Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey

Kilic B, Kalaca S, Unal B, Phillimore P, Zaman S have published a review capacity of Turkish health system. How do we effectively monitor and manage NCDs?


What did the study aim to do?

Review of the capacity of the Turkish health system. Develop appropriate policies for cardiovascular diseases (CVD), diabetes mellitus (DM) and related risk factors.


"How are policies implemented in health care settings?"

"How is the implementation of these policies monitored?"

Why is this important?

There is an ageing population in Turkey. As with many other countries, the lifestyle has changed, resulting in a rise in chronic illness. The rate of heart disease and prevalence of type 2 diabetes are particularly alarming. It is crucial to establish changes in policy and feasible interventions to prevent further increases in CVD-DM.

Where did the data come from?

Documentation from the Ministry of Health and other relevant healthcare providers. The 17 documents include: national policy documents, national strategies, legislation, diagnosis and treatment protocols. In addition, some national survey results were analysed.

Eleven Key Informant (KI) interviews were conducted; three "decision makers" for chronic disease policy from the Ministry of Health, two "health directors" involved in organising and applying primary care, two academics, two representatives from non governmental organisations, one KI from a pharmaceutical company and a representative from the media, who has an interest in health and medicine. The interviews took place in Instanbul, Ankara and Izmir.

Additionally, observational fieldwork took place in four healthcare facilities in Izmir, with a mixture of public and private, rural and urban.

What did they find?

Although CVD-DM was strongly addressed in strategic documentation, there is a lack of standardised data with which to prevalence and treatment of NCDs, as well as implementation of policy. The introduction of a health information system and electronic online system was a good thing, but KIs found it wanting. Thus KIs called for large scale studies to determine mortality, and how the risk factors for developing CVD-DM were spread throughout the population.

There were inefficiencies in the way healthcare was managed in the Ministry of Health, with different divisions having overlapping aims and there existing a lack of communication between them. There was also a lack of communication and trust between different bodies that were supposed to work together.

"There is no institutional culture of cooperation. There is a perpetual mistrust"

A family doctor system was introduced in 2006, where the family doctor is paid according to how many patients are on their register, and is responsible for their care. KIs thought this system is key in the prevention, diagnosis and treatment of non-communicable diseases. A performance-based system has been rolled out in both primary and secondary care. This was identified as a disincentive for treating patients with chronic diseases that require long term management of their condition, without "results" that can be charged for. As a consequence, doctors will often not want these patients on their registers.

"I am sure that there will be some problems with family doctor system in the future because of the belief that DM patients take a lot of time. Family doctors will not want to examine and follow-up DM patients in the future" (Academic KI)

The family doctor system's role in monitoring the diagnosis and treatment of NCDs is undermined by the lack of a referral system. Patients can go directly to secondary or tertiary care without using primary care, overwhelming public hospitals and causing issues with appointments. The role nurses in prevention and management of NCDs was undervalued.

The observational data revealed that protocols and treatment guidelines were not always adhered to. This was connected to lack of training and which drugs were on the list for reimbursement to the facility.

What did the authors recommend?

A proper referral system should be established between primary and secondary care, as well as countrywide early detection and screening programs for CVD-DM risk.

Government and policymakers need to improve the intersectoral collaboration amongst the different institutions and healthcare providers to establish "trust" for more cohesive and efficient prevention, management and monitoring of NCDs.

The performance-based reimbursement system should include payment for appropriate management of long term chronic conditions, such as long term follow ups.

Reference and link:

Kilic B, Kalaca S, Unal B, Phillimore P, Zaman S. Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey International Journal of Public Health. 2014