Please cite this article in press as: Ökem ZG, C ¸ akar M. What have health care reforms achieved in Turkey? An Appraisal of the “Health Transformation Programme”. Health Policy (2015), http://dx.doi.org/10.1016/j.healthpol.2015.06.003 ARTICLE IN PRESS G Model HEAP-3424; No. of Pages 11 Health Policy xxx (2015) xxx–xxx Contents lists available at ScienceDirect Health Policy journa l h om epa ge: www.elsevier.com/locate/healthpol What have health care reforms achieved in Turkey? An Appraisal of the “Health Transformation Programme” Zeynep Güldem Ökem a,∗ , Mehmet C ¸ akar b,1 a Department of International Entrepreneurship, TOBB University of Economics and Technology, Sö˘ gütözü Cad No: 43, Sö˘ gütözü, Ankara 06560, Turkey b Department of Management, Bas ¸ kent University, Ba˘ glıca Kampüsü Eskis ¸ ehir Yolu 20. Km Ba˘ glıca, Ankara 06810, Turkey a r t i c l e i n f o Article history: Received 15 December 2014 Received in revised form 5 May 2015 Accepted 17 June 2015 Keywords: Healthcare reforms Turkey Efficiency Equity Financial sustainability Quality General/social health insurance Evidence-based evaluation Health Transformation Programme a b s t r a c t Poor health status indicators, low quality care, inequity in the access to health services and inefficiency due to fragmented health financing and provision have long been problems in Turkey’s health system. To address these problems a radical reform process known as the Health Transformation Programme (HTP) was initiated in 2003. The health sector reforms in Turkey are considered to have been among the most success- ful of middle-income countries undergoing reform. Numerous articles have been published that review these reforms in terms of, variously, financial sustainability, efficiency, equity and quality. Evidence suggests that Turkey has indeed made significant progress, yet these achievements are uneven among its regions, and their long-term financial sustainability is unresolved due to structural problems in employment. As yet, there is no comprehensive evidence-based analysis of how far the stated reform objectives have been achieved. This article reviews the empirical evidence regarding the outcomes of the HTP during 10 years of its implementation. Strengthening the strategic purchasing function of the Social Security Institution (SSI) should be a priority. Overall performance can be improved by linking resource allocation to provider performance. More emphasis on prevention rather than treatment, with an effec- tive referral chain, can also bring better outcomes, greater efficiency gains and contribute to sustainability. © 2015 Elsevier Ireland Ltd. All rights reserved. 1. Introduction A decade ago the health system in Turkey was charac- terized as highly inequitable. There were major problems in access due to insufficient and unequal distribution of health personnel and infrastructure [1–3]. The level of health spending was low compared to levels in other OECD countries in the 1990s and Turkey had poor health ∗ Corresponding author. Tel.: +90 3122924219; fax: +90 312 2924381. E-mail addresses: zgokem@etu.edu.tr (Z.G. Ökem), mcakar@baskent.edu.tr (M. C ¸ akar). 1 Tel.: +90 312 2466666x1664. status indicators compared to other European countries [4,5]. Regional disparities in health status were found, with poorer levels in eastern and northern regions and in rural areas compared to urban [6,7]. Health financing and provision were highly fragmented, leading to inefficiencies [8–12] and there were three sep- arate statutory health insurance schemes. The poor were covered by the Green Card (GC) Scheme, financed by the government, but these schemes provided varying bene- fit packages to their members. Provision was also highly fragmented because several ministries and health insur- ance schemes offered or purchased different benefits from public or private providers. http://dx.doi.org/10.1016/j.healthpol.2015.06.003 0168-8510/© 2015 Elsevier Ireland Ltd. All rights reserved.