First published in ITIJ 94, November 2008
Turkey is a country of extremes. Roger St Pierre and Sarah Watson examine healthcare and assistance issues in one of the world’s fastest growing economies
Turkey is a country of never-ending enigma. It stoutly maintains the strictly secular constitution set in place in 1923, when, in the aftermath of the First World War, the charismatic Mustafa Kemel Ataturk dragged it into the modern era; yet it has a Muslim government – under the Justice and Development Party. In 2003, this government introduced sweeping healthcare reforms aimed at making healthcare available to a larger share of the population through a universal health insurance, and increasing the ratio of private to state health provision. The country’s healthcare provision is still dominated by a centralised state system, but the private health industry has grown rapidly since the 1990s when the Ministry of Health began to restructure the health system.
Turkey is an Asian country with a toehold in Europe: this populous land of 74.8 million has a modern, free market economy and is poised for eventual entry into the European Union, but long-established protectionist policies have been hard to kill off. Thus, there is still a large measure of poverty in the country, especially in remote areas of Anatolia. In such rural areas, hospital provision is seriously lacking, and poor road infrastructure further hampers access to care. Where clinics do exist, doctors and physicians rarely speak any language other than Turkish.
Although, overall, Turkey’s population profile continues to resemble a developing country more closely than a developed state due to its high rural population, the country’s advantageous geographical location, together with its recent progress in membership negotiations with the EU, have increased Turkey’s attractiveness to companies wishing to expand to new regions. In fact, General Electric Company, a subsidiary of GE Healthcare – worth €17 billion – moved its international managing operations base in the eastern and African growth markets to the country in June.
At the same time, Istanbul has 35 billionaires – placing it fourth behind Moscow, New York City and London – while the country’s GDP growth rate between 2002 and 2007 averaged 7.4 per cent, making it one of the world’s fastest growing economies, with the bonus of well contained inflation. Only 7.6 per cent of GDP in 2005 was actually spent on public healthcare, however, although this has increased steadily since 2000.
A resultant growth in overall wealth has led to a booming travel industry. The Asia Pacific region is now a favoured destination for Turkish travellers, along with the great cities of the US and Europe, with shopping a powerful draw for an increasingly affluent people. In fact, outbound tourism has increased from 515,000 people, spending US$12 million in 1970, to 8.02 million people and a US$2.87-billion spend in 2005, the last year for which figures are currently available. Meanwhile, some 1.2 million Turks choose to live and work abroad. This has helped fuel an already flourishing insurance market, and has seen the continued development of the travel insurance and assistance industries in the country.
The country’s healthcare provision is still dominated by a centralised state system, but the private health industry has grown rapidly since the 1990s
Turkey is also a huge draw for tourists, with thriving international resorts and modern amenities. It does not have any reciprocal healthcare agreements, so comprehensive medical insurance cover is essential, as even emergency care in a state-run hospital must be paid for by foreign visitors. Despite this, there were just over 27 million visitors to Turkey in 2007, contributing a massive US$18.5-billion to the national coffers and making it one of the world’s top 10 destinations, according to Professor Ferda Halicioglu of Tourism Economics journal.
As with any country dealing with the number of tourists each year that Turkey does, healthcare standards in the country have developed to reflect a growing need for world-class medical care, especially in tourist destinations. A founder member of the OECD and the G20 industrial nations group, Turkey continues to work on its state healthcare policy, and at the same time has a flourishing private sector. Establishments in both of these sectors are used to working with international assistance departments, but these relationships can be tumultuous due to complex bureaucracy and problems with over-charging, as we shall see later in this feature.
Scratching the surface
The standard and availability of healthcare in Turkey varies massively between regions and between towns, with most large towns and all major cities housing a mixture of state and private medical facilities. The healthcare and social medicine system has seen spectacular modernisation since the Ottoman era yet in rural areas hole-in-the-ground toilets and primitive hygiene standards are still abundant when you scratch the surface of modernity. At the other end of the spectrum, in the main cities some ‘five-star’ private hospitals pride themselves on the employment of top chefs for the creation of a range of a la carte meals for patients. A stay in such an establishment will set you back a bit, though: in Istanbul, the Acibadem Hospital charges YTL 700 per day (€380; US$ 520), the American Hospital YTL 390 for a double room, and Memorial Hospital charges YTL 302.
According to the Health Ministry, there are some 77,344 doctors working across the state and private health sectors of whom just over half (51 per cent) are employed by state institutions, 18 per cent by medical schools, 10 per cent in social insurance institutions and 15 per cent in private hospitals. However, many doctors work in both the state and private healthcare sectors.
The socialised health service was introduced in 1961, since when successive governments have been committed to a programme of rationalisation that will ensure primary care in both urban and rural areas, and will create effective preventive and curative services for all the population. As the bedrock of the state system, some 11,905 health posts provide village level healthcare, each of them serving the needs of between 2,500 and 3,000 people. Some 5,366 health centres are spread across the country, each serving between 5,000 and 10,000 people. Each of these has a full-time medical team, headed by a physician but, unfortunately, most of these have had no residency training in family medicine and little clinical training. Says Dr Hakan Yaman if the medical facility at the University of Akdeniz in Antalya: “Turkey is now in the first world when it comes to medical care provision though work still remains to be done on the restructuring of primary healthcare.”
The Asia Pacific region is now a favoured destination for Turkish travellers, along with the great cities of the US and Europe
Some 1,180 hospitals, half of them run by the Turkish Ministry of Health, provide in-patient care. The remainder of the country’s public hospitals are run by public universities and social security institutions. Overall standards in state hospitals are generally below those of western European countries, and overcrowding is a big problem. A lack of funding means that care can be basic and facilities limited.
State facilities also lack the level of nursing care that visitors to Turkey may be used to in their home country. For example, the family of a patient is expected to take on many of the auxiliary tasks such as changing bedding and providing emotional support. This said, some of the best hospitals in Turkey are the university hospitals, some of which are public and some private. These institutions are often a top choice when it comes to choosing a medical establishment for a specific procedure as usually the best surgeons are affiliated with one of the main university hospitals, such as Cerrahpasa Medical Faculty Hospital in Istanbul, Ege University Hospital in Izmir and Hacettepe University Hospital in Ankara.
Some 43 per cent of the nation’s total health service resources are funded from the Turkish government’s general budget, 25 per cent from private insurance payouts and 32 per cent from fee-paying patients within the state system. According to figures from the Social Security Institution and the Association of Turkish Insurance and Reinsurance companies, some 65 per cent of the population is covered by state provided health insurance. Despite this, more and more people are buying separate private health insurance in order to get better quality of care if they’re ill. The private health insurance market is relatively well developed in Turkey, with around 28 health insurers providing policies to around 1.4 million people annually. According to US’s Library of Congress Federal Research Division, however, around 75 per cent of private health expenditures in Turkey in 2005 were out-of-pocket rather than being covered by insurance.
Paying for private
The private medical sector in Turkey is fast expanding and already boasts equipment and care levels on a par with international standards. In the country’s largest cities and resorts that have a high number of tourists and expatriates – such as Izmir, Istanbul, Marmora and Bodrum – hospitals are abundant. Antalya alone boasts some 50 private medical centres, employing between them more than 2,500 doctors and medical staff. In these areas, there are also several private clinics where English, German and other languages are spoken, and where it is possible to arrange a consultation with a qualified, multi-lingual foreign-trained physician. Foreign residents with chronic ailments requiring medication are advised to keep a six-month supply on hand, however, as local pharmacies may not be able to fill certain prescriptions reliably.
Today, Turkey has some 370 private hospitals and these provide around 15 per cent of the nation’s healthcare, including providing some treatments under contract for state system patients. Turkey’s leading private hospital organisations include Memorial Group, Acibadem Group, Anadolu Saglik Merkezi, Medical Park and the Universal Group. Many such hospitals in tourist and expatriate areas have direct agreements with BUPA and similar international health insurance companies.
many doctors work in both the state and private healthcare sectors
The cost of private care in the country is extremely competitive, if not inexpensive. As such, international insurers prefer to evacuate their patients from more remote areas to Turkish cities as opposed to flying them into neighbouring countries such as Greece, Egypt and Israel. Depending on the nature of the patient’s condition or injury, however, they may sometimes be sent for treatment at a large state or university hospital where a more specific or sophisticated level of care can be found.
Turkey now has close on a dozen assistance companies in all. Most of these are operating as the branch offices of large and well-established foreign assistance companies, including Europ Assistance, Mondial and Coris International, but include local providers such as Marm Assistance and Aegean Assistance. They all operate in a challenging market. Overbearing bureaucracy and the poor infrastructure often found in rural areas of the country are just two of the problems faced.
Meanwhile, some medical facilities do all they can to avoid co-operating with assistance companies, preferring to work directly with insurance companies so they can avoid cost containment scrutiny procedures that expose over-charging, overtreatment, fraud and other problems. Reportedly, insurers working directly with such hospitals often run into major problems with the customs authorities because they do not understand the often complex way in which routine procedures work in Turkey, nor do they appreciate the need to involve expert input from the very beginning of a case history.
“We have around 800 contracted hospitals on our database, including state hospitals, private hospitals, university hospitals and clinics,” says Marm Assistance’s Emre Dursum, “Our audit team periodically updates our database to ensure that the hospitals we use are of a high standard. We have ‘preferred service providers’ that are catagorised by their specialty departments, number of physicians and beds, ICU capabilities, medical equipment standards, hygiene standards, logistics and location.”
Stars Crescent Assistance (sca) is another local player, owned by Marm’s umbrella company, which provides amongst other things medical assistance programmes to the oil and gas industries: “Through our multinational medical team we are now able to provide services throughout Turkey, the Caucasus region, the Balkans and beyond,” said a spokesperson. Among sca’s diverse offering is a ‘medical counselling service’ that collates information from hospitals, patients’ doctors and other involved parties to present a comprehensive and customised case report to insurance companies. This service, says the company, helps avoid the communication problems that can occur between an attending physician and the insurance company’s medical staff due to language barriers and unfamiliarity with the Turkish health system.
The different medical approaches favoured by local and foreign physicians is often the cause of dispute, but being intimately familiar with the local health system, local assistance company doctors can determine whether or not there are any discrepancies or indications of malpractice and whether unethical decisions have been made. Furthermore, it is often difficult and time-consuming for foreign insurers to reach an attending doctor via an international telephone call, so again sca acts as an intermediary through its doctors being able to communicate with attending physicians on a continuous basis, substantially reducing the often expensive international communications costs incurred by the foreign insurance company.
Aegean Assistance, which has its head office in Izmir and has worked on behalf of clients including Roland Assistance, Assistance International, Inter Group Assistance Services, med con team and Mayday Assistance, also urges international insurers and assistance companies to make use of the knowledge of local assistance providers to help overcome issues such as price inflation and over-treatment. Says the company’s Diray Oran: “If foreign assistance companies or insurers allow local assistance companies to act as a third eye on their behalf, problems could be kept to a minimum.” With a preferred medical providers list spanning Turkey and North Cyprus Aegean has closely monitored many international patients, right from their initial admission to hospital, and advises clients to transfer the patient if they are received into a medical establishment not on their list. The company does not sell assistance services to people residing in Turkey, but works solely on behalf of international clients.
healthcare standards in the country have developed to reflect a growing need for world-class medical care, especially in tourist destinations
“Turkey is a country where assistance companies have an important role to play,” a Europ Assistance Turkey spokesperson told ITIJ. “We need to be fully aware of the quality of medical facilities available and of the logistics linked to every claim.” This is especially important, he said, due to the increase in the number of travellers visiting Turkey. This increase has subsequently meant an increase in the number of serious medical cases treated in Turkish hospitals. Although most tourists present with ear infections or gastroenteritis, the number of hospitals and clinics treating either inpatient or outpatients has increased by a third since last summer. One concern, said Europ Assistance, is that the ratio of hospital admissions is much higher in Turkey than in other Mediterranean countries. Often, hotel guests seek treatment at an on-site outpatient clinic only to be redirected to a hospital, sometimes without even being examined. The company has also heard of instances where patients have been transported from a state to a private hospital once it has been realised that the patient has travel insurance. It is also familiar with the issue of over-charging and over-treatment, which it says must be challenged – and recorded – on the spot in order to help change the attitude of medical providers in the country. This has successfully been achieved in other countries with an older tourism industry, and it is something Europ Assistance is working on with its cost containment partner ChargeCare International.
“It is important to have an open and continuous dialogue with hospitals and doctors in Turkey to negotiate fees and adjust payments according to findings,” says Europ Assistance Turkey. “Overall, our medical expenses in Turkey are well controlled and we use a notification process to flag up significant costs, but it is still important to be informed and vigilant.”
Close on 300,000 travel insurance policies are currently in force in Turkey. However, as Dursun points out: “There is a big gap in coverage levels between standard Turkish travel insurance policies – with a general ceiling of just €30,000 – and those obtainable in other European countries. This means that assistance services are not generally included and it is usual for separate cover to be taken out for such needs. Otherwise, Turkish tourists abroad have to pay their medical treatment expenses themselves and reclaim them on their return while repatriation is at their own cost.”
Thus, evacuation and repatriation are important issues. Especially so given the fact that, like people in many other nations, Turkish citizens prefer to continue their treatment in their homeland, rather than in the country where they have been living and working or holidaymaking.
Turkey’s insurance industry is well established and substantial in size. Every insurance company, native or foreign, that operates in the country is obliged by law to become a member of the Association of Insurance and Reinsurance Companies of Turkey within three months of being licensed by the Undersecretariat for the Treasury. The organisation currently has around 60 members and is headquartered in Istanbul.
Once inward looking, the Turks now set their sights on international horizons. “Just a couple of decades ago, there was virtually no such thing as travel insurance for Turkish residents,” observes Dursun. “In the 22 years since our company began its operations, the Turkish assistance industry has developed rapidly into an attractive sector to play in. Last year, we provided assistance for more than 10,000 individuals and we reckon we have around 20 per cent total market share.”
Marm was very much a pioneer of assistance services in Turkey and now has more than 75 staff working in its dedicated call centre, including doctors, registered nurses, social workers, customer representatives, mechanics, pilots, communication specialists and support personnel who are able to communicate in 14 different languages. Today, the company provides its wide range of services not only in Turkey but throughout the Balkans, the Caucasus, the Middle East and Central Asia.
At the same time, Mondial Assistance Turkey, which has been in operation since 1997, is ranked in third place in the local market in terms of sales. It has established good relationships with local medical establishments and renews the contracts it has with its network providers on an annual basis. These providers are based all over Turkey. Due to the high volume of patients the company puts through hospitals in tourist areas, it is also able to negotiate good discounts with providers who would otherwise be very expensive.
international insurers prefer to evacuate their patients from more remote areas to Turkish cities as opposed to flying them into neighbouring countries such as Greece, Egypt and Israel
With regards to air ambulance services in Turkey, Redstar Aviation, a sister company of Marm Assistance, is the only air ambulance company in Turkey to have been given accreditation by the Turkish Ministry of Health. Redstar currently operates one fixed-wing aircraft and four helicopters.
Due to the poor quality of many Turkish roads, especially in and around the smaller towns, road ambulance providers have to install specific medical equipment, itemised and defined by the Turkish Ministry of Health. The medical personnel aboard either a road or an air ambulance must include an IC doctor, and an IC nurse or paramedic.