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Family Medicine for Universal Health Coverage: the Case of the Health Transformation Programme in Turkey

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Family Medicine for Universal Health Coverage: the Case of the Health Transformation Programme in Turkey Family Medicine for Universal Health Coverage: The Case of the Health Transformation Programme in Turkey Ana Belén Espinosa González Centre for Global Health Trinity College Dublin The University of Dublin This dissertation is submitted to the University of Dublin in partial fulfilment of the requirements for the award of MSc Global Health degree. July 2015 DECLARATION I declare that the work described in this dissertation is, except where otherwise stated, entirely my own work and has not been submitted as an exercise for a degree at this or any other university. I also agree that the Library of the University of Dublin, Trinity College may lend or copy this dissertation upon request. Signature: _____________________ Ana Belén Espinosa González Date: 26 July 2015 ii ACKNOWLEDGEMENTS I would like to thank my supervisor, Prof. Charles Normand, for his valuable advice during the course of the master’s programme and the time he offered for the supervision of this dissertation. I also want to thank all the interviewees that participated in this study, who will remain anonymous due to the research guidelines I need to follow. They offered a considerable amount of their valuable time for meeting me in person and answering my questions, at the same time extending their hospitality and making me feel warmly welcome in their work environments. I am very pleased to have met them. Lastly, this dissertation could not have been written without the support of family and friends, especially Erkin Etike, who helped me arrange an important part of the interviews. I would like to give my special thanks to Atılım Güneş Baydin for his continuous support, help and patience. Ana Belén Espinosa González, July 2015 iii ABSTRACT Family Medicine for Universal Health Coverage The Case of the Health Transformation Programme in Turkey Ana Belén Espinosa González Supervisor: Prof. Charles Normand Keywords: family medicine, primary health care, health transformation, Turkey This study aims to assess the integration of primary health care (PHC), especially family medicine (FM), in the Turkish health system after the implementation of the Family Medicine Programme (FMP) that was initiated in 2005. Objectives: The study evaluates, firstly, the association between the utilisation of the PHC and secondary and tertiary services; and secondly, the challenges encountered by family physicians (FPs) and FM academicians in the implementation of the FMP. Methodology: The study follows a mixed-methods design. An ecological cross- sectional analysis is performed, to measure associations by running correlations and hierarchical multiple regressions on secondary statistical data covering the period of 2008 – 2013. This is followed by a qualitative analysis of data collected through semi-structured field interviews conducted with 7 FPs working in the FM service and 8 academicians. The analysis is carried out through the framework method by applying predefined categories which emerged from the quantitative analysis in the initial management of the data. Results: Descriptive statistics show a general increase in the utilisation of health services. Accordingly, the Pearson Coefficient between PHC visits and secondary and tertiary care visits is positive. Regression analysis does not provide conclusive results, except for one year, 2010, when PHC visits significantly predict a decrease in secondary and tertiary visits. However, this is not supported by the literature review or the descriptive statistics. The main themes obtained in the qualitative analysis are the inadequate planning of the reforms, insufficient political commitment to integrate FM in the system and implications of the market model implementation, which were considered responsible for the difficulties experienced with the FMP. Concerns regarding the quality of health care after the FMP, public education, and FPs’ ethical values have arisen during the interviews. The positive aspects of the FMP have been the increase of the public trust in the service, the better acknowledgment of the FM discipline and the increased interest from medical students in FM specialisation. Results highlight, at the governance level, the importance of the proper planning of the reforms with all FM stakeholders included in the policy making, and at the process level, the need to implement a working referral system to allow the gatekeeping function of FM. Word count: 14,873 iv TABLE OF CONTENTS Declaration .................................................................................................................................... ii Acknowledgements ...................................................................................................................... iii Abstract ........................................................................................................................................ iv Table of Contents .......................................................................................................................... v Abbreviations .............................................................................................................................. vii List of Figures ............................................................................................................................ viii List of Tables ............................................................................................................................. viii 1. Introduction ........................................................................................................................... 1 2. Aims and Objectives ............................................................................................................. 5 3. Literature Review .................................................................................................................. 6 3.1. Family Medicine and Primary Health Care ................................................................... 6 3.2. The Role of WHO and the World Bank ........................................................................ 8 3.3. The Family Medicine Programme in Turkey .............................................................. 11 4. Methodology ....................................................................................................................... 15 4.1. Quantitative Study ....................................................................................................... 15 4.1.1. Design ................................................................................................................. 15 4.1.2. Methods ............................................................................................................... 15 4.2. Qualitative Study ......................................................................................................... 19 4.2.1. Design ................................................................................................................. 19 4.2.2. Methods ............................................................................................................... 20 5. Results ................................................................................................................................. 23 5.1. Quantitative Study ....................................................................................................... 23 5.1.1. Descriptive Statistics ........................................................................................... 23 5.1.2. Screening the Data .............................................................................................. 24 5.1.3. Correlation .......................................................................................................... 25 5.1.4. Hierarchical Multiple Regression........................................................................ 27 5.2. Qualitative Study ......................................................................................................... 31 v 5.2.1. Sample Description ............................................................................................. 31 5.2.2. Process ................................................................................................................ 32 5.2.3. Application of Framework Method ..................................................................... 33 5.2.4. Themes ................................................................................................................ 36 6. Discussion ........................................................................................................................... 48 7. Limitations .......................................................................................................................... 53 8. Conclusions ......................................................................................................................... 55 8.1. Further Research ......................................................................................................... 56 References ................................................................................................................................... 57 Appendices .................................................................................................................................. 66 vi ABBREVIATIONS The following is a list of abbreviations commonly used within this dissertation. CHC: Community health centre DV: Dependent variable FM: Family medicine FMP: Family Medicine Programme
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