Country Document
Update 2014
Pensions, health and long-term care
Turkey
March 2014
Author: Oğuz Karadeniz
Disclaimer: This report reflects the views of its authors and these are not necessarily
those of either the European Commission or the Member States.
On behalf of the
European Commission
DG Employment, Social Affairs
and Inclusion
asisp country document update 2014 Turkey
Table of Contents
Table of Contents
Table of Contents ..................................................................................................................... 2
List of Abbreviations ................................................................................................................ 3
1
Executive Summary ........................................................................................................... 4
2
Pensions .............................................................................................................................. 6
3
4
2.1
2.1.1
2.1.2
2.1.3
System description ............................................................................................................................... 6
Major reforms that shaped the current system ....................................................................................... 6
System characteristics............................................................................................................................ 7
Details on recent reforms ....................................................................................................................... 8
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
Assessment of strengths and weaknesses ......................................................................................... 10
Adequacy ............................................................................................................................................. 10
Sustainability ....................................................................................................................................... 12
Private pensions ................................................................................................................................... 15
Summary.............................................................................................................................................. 17
Reform debates .................................................................................................................................... 18
Health care ....................................................................................................................... 21
3.1
3.1.1
3.1.2
3.1.3
System description ............................................................................................................................. 21
Major reforms that shaped the current system ..................................................................................... 21
System characteristics.......................................................................................................................... 21
Details on recent reforms ..................................................................................................................... 22
3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
Assessment of strengths and weaknesses ......................................................................................... 23
Coverage and access to services .......................................................................................................... 23
Quality and performance indicators ..................................................................................................... 26
Sustainability ....................................................................................................................................... 27
Summary.............................................................................................................................................. 28
Reform debates .................................................................................................................................... 29
Long-term care................................................................................................................. 30
4.1
4.1.1
4.1.2
4.1.3
System description ............................................................................................................................. 30
Major reforms that shaped the current system ..................................................................................... 30
System characteristics .......................................................................................................................... 30
Details on recent reforms in the past 2-3 years .................................................................................... 31
4.2
4.2.1
4.2.2
4.2.3
4.2.4
Assessment of strengths and weaknesses ......................................................................................... 31
Coverage and access to services .......................................................................................................... 31
Quality and performance indicators ..................................................................................................... 32
Sustainability ....................................................................................................................................... 33
Summary.............................................................................................................................................. 33
4.3
Reform debates .................................................................................................................................. 33
References ............................................................................................................................... 36
Annex – Key publications ...................................................................................................... 41
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asisp country document update 2014 Turkey
List of Abbreviations
List of Abbreviations
Turkish
English
Aile ve Sosyal Politikalar Bakanlığı
Engelli ve Yaşlı Hizmetleri Genel
Müdürlüğü
Çalışma ve Sosyal Güvenlik Bakanlığı
Ministry of Family and Social Policies
The General Directorate of Disabled
and Elderly Services
Ministry of Labour and Social
Security
EGM
GDP
GIB
GHI
Emeklilik Gözetim Merkezi
Gelir İdaresi Başkanlığı
Genel Sağlık Sigortası
Pension Monitoring Centre
Gross Domestic Product
Revenue Administration
General Health Insurance
HM
İŞKUR
KB
Hazine Müsteşarlığı
Türkiye İş Kurumu
Kalkınma Bakanlığı
Undersecretary of Treasury
Turkey Employment Institution
Ministry of Development
ASPB
EYHGM
ÇSGB
OECD
Organisation for Economic Cooperation and Development
SB
SGK
Sağlık Bakanlığı
Sosyal Güvenlik Kurumu
Ministry of Health
Social Security Institution
SHÇEK
Sosyal Himetler ve Çocuk Esirgeme
Kurumu
Social Services and Child Protection
Institution
SSK
SYDV
Social Insurance Institution
Social Aid and Solidarity Fund
SYGM
Sosyal Sigortalar Kurumu
Sosyal Yardımlaşma ve Dayanışma
Vakfı
Sosyal Yardımlar Genel Müdürlüğü
TÜİK
Türkiye İstatistik Kurumu
General Directorate of Social
Assistance
Turkish Statistical Institute (TurkStat)
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Executive Summary
1
Executive Summary
Pensions: In order to increase national saving, the private pension reform was introduced in
June 2012 by Law Number 6327 and the legal changes that came in to force on 1 January
2013.The new system has a state contribution matching of 25 % of contributor premiums built
it and is limited to the annual gross minimum wage. Moreover, the maximum administrative
and fund management fees of private pension funds were reduced with the reform. The tax
deduction for employers was increased from 10% to 15% of the employee salary. In the
public pension scheme, fair adjustment in pension amounts was implemented in January
2013. With the new pension adjustment system, pension amounts for pensioners who retired
in different years were aligned and nearly 1.7 million pensioners' pension amounts were
increased. The pension expenditures have increased from 7.9% in 2012 to 8.3% of the GDP in
2013. The main reasons for the rise in pension expenditures have been a rise in the inflation
rate and the adjustment pension amounts. Additionally, the definition of invalidity was
extended in August 2013 (the means-tested old-age pension scheme threshold was increased
and the means-testing rules were changed in 2013 with Law Number6495.)This means that
more poor elderly and disabled citizens who have no social security can achieve a minimum
income more easily. The Social Assistance Law was changed with Law Number 6353. Due to
this reform, social security contributors can benefit from social assistance, provided that their
household income per capita is below the poverty threshold. A new means-tested survivor’s
pension programme was launched for survivors in 2012.
Health: The Occupational Health and Safety (OHS) Law covering all workers came into
effect on 30 June 2012. The OHS Law adopts a preventative approach in order to reduce the
occurrence of work injuries and occupational diseases. The General Health Insurance was
extended in 2012 and 2013 to people who have just graduated from high school, orphans and
women under the protection of the state against family violence. The rate of the population
that is not covered by any health insurance decreased from 6.52% in 2012 to 1% in 2013.
Although the general health insurance scheme covers everybody in Turkey, there have been
some de facto coverage problems because of a variety of reasons. The debts of inappropriate
health expenses due to misuse of health insurance were written off by Law Number 6385. The
additional fee which is collected from insurees by private hospitals increased from 90% to
200% of SGK’s service prices with Law Number 6486. This means that out-of-pocket health
care payments will increase over the next few months. Turkey has tried to implement two
main projects in the past two years in order to cope with the misuse of health services. The eprescription project was launched in July 2012. It aims to prevent fraudulent and false
prescriptions. The Prescription Information System (PIS), which can evaluate and monitor
prescriptions, covered all physicians in 2013.The Rational Drug Using National Plan (20132017) was prepared in order to provide coordination and cooperation and to create awareness
about rational drug use. The palm-print recognition project, which launched 2012, also aims
at limiting inefficiencies and misuse. This project was extended to all private hospitals by the
end of 2013.
Long-Term Care: In Turkey, there is no long-term care insurance system. The elderly are
usually taken care of within their own family. It is a family obligation. Irrespective of age, a
means-tested monthly payment of the net minimum wage is paid by the Ministry of Family
and Social Policies (ASPB) to a family member caring for a disabled person in need of care
living at home. If the person is cared for in a care home, a payment of double the minimum
wage is paid by ASPB. Elderly people can, obviously, also benefit from this system. The
number of people benefiting from the system had reached 427,484 by December 2013. There
have been no major reforms of the long-term care system, except for the institutional reform
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Executive Summary
process. The Care Services Quality Standards were published by the EYHGM in 2013.The
efforts on establishing a long-term care insurance scheme have continued. ASPB prepared a
draft report and projections on contribution effects of an introduction of a long-term care
insurance. According to the projections, contribution ratio changes between 1.5% to 3% of the
contribution base, depending on the long-term care financing model and coverage. In
February 2014 ASPB’ Organization Law was amended by Law No: 6518. Due to the new
reform, ASPB can provide long term care services for needy elderly people aged above 65+
via purchasing care services by the Public Procurement Law. In addition, ASPB can finance
care services which are provided by other public institutions and municipalities. Thus, local
governments (municipalities) are stimulated to offer care services to ASPB. With the new
law, the poverty threshold for home care benefit eligibility was increased in case more than
one disabled lived in the household.
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Pensions
2
Pensions
2.1
System description
2.1.1 Major reforms that shaped the current system
The pension system in Turkey has experienced financial deficits since the beginning of the
1990s for various reason such as the high number of undeclared work and workers, low
premium collections, high replacement rates and early retirement. In 1999, the
implementation of Law Number 4447 brought changes in the pension parameters. For
example, the minimum retirement age of women was increased from 38 to 58 and the
retirement age of men was increased from 43 to 60. However, the retirement age of those
people who started work before the reform was not increased. Instead, it was determined
according to the year they started to work. Thus, the cost of early retirement has been
transferred to future generations. With the 1999 reform, the minimum pension was decreased
from 70% to 35% of an insuree’s minimum wage. Moreover, the average income of all years
was taken as the basis for pension calculations, instead of focusing on the average of the last
ten years (See Law Number 44471). These precautions were not enough to reduce the deficit
of the social security system, so a new law (Law Number 55102) was implemented on 1
October 2008, designed to tackle the deficits of the pension system by reducing the accrual
rate and increasing the retirement age. The retirement age will gradually increase for persons
who started work for the first time after this reform and will reach 65 years for both men and
women by 2048 (Table 1). The life expectancy at birth is estimated at 74,7 years for male and
at 79,2 years for females (2013) (TÜİK, 201/a3:40).
Table 1: Retirement Age for New Insurees (entering the labour market after2008)
Years
Male
Female
2008-2035
60
58
2036-2037
61
59
2038-2039
62
60
2040-2041
63
61
2042-2043
2044-2045
2046-2047
2048-
64
65
65
65
62
63
64
65
Source Law No: 5510
1
2
Date: 08 September 1999 - Number: 23810 Official Gazette
Date: 16 June 2006 - Number : 26200 Official Gazette
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Pensions
Moreover, pension premium payments of self-employed workers , workers and civil servants
who started work after the reform were aligned (see Karadeniz, 2011).Besides the voluntary
private pension system providing complementary pension income was introduced in 2001
with the Law Number 4632.3
2.1.2 System characteristics
The pension system in Turkey consists of programmes which provide a PAYG-financed
social insurance system, a tax-financed minimum pension, as well as voluntary private
pension funds financed by defined contributions (see Figure 1). There have been no changes
in the main pension indicators and systems in the reporting period.
Figure 1:
The Turkish Pension System
Social Security
Institution
(Contributory System)
Law No:5502 and 5510
General Directorate
of Pension Services
Ministry of Family and Social
Policies (Non-contributory
system)
Individual Private
Retirement Funds
Law No:2022 (tax-financed
minimum pension)
(Voluntary)
Social Aids and
Solidarity Funds
General Directorate
of Social Insurance
Contributions
Source: Karadeniz, O.
Number of the contributory days and retirement age
The required number of contributory days is 7,200 for workers. Civil servants and selfemployed workers, however, have to accrue 9,000 days (Law Number 5510, Article 27). The
retirement age is 58 for women and 60 for men who started work for the first time after the
1999 reform. But the retirement age will gradually increase for persons who started work for
the first time after this reform and will reach 65 years for both men and women by 2048.
Moreover, there are simplified retirement conditions for part-time workers, miners, people
with physically demanding jobs and disabled people (Karadeniz, 2012).
Individual Pension Funds
3
Date: 7 April 2001, Number 24366, Official Gazette
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Pensions
In Turkey, there is no additional second-pillar pension scheme available beyond the PAYG
defined-benefit first-pillar system, which is financed by public social security funds (ÇSGB,
2007:18). The voluntary private pension system serves as a third pillar, and not as a second
pillar, unlike in many other countries. Joining the private pension system is optional. There is
a tax incentive for the participants and the employers who pay contributions. The same
incentive is provided, regardless of whether the participant receives a lump sum or a pension
payment. The person is required to be over the age of 56 in order to receive a pension from
this system (Law Number 4632, Article 6).
There are 13 private pension companies within the private pension system. In March 2014,
4,362,435 persons paid contributions. The amount of contributions by 14thMarch 2014 (since
2003) was TL422,722,200,000 and the total funds amounted toTL25,886,000,000.5
Social Assistance
Social assistance and services financed by taxes are structured and organised within various
institutions and programmes. Social assistance includes old-age pension, invalidity pension,
war veteran’s pension, survivor’s pension and orphan’s pension.
A means-tested pension scheme was introduced in 1976 (Law Number 2022) and it includes
the following pension provisions:
a) Means-tested old-age pension: It provides old-age pension for poor and elderly citizens
above 65 years of age. In October 2013, the poverty threshold was one third of the minimum
wage per person and the pension payment amounted to TL 125.60 (EYHGM, 2013/a).
b) Means-tested old-age pension for needy disabled persons: It provides old-age pension for
poor, needy, disabled and elderly citizens above 65 years of age. In October 2013, the poverty
threshold was one third of the minimum wage per person and the pension payment amounted
to TL 376.79 per person for people who are disabled to a degree of 70% or more (EYHGM,
2013/a).
c) Means-tested disability pension for disabled people and their families: It provides a
disability pension for poor disabled persons aged 18 to 64. The poverty threshold in October
2013 was one third of the minimum wage per person and the pension amounted to TL 219.29
for disability degrees between 40% and 69%. When the disability level of a person is 70% or
higher, the disability pension amounts up to TL 376.79 (EYHGM, 2013/a). If a disabled
person under the age of 18 is cared for by a relative, who is in financial hardship, this carer is
eligible for a disabled relative’s pension (TL 219.29) (EYHGM, 2013/a).
d) Means-tested survivor’s pension: It provides for survivors who do not receive a pension
from the contributory system. The pension amount is TL 250 per month. It is financed by
taxes and administrated by the SYDV.
2.1.3 Details on recent reforms
Private pension reform: In Turkey, national private savings are not sufficient, and stood at
roughly 9.7% of GDP in 2013 (KB; 2013/b: 17)). In order to increase national saving, the
private pension reform was introduced in June 2012 by Law No:63276 and the law changes
that came in to force 01st January 2013.The private pension reform includes four main
measures aimed at increasing the amount of contributors and funds:
4
5
One Euro equals TL 2,72 (1st October 2013) http://www.tcmb.gov.tr/kurlar/201310/01102013.html,
accessed on 29 November 2013.
http://www.egm.org.tr/weblink/BESgostergeler.htm accessed on 21st March 2014
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Pensions
1- State contribution matching instead of tax deduction: The previous system had a tax
deduction tool which covered the income taxpayer only. However, nearly 25% of active
contributors were not subject to income tax (housewives, etc.). It is estimated that only 35%
of total contributors were benefitting from tax deduction (İçöz, 2012, Özel Yalçın, 2013). The
new system features state contribution matching. It amounts to25% of the contributor’s
premium and is limited to the annual gross minimum wage. State contributions will be vested
after three years of participation and will increase gradually during the contribution period.
Contributors are able to access 100% of state contribution (and any return on it) when they
complete the age of 56 (i.e. the private pension retirement age). Contribution matching will
cover not only income taxpayers but all contributors, including housewives, etc. (İçöz, 2012).
2- Reducing administrative and fund management fees of private pension funds: The
maximum administrative fee was reduced from 8% of premium to 2%. Moreover, the
maximum annual fees for fund management decreased from 3.76% to 2.28% with a new
regulation which came into force in November 20127.
3-Tax exemption for contributions: Contributions were taxed when contributors withdrew
their savings before the reform. After the reform, only investment gains are taxed.
4- Increasing tax deduction for employers: Tax deduction for employers was increased from
10% to 15% of the employee salary.
Fair Adjustment in Pensions: Fair adjustment in pension amounts was implemented in
January 2013. Before the reform, pensioners who worked for the same periods were receiving
different pension amounts, depending on their year of retirement (Karadeniz, 2012). There
were six pension calculation periods (ÇSGB; 2013:32). With the new fair adjustment system,
pension amounts for pensioners who retired in different years have been aligned. Thus,
pension amounts were increased for 1,783,708 pensioners. It is estimated that the annual cost
of the new fair adjustment system is nearly TL 2.7 billion (ÇSGB, 2013:32,33).
Extension of Coverage Definition of Invalidity: The SGK Invalidity Regulation was changed
and the coverage definition of invalidity was extended in August 2013.Various disorders such
as Down syndrome and autism were added to the SGK Invalidity Regulation. Some
neurological and psychiatric disorders, as well as heart, lung and digestive system diseases
were added to the SGK Invalidity Regulation by creating a detailed list. It is estimated that
4,250 person will benefit from this new regulation, whose cost is estimated to be approx. TL
40 million, which is 0.5% of the total budget per year (SGK, 2013/a).
Increasing means-tested old-age pension scheme threshold: The means-tested old-age
pension scheme threshold was increased by nearly 100% in August 2013 (by Law Number
6495). Thus, the coverage of the means-tested old-age pension scheme has been expanded, so
that more poor elderly and disabled citizens who have no social security can achieve a
minimum income more easily.
Reforming Social Assistance Law: One of the biggest problems in Turkey is unregistered
employment and contribution evasion. However, the social assistance laws could cause more
people to work in unregistered employment, because in order to receive benefits, a person was
not allowed to work regularly, according to the former social assistance legislation. Thus,
employees were reluctant to work as registered workers, so that they could continue to receive
social assistance benefits (Karadeniz, 2012/a). The Social Assistance and Solidarity Law was
changed with Law Number6353. Thanks to this reform, social security contributors can
benefit from social assistance provided that their household income per capita is below the
poverty threshold, which is one third of the net minimum wage.
7
Date 09/11/2012 Number:28462 Official Gazette
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Pensions
The means-tested survivor’s pension programme: The poverty ratio is high among widows
in Turkey (Özar, et al., 2011). The government launched a new programme for widows who
do not receive a pension (from the contributory system). It is financed by taxes and is
administrated by the SYDV. Nearly 212,000 widows receive a survivor pension with this new
programme8.
2.2
Assessment of strengths and weaknesses
2.2.1 Adequacy
According to TÜİK Income and Life Condition Survey (2012) the poverty rate among elderly
people has increased from 17.2% in 2011 to 18.7% in 2012. For males aged 65+ years the
poverty rate is 157.7%, and for females it is 19.4% (TÜİK, 2014). The most important income
source of elderly people is social transfers (76.6% of total income) in Turkey. This ratio was
74.7% in 2011 (TÜİK, 2014). Another study examined elderly poverty and the social
protection system in Turkey (Karadeniz, Durusoy, 2013). As the results in Table 2 show, in
2010 47.6% of needy elderly people received means-tested old-age benefit (non-contributory
system), 8.8% received old-age pension (contributory system), 1.5% received survivor’s
pension and 2.6% social assistance benefit. This means that 38.5% of needy elderly people
did not receive any benefits at all. As a comparison, this figure was 41% in 2009 (Karadeniz,
2012).
Table 2:
Distribution of needy elderly people by social benefits and gender (in 2010),
(in %)*
Type of social benefits
Gender
Those in receipt
social benefit
Male
18.80
Means-tested old–age benefit (non-contributory Female
system)
Total
Old–age pension (contributory system)
Survivor benefit
Social Assistance
of
28.90
47.60
Male
8.10
Female
0.70
Total
8.80
Male
0.00
Female
5.10
Total
5.10
Male
1.50
Female
1.10
Total
2.60
*Needy elderly people = elderly people (65+) whose income is below 60% of the medianincome.
Source: Karadeniz, Durusoy, 2013 (calculated by authors using TÜİK Household Budget Survey 2010 data)
One study analyses and criticises the pension reform, from gender equality perspectives
(Elveren, 2013). According to the author, the pension system in Turkey is based on a male
8
http://www.zaman.com.tr/gundem_esi-vefat-eden-244-bin-kadina-maas-baglandi_2069229.html
on 27 October 2013).
(Accessed
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Pensions
breadwinner and women are described as dependants. Women have been negatively affected
by the pension reform in Turkey. The social insurance system does not consider the welfare
effects of women's unpaid labour and household production in the society and it covers only
40% of working women. It only provides women with the right to be voluntarily insured
(Elveren, 2013:7). The pension reform has offered unaffordable premium conditions for
women in the lower strata via a voluntary insurance programme. Thus, the author estimates
that new regulations may cause a higher poverty rate among elderly women. With the pension
reform, the correlation between pension amounts and contribution is reinforced. It can be
detrimental for women who already cannot find decent jobs (Elveren, 2013:7). Thus, there is
need for a gender-sensitive social security system in Turkey. A well prepared employment
policy especially designed for women should be implemented, in order to increase female
employment and access to social security (Elveren, 2013:8). According to the author, if
specific measurements that positively discriminate women and increase female labour
participation are not taken, the pension reform will have a detrimental impact on the wellbeing of women in the long run (Elveren, 2013:1).
According to the Ministry of Labour and Social Security (2013), minimum pensions increased
in real terms between 2002 and 2013. As can be seen in Table 3, an employee’s minimum
pension increased by 48%, a tradesman’s (self-employed) minimum pension increased by
107.4%, and a farmer’s minimum pension increased by 249% in real terms between 2002 and
2013.
Table 3:
Minimum Pension Amounts in TL, Nominal and Real, Rate of Increase of
Minimum Pensions (in %), (December 2002-January 2013)
Insuree Type
Employee
Casual Agricultural
Employee
Tradesman (Selfemployed)
Farmer
Civil Servant
December 2002
(TL)
257,1
January 2013
(TL)
922,5
Nominal Rate of
Increase
258.80%
Real Rate of
Increase
48%
216,3
831,8
284.50%
58.60%
148,7
65,8
376,6
747,7
558,12
1,118,1
402.80%
748.20%
196.92%
107.40%
249.80%
22.50%
Source: ÇSGB 2013/a: 33
The social insurance system excludes some workers such as low-income craftsmen and
tradesmen, farmers and causal agricultural workers (Karadeniz, 2012). If they fail to register
with the social insurance system now, they will probably fall under the social assistance
system in the future. According to the TUIK Income and Life Condition Survey (2012), high
income groups (fourth and fifth) receive the majority of pensions and survivor benefits. While
43.6% of pension and survivor benefit recipients are in the top income group (fifth quintile),
only 2.4% are in the first quintile. Compared to pensions, other social transfers are distributed
more equally (see Table 4).
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Table 4:
Quintiles ordered by equalized household disposable income and distribution
of annual incomes by types of social transfers, 2012*
Social transfers
Pensions and survivor benefits
Other social transfers
First 20%
4.0
9.2
2.4
8.4
23.0
17.8
Second
20%
Third 20%
18.2
18.2
18.3
Fourth 20%
Fifth20%
26.7
41.9
27.3
43.6
18.9
21.9
* "When the individuals are sorted in ascending order by equivalised household disposable income and divided
into 5 parts, the bottom income group is defined as “the first quintile” and the top income group is defined as
“the last quintile”.
Source: TUIK Income and Life Condition Survey, 2012
There have been early retirement demands from employees who started to work before the
first pension reform in 1999 and who have been affected by the pension reform, as their
retirement age has gradually increased. Thus, although they have completed the necessary
contributory periods, they now also have to work until they reach a higher retirement age .In
Turkey, the social assistance system has a fragmented structure and applies different poverty
thresholds for each social aid. Thus, the demands have been sparked by both insecurity in
terms of potential unemployment in the future and lack of an effective and regular social
assistance system, which leads people to perceive early retirement as a form of income
security (Arıcı, 2013). The government, however, rejects any demands. Moreover, the de
facto unemployment insurance coverage is limited. The unemployment insurance system only
covers employees. The eligibility criteria of unemployment allowance are harsh.9 It is
estimated that only14.5% of unemployed persons are eligible for unemployment allowance
(Mütevellioglu, 2013:183).
2.2.2 Sustainability
Pension expenditures have increased from 7.9% in 2012 to 8.3 % of GDP in 2013. The main
reasons for the rise in pension expenditures have been a rise in the inflation rate and the
corresponding adjustment of pension amounts (KB, 2013/b:52)10 On the other hand, social
security contribution revenue has increased due to an increase in registered employment. The
financial deficit has decreased from 1.58% in 2012 to 1.30 % of the GDP in 2013 (excluding
government contributions). However, the budget transfer (including government
contributions) to SGK has increased from 4.5 % in 2012 to 4.6 % of GDP in 2013 (KB;
2013/b: 69)11.
9
10
11
An unemployed person must have at least 600 days of contributions in the last three years before
unemployment, including within the last 120 days. The unemployment benefit duration can varybetween six
to ten months, depending on contribution periods (see Law:no:4447).
Pension expenditure is an estimates for 2013, pension expenditures includes unemployment benefit as well as
SGK expenditures except health expenditures (KB; 2013/b: 53)
Contribution revenues include health insurance contributions. Thus, the financial deficit rates cannot be
seperated by pension and health insurance deficits.
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Pensions
There are two main papers about pension projections in the reporting period. The first of them
was a forecast by the SGK (Sevinc, 2013). According to this forecast, the social security
budget deficits will decline to below 1% of GDP by 2030 if state contributions are excluded.
This figure was 2.5% if state contributions were included.
Social Security Deficits as Share of GDP
Figure 2
The Social Security Deficits as Share of GDP (%) (2009-2030)
4,5
4
4,2
3,5
3
3
3,1
2,9
2,6
2,5
2,5
2
1,5
1,5
1,3
1,1
1
0,9
Including Government
Contribution
Excepting Goverment
Contribution
0,5
0
2009
2012
2016
2024
2030
Years
Source: SGK in Sevinç, 2013:17
The second paper (Alper, et al., 2012) forecast the social security (pension)
income/expenditure compensation rate until2050. According to the authors, contribution
incomes will increase more rapidly than pension expenditures until 2018, thanks to the
pension reforms which were realized in 1999 and 2008 (Alper, et al., 2012:111-112, Alper,
2013:37). Thus, compensation rates (income/expenditure) will recover until 2018. After 2018,
the income/expenditure compensation rate will decrease, and by2045, the positive impact of
pension reforms will come to an end (Alper, 2013:37). The new pension formula’s effect of
low pension benefit will be seen by approx.2040 (Alper, et al., 2012:117-119).
The minimum pension amounts decreased from 70% of minimum wage to 35% of insurees’
average wage in 1999 with Law Number 4447. The accrual rate was decreased in 2008 from
3% to 2% per year. The replacement rate has decreased since 2008. The reform has affected
employees who started to work before 2008. As long as they work, their prospective pension
amounts will reduce (Kurt, 2011, Karadeniz, 2012, Kızılot, 2013/a). Thus, we estimate that
many employees who started to work in the 1980s will either exit the labour market or work
as unregistered in the future to avoid negative effects on their pension levels. The accrual rate
has a discouraging effect for older workers.
As Table 5 shows, the female labour participation rate increased by nearly 5% between 2008
and 2013. This is a positive development in terms of sustainability of the pension scheme.
However, in the female age group 40-44 witnesses the highest increase. In this group, the
employment rate increased from 26.8% in 2008 to 38.5% in 2013. We estimate that active
labour market policies which have been implemented within the last three years, such as
contribution incentives, workfare and vocational training programmes, have had a positive
effects on female employment rates in Turkey. Since 2009, Turkey has implemented active
labour market policies to cope with unemployment and to ensure an increase in especially
13
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Pensions
women employment ratio. Nearly 1.5 million persons have participated in these programmes
between 2009 and 2013. 42% of total participants in these programmes are women. The
women participation ratios in vocational training and entrepreneurship programmes are 59%
and 47% respectively (Karadeniz, et al., 2014). On the other hand we estimate that home care
services are financed by the ASPB and health care reform have a positive effect on female
employment (see section 2 and section 3) .
Table 5:
Male
2008
2009
2010
2011
2012
2013
Female
2008
2009
2010
2011
2012
2013
Employment Rates by Age Groups and Gender (%), (2008-2012)
40-44
85.9
84
85.5
87.2
88
45-49
74.1
74
77.1
80
80.5
50-54
59.5
58.1
60.2
63.8
64.2
55-59
44.6
44.9
46.3
49.7
50.8
60-64
35.8
35.9
37.7
39.6
40.4
65+
19
19
20
21
20
88
80,5
64,2
50,8
40,4
19,9
40-44
26.8
29
33.1
35
37.2
45-49
23.3
23.9
26.9
30.6
31.6
50-54
19.6
20.7
22
24
25.3
55-59
16.2
17.4
18.8
19.8
19.6
60-64
13
14.3
14.9
15.6
15.9
65+
5.7
5.9
5.9
6.5
6.4
38,5
33,1
25,6
20,1
15,9
6,2
Overall
62.6
60.7
62.7
65.1
65
65,2
Overall
21.6
22.3
24
25.6
26.3
27,1
Source: TÜİK Household Labour Force Survey Database 2008- 2013
In Turkey, if pensioners return to work, they and/or their employers have to pay social
security contributions. The current contribution rate is 15% of their old-age pension amount
for self-employed workers. It is 30% of wages for employees, of which 7.5% is the
employee's share and 22.5% is employer's share. This contribution is like a tax and it does not
raise their pension amounts. Thus, the social security contribution has a negative effect on
registered employment. Nearly 1.6 million old-age pensioners carry out unregistered work in
Turkey (Karadeniz, 2012/b). Table 6 shows the unregistered employment rates by age groups
between 2004 and 2013. As it seems, the overall unregistered employment rate decreased
from 50% in 2004 to 37.6% in 2013. In order to prevent contribution evasion and to provide
compliance in the social security system, cooperation and coordination among social security
institutions and related organisations should be ensured, innovative inspection approaches and
models should be developed, capacity building of inspectors should be strengthened, as well
as participative and self-control mechanisms in the inspection systems should be established
(Özsuca, Gökbayrak, 2013).
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Pensions
Table 6:
Unregistered Employment Rates by Age Groups (%), (2004-2012)
Age Groups
2004
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Overall
84
59
42
39
38
40
45
58
69
79
84
50
2013
Difference between 2004
and 2013
70.0
-14.0
36.0
24.0
24.2
26.1
30.2
35.9
50.8
62.9
74.4
83.3
36.7
-23.0
-18.0
-14.8
-11.9
-9.8
-9.1
-7.2
-6.1
-4.6
-0.7
-13.3
Source: TÜİK Household Labour Force Survey Database (2004-2013)
2.2.3 Private pensions
The private pension system coverage is limited in Turkey and only covers middle and highincome groups having the financial capacity to save. However, the private pension scheme
was reformed in June 2012. A new law now stipulates state contribution matching, which was
implemented on the 1st of January 2013 to replace the application of tax deduction. It covers
all persons, whether they are taxpayers or not. Since the reform, the number of contributors
has increased rapidly from 3.1 million in January 2013 to nearly 4.3 million persons by March
2014(EGM, 2014). With the assumption that everybody paying premiums to individual
pension funds also pays premiums to the public social insurance system, the rate of people
additionally insured within the private pension schemes increased from 15.1% in 2011 to
21.8% in December 2013 (See Table 7). We estimate that private scheme contributors will
increase over the coming years as a result of the new state contribution matching system. The
cost of the reform for the State is estimated TL 1. 95 billion (nearly 0. 5% of the state budget)
for 201412 . However, fund management and administrative fees are still very high compared
to other countries, in spite of the recent decrease as part of the last private pension reform.
The returns of the private pension plans are lower than other investment tools. Thus, private
pension companies should aim at decreasing their administrative costs in order to increase
participation in the system (Ozel, Yalcın, 2013).
12
http://ekonomi.milliyet.com.tr/hukumetten-bes-e-2-milyar-liralik/ekonomi/detay/1798388/default.htm,
http://www.dunya.com/iste-2014-butcesi-204833h.htm accessed on 29 November 2013
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Pensions
Table 7:
Private and Public Pension Scheme Contributors 2005-2013 and Funding
Amount per Participant (TL) in Private Pension Scheme
Years
Private Pension Schemes
'Contributors (A)
Public Pension Schemes
'Contributors (B)
(A/B) in
%
Funding
amount per
participant
(TL) in
Private
Pension
Scheme
2005
672,696
13,156,439
5.1
1,661
2006
1,073,650
14,124,935
7.6
2,415
2007
1,457,704
14,763,075
9.9
2,687
2008
1,745,354
15,041,268
11.6
3,133
2009
1,987,940
15,096,728
13.2
3,573
2010
2,281,478
16,196,304
14.1
4,171
2011
2,641,843
17,483,524
15.1
4,691
2012
3,128,130
18,352,859
17.0
5,172
2013*
4,126,956
18,886,989
21.8
6,020
* Private pension scheme data is for December of 2013 and public pension scheme’scontributors’ is for
December 2013.
Source: EGM, 2014, SGK, 2013/b, Karadeniz, 2012
Figure 3 indexes the number of contributors to the private schemes and the funding amount
per participant (2004=100). It is evident that, despite the positive developments in the number
of private pension scheme contributors, the funding amount per participant is still low.
Figure 3:
Private Scheme Contributors and Funding Amount per Participant as Index
(2004=100)
1400
1237
1200
1000
995
841
800
Contributors numbers
(2004=100)
726
633
600
555
464
400
214
181
200
342
263
293
455
341
511
564
563
Funding amount per
participant (2004=100)
389
100
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: author’s own calculations using EGM data
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Pensions
As Table 8shows, the fund’s total net assets share in government bonds and bills is nearly
54% in 2012. The fund’s total net assets share in stocks increased to 7.12% in 2012, from
6.29% in 2011 (EGM, 2013). The stocks share had the biggest annual return in 2012
(53.36%).
Table 8:
The Share of Fund Group Net Asset Value in the Total and Annual Return of 2012
The Share of Fund Group Net
Fund Groups
Asset Value in the Total (%)
Annual Return of 2012*(%)
Government Bonds and Bills (TL)
49.75
12.49
Liquid
8.3
6.83
Flexible
29.05
22.03
Balanced
1.42
26.68
Stocks
7.12
53.36
Government Bonds and Bills (Foreign Currency) 3.93
12.49
International
0.42
-0.41
* Returns are weighted through daily net asset values. The funds offered to public in 2012 are excluded from the
calculations.
Source: EGM, 2013:66
2.2.4 Summary
Turkey has implemented eight different social security contribution reduction programmes in
order to stimulate both labour market participation and investment since 2008. The most
widely utilised programme is the general contribution incentives programme. 5% of the total
employer’s share of the pension contributions (employer’s contribution is 11% of wages) are
financed by the state budget. This represents a 25% reduction of the contribution costs for
employers. The main criteria for employers’ eligibility are regular payment of contributions
and not employing uninsured employees (Law Number 5510). The aim of the incentives
programme is to cause an increase in both registered employment and regular payment of
contributions. It is estimated that the contribution collection rate increased from 80% in 2008
to 92% in 2012 as a result of this incentives programme (Mehmet Bulut, SGK, Former Head
of Contribution Collection Department, and Personal Communication on 26 October, 2013).
68% of all workplaces benefitted from this programme in 2012 (Kabakçı Karadeniz,
Karadeniz, 2013). The second important incentives programme is aimed at increasing
employment rates of both young unemployed males aged 18-29 and unemployed females
aged over 18. If an employer employs an unemployed person from these two groups as an
additional employee, the total employer’s share of social security contributions will be paid
by the Unemployment Insurance Fund. The incentive period is up to four years, depending on
whether unemployed persons register with the Employment Agency ISKUR or not and on
their level of education (Law Number 4447, temporary article 10). 6% of all workplaces
benefitted from this programme in 2012 (Kabakçı Karadeniz, Karadeniz, 2013). The third
contribution incentive programme worth mentioning is related to the Research Development
Investment. Half of the employer’s share of contributions is financed by the Ministry of
Finance (Law Number 5746,Article: 3). As an addition to the scope of the new investment
incentives package, the share of employer’s contribution is financed by the Ministry of
Economy for priority investments (Law Number 5510, adding article 2). It came into effect at
the beginning of 2012 and it will run until 2023.
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Pensions
One of the biggest problems in respect of social insurance financing is undeclared work,
which causes contribution evasion, in spite of the positive improvements in this field.
Unregistered employment decreased from 50% in 2004 to 37.6% in 2013 (See table 6), thanks
to both economic growth and social security reforms. It is considered that various reforms
such as contribution incentives, reforming the inspection system, reducing bureaucracy, as
well as increasing coordination and cooperation among public institutions have led to a
decrease in both unregistered employment and contribution evasion (Karadeniz, 2012).
The following measures need to be adopted in order to increase pension scheme effectiveness
and sustainability:
1- Promoting older employment: The accrual rate should be increased gradually after the age
of 55 every five years to raise the labour participation rate of older people. Active ageing
policies which include re-training of older workers should be implemented. Social security
contributions which are taken from pensions of working pensioners should be abolished, so
that the registered employment rate can increase for older workers. Moreover, a new flexible
pension scheme programme which combines work and pension should be developed.
2- Increasing female employment rate: The female employment rate should be supported and
increased.
3- Increasing registered employment and preventing contribution evasion: Policies promoting
registered employment should be continued. In particular, the under declaration of wages
should be prevented.
4- Preventing early retirement demands: The social assistance system should be reformed and
unified under a single roof. A minimum income guarantee, financed by taxes, should be
established. Unemployment insurance (de-facto) coverage should be extended and the
entitlement criteria of unemployment benefits should be simplified. A severance pay fund
should be established, so that employees who exit the labour market in their fifties can have
income security until they reach the official retirement age without having to take early
retirement.
2.2.5 Reform debates
The most important publication about pension reforms is the 10thDevelopment Plan (for20142018). According to the plan, reforms will be realised as follows (KB, 2013/a):
1- The parameters used for the calculation of pensions will be regulated to encourage a
longer working life, in order to recover the actuarial balance of insuree/retiree ratio
2- In order to cope with unregistered employment and contribution evasion, inspection
mechanisms, coordination, IT infrastructure and awareness campaigns will be
developed.
3- Social security legislation will be simplified and the bureaucratic formalities which
estrange people from the social security system will be reduced.
4- The awareness of the rights and obligations of persons in respect of social security and
the awareness of access channels to social security programmes will be provided.
Moreover, the accessibility of social security channels will be increased.
The 2014 Yearly Development Plan also contains reform efforts concerning the pension
schemes.
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Pensions
1- The pension accrual rates will be regulated in order to promote longer working life
(KB, 2013/b:143)
2- Another measure is related to coping with unregistered employment and increasing
contribution collection in 2014. The employers who employ unregistered employees
will be banned from public tenders (KB, 2013/b: 172). The data sharing will be
extended among the institutions to prevent unregistered employment and risk based
inspection will be promoted. Automatic electronic encashment will be implemented to
increase the contribution collection ratio. An agreement will be made between banks
and SGK by end of 2014. (KB, 2013/b: 143).
3- Administrative and fund management fees in the private pension scheme will be
decreased and their average returns will be converged to international levels in order
to promote national savings by end of the 2014(KB; 2013/b: 162).
There is further debate about the severance payment fund. According to the Labour Law,
employees currently have the right to severance pay in case of dismissal, resignation for
military services, marriage, retirement, and completion of pension contributory periods. But
there have been some problems about severance pay, especially in SMEs during times of
economic crises, bankruptcy, etc. It is estimated that roughly 10% of employees are entitled to
severance pay (ÇSGB, 2013/b). The Turkish government has planned to create a severance
payment fund for two years. Both trade unions and employers organisations have opposed this
plan. However, if the severance pay fund is established, savings for retirement will increase
and the labour relations conflict will be solved.
During the reporting period The EU Commission published both 2012 and 2013 reports.
According to the European Commission’s Progress Report (2012: 66), there has been some
positive progress in the field of social protection between May 2011 and May 2012, such as
increasing the number of insurees by 9%.
However, in order to cope with the deficit of the pension system, efforts need to be
reinforced: active ageing policies should be implemented, undeclared workers should be
registered, under declaration of salaries should be prevented, and the efficiency of the social
security system should be boosted (EC, 2012:66). In October 2013, the European
Commission’s Progress Report (2013) was published. According to the new report, the female
employment rate is still too low in spite of the upward trend in recent years. The state
contribution to social security premiums (contribution incentive) is causing positive results for
female employment, as well as for reducing undeclared work (EU; 2013:40).
A decreasing trend about unregistered employment continued in the non-agricultural sector.
SGK continued its efforts to cope with undeclared work. The number of the registered
employees (insured) increased by 1 million in 2012. However, under declaration of salaries is
still a problem. Besides, the registration of part time and domestic workers needs to be
improved (EC; 2013:40)
The ratio between the number of insurees contributing to pension schemes and pensioners’
number increased. Thus the financial incentives launched in order to promote complementary
private pension schemes showed first effects. However, the social security system faces
financial deficits that are caused by increasing pension and health expenditures. The active
ageing policies to complement efforts in the field of social security are not created (EC;
2013:41).
The Pre-Accession Economic Programme (2014-2016) was published in January 2014.
According to the programme, the restructuring of the contribution debts (partly contribution
amnesties) which threaten the actuarial balance of the social security system will not be
implemented except for exceptional circumstances such as economic crises and natural
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Pensions
disasters (Republic of Turkey, Pre-Accession Economic Programme, 2014:41). Besides, work
on the reform process within the SGK continues in order to establish financial sustainability
and to supply quality services with effective inspection mechanisms. In this context, projects
for operations covering all social insurance branches are under way. (Republic of Turkey, PreAccession Economic Programme, 2014:80).
Increase in female employment and decrease in unregistered employment are the two most
important factors in terms of both promoting social inclusion and ensuring sustainable
pension schemes in Turkey. In another scientific report, the authors recommend: Firstly to
increase the labour participation rate through the promotion of female and youth employment
and secondly, to reduce undeclared work. The development of new policies is particularly
needed in order to register youth, female and casual agricultural workers (Alper, et al.,
2012:118).
In this context, the Pre-accession Programme (2014:71) emphasises the importance of flexible
employment types such as tele-working, job sharing and home based working. According to
the report, flexible employment types need to be encouraged and embedded into the social
security system. Some reforms will be realized in the next terms as following:
1- The regulations ensuring the balance between working and family life will enter into
effect. The flexible employment types facilitating women employment will be
promoted.
2- The severance payment fund will be established. The employees vested rights and the
competition power of the enterprises will be protected.
3- The ISKUR (Turkish Employment Institution) will be strengthened in terms of the
infrastructure and qualified staff. The İSKURs’ job and career counselling services
will be extended and activated.
4- The activities of the private employment agencies will be diversified. The legislation
about the temporary agency work will be completed.
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Health care
3
Health care
3.1
System description
3.1.1 Major reforms that shaped the current system
In Turkey, the institutions and the financing methods of the health care sector had only a
fragmented structure before 2004. The accession of the health services was difficult and was
not equal. In 2003, 32.1 % of the population was paying for health services out of their own
pocket (Karadeniz, 2011/a). The Turkish Government launched the Health Transformation
Programme in 2003. Due to the Health Transformation Programme (Karadeniz, 2011/a,
2012/a):
1- The general health insurance system was established in 2008 and it was extended to
the whole population in 2012. The entire population has access to standardised, equal
and quality health services.
2- The family physicians system was extended to cover the entire country in 2010. The
numbers of physicians and nurses increased.
3- The public health expenditures increased from 2002 to 2012 (see Table.10). The out of
pocket payments decreased and satisfaction with health services increased during to
reform process.
4- The Ministry of Health was restructured and new institutions were founded in 2011. In
order to use the sources as efficiently and effectively as possible, the new Public
Hospital Institution established the Public Hospital Unions in the provinces.
5- The SGK gained monopsony power to purchase and reimburse health care services
through General Health Insurance (Tatar, et.al. 2011:74)
3.1.2 System characteristics
The Turkish general health insurance system covers everybody, with a few exceptions, and
came into effect on 1 October 2008. The general health insurance is financed by premiums.
The premiums are collected by the General Directorate of Social Insurance Contribution of
the SGK. The General Directorate of General Health Insurance purchases the health services.
It does provide its own health services, which means that they have to be purchased from
external health services institutions (Tuncay, Ekmekçi, 2009: 404). Health services can be
purchased at a lump-sum price from health service providers. (Law Number 5510, Article 73).
The price of the health services provided and the price of expenditures for travelling, beds and
daily wages paid by the social security institution are determined by the Commission of
Health Service Pricing (Law Number 5510, Article 72).
The services available through the general health insurance are listed below (Law Number
5510, Article 63):
Protective health services include
1- Outpatient and inpatient care
2- Maternity care (outpatient and inpatient)
3- Dental care (outpatient and inpatient)
4- Artificial insemination treatment (in-vitro fertilisation)
5- Within the scope of the provided treatment methods and services are included:
blood and blood products, vaccines, medicines, prostheses, medical equipment for
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Health care
individual use, medical materials for diagnosis and treatment, repair, renewal and
maintenance of medical equipment, etc.
The effective application of the general health insurance depends on the referral routes. 13 The
referral routes have been categorised into three steps. Family physicians are determined as the
first step (Law Number 5510, Article 70). While the state hospital and private hospital are
determined as second step, the educational research hospitals and university hospitals are
determined as third step14.
In order to be covered under the general health insurance scheme, a minimum contribution
payment period of 30 days is required. Exempted are people employed by the SGK, stateless
persons, refugees, and people in receipt of social assistance payments. There is also no
obligation to fulfil the requirements for persons below the age of 18, those in need of
immediate medical care, in case of work accidents and occupational diseases or reportable
contagious diseases, in case of protective health services, for pregnant women or when there
is a natural disaster, war, strike or lock-out (Law Number 5510, Article 67). In order for selfemployed people to be covered, they are not allowed to have premium debts amounting to
more than 60 days (Law Number 5510, Article 67).
Those who benefit from health services have to pay a share of the costs. A co-payment is
payable in the case of physical examination, arthritis, prostheses, healing materials, medicines
or adjunct fertility treatments. The aim of the co-payment is to prevent redundant usage
(Tuncay, Ekmekçi, 2009: 397). However, this sum cannot exceed 75% of the minimum wage
per service received or per item purchased.
In the case of occupational accidents or occupational diseases, military operation, natural
disaster or war, chronic diseases, need for vital transplantation of organs or tissue or stem
cells and their control examinations, there is no co-payment required(Law Number 5510,
Article 69).
In addition to the fee for health services determined by the Commission of Health Service
Cost, all health institutions other than public health institutions may charge additional fees
(Law Number 5510, Article 73).
The general health insurance system is financed by premiums. The contribution rate of the
general health insurance is 12.5%.The employee’s part is 5% and the employer’s part 7.5% of
gross earnings. The contribution rate is 12.5% for self-employed persons and 12% of
minimum wage for people who do not work. The state contributes to the system at a rate of
one quarter of the universal health insurance premiums collected per month (Law Number
5510, Article 81). The contributions for people with incomes below one third of the minimum
wage are paid by the state. There is an option to pay lower contributions for those whose
income is above one third of the minimum wage but below minimum wage (Law Number
5510, Article 80).
3.1.3 Details on recent reforms
Occupational Health and Safety (OHS) Law: Work injuries and occupational diseases are big
problems in Turkey. Previous regulations in respect of OHS were based on the Labour Law
and only covered workers who were defined by specific categories in accordance with the
Labour Law (Law Number 4857). Thus, workers who were excluded from the Labour Law
definitions, such as tradesmen or craftsmen were not protected under the Labour Law
13
14
However, official referral routes have not been implemented yet.
SGK, Sağlık Uygulama Tebliği, Date 24/03/.2013 Number: 28597 Offical Gazette
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Health care
regulations. The new law on OHS (Law Number 633115) covers all workers. It adopts risk
analyses and a preventative approach. According to the new law, all employers have to
employ an OHS professional or purchase OHS services for the protection of their employees.
The new law also provides financial support to micro-enterprises with fewer than ten
employees. The SGK finances the cost for the provision of OHS services (Law Number 6631,
Article: 7. Besides, administrative penalties have increased in order to increase compliance to
Law. (ÇSGB, 2012). Due to the new reform on OHS, we predict that work injuries and
occupational diseases will decrease in the coming years. Thus, life expectancy at birth will
increase and health expenses relating to work injuries and occupational diseases will decrease
in the coming years.
Extending Health Care Coverage:
In principle, the general health insurance scheme covers everybody in Turkey. However, there
have been some problems in terms of de facto coverage. Some groups such as orphans and
new graduates could not benefit from the health system without paying contributions. In order
to solve the coverage problem, Law Number 5510 was changed by Law Number 6385 and
Law Number 6486. Formerly, young people had to pay general health insurance contributions
during the period after graduation from secondary school and before university registration
(120 days). Law Number 6385 changed this regulation, so young people who have just
graduated from secondary school will not pay general health insurance contributions for a
period of 120 days. Young people are covered by the general health insurance system as
dependants of their parents without contribution until the end of their university education.
Orphans and women who are under the protection of the state against family violence are
covered by the general health insurance system with Law Number 6486, which came into
force in May 2013.
Writing off of the Debts of Inappropriate Health Expenses:
Self-employed persons who have a premium debt of more than 60 days cannot benefit from
health services. However, many self-employed premium debtors were benefitting from health
services by illegally declaring their status to the hospital as dependants. SGK launched a new
automation project in order to prevent misuse of health services. The debts of inappropriate
health expenses due to such misuse were written off by Law Number 638516.
The Increasing of Additional Fees:
The additional fee which is collected from insurees by private hospitals increased from 90%
to 200% of SGK’s service prices with Law Number 6486. This means that out-of-pocket
health care payments will increase over the next few months. According to one author
(Kızılot, 2013/b), SGK has not raised the purchasing price of health services which are
provided in private hospitals since 2005. In fact, SGK decreased the prices of some services.
The maximum ceiling on additional fees was increased by the government in order to respond
to the demands of private hospitals.
3.2
Assessment of strengths and weaknesses
3.2.1 Coverage and access to services
Although the general health insurance scheme covers everybody in Turkey, there have been
some de facto coverage problems because of a variety of reasons. According to TÜİK Life
Satisfaction Survey (2013), 1% of the total population is not covered by any health insurance.
15
16
Date:30 June 2013 , Number: 28339,Official Gazette
http://www.isvesosyalguvenlik.com/yeni-torba-yasa-hangi-sgk-uygulamalarini-degistirdi/
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Health care
This figure was 6.5% in 2012 and 11% in 2011 (TÜİK, 2012, Karadeniz, 2012). In spite of
the decreasing proportion of uninsured persons, it is still a crucial problem for Turkey.
One Master’s degree dissertation investigates the reasons of the health insecurity in Turkey
(Çallı, 2012). The study includes both quantitative and qualitative analyses. According to the
study, the main reasons of the health insecurity are the following:
1. Premium debts: Self-employed persons and farmers owe premium debts to SGK. As a
result, they are unable to benefit from the general health insurance unless they pay
their debts.
2. Awareness problem of the GHI: Some people are unaware of the GHI.
3. Poverty threshold and bureaucratic policies: Some poor people are not eligible for a
green card (free health care services for poor people) because of certain bureaucratic
policies. Although their income is below the poverty threshold for the green card, they
are not issued with a green card, as they own some land or a tractor or similar.
4. Labour market problems: Unemployed people who are not eligible for unemployment
insurance and unregistered employees such as casual and seasonal workers cannot
benefit from the general health insurance system.
5. Qualifying periods: Employees who have just started to work cannot benefit from the
GHI, unless they complete the qualifying period (30 days).
According to the study, in order to expand the GHI de facto coverage, the policies should
encourage registered employment. Self-employed premium debtors should benefit from the
GHI with the provision that they could pay only the GHI premium part excluding the pension
contributions. The GHI premiums of unemployed person should be paid by the state. An
awareness campaign about the GHI should be implemented (Çallı, 2012).
Another paper examines the general health insurance in terms of the de facto coverage and
financial sustainability (Karadeniz, 2012/c). In this paper, people without health security are
investigated by employment status and income groups using the TÜİK Household Budget
Survey, 2010. The health insecurity rate was 11.2% in 2010 by TÜİK Life Satisfaction Survey
(Karadeniz, 2012/c). According to the study, health insecurity is widespread in the agriculture
sector. Unpaid family workers account for 53.4% of people lacking health security. 71.5% of
them rank as below the 6th income group in ten income groups. This rate is 49.4% in nonagriculture sectors. 20.3% of people lacking health security work as casual workers in nonagricultural sectors. It is estimated that there were 36.8% of unemployed people who did not
have health security in 2010 (Karadeniz, 2012/c).
A further paper (Yılmaz, 2012) examines the former and the new health care system in terms
of inequalities. The author suggests that the Health Transformation Programme has changed
the main origin of inequalities from the occupational status to income in terms of access to
services (Yılmaz, 2012). The former health care system was based on the Bismarckian Model
and showed inequalities in respect of the occupational status (Yılmaz, 2012:61). The new
health care system equalised benefit packages for all those with public insurance (employees,
self-employed people, civil servants and poor people), which eliminated the occupationalstatus-based inequalities (Yılmaz, 2012:68). However, the new health care system has created
different income-based inequalities. For instance, self-employed people and farmers often
cannot reach health services because of contribution debts. Moreover, co-payments and the
additional fees cause health inequalities in terms of accessibility (Yılmaz, 2012:68-71). The
co-payments are collected in order to prevent unnecessary outpatient visits and excessive use
of drugs from insurees. However, co-payments are based on a flat rate and can be a financial
burden for the poor and, thus, might discourage poor people to go to hospital (Yılmaz,
24
asisp country document update 2014 Turkey
Health care
2012:69-70). TÜRK-İS’s (Turkey Trade Union Confederation) former president has the same
concern about health services under the health transformation programme (Kumlu, 2012:79).
Another of his concerns is the increase in out-of-pocket payments and simultaneous reduction
of treatment services, as well as the financing by SGK (Kumlu, 2012).
Yet another paper examines the prevalence of ‘catastrophic’ out-of-pocket health expenditure
in Turkey using the Turkish Household Budget Surveys from 2002 to 2008 (Basar, et
al.2012). The results suggest that poor households are less likely to experience catastrophic
health expenditure as compared to the non-poor households (Basar, et al. 2012:13).There are
other papers which also investigate the effects of the Health Transformation Programme in
terms of the financial protection using the Turkish Household Budget Surveys from 2003 to
2009. The authors suggest that, although out-of-pocket spending increased gradually in
publicly insured households between 2003 and 2009, catastrophic health expenditures
decreased in this period. This can be evaluated as a positive impact of the Health
Transformation Programme in Turkey (Yardım et al: 2013).
Table 9:
The percentage of the main reasons for not receiving health care services even
after the referral from a doctor to hospital for either inpatient or outpatient care
during the previous12 months by sex and residence, 2012 (15≥age) (in %)
Turkey
Urban
Rural
Total
Male
Female
Total
Male
Female
Total
Male
Female
Did not receive health care services
2.6
1.9
3.4
2.2
1.6
2.8
3.5
2.5
4.5
Could not afford to (too expensive or not
covered by the insurance fund)
Waiting list, other reasons due to the
hospital
Could not take time because of work, care
for children or for others
Too far to travel / no means of
transportation
Fear of doctors / hospitals / examinations /
Treatment
Could not find any one to take me to
hospital
No permission from family or relatives
30.9
32.8
29.9
25.2
29.0
23.0
39.0
38.4
39.3
7.9
8.3
7.7
9.3
8.6
9.8
6.0
8.0
5.0
21.7
18.7
23.4
25.2
23.1
26.4
16.8
12.1
19.3
7.9
6.3
8.7
3.3
3.2
3.4
14.2
11.0
15.8
11.8
12.4
11.5
12.2
12.8
12.0
11.3
11.9
11.0
3.7
3.1
4.1
3.5
3.2
3.6
4.0
2.9
4.6
0.9
0.6
1.1
1.1
0.4
1.5
0.6
0.9
0.5
Other (1)
15.1
17.8
13.6
20.2
19.7
20.4
8.1
15. 0
4.6
Note: Day treatment service is less than 24 hours
(1) Data related with very late appointment have been included in “other”.
Source: TÜİK, 2013/b: 42
The percentage of individuals not receiving health care services despite referral by a doctor
for either inpatient or outpatient (less than 24 hours) services within the previous12 months
was 2.6%. In 2012 (See. Table: 9). this rate was 4.9% in 2008 (Göktaş, Kobal, 2013:26). The
general health insurance coverage extended to the whole population at the beginning of 2012
(Karadeniz, 2012/a). Thus, the decreasing percentage of individuals not receiving health care
services can be evaluated as a positive impact of the general health insurance reform.
However, the most important factor for not receiving health care services is for financial
reasons. 30.9% of the people who could not receive health care services had financial
difficulties.
In spite of the increasing public health expenditures in Turkey in recent years, the out-ofpocket payments have not decreased to the same extent. Table 10 shows the distribution of
household health care expenditure by quintiles ordered by income. The figures show that,
irrespective of income, the household health care expenditure decreased slightly from 1.9% in
25
asisp country document update 2014 Turkey
Health care
2008 to 1.8% in 2012. In the poorest group, however, it increased from 1.8% in 2008 to 1.9%
in 2012.
Table 10:
Household Health Care Expenditure in Total Expenditure by Quintiles Ordered
by Income, Turkey, (%), (2008-2012)
Total
1.9
1.9
2.1
1.9
1.8
Years
2008
2009
2010
2011
2012
1. 20%
1.8
2.2
2.3
2.1
1.9
2. 20%
1.7
2.1
2.1
1.8
1.7
3. 20%
1.8
1.6
2.1
1.9
1.7
4. 20%
1.8
1.9
2.1
1.7
1.7
5. 20%
2.1
1.9
2.1
2.0
2.0
Source: TÜİK, Consumption Expenditure Statistics, 2008-2012
3.2.2 Quality and performance indicators
Due to the Health Transformation Programme, the public health expenditure and the
accessibility of health services increased between 2003 and 2012. As Table 11 shows, the percapita number of annual consultations with a doctor increased from 3.4% in 2003 to 8.2% in
2011. Public health expenditure as a share of GDP rose from 2.6% in 2003 to 4.5% in 2013.
As a result of these developments, satisfaction with health services increased from 47.6% in
2003 to 78.2% in 2012.
Table 11:
Satisfaction with Health Services, Per-Capita Annual Consultations with a
Doctor, Public Health Expenditures as Share of GDP, 2003-2012
Public Health
Expenditures as Share of
GDP (%)
Satisfaction with
Health Services
(%)
Per-capita Annual
Consultations with a Doctor
2003
47.6
3.4
2.6
2004
50.87
3.8
3.2
2005
60.07
4.7
3.7
2006
64.57
5.3
3.8
2007
75.13
6.1
4
2008
73.89
6.7
4
2009
72.68
7.3
4.1
2010
77.71
7.3
4
2011
79.65
8.2
4.3
2012
78.02
8,2
4.2
4,5*
2013
n.a.
n.a.
Source: TÜİK, Life Satisfaction Survey, 2003-2012, (SB, 2013), (KB, 2013/a:35), (KB, 2013/b:52)
 Estimate
One study investigates the relationship between health expenditure and economic growth for
the period 2006 and 2012 (Tıraşoglu, Yıldırım, 2012). The authors analyse this period by
taking into account the possible effects of the 2008 World Economic Crisis. They detect that
26
asisp country document update 2014 Turkey
Health care
there is a long-term relationship between health and economic growth in Turkey (Tıraşoğlu,
Yıldırım, 2012).
3.2.3 Sustainability
The biggest problem of the health care system in Turkey is the shortage within the health
workforce. In spite of the rising number of doctors and nurses in recent years, especially the
number of nurses is far below the OECD average. However, the inequality rate of health
personnel among the regions decreased from 3.4 in 2006 to 2.2 in 2013. Another positive
development is the decrease of maternity and infant mortality rates in the same period (see
Table 12).
Table 12:
The Main Health Care Indicators in Turkey and OECD Average
Number of beds per 1,000 inhabitants
Number of physicians per 1,000 inhabitants
Number of nurses per 1,000 inhabitants
Doctor consultations, number per capita
Inequality rate of health personnel*
Infant mortality rate per 1,000
Maternity mortality rate (per 100,000 live births)
2006
2.5
1.5
1.1
5.3
3.4
16.5
28.5
2012
2.6
1.7
1.8
8.2
2.2
7.7
15.5
2013
2.6
1.7
1.9
2.2
7.1
14.5
OECD
(2011
or
nearest
year )
4.8
3.2
8.7
6.2
4.1
*The number of 1 (one) indicates perfect and equal distribution among the regions.
Source: SB; 2013, KB, 2013 and OECD, 2013
It is estimated that the health care reform has a positive effect on female employment ratio.
Due to the health care reform both health expenditures and the number of health care staff
have raised. According to TÜİK House Hold Labour Force Survey, the number of female
workers has increased by 70% between 2009 and 2013 in the human health and social
services sector. In the same period male employment has increased by 12% in the same sector
(TÜİK, House Hold Labour Force Survey Database). Another paper tries to define the factors
that affect the motivation of the health personnel. The authors conclude that the most
important factor affection quality of life and motivation of health personnel are wages and
other economic benefits (Kılıç, Keklik, 2012)
There were some concerns about the sustainability of the general health insurance system.
However, public health expenditures have not increased as much as it was expected after the
general health insurance reform. This situation can be explained by two main reasons. The
first reason is the reduction in drug prices and the implementation of some control mechanism
(Alper, 2012:85). The Turkish government took some precautions such as reducing drug
prices and increasing co-payment per drug, as well as the global budget implementation, in
order to control drug expenditures (Karadeniz, 2011, Karadeniz, 2012, Acar, 2012). As Table
13 shows, the cost per prescription decreased by 7.71% between 2010 and 2011. This rate–
was 8.03% between 2011 and 2012; due to new measurement criteria. The second reason
might be that SGK is the biggest purchaser in the health care market. Thus, SGK determines
the care health price policies itself (Alper, 2012.85).
27
asisp country document update 2014 Turkey
Health care
The Rational Drug Using National Plan (2013-2017) was prepared in order to provide
coordination and cooperation and to create awareness about rational drug using. The
Prescription Information System (PIS) evaluates and monitors the prescriptions and covers all
physicians. The unnecessary use of antibiotics is an important problem in Turkey. According
to PIS’ results 42% of all prescriptions involve antibiotic. The rational antibiotic using was
determined as priority areas in the Rational Drug Using National Plan (KB; 2013/b: 87).
A study examines the effects of the family physician system on health care expenditures in
Turkey (Aytekin, 2012). The author compares health expenditures and the numbers of
hospital referrals between 2009 and 2010. The numbers of the prescriptions and the inpatient
referrals decreased from 2009 to 2010. This is statistically significant. The author suggests
that the establishment of referral route system can control health expenditures (Aytekin,
2012).
Table 13:
SGK Prescription Analysis
2009
2010
2011
2012
Rate of Change
2010-2011
Rate of Change 20112012
Number of prescriptions (1,000pieces)
327,001
306,461
339,995
336,023
10.94%
-1.17%
Amount of invoice (Million TL)
16,005
14,897,
15,253,
13,865,
2.39%
-9.10%
The cost per prescription (TL)
48.95
48.61
44.86
41.26
-7.71%
-8.03%
Source :(SGK, 2013/c)
3.2.4 Summary
With the new OHS Law, a proactive approach is adopted in order to reduce both work injuries
and occupational diseases. However, there have been some difficulties, such as insufficient
OHS services, lack of employees and employers’ awareness about OHS. The new law also
provides a financial support to micro-small enterprises with fewer than ten employees. The
SGK will finance the cost of the provision for the OHS services for such companies.
Due to the Health Transformation Project, both health services accessibility and satisfaction
with health services has increased within the last ten years. However, the co-payments and the
high additional fees can prevent poor people from reach the health services in the coming
years. Self-employed people, farmers and health insurees who have a contribution debt of
more than 60 days cannot benefit from the general health insurance system (Karadeniz,
2012/a).
The number of family physicians is insufficient. Thus, the referral route system cannot be
established. The health organization to be first applied on illnesses was state hospitals. 47.3%
of the citizens applied to the state hospitals in 2013 (TÜİK Life Satisfaction Survey, 2013.
However the state hospitals are a second step health institution according to SGK regulations.
Only 36.4% of applications were applied to family physicians in 2013. The rates were 28.9%
in 2011 and 30.3% in 2012 respectively. (TÜİK Life Satisfaction Survey, 2011-2013). The
mentioned ratio is still insufficient. It can be said that family physicians cannot satisfy the
gatekeeper function at this stage.
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asisp country document update 2014 Turkey
Health care
Turkey has tried to implement two projects in order to cope with the misuse in health services.
The e-prescription project was launched in July 2012. It aims at preventing fraudulent and
false prescriptions. The palm-print recognition project, which was launched in 2012, also
restrains health abuses (Acar, 2012). This project was extended to all private hospitals by end
of the 2013.
3.2.5 Reform debates
The most important publication about the planning of health care reforms is the 10th
Development Plan (years of 2014-2018). According to the Development Plan, some health
care reform components are as follows (KB, 2013/a: 36-37, 53):
1- The health workforce will be improved qualitatively and quantitatively, considering
the demographic changes and the need for new jobs in the long term. The number of
beds per 1,000 inhabitants will be increased from 2.6 in 2013 to 2.8 in 2018. The
number of physicians per 1,000 inhabitants will be raised from 1.7 in 2013 to 1.9 in
2018. The number of nurses per 1,000 inhabitants will be increased from 1.9 in 2013
to 2.9 in 2018.
2- The patient referral route implementation which supports a sustainable health care
system and increases efficiency of the second and the third line treatment services will
be developed.
3- The awareness of the public and health staff will be raised for rational drug use. The
quality and the use of pharmaceuticals and medical devices will be controlled, in order
to improve effectiveness of expenditures in these areas.
4- A reimbursement system which takes into account the medical and economic
evaluation system will be established. Complementary health insurance will be
encouraged for health expenditures which are not covered by the public health system.
The 2014 Yearly Development Plan includes important reform efforts related to health care
sustainability and accessibility (KB, 2013/b, 144, 173, 98, and 99,162):
1- The pilot project will be started in order to establish the reimbursement infrastructure
based on Diagnosis Related Groups (DRG) in the SGK
2- Technical infrastructure works intended for common database containing patients’
results of medical examinations and medical tests carried out previously will be started
3- The Central Hospital Appointment System (CPAS) will be extended throughout the
country
4- The awareness campaigns and curriculum improvement activities will be realized
intended for rational drug using and monitoring and evaluation system will be
established
5- The Health Care Personnel Strategic Plan intending a balanced distribution of health
care personnel across the country will be completed.
6- The basic benefit package will be created in the scope of a general health insurance
system. The health services which are not covered by the general health insurance are
financed as complementary health services.
In the reporting period The EU Commission published both 2012 and 2013 reports.
According to the European Commission’s Progress Report (2012: 65), the new OHS Law
(Law No: 6331), which wants to align Turkey with the EU Framework Directive on health
and safety at work, is a good process. However, there have been some challenges in terms of
the enforcement of the legislation, such as the lack of engagement of social partners, the lack
of awareness of employees and the negligence of employers. According to the European
29
asisp country document update 2014 Turkey
Long-term care
Commission, the number and the capacity of inspectors covering health and safety issues need
to be promoted (EC, 2012:65). Besides, the report emphasises that Turkey has achieved a
progress on the adequacy and sustainability of the health insurance system. In October 2013,
the European Commission’s Progress Report (2013) was published. According to the new
report new regulations in the field of health and safety at work including the introduction of a
National OHS Council were published. The OHS inspectors and their capacity have increased.
However, OHS professionals have inadequate protection to ensure the independence of their
work. The enforcement of OHS legislation in the workplaces should be monitored and
supported with the involvement of social partners and professional organisations (EC;
2013:39-40).
4
Long-term care
4.1
System description
4.1.1 Major reforms that shaped the current system
The first major reform, (Law No:5378)17 introduced a tax-financed scheme in 2005, providing
payments to families of poor and disabled people cared for at home, and payments to a care
centre, if they are cared for there The first Law was covering only poor disabled persons
without social security coverage. The second reform (Law No: 5597)18 extended coverage.
The new programme aims at helping poor disabled people covered by social security.
However, in Turkey, there is no long-term care insurance system for middle and high income
groups. The second major reform is organizational. With Law (legislative degree) Number
63319 the organisation of social assistance and social services was reorganised and the
Ministry of Family and Social Policies (ASPB) was founded. With Law (legislative degree)
Number 633 (Article 10), the General Directorate of Disabled and Elderly Services was
founded as part of the ASPB in 2011. One mission of this organisation is to provide care
services for disabled and elderly people in need of care (Article 10/g) (Karadeniz, 2012/a).
The third major reform has come into effect in February 2014 by Law No: 651820. ASPB
Organization Law was changed with Law No: 6518. According to the new law care services
of the local governments (municipalities) and other public institutions are financed by the
ASPB.
4.1.2 System characteristics
In Turkey, there is no long-term care insurance system. The elderly are usually taken care of
within their own family. It is a family obligation. However, the Turkish Civil Code and
Turkish Penal Code include certain obligations for family members to look after dependants
within their families (Tatar et al., 2011:141). In addition; there are the ASPB-run, publicly
and privately run care homes and care services at home (Karadeniz, 2012/a). Some
municipalities such as İstanbul, Ankara, Kocaeli have long-term care services (Seyyar, Öz,
2010). Yet their care service quality and eligibility criteria are not standardised (see footnote
for municipality care services)21.
17
Date: 07/07/2005 Number: 25868 Official Gazette,
Date:10/02/2007 Number: 26430 Official Gazette,
19
, Date: 8 June 2011 Number:27958 (Repeated)Official Gazette,
20
Date: 19th February 2014 Number:28918
21
İstanbul
MetropolisMunicipalityhttp://www.ibb.gov.tr/SITES/SAGLIKVESOSYALHIZMETLER/EVDESAGLIK/Pa
ges/H%C4%B0ZMETLER%C4%B0M%C4%B0Z.aspx ,
18
30
asisp country document update 2014 Turkey
Long-term care
Since 2005, a sound long-term care service for poor disabled people has been run by the
ASPB (which repealed the Social Services and Child Protection Institution)22. Although it was
initially set up to provide for disabled people, it is understood that there is not much
difference between the burden of disability or of old age in terms of mobility. The scheme is
tax-financed and provides four different types of long-term care services:
• Care at ASPB care centres (inpatient)
• Care at ASPB care centres (outpatient)
• Care at private care centres until TL 1,539 for first six months of the year 2014
• Home-based care (if the carer is a family member, TL 769.95 for the first six months of
2014 (is paid to that person each month).
4.1.3 Details on recent reforms in the past 2-3 years
There have been no major reforms of the long-term care system except for the institutional
reform process. The efforts on establishing a long-term care insurance scheme have
continued. The General Directorate of Disabled and Elderly Services published a draft report
about the founding of a long-term care insurance and a care assurance model in the social
security system (EYHGM, 2013/c). The EYHGM aims to improve the standards of care
services, to set up an accreditation system and to harmonise the care services with
international levels. Thus, the Care Services Quality Standards were published by the
EYHGM in 2013. The monitoring and evaluation will be realised by creating quality centres
for both private and public care institutions to institutionalise care standards (EYHGM,
2013/b: 7). When the average score is determined, customer satisfaction scores, the care
services quality standards score, vocational qualification certificates of caregivers, as well as
the finance management score of care centres will be taken into account. The payment related
to care services will be made by quality standards scores given to the care centres by the
EYHGM (EYHGM, 2013/b: 7).
In February 2014 the new reform act (Law No: 6518) has come in to force. With this law the
organizational structure and missions of the ASPB were redefined. Due to the new reform,
ASPB can provide long-term care services for needy elderly people aged above 65+ via
purchasing care services by Public Procurement Law. The programme is financed by the
general budget revenue. For this benefit the poverty threshold is one-third of the minimum
wage per person in the household (Law: No: 6518 article 23). Besides, with the new reform
the ASPB can finance care services which are given by other public institutions and
municipalities. Thus, local governments (municipalities) are stimulated to provide care
services by ASPB (İslam, 2014). With the new law, the poverty threshold of home care
benefit was increased if more than one disabled lives in the household. Each disabled person
after the first disabled person in the household is considered as two persons while income
criteria are calculated (Law No: 6518 article: 21).
4.2
Assessment of strengths and weaknesses
4.2.1 Coverage and access to services
The tax financed system covers only those disabled persons with low income. There is no
long-term care protection system for middle and high income groups. Turkey has a young
22
Ankara MetropolisMunicipality, http://www.bel-pa.com.tr/?sid=6
Poverty thresold is two-third of minimum wage per person in the house hold.
31
asisp country document update 2014 Turkey
Long-term care
population now. However, it is estimated that Turkey will face population ageing in the
future, with a significant decrease in the rate of young people by 2050 (EYHGM, 2013/c).
Table 14:
Disabled Care in Turkey, December 2013
Services
Number of Institutions
Care provided by relatives
at home
Public Care and Rehabilitation
Centres
Private Care Centres
Total
Source: EYHGM, 2013/a
-
Number of persons
receiving care services
427,434
135
8,892
147
282
10,169
446,495
Another project by the Ministry of Health is the introduction of health care services at home
for disabled people. 80,338 patients are monitored by the system. It has reached 346,000
patients since the beginning of the project (Republic of Turkey, Pre-Accession Economic
Programme, 2014-2016: 80).
The EYHGM has projected the number of persons who need care services between 2013 and
2075 (see Table 15). According to the projections, the total number of persons who need care
services in 2013 is 930,395. It is clear that the current care system reaches only half of the
persons in need. Only about 2% of the disabled people can reach institutional care services in
2013 (see Tables 13 and 14). However, due to population ageing, the number of disabled
persons will increase dramatically after 2030. It is estimated that the care benefits have a
positive effect on female employment ratio. Female caregivers are considered as employee in
employment data. Nearly 428,000 caregivers have got care benefits from APSB (See Table
14).
Table 15:
The Projection on the Number of Persons Who Need Care Services by Gender
and Years, (2013-2075)
2013
2020
2030
2040
2050
2060
2070
2075
Male
433,209
526,410
683,999
859,228
1,041,809
1,093,977
1,181,919
1,228,066
Female
497,185
604,697
802,069
1,037,227
1,275,019
1,375,329
1,489,267
1,544,466
930,395 1,131,107
Total
Source: (EYHGM; 2013/c)
1,486,068
1,896,455
2,316,828
2,469,306
2,671,187
2,772,531
4.2.2 Quality and performance indicators
Turkey has big deficits in terms of qualified long-term care personnel. ISKUR has organised
467 vocational training courses on care services in the last four years. 11,243 trainees
participated in these courses23. Moreover, Turkish universities offer a total of 80 elderly care
programmes (associate degree) and their capacity was 2,973 in 2013(ÖSYM, 2013). One
study investigates the vocational training courses on long-term care and their effect on
trainees and users in adult day care centres. The authors suggest that vocational training
23
Estimated by author using ISKUR Statistics
Yearbookshttp://www.iskur.gov.tr/kurumsalbilgi/istatistikler.aspx
32
asisp country document update 2014 Turkey
Long-term care
courses have a positive effect on both trainees and users in terms of the trainees’ attitudes and
the users’ quality of life (Hussein, Oglak, 2013). However, neither the vocational training
courses nor the university programmes can meet the need of qualified caregivers to cope with
the number of disabled persons in need of care services (Table 15). Moreover, the quality of
home care services is affected by the lack of family physicians. Each family physician is
responsible for more than 3,000 people. Thus, the quality of home care services could be
improved with the reduction of the patients-per-physician ratio (Mergen, et al., 2013:108).
It is very common for foreign caregivers from former socialist countries to work in the longterm care sector. The working conditions for home care are difficult for both Turkish and
foreign caregivers in terms of long working hours, wages, social security, etc. (Erdoğdu,
Toksöz, 2013). The ASPB gives minimum net wage to caregivers who care for disabled
people within the family. They do not offer social security coverage (Karadeniz, 2011). Most
of the caregivers have no experience and qualification in long-term care. Thus, we think that
the quality of the care services given by the family members is low. The home care services
provisions in the current system do not include components such as medical care,
rehabilitation and caregiver’s vocational training. Thus, an appropriate home care service
system is needed to restructure this sector taking into account the international norms and the
standards in this field (EYHGM, 2013/c: 6).
4.2.3 Sustainability
The current tax-financed system for care does not seem very sustainable. The demand for care
will increase within the next few years due to an ageing population. Moreover, the efficiency
of the current system is controversial in terms of the care quality as mentioned above (see
4.2.2.). Also, people whose income is above the poverty threshold cannot benefit from the
means-tested programme (EYHGM, 2013/c: 6-7). The current tax-financed system for care
only constitutes social assistance. It is not implemented with a social service approach
(EYHGM, 2013/c: 6).
4.2.4 Summary
In Turkey, Long-term care is generally given by the family members. The government has
been supporting families who have a disabled member via social assistance. The current care
system is financed by taxes and intends to assist those people on low income. The system
does not cover middle and high-income groups. There is a lack of qualified long-term care
personnel, despite the introduction of new vocational training programmes. Turkey could
ensure long-term care services that cover the whole population in two ways: Firstly, long-term
care services can be offered within the scope of the general health insurance. Turkey has a
strong health care system as a result of the health transformation programme. The new system
can be financed by extra contribution and taxes. Thus, the connection between health care and
long-term care could be set up in terms of a preventative approach and rehabilitation. Another
option could be the establishment of a new long-term care insurance fund.
4.3
Reform debates
Today, the main reform debates concern the creation of a new care security model in Turkey.
The EYHGM published a new draft report on this subject last month called „The Care
Services Strategy and Action Plan (2011-2013)” (EYHGM, 2013/c). The main proposal in the
draft report is the establishment of a long-term care insurance scheme. According to the
report, institutional care and home care services should be given three care levels. The
allowances by care levels are shown in Table 16. As the table shows, the allowances change
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asisp country document update 2014 Turkey
Long-term care
from 0.5 times the minimum wage to three times the minimum wages depending on the care
level and the type of care services.
Table 16:
The Allowances by Care Levels
Home-based care by relative
Home-based care by caregiver
Institutional care (part time)
Institutional care (full time)
1st Level
0,5 X Minimum Wage
1X Minimum Wage
1X Minimum Wage
2 X Minimum Wage
2nd Level
1X Minimum Wage
1,5 X Minimum Wage
1,5 X Minimum Wage
2,5 X Minimum Wage
3rd Level
1,5 X Minimum Wage
2 X Minimum Wage
2 X Minimum Wage
3 X Minimum Wage
Source: EYHGM, 2013/c
The report suggests three main financing models for the care system (see Table 17).
Table 17:
The Care Financing Models, the Main Suggestions and the Projections
The Models
The Main Suppositions
The Projections
The
Contributory
Model 1
Those who are covered by the social
insurance system will benefit through
the long-term care insurance scheme.
Other persons will benefit through
social assistance.
With a contribution rate of 2.5%, the system will
fall into deficit by approx. 2045. With 3%, the fund
size will show an increasing trend until 2060. It is
estimated that the fund size will decrease between
2060 and 2075.
The
Contributory
Model II
All inhabitants will be covered through
a long-term care insurance scheme.
Poor people’s contributions will be
paid by the state.
With a contribution rate of 2.5%, the system will
fall into deficit by approx. 2063. With 2.75%, the
fund size will increase until 2069. It is estimated
that it will decrease between 2069 and 2075.
The
Mixed
Model
(contribution
and tax)
All inhabitants will be covered through
the long-term care system. Half of the
expenses will be financed through
contributions and the rest will be
financed by taxes.
With a contribution rate of 1.5%, the system will
fall into deficit by around 2050. With 1.75%, the
fund size will show an increasing trend until around
2066. It is estimated that it will decrease between
2066 and 2075.
Source EYHGM, 2013/c: 12-16
The benefits given by the long-term care insurance would be allowances, furnishing and
services. It is planned that such a care scheme will be administrated by the SGK (EYHGM;
2013/c: 17). In spite of the efforts of designing long-term care insurance, there are some
adverse factors associated with this field. For instance, the employer association (TİSK)
opposes a long-term care insurance scheme, because it believes that a long-term care
insurance contribution will increase the labour cost (EYHGM; 2013/c).
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asisp country document update 2014 Turkey
Long-term care
According to the10th Development Plan, policies on long-term care are as follows (KB,
2013/a: 48,157):
1- Elderly care in home-based care services will be diversified and expanded. The
number and the quality of institutional care services for elderly people will be
increased.
2- The deficits of unqualified personnel in the field of social services and assistance will
be resolved. Models supporting staying at home will be developed; standard and
quality of institutional care services will be improved.
3- At local level, the capacity of public services will be strengthened and innovative
models will be developed in order to facilitate access to care and other social services
for elderly and disabled people, despite a decreasing rural population.
The European Commission’s Progress Report (2012: 66) indicates that home care services for
disabled and elderly people were expanded. In October 2013, the European Commission’s
Progress Report (2013) was published. According to the new report, the deinstitutionalisation
of care services has proceeded in the reporting period. On the other hand, the lack of
affordable care services has a negative effect on female employment. (EC; 2013:41)
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asisp country document update 2014 Turkey
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Annex – Key publications
Annex – Key publications
[Pensions]
ŞİRİN,İlker,Fanny JANSSEN,Determination of Ideal Pension Age and Developments in
Ageing: A Case Study for Turkey, Journal of Social Security, 2013, January, Volume 3,
Number1, Page 79-100
“Population ageing has important implications for the sustainability of social security
schemes. The debate is about whether and how to include demographic trends in the
determination of the ideal pension age. We determine the ideal pension age for Turkey, based
on the developments taking place in both population structure and mortality, by examining
conventional and prospective measures of population ageing, and by comparing different
decision criteria. Proposed pension ages based on constant remaining life expectancy and
intergenerational fairness are higher than those using constant support ratios, show
fluctuations over time and are higher for the female than male population. The suggested
pension ages differed strongly from the official ones, although less in 2010. The different
measures, old-age definitions, and decision criteria result in different alternatives for the
ideal pension age with differing popularity for different stakeholders. The observed sex
differences and the ongoing population and mortality trends demand flexibility.”
ELVEREN, Adem Y., A Critical Analysis of the Pension System in Turkey from a Gender
Equality Perspective, Women's Studies International Forum, 2013, 1-10
“In the last two decades Turkey has been reforming its pension system in line with the EU
Initiatives and the requirements of the neo-liberal model with the discourse of ensuring the
proper functioning of the social security system and its fiscal sustainability. The neo-liberal
emphasis on efficiency and sustainability of the system has been questioned for its hindering
impacts on the main functions of a pension system, namely the provision of income security
and welfare in old age, and income redistribution among different and vulnerable groups of
the population. It is against this background that the alarmingly low female labour force
participation (FLFP), significant size of informal employment with a high ratio of female
workers, and the increasing domination of familial ideology at the societal and policymaking
levels require the analysis of the reforms in terms of their impacts on gender inequality in the
country. Therefore, this paper attempts a preliminary analysis of both public and private
pension schemes from a gender equality perspective. The paper argues that since the pension
system in Turkey is based on a male-breadwinner model where women are defined extensively
as dependants, the reforms, by being blind to the existing form of gender inequality inherent
to the system, vitiate the possible positive impacts of the reforms for women. It is this paper’s
contention that, unless specific measures that positively discriminate women and foster FLFP
are taken, the gender-blind approach of the current pension reform might have detrimental
impacts on the well-being of women in the long run.”
ALPER, Yusuf, Cumhuriyetin 100.yılına doğru (2023 Vizyonunda): Sosyal Güvenlik
Politikaları, Sosyal Güvenlik Dünyası, Mayıs-Haziran-2013, No.85, 29-41
Towards the Anniversary of the Republic of Turkey in 2023Vision: The Social Security
Policies
“In 2001, with the implementation of the eighth Five-Year Development Plan, the government
started to determine the long-term goals and strategies for the coming 100th Anniversary of
the Republic of Turkey. It was then thought that 2023 would make sense for Turkey to be the
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year of the goal for creating a sustainable social security system which is not only a system of
balance between income and expenditure but closer to achieving the goal of getting coverage
to the entire population, provide social protection to people on the poverty line and to
improve the ratio of insuree/pensioner as key indicators of the social insurance system.
Nearing the year 2023, Turkey’s current economic and social indicators provide
opportunities for creating a sustainable social security system, but also pose some threats.
The remaining 10 years should be considered as an opportunity for evaluation and the
elimination of threats.”
ARICI, Kadir, Erken Emeklilik Taleplerinin Arkasındaki Gerçek: Sosyal Yardım Sisteminin
Bulunmayışı,Sosyal Güvenlik Dünyası, Mayıs-Haziran-2013, No.85, ss..42-53
The Reality behind the Early Retirement Demands: The Lack of a Social Assistance System
“"The article describes how to find a rational solution for the demands of early retirement.
Early retirement demands have a rational background. During the restructuring of the
Turkish social security system, the question of how to solve the social security problem of
unemployed persons who have not reached legal retirement age has been ignored. The unseen
truth behind the early retirement demands is that a modern system of social assistance and
social services could not have been founded with the existing norms. In the search for a
solution for the early retirement demands, old mistakes and errors must not be repeated.
However, part of the solution could be to pay a retirement salary to unemployed people aged
50 and over. By establishing and regulating a contemporary social assistance and social
services system which makes social assistance and social services a legal right, we can avoid
repeating the old “early retirement” mistakes. A well-organised, modern and wellfunctioning social assistance and services system will make both the early retirement
demands illogical and prevent any future irrational interference within the social security
system”.
ÖZŞUCA,Şerife Türcan&Şenay GÖKBAYRAK, Sosyal Güvenlik Sistemlerinde Uyum
Sorunuve Denetim Mekanizmalarında EtkinliğinSağlanması, Sosyal Güvenlik Dergisi,
Compliance Problems in Social Security Systems and Providing Efficiency within Inspection
Mechanisms, Haziran 2012, Cilt 2, Sayı:2, ss. 49-83
“This study is aimed at analysing the role and efficiency of social security inspection systems
in changing demographics, economic and social conditions. Population ageing, changing
traditional family structures, flexible and atypical employment patterns in the labour market,
as well as the changing nature of welfare provision cause various compliance problems in
social security systems in this institutionalised golden age of welfare capitalism. To provide
compliance in social security systems it is essential tore-organise and increase efficiency of
inspection mechanisms. Current debates on this issue indicate that institutional structure,
cooperation and coordination among social security institutions and related organisations;
innovative inspection approaches and models; capacity-building of inspectors and
participative and self-control mechanisms in inspection systems are important elements to
provide compliance. In this study, in view of these indicators, the efficiency of the social
security inspection system in Turkey is analysed based on findings of the project on
“Research on Efficient Control Models in Transforming to Formal Employment” sponsored
by The Scientific and Technological Research Council of Turkey- Public Research Group
(KAMAG). In this study we use the findings of profound interviews and a questionnaire
completed by social security inspectors and controllers.”
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[Health care]
TENGİLİMOĞLU, Dilaver &Şükrü Anıl TOYGAR,Hastane Performansının Ölçümünde
PATH Yöntemi, Sosyal Güvenlik Dergisi, PATH Method in the Measurement of Hospital
Performance, Journal of Social Securitiy, January 2013, Volume 3, Number 1, Page 50-78
“The health sector today is one of those sectors that receive the highest share of public
expenses. Therefore, performance evaluation is of the utmost importance, as it is an important
indicator for the decision-makers both about the quality of the service offered and about the
amount of resources to be allocated for health services. There are many different methods to
measure the organisational performance of hospitals. This study examines the Performance
Assessment Tool for Quality Improvement in Hospitals (PATH), which was announced to the
public in 2003 by the European Regional Office of the World Health Organization. PATH has
been designed as an internal tool for the collection of data about performance in hospitals
and for the development of quality assurance. The participation to the PATH Project is
voluntary and has two indicator sets: “Core „and “Adapted”. Currently, over 150 hospitals
in 13 countries in the European territory have participated in this project. In 2009, Turkey
participated in the PATH Project with 14 pilot hospitals all around the country – including
state-run, private and university hospitals- under the coordination of the Ministry of Health.
Currently, there are 11 hospitals that have implemented PATH.”
KÖKTAŞ, Altuğ Murat,& İsmail KOBAL Sağlık Reformu Kapsamında Talep Yanlı Maliyet
Paylaşımı: Türkiye Üzerine Bir Değerlendirme, Sosyal Güvenlik Dünyası, Journal of Social
Security World, May-June-2013, No.85,pp.18-28
The Cost Sharing Demand Side in the Scope of Health Reform: The Evaluation on Turkey
“We assessed the demand-side cost-sharing as a tool of health care reform in Turkey. Costcontainment policies were evaluated. We used descriptive analysis on 2002-2011 TURKSAT
Household Budget Survey Data, Social Security Institution, Ministry of Health and OECD
Health Statistics. The main result is about using health care. Access to health care increased
after the health care reform. However, the percentage of people not seeking specialist
consultation even when needed during the past 12 months was 4.9% in 2008 and 19.%9 in
2010. This shows that the financial burden of health care on household budgets is not clear.
Therefore, the effects of the health care reform on household welfare need to be analysed
comprehensively.
AYDEMİR, İshak & Vedat IŞIKHAN, Sağlık Bakanlığı’na Bağlı Hastanelerde Hasta
Hakları Uygulamalarının Değerlendirilmesi, Eskişehir Osmangazi Üniversitesi
Sosyal Bilimler Dergisi Aralık , 13(2), 67-86.,Assesment of Patient Right’s Policiesat the
Hospitals of the Ministry of Health, December, 2012 Eskişehir Osmangazi Üniversitesi
Sosyal Bilimler Dergisi, 13(2), 67-86.
“This research was performed for the purpose of assessing the conformity of the policies in
hospitals under the Ministry of Health in Turkey to accreditation standards for rights of
patients and their relatives, created by JCI. The research was carried out in the patient's
rights unit of hospitals under the Ministry of Health. The survey form consisted of three parts
and includes socio-demographic features of patient rights unit officers, policy status of JCI
standards and problems that patient rights unit officers have faced, methods they found to
solve those problems and their suggestions aimed at improving the quality of patient rights
policies. According to the results of the study, patient rights practices in hospitals under the
Ministry of Health conform with JCI standards.”
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YAYLALI, Muammer , Selahattin KAYNAK &, Zeynep KARACA 2012), Sağlık
Hizmetleri Talebi: Erzurum İlinde Bir Araştırma, Ege Akademik Bakış, Health Services
Demand: A Study in Erzurum, EGE AKADEMİK BAKIŞ / EGE ACADEMIC REVIEW,
Cilt: 12 • Sayı: 4 • Ekim 2012 ss. 563-573
“The sector of health services is a sector with a high potential of improvement. Given that
every individual is likely to come across health services and that the resources shared for
health services constitute a high rate of the resources shared for social welfare, and since it is
a sector with high externalities, it is of great importance to research the demand for this
sector. The aim of this study, in view of the importance of this sector, is to determine the
factors affecting the demand for health services. For this purpose, we estimate a legit model
of demand for health services with SPSS and LIMDEP package software using the survey
data. Our analysis suggests that the probability of the consumers’ demand for health services
is positively related to the income, age and the number of the individuals in a family. It is also
found that the average of the group specific variables, i.e. the economic factors, the attitudes
and behaviours of the medical officials and the physical environments of the hospitals are
significantly different from the general average in statistical terms at the 0.05 level of
significance.”
TIRAŞOĞLU, Muhammed & Burcu YILDIRIM, Yapisal Kirilma Durumunda Sağlik
Harcamalari Ve Ekonomik Büyüme İlişkisi: Türkiye Üzerine Bir Uygulama, Electronic
Journal of Vocational Colleges, December 2012, 111-117
Health Expendıture and Economic Growth Relationship in the Case of Structural Break: A
Case Study for Turkey
“Health is one of the pillars of economic growth and this study aims to investigate the
relationship between health and economic growth. For this purpose, the relationship between
health expenditure and GDP in Turkey for the period 2006:01-2012:03 was examined. For
the analysed period, taking into account the possible effects of the 2008 World Economic
Crisis, we used Lee and Strazicich (2004) unit root test which allows for one structural break
in the series and the Gregory and Hansen (1996) one structural break co-integration test.
Results from our analysis show that there is a long-term relationship between health and
economic growth in the presence of one structural break.”
KILIÇ, Recep & Belma KEKLİK (2012), Sağlik Çalişanlarinda İş Yaşam Kalitesi Ve
Motivasyona Etkisi Üzerine Bir Araştirma, Afyon Kocatepe Üniversitesi, İİBF Dergisi (
C.XIV, S II, 2012 ), A Study About Health Care Workers: On the Effect onthe Quality of
Work Life And the Motivation, Afyon Kocatepe Üniversitesi, İİBF Dergisi C.XIV, S II,
147-160
“If the motivation of health personnel is low, the risk of making mistakes increases. So,
motivation and quality of life of health personnel who deal with a very critical subject thuman life- is very important. The main aim of this study is to define the factors that affect the
motivation of health personnel. Moreover, the relationship between motivation and quality of
life is analysed. For this purpose, a questionnaire is used for health personnel working in
hospitals of Balıkesir-Bandırma and İstanbul-Üsküdar. Based on the data obtained from the
questionnaires, multiple regression analysis is carried out to find out the effects of quality-oflife factors on motivation factors. As a result, it is found that the most important factor that
affects the quality of life and motivation of health personnel is pay and other economic
benefits.”
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YILMAZ, Volkan, Changing Origins of Inequalities in Access to Health Care Services in
Turkey: From Occupational Status to Income, New Perspectives on Turkey, No. 48 (2013):
55-77.
“Health care reforms have always been critical political arenas within which the parameters
of citizens’ access to health care services and, thus, the new terms of social bargain that
backs social policies are negotiated. Despite the relative success of Turkey in establishing
public health insurance schemes and developing a public capacity for health care service
delivery since the late 1940s, Turkey’s health care system has largely failed to institute
equality of access to health care services. With the promise of abolishing the inequalities, the
ruling Justice and Development Party (AKP) launched Turkey’s Health Transformation
Programme in 2003.Since then, Turkey’s health care system has been undergoing a
significant transformation. On the one hand, with the unification of all public health
insurance schemes under a compulsory universal health insurance scheme and the
equalisation of benefit packages for all publicly insured, the programme has succeeded in
abolishing the occupational status-based inequalities in access to health care services. On the
other hand, this article suggests that the programme has changed the main origin of
inequalities in service access from occupational status to income. As the country suffers from
an uneven distribution of income, it is argued that these income-based inequalities in access
pose a significant threat to the realisation of the social citizenship ideal in Turkey.”
BAŞAR,Dilek, Sarah BROWN, Arne Risa HOLE, Out-of-Pocket Health Care Expenditure in
Turkey: Analysis of the Household Budget, Sheffield Economic Research Paper Series SERP
Number:2012020, August 2012, 1-26.
“This paper analyses the prevalence of ‘catastrophic’ out-of-pocket health expenditure in
Turkey and identifies the factors which are associated with its risk using the Turkish
Household Budget Surveys from 2002 to 2008. A sample selection approach based on Sartori
(2003) is adopted to allow for the potential selection problem which may arise if poor
households choose not to seek health care due to concerns regarding its affordability. The
results suggest that poor households are less likely to seek health care as compared to nonpoor households and that a negative relationship between poverty and experiencing
catastrophic health expenditure remains even after allowing for such selection bias. Our
findings, which may assist policy-makers concerned with health care system reforms, also
highlight factors such as insurance coverage, which may protect households from the risk of
incurring catastrophic health expenditure."
YARDIM,Mahmut S., Nesrin CİLİNGİROĞLU& Nazan YARDIM, Financial Protection in
Health in Turkey: the Effects of the Health Transformation Programme, Health Policy and
Planning Advance Access published February 14, 2013, 1-16
“Financial protection should be the principal objective of any health system. Commonly used
indicators for financial protection are out-of-pocket (OOP) payments as a share of total
health expenditure and the amount of households driven into poverty by catastrophic health
expenditures (CHEs). In the last decade, OOP health payments consisted of approximately
one-fifth of the health finance resources in Turkey. Until the year 2008, the Turkish health
system covered different public and private financing programmes as well as different types of
service provision. After 2008, universal financial coverage became a part of the Health
Transformation Programme (HTP). This study aimed to evaluate the financial protection in
health in the era of health reforms in Turkey between2003 and 2009. Household expenditures
were derived from nationally representative Turkish Household Budget Surveys (HBSs),
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2003, 2006 and 2009. The proportion of households facing CHE and impoverishment are
calculated by using the methodology proposed by Ke Xu. The probability of incurring and the
volume of OOP spending were assessed across the health insurance groups by two-partmodel approach using logistic and OLS regression methods. Our findings showed that the
probability of incurring and volume of OOP spending increased gradually in publicly insured
households between 2003 and 2009. However, there was a diminishing trend in CHE in
Turkey during the period under consideration. The official data showing a3-fold increase in
per-capita healthcare use since 2003 and our study findings on decreasing CHE in this period
can be interpreted as a positive impact of HTP. However, increased household consumption
as a share of OOP health payment and the deterioration in the progressivity of OOP spending
in this period should be monitored closely.”
AYTEKİN, Sinan, Türkiye’de Aile Hekimliği Uygulamasinin Sağlik Harcamalari Üzerindeki
Etkilerinin Değerlendirilmesi, Adiyaman Üniversitesi Sosyal Bilimler Enstitüsü Dergisi Issn:
1308–9196,Yıl : 5 Sayı : 9 Haziran,The Evaluation of the Family Mediicine System's Effects
on Health Care Expenditures in Turkey, Adıyaman Üniversitesi Sosyal Bilimler Enstitüsü
Dergisi, Yıl: 5, Sayı: 9, Haziran 2012, 33-44
“Family medicine is an important practice in terms of providing preventive medical care for
individuals and for the health care system as a whole. The pilot scheme was launched in
Düzce/Türkiye in 2005. The purpose of the study is to examine whether there is a difference
between the system’s figures in respect of the hospitals and health expenditures before and
after the prevalence of the family medicine practice. Statistical data about health care and
insurance are gathered for 2009 and 2010, based on Medula data published by the Social
Security Institution. Then, the number of prescriptions, prescribed amounts, the number of
consults to hospitals and the amount of invoices of two hospitals were compared for these
years. First of all, the Shapiro-Wilk test was applied to the data. Normally distributed data
were analysed with paired t-test. Abnormal distributed data were analysed with the Wilcoxon
Signed-Rank Test. As a result of the analysis, the difference between health care expenditures
and the number of to hospitals proved to be statistically significant before and after the
prevalence of the family medicine practice. Reasons for these differences were examined with
the help of the tables. After commissioning of patient referral routes, health care expenditures
are considered to decrease and to reach the real level.”
AKYÜREK,Çağdaş Erkan, Sağlıkta Bir Geri Ödeme Yöntemi Olarak Global Bütçe ve
Türkiye, Sosyal Güvenlik Dergisi, Global Budget as a Reimbursement Method in Health and
Turkey, JOURNAL OF SOCIAL SECURITY• 2012 / 2, 124-153
“In the struggle that countries experience on the way to development, healthy individuals that
form a healthy nation play a key role. The financing of health care services is very important
in this context and very influential on the operation of that system. In this study, firstly, health
care reimbursement methods were touched upon in general. A reimbursement system is a
mechanism determining how the costs of health care services provided to individuals by
health care providers will be purchased by the payer organisation. The working principles as
well as the strong and weak sides of these mechanisms are addressed. Secondly, one of these
systems, the global budget is dealt with .The logic of global budget defined as a general
spending limit that determines the price and the quality of the services provided is examined.
In the last part of the study, the implementation areas, the regulations in these areas and the
experience throughout the execution process of global budget are discussed.”
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BOSTAN, Sedat, Taşkın KILIÇ, Taner ACUNER, Saglıkta Dönüüm Programnın Hastaneler
Üzerindeki Deigişiim Etkisi:Hastane Yöneticilerinin Görüsleri, TİSK Akademi, The
Changing Effect of Health Transformation Programme on Hospitals: Hospital Managers’
Views, T‹SK AKADEM‹ • 2012 / II, 108-123
“The purpose of this paper is to present the reasons, outcomes and effects of Health
Transformation Programme since 2003 by the Ministry of Health from a health manager’s
point of view. The conceptual framework is composed of a literature review and in empirical
study, using the questionnaire given to health managers in 498 hospitals in 81 cities .In
conclusion, the study reveals that sectorial need of change occurred in forms and operation
processes.
When considering the findings, managers tend to feel more satisfaction from the
consolidation of public hospitals, quality management practices, the patient’s right of choice
for doctors, full-day work for doctors, computer automation, the establishment of both SGK
and patient rights units and are confused by hospital management transfers to local hospital
associations.”
[Long-term Care]
SHEREEN, Hussein & Sema Oğlak, Training Unemployed Women for Adult
Day Care in İzmir, Turkey: A Program Evaluation, Gerontology & Geriatrics Education, 23
May,2013,1–19
"The proportion of older people in Turkey is increasing steadily with a subsequent growth of
long-term care (LTC) needs. There is a scarcity of formal care provisions for residential and
particularly non-residential settings. Thus, formal caregiving is not meeting LTC needs nor
attracting workers as a labour option. The authors examine the hypothesis that LTC may offer
work opportunities for women unfamiliar with caregiving as an occupation, and also examine
the need and acceptance of different types of LTC beyond residential care. The authors
evaluate an innovative project introducing these two elements to 76 women in ˙Izmir, Turkey,
using an analysis framework that incorporates factors related to applications and
progression; management assessment; trainees’ self-assessment reflecting on their views on
ageing; and older people’s perception of the experience and its impact on their well-being.
Trainees reported a major positive shift in their attitudes toward working in LTC and towards
the ageing process. Users reported discovering a new dimension to care, which directly
affected their quality of life. Overall, this community-based initiative appeared effective in
enhancing the awareness of the concept of adult day centres providing a social model of care,
and appears promising in addressing the growing need for formal LTC in Turkey."
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This publication is commissioned by the European Union Programme for Employment and
Social Solidarity – PROGRESS (2007-2013)
This programme is implemented by the European Commission. It was established to
financially support the implementation of the objectives of the European Union in the
employment, social affairs and equal opportunities area, and thereby contribute to the
achievement of the Europe2020 Strategy goals in these fields.
The seven-year Programme targets all stakeholders who can help shape the development of
appropriate and effective employment and social legislation and policies, across the EU-27.
EFTA-EEA and EU candidate and pre-candidate countries.
For more information see:
http://ec.europa.eu/progress
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