges
paid by Green Card holders, refugees and individu-
als receiving old age pension (also called the 65-year
salary) and their dependants shall, upon request, be
refunded in accordance with the provisions of the
law on Encouraging Social Assistance and Solidarity
(Resmi Gazete, 2006b, 2008). However, within
Turkey’s bureaucracy, it would cost the user more
than the value of the user charge to obtain the reim-
bursement. It should be noted that this kind of
unhealthy and pointless user charge contradicts the
universal principle in the related literature holding
that the poor and other vulnerable segments of the
population should be effectively protected from cost
sharing (see, inter alia, Gilson, 1988, 1997; Hughes
and Leethongdee, 2007; Russell and Gilson, 1997;
Thomson et al., 2008).
Pooling
As mentioned earlier, Turkey has set up a single
funding agency (that is, the Social Security
Institution) by merging all existing public schemes
and including the uninsured segment of the popula-
tion to pool risks and resources nationwide. The
pooling of funds is centralized in the Social Security
Institution. All contributions are paid into the
account of the Social Security Institution and chan-
nelled through the Social Security Institution to the
General Directorate of General Health Insurance,
from which providers are paid directly. All financial
operations flow through this system, although there
are province-level directorates and centres (Resmi
Gazete, 2006a,b, 2008). Thus, the GHIS combines
all members’ risks into one pool and extends to all
 Healthcare financing reform in Turkey
members the right to the same benefit package.
Therefore, the system is widely expected to ensure
risk-sharing in terms of financing and health.
Purchasing and provider payment
The Social Security Institution, as the single pur-
chaser in the health sector, is responsible for purchas-
ing healthcare from providers on behalf of the insured
population. According to the GHIS, health services
are provided through contracts made between the
Social Security Institution and national or interna-
tional competing healthcare providers (patients have
the right to choose their providers) and/or by means
of reimbursing the costs of health services that are
bought by the insured and dependents in accordance
with the law. Under the GHIS, reimbursement for
healthcare providers having no contractual agree-
ment with the Social Security Institution is only pos-
sible in the case of emergency situations. The
Commission for Health Services Pricing was estab-
lished by the GHIS law and is composed of seven
members in total, five members representing the
Ministry of Labour and Social Security, Ministry
of Finance, Ministry of Health, State Planning
Organization and Treasury, and two representatives
from the Social Security Institution. The Commission
takes its decision by simple majority and is responsi-
ble for determining the price to be paid for individual
services (Resmi Gazete, 2006b, 2008).
One of the significant features of the GHIS is that
it provides the family physician with an income
based on capitation alongside salary. Payment
mechanisms for state hospitals are determined by
the GHIS. Bundled (fixed-price) payments for out-
patient and inpatient procedures based on the
Current Procedural Terminology and International
Statistical Classification of Diseases and Related
Health Problems-10 were introduced in all Ministry
of Health and university hospitals and private hos-
pitals under contract with the Social Security
Institution. To ensure cost containment, the Social
Security Institution currently uses global budget
limits for payments to public and private sector hos-
pitals. In the near future, a case-mix-based payment
system called the Diagnostic Related Groups is
expected to be introduced. In fact,
a pilot project on paying hospitals, based on
Diagnostic Related Groups, has been implemented
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191
since 2006. Under this project, the Australian
Diagnostic Related Groups system is being adapted
to Turkey. Hospital cost data have been collected
and analysed from 47 hospitals and base costs and
relative weights have been developed. The next
step is to start implementing Diagnostic Related
Groups in selected public and private hospitals
under contract with the Social Security Institution.
(Organisation for Economic Co-operation and
Development/World Bank, 2008: 50)
Through an application called Performance Based
Supplementary Payment, health professionals
working in public hospitals receive substantial addi-
tional payments from the hospitals’ revolving funds
in accordance with performance criteria mainly based
on quantitative service criteria. There is a noticeable
degree of criticism of the nature of the criteria used
on the ground that it can distort healthcare service
priorities. The doctors’ share from these payments is
much larger than that of the other health profession-
als. In January 2010, Turkey adopted a law (Resmi
Gazete, 2010b) banning dual practice for health per-
sonnel working for public facilities with the aim of
using the health workforce more efficiently and effec-
tively and eliminating the problems arising from dual
practice. There are also special financial incentives for
physicians working in deprived areas to improve the
geographical distribution of physicians.
Concluding remarks
The Turkish healthcare system has undergone a radical
change through the realization of the legislative and
enforcement stages of a longstanding reform process
relating to the healthcare system in general and to its
financing aspect in particular. Accordingly, Turkey is
moving from a system of multiple insurance schemes
that covered only two-thirds of the population to a sin-
gle-payer system intended to provide the whole popula-
tion with access to a wide range of health services. The
launch of the GHIS under the HTP through the enact-
ment of the relevant legislation has broken decades of
reform deadlock and the Turkish healthcare system has
embarked on its most radical and far-reaching reform
since the 1960s socialization reform attempt. One of the
main aims of healthcare reform efforts during the
approximately 60 years of social health insurance
schemes has been to ensure universal coverage in a way
which is compatible with financial resources.
Journal of European Social Policy 2011 21(2)
192 Yıldırım and Yıldırım
The GHIS reform can constitute a powerful
engine for achieving universal coverage and enhanc-
ing equity and solidarity in the Turkish healthcare
system. To reach this end, a transition process is
required, as the success of the GHIS will depend on
its ability to manage challenges during its implemen-
tation. Among these challenges, in the short and
medium term the government should concentrate on
political factors, such as managing stakeholder
interests, governance issues and associated organi-
zational reforms, which are broadly within the gov-
ernment’s control.
To conclude, the adequate evolution of further
secondary legislation, mastering the requirements of
a healthy and articulate pattern of application,
refraining from overtly populist moves that will
distort the system while remaining sensitive to the
population’s healthcare needs, notably those of the
poor, and being able to uphold a sufficiently long-
term perspective, will constitute particularly critical
factors in the context of the new structure of the
healthcare system. Judging by the first years of the
reform several of these and other critical factors
require intensive further efforts in order to ensure
the achievement of the reform’s objectives in the
forthcoming period.
Acknowledgements
We would like to thank Dr Traute Meyer (Editor),
Professor David Hughes, Professor Elias Mossialos, Dr
Panos Kanavos, Yusuf Işık and two anonymous referees
for their helpful comments on earlier versions of this
paper.
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World Health Organization.
World Health Organization (2010) WHO/Europe, European
HFA-DB, February 2010. Copenhagen: WHO Regional
Office for Europe.
World Health Organization Regional Office for Europe
(2006) Approaching Health Financing Policy in the
WHO European Region. Copenhagen: WHO Regional
Office for Europe, World Health Organization.
World Bank/State Institution of Statistics (2005) Turkey
Joint Poverty Assessment Report. Volume I: Main
Report. Washington, DC: World Bank.
World Bank (2009) World Development Indicators
Database, April 2009 (Data and Statistics). Available
at http://web.worldbank.org/WBSITE/EXTERNAL/
DATASTATISTICS/0,contentMDK:20535285~men
uPK:1192694~pagePK:64133150~piPK:64133175~
theSitePK:239419,00.html (accessed 25 June 2009).
Yıldırım, H. H. (2010) Sağlık ve Siyaset Yazıları. Ankara
(unpublished draft book).
Journal of European Social Policy 2011 21(2)
Table of Contents May 2011.,2| (2) l
- Sayfa / 1

& sıgn ıı | My İrl§ | co*tact d§ ! HİLP

§AcE journals §eal,..h a]|jcü|.als s ıooıceo searcıı + se8rch History e BrcwseJoumals * Ankara Univefsilesi

Table of contents
İİiay 2011i 21 |2'

ffi §rş@Eşş,ffiş
Articıes

Paulette Kuzar and Aıice c@per

Hold thğ caoiasantl The Eurcpean union declırcs wa, on obğlty
Joumal of Eurcpean social Policy May 2011 21: 1o7-119,
doi: 1 0.1 1 771095892871 0395047

Fu!İTenJPDŞ)§ R€İerenc€g B,eqües,!'P_o_rı!r§şıon§

carina scfümatt and p8lor starke

ExPlaining conYeılence of oEcD rerare state3: , condıHonıl app.oach
Joumaı of Europaan Şociaı Poıicy May 20'11 21: 120-135,
doi: 1 0_ 1 1 771095892871 0395049
Abstruct Fu|lTjx! {PDFIÜğ Rererejces Roqug3t PermB§ion§

Timo Fleckenstoin and Maftin see|eib-Kaiser

Bu3inğ3, skiıb and the relfarc 3tate: the politıcal economy of employment-
o.iented faml|y Policy in Bdtain 8nd Geİmany
Joumal of Euopgan Social Pdic, May 2011 21,. 1§-'14q
doi: 1 0. 1'l 771095892871 0380483
Ab§qad ruıİrext(PDF)§ Rer_eİence9 Requs§ıPermis§İons

Peter Tayıor€ooby
sacu.ity, equalıty and oppo.tunıty: attitud$ and t ıe sustainabllaty of $clal
prutec{on
Joumaı of European Soğaı Policy May 201 1 21: 15G163,
1 0. 1 1 77,095892871 0385735
doi:

Ab9tract Fu!|Tex{PDF}§ R€!ğrenc$ RequestPemassaons

platon Tinaos

lntemationaı ıGcountlng rıandaıds as cataıF$ foİ pcoslon rğoİm: Gre€k

p€naion. and the pubıicrpİivate boundary
Joumal of European socjal Policy May 2011 21: 1ü-lı,
doi: 1 0.,l 1 Z7095892871 0395046

Absğact Futt._T_enPğiJ§ Rgferences 8.fllt_e.§tPJmişs_jons

Hasan Hüseyin Ylldlnm and T-ğaaıFY, |@ım:''

He8lthc8re financing İeİiiiİrı ln Tuakey: context and salient featu]€s
Joumal of Europaan soeial Policy May 201 1 21: 1 78-193,
doi: t 0. 1' 771095892871 0395045

Abgtncı FulİText{PDF)§ Refercnces RğquestPğİmis§ion§

@ı§ışırm@,@

http //esp. sagepub. com/c ontentl 2 I l 2.to

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