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Chapter 7 Health Reforms Process in Turkey

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CHAPTER 1 COUNTRY PROFILE Nazan YARDIM,MD,Public Health Specialist Serap ÇETİN ÇOBAN,MD,Public Health Specialist 1.1. GEOGRAPHY Turkey is a Eurasian country that stretches across the Anatolian peninsula in southwest Asia and the Balkan region of southeastern Europe. Turkey is situated between 36-42° northern latitudes and between 26-45° eastern longitudes. There is a 76-minutes time difference between its easternmost and westernmost tips. Its area is 814.578 square kilometers. Turkey borders the Black Sea in the north; Commonwealth of Independent States (Armenia, Georgia, Nahcevan), Iran in the east; Iraq, Syria and the Mediterranean Sea in the south; the Aegean Sea in the west; and Greece and Bulgaria in the northeast. Marmara Sea is located in the middle of Turkey’s northwest. Marmara Sea is connected to the Aegean Sea by the Dardanelles and to the Black sea with the Bosporus Strait. The Aegean Sea is an arm of the Mediterranean Sea. The Mediterranean Sea is connected to the Atlantic Ocean with the Gibraltar in the West. Thus, Turkey’s surrounding seas open to world oceans. The Straits carry importance for Turkey and Black sea countries. Moreover, the Bosphorus Strait and the two bridges on it (Bosphorus and Fatih Bridges) connect Asia and Europe on the land. In the south, Turkey is very close to North Africa countries. In short, Turkey is located between Europe-Asia and Africa continents. Land border of Turkey is 2.753 km. in total. Turkey has the longest land border with Syria (877 km.). Turkey also has land borders with Georgia (276 km.), Armenia (316 km.), Nahcevan (Azerbaijan) (18 km.), Iran (454 km.), Iraq (331 km.), Bulgaria (269 km.), and Greece (212 km). The coastline of Turkey’s four seas is 8.333 km. (Anatolia coast 6480 km., Thrace coast 786 km., The Islands coast 1067 km). Thus total border line of Turkey reaches to 11.086 km. (1). Anatolian Peninsula is bounded by highlands on the east, north and south, and is a semi-arid plateau. North Anatolia in the north and Toros Mountains in the south extend along Black sea and Mediterranean coasts and meet in the east. Median altitude of Turkey is 1,130 meters, yet there are regional differences: while the altitude is 500 meters in the West, it reaches up to 2000 meters in the East. Climate in Turkey varies in terms of temperature and precipitation due to land shape and heights. Annual precipitation averages about 500 millimeters; yet it rises to 2,000 millimeters in Rize along the Black Sea coast, and falls below 300 millimeters in some parts of Central Anatolia. Typically, the summers are hot and dry, and the winters are bitterly cold, rainy, windy and with frequent heavy snowfall in the Central o and Eastern Anatolia Regions. In the summers, temperature does not vary greatly between the regions but in the winters significant temperature variations are observed in different regions. Winter temperature average below –10°C in the east, while it average about +10°C in the South (2). 1.2. ADMINISTRATIVE STRUCTURE 1.2.1. Administrative Distribution and Political Organization Since the foundation of the Republic, Turkish administrative structure has been shaped by 1924, 1961, and 1982 Constitutions. The Constitutions declares that Turkey is a Republic with a parliamentary system and the will of people be vested in the Grand National Assembly of Turkey (GNAT). All constitutions adopted basic individual, social and political rights and the principle of separation of powers (legislative, executive, and judiciary). GNAT is the legislative body of the Republic. 500 members of the Parliament are elected by general vote of the people every five years. The President of the Republic is elected by the parliament and stays in duty for seven years. The Council of the Ministers is the executive body and composed of the Prime Minister and the Ministers. Judiciary power belongs to the Supreme Court (Constitutional Court), Supreme Court of Appeals, Supreme Court of Military Appeals, Council of State, court of administration and justice, and military courts (2). Administrative organization of the Republic of Turkey is divided into two, namely “Central Administration” (state) and “Local Administration Institutions”. Central administration is divided into two as capital organization and provincial organization. Local administration bodies are divided into two categories; those bodies based on locality (local government organizations) and those based on services provided (public institutions) (3). o o 2 REPUBLIC OF TURKEY ADMINISTRATIVE Central Adm(=State Adm.) Local Administration Institutions 1- Capital City Org. 2-Provincial Org. 1-Local Gov. 2-Public Institutions • The President • Provinces • Spec. Prov. Adm. • Universities • The Prime Minister • Districts • Municipalities • TRT • The Council of Ministers • Sub-districts • Village • STRCT • The Ministries • SIO • Auxiliary Institutions • Retirement Fund o Council of State • SEEs o Court of Accounts • IPATME o NSC and others After the Constitution of 1921, existing livas (an administrative unit in Ottoman period) were transformed into provinces and so 74 provinces came into being. Looking at the number of provinces after the foundation of the Republic, it is observed that while there were 63 provinces in 1926, the number of provinces was reduced to 57 in 1933, yet increased again to 67 in 1957, 74 in 1991, 76 in 1992, 79 in 1995, and 80 in 1996 (4). The number of provinces increased to 81 in the year 2000 (5). These provinces are divided into administrative units as districts, subdistricts and villages. The head of the province is the governor who is appointed by the Council of Ministers, approved by the President of the Republic and is responsible to the central government. As the highest-level administrative officer in the province, the governor carries out the policies of the central government, supervises the overall administration of the province, coordinates the work of the various ministry representatives appointed by the central government in the capital Ankara, and maintains law and order within his/her jurisdiction. Local authorities (Municipalities) who come to power with local elections held every five years are administered by the Mayor and members of Municipal Council. According to the legislation, a municipality may be established in places having a population of more than 2.000 people. Among the duties of the municipalities are provision of infrastructure services such as electric, water and gas services, road construction and maintenance, sewerage, and garbage collection within the borders of o o 3 municipality. Education and health services are in fact provided by the central government, yet municipalities also provide health care services for those living in low economic and social conditions (2). Turkey is divided into seven geographical regions: Marmara, Aegean, Black sea, Central Anatolia, Mediterranean, Eastern Anatolia, and Southeastern Anatolia. Five Regions (West, South, Central, North, and East) are distinguished, reflecting, to some extent, differences in socioeconomic development levels and demographic conditions among sections of the country. This regional breakdown is frequently used for sampling and analysis in social surveys (Turkey Demographic and Health Survey and National Burden of Disease-Cost Effectiveness Study). WESTERN REGION PROVINCES: Edirne, Tekirdağ, Kırklareli, İstanbul, Kocaeli, Sakarya, Çanakkale, Yalova, Bursa, Bilecik, Balıkesir, Kütahya, Manisa, Uşak, Afyon, Denizli, İzmir, Aydın, Muğla SOUTHERN REGION PROVINCES: Isparta, Antalya, İçel, Adana, Hatay, Burdur, Osmaniye, Kahramanmaraş, CENTRAL REGION PROVINCES: Eskişehir, Ankara, Kırıkkale, Kırşehir, Çankırı, Yozgat, Sivas, Kayseri, Nevşehir, Aksaray, Konya, Niğde, Karaman NORTHERN REGION PROVINCES: Zonguldak, Karabük, Bartın, Sinop, Kastamonu, Samsun, Ordu, Giresun, Trabzon, Bayburt, Gümüşhane, Amasya, Artvin, Bolu, Rize, Tokat, Düzce, Çorum EASTERN REGION PROVINCES: Kars, Erzurum, Iğdır, Van, Muş, Elazığ, Malatya, Adıyaman, Diyarbakır, Siirt, Şırnak, Mardin, Şanlıurfa, Gaziantep, Ağrı, Bitlis, Erzincan, Batman, Ardahan In addition to the five geographic regions traditionally used in field research, in the direction of EU adaptation process, in accordance with Law No: 2002/4720, State Planning Organization and Turkish Statistical Institute have developed NUTS (The Nomenclature of Territorial Units for Statistics) in three different levels. NUTS is the statistical region categorization used by EU countries. 81 provinces form NUTS Level 3. 26 regions developed out of province grouping form NUTS Level 2, and 12 regions achieved through grouping 26 regions form NUTS Level 1 (2, 6). o o 4 1.3. DEMOGRAPHIC CONTEXT 1.3.1. Population Structure The first successful population survey took place in 1831. The main purpose of this survey was to determine the number of people eligible for military service and to identify new tax resources, and it covered the whole Muslim and Christian male population residing in Rumelia and Anatolia (7). According to this survey, there was total 4 million male population, 2.5 million men in Anatolia, and 1.5 million men in Rumelia. Since the purpose of the survey was to determine the number of males eligible for military service, false information was provided so as to avoid military service, and non-Muslim ecclesiastics did not provide accurate information about their congregations. Moreover, male population was tried to be calculated accurately but necessary sensitivity was not applied in terms of female population (8). After the 1831 population survey, a new survey was conducted in 1844, and though another one was attempted in 1854, it could not be completed. A general population survey was decided to be conducted in 1870 but could not be implemented. The population Survey conducted in Danube provinces in 1874 was followed by another survey initiated and carried on for a long period in the Ottoman period. In that survey which followed the Russian War in 1878, the population residing in Istanbul was counted but the population in Tripoli and Arabia was just estimated. At the same period, the Regulation on Population Registry was issued and first Directorate of Population and Census was founded.
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