The Political Economy of Health Reform: Turkey's Health Transformation Program, 2003-2012

Abstract

This dissertation explores the political economy of Turkey’s large-scale health systems reform, known as the Health Transformation Program (HTP) (2003 – 2012). It does this by analyzing the role of institutions, physicians, and patients in the Ministry of Health’s efforts to adopt and implement changes to the country’s health financing, health workforce, and primary care systems. In the first chapter, I present a qualitative case study that uses primary interview data to explain how Turkey adopted a universal and unified health coverage system between 2003 and 2008. By applying Immergut’s institutional veto points theory, I show Minister of Health Akdağ (2002-2013) and his team of advisors used targeted strategies to overcome obstacles at critical veto points blocking adoption. This analysis fills an important gap in the literature on universal health coverage by providing a theory-based explanation for how a reform can be accomplished. The second paper then looks at how Minister Akdağ overcame opposition from an organized physician group, the Turkish Medical Association (TMA), to adopt legislation that banned physician dual practice. This analysis contributes to the literature on the role of physicians in health reform by presenting a case study where an organized physicians association was not able to act exert veto power to block policy adoption. Rather, I argue that Minister Akdağ used a divide and then conquer political strategy, where he acted to exploit coordination problems among physicians by appealing to their individual interests and undermining the authority of TMA and its base of university physicians, to create a favorable political environment to ban dual practice and strengthen service delivery capacity. The fourth chapter considers how the HTP affected public opinion of Turkey’s reformed primary health care system, known as the Family Medicine System. I take advantage of the staged-rolled out of the Family Medicine System at the provincial level to estimate its effect on patient satisfaction using provincially-representative patient exit survey data from 2010, 2011 and 2012. This study provides some of the first national level evidence that primary health care reform underpinned by the FM system can effectively improve patient satisfaction - a health system goal. The final chapter summarizes the main results of Chapters 2, 3, and 4, discusses their limitations, and presents policy implications that can be derived from this research.