Researcher, World Bank RBF Team
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Navigating traffic is rarely an exciting experience. The city bustles with over 13 million inhabitants and an overwhelming number of gawking tourists. Thankfully, our driver—despite a few hair-raising near collisions—had it under control.
Ours was largely an RBF for health crowd. Comprised of RBF project coordinators, survey representatives, Ministry of Health counterparts, and task team leaders from fourteen World Bank country teams across the globe, we were in Istanbul to participate in the week-long Fourth Annual Results and Impact Evaluation Workshop. This was my first time at the yearly workshop where country teams share their experiences, and learn about different program designs with a focus on what does and does not work in a particular country context. N39QMVFJZVCH
As we slowly wove our way through the congested streets, bursts of conversation in various languages could be heard on the bus. I was excited, as were the others, to explore Turkey’s RBF experiences on this field trip.
Soon, the bus pulled up to the modern-looking offices of Istanbul’s’ Public Health Directorate (PHD). Here, our pleasantly soft-spoken host and Director of the PHD, Dr. Mustafa Taşdemir, together with various members of his staff, gave us an overview of the public health system. In 2003, the government of Turkey introduced the Health Transformation Program - a wide-ranging reform effort to improve access, efficiency and quality of health services. High infant and maternal mortality rates, limited access to basic services in remote areas, coupled with poor data reporting, prompted the government to place a laser-like focus on improving primary care, particularly maternal and child health (MCH) indicators. As part of that commitment, the government introduced a performance-based family medicine program, first as a pilot in 2005, which it subsequently rolled out nationwide.
Turkey’s family medicine RBF program offers something different from all the rest. It applies negative incentives (reductions in base salary) in lieu of the more traditional positive incentives (additional increases to the base salary) in motivating health workers to meet performance targets. Under the program, the negative incentives (for not meeting MCH indicator targets) are mostly defined in terms of quantity of primary care services, with some quality aspects, namely quality audits conducted by an independent unit within the PHD and via patient satisfaction surveys.
The RBF program also places an emphasis on increasing access to at-risk groups, and on better registration of the population with a primary care provider. It provides higher payment coefficients for physicians treating groups such as children, pregnant women, the elderly, prisoners and disabled persons. Other population-related factors, such as socio-economic status, geography and the number of people living in the catchment area also play into the physician’s payment matrix.
I was interested to learn about some of the unique design features of Turkey’s RBF program. First, physicians working in a remote area among any of the risk groups could conceivably earn significantly more than their urban counterparts. Second, facilities receive a grade, ranging anywhere from A to D. A good grade generally elicits more funding from the Ministry of Health (MOH) to put towards supplies, medical equipment, and the recruitment of additional staff. Third, a central data system works behind the scenes to capture data from individual centers for progress monitoring. Fourth, verification systems are fairly well-developed and being continually strengthened. This includes random sampling of 10% of the family physicians on a monthly basis to verify results, a public hotline where patients can report any concerns about the quality of care received, and a six month visit by PHD staff to each facility to assess compliance with standards. These measures all help to keep the system honest.
On our next stop we had the good fortune to speak to some of the family medicine physicians at the Bahcelievler Family Medicine Center, located in one of Istanbul’s well-performing districts, and to learn about their response to the incentives. In my opinion, the true workhorses of Turkey’s RBF Program are these foot soldiers who treat patients. In this facility, doctors dedicate a couple of hours each week to follow up on patients in their homes. The goal - leave no one in the community behind, particularly when it comes to meeting critical MCH targets, such as vaccination. If physicians fall short of meeting those targets, up to 20% of their base salaries are “at risk”. And that’s not all. If wrong data is being reported, an admonition point system deducts 50 points after detailed review. Falsifying data twice within a contract period can result in contract termination. Perhaps, these measures may seem a tad too tough for overworked family physicians but they have not deterred voluntary participation in the scheme.
Bahcelievler Family Medicine Center had an open, welcoming ambience, befitting of its community-serving purpose. As we stood in the waiting area speaking with the doctors, and observing their interactions with patients, it was clear that the relationship between doctors and their patients are close. And with its huge emphasis on MCH, there has also been a noticeable nationwide decline in the maternal mortality rate from 61 in 2003 to 15.5 per 100,000 live births in 2011, with a similar downward trend observed in the infant mortality rate as well.1
When asked what they liked most about the new program, one physician responded: “You get to know all your patients well, which helps to design personalized treatment plans for them.” For others, it is the fact that doctors can keep better track of their patients’ medical histories.
But there are challenges too. Not surprisingly, the new system has raised expectations—patients are demanding more services from their primary care givers. Also, an average physician to patient ratio of 1 to 3590 patients is a tough workload. However, the government has plans to improve conditions: for example, it aims to reduce the doctor per patient ratio to 1 per 2000 patients over the next decade.
As we made our way back to our hotel, the bus was noticeably quieter. The mood was reflective. Running through my mind was the sobering knowledge that improving the provision of public health services for better health outcomes is never an easy task. It can be downright challenging, with no easy solutions to issues such as pervasive inequality between urban and rural areas, lack of doctors and increasing patient loads. Yet, the commitment and enthusiasm among the family physicians we met had been palpable and inspiring. These positive attitudes are integral to sustaining a healthcare system and to saving the lives of Turkey’s mothers and children.
1 Source: “Family Medicine in Turkey.” Presentation made by Ministry of Health, Republic of Turkey to participants of the 2012 Annual Results and Impact Evaluation Workshop: November 12-16, 2012. Copy of presentation on file with the team.