DRAFT
PERFORMANCE MANAGEMENT POLICIES OF HEALTH SYSTEMS IN TURKEY AND ENGLAND:
A CRITICAL COMPARATIVE REVIEW
Dr. Pinar Guven-Uslu[1]
Dr. Gulbiye Yenimahalleli Yasar[2]
ABSTRACT
The aim of this study is to investigate and critically review newly implemented performance management policies of the Turkish Health System following the publication of ‘Health Transformation Programme-HTP’ in 2003. The critical review includes some comparisons with performance management of the English National Health Service (NHS).
The HTP (Ministry of Health-MoH, 2003) policy document is expected to bring fundamental changes to how the system is managed and how services are delivered. Important policy changes included the introduction of organisational performance metrics and associated financial incentives, hospitals gaining autonomous business organisation status so that MoH does no longer appear as the provider of health services, the introduction of a family-medicine-scheme managed by the MoH and, finally, the introduction of a general-health-insurance-system which does not provide universal coverage.
The paper compares organisational aspects of performance management in the HTP to that of the NHS in England and concludes that there are some fundamental differences in terms of the management of performance at provider organisations, process of target setting, calculation of performance metrics and influences on Government funding mechanisms. Excessive private sector provision and inequalities in health service delivery are seen as the main reasons for these fundamental differences. These reasons are considered important because they provide insight to understand some of the issues about the introduction of competition to the health service market in England and contribute to the international dimension of this debate.
Introduction
New Public Management (NPM) has influenced a number of public policy changes around the world and has brought about increasing demands on health care organisations to deliver improvements on outcomes measures which are defined and directed by central Governments. The methods and approaches to direct, control and measure performance of health care organisations are diverse and numerous, ranging from management control systems to various organisational incentives (Walshe and Smith, 2006). In this paper we are looking at recent policy changes around performance management in the Turkish health care system with the aim of making comparisons with English health service management. Our purpose here is to understand the differences and similarities so that areas for future empirical research could be identified. This approach also helped us to speculate on some of the medium and long term implications of a number of performance management related policies for both health care systems.
The paper has the following sections: the first part is an introduction to the theoretical approach adapted in this paper. We then present review of official policy documents that introduced reform programmes in health services in Turkey. This is followed by a summary of main aspects of reform in English Health Service since 1997. In the section following that; a comparison with help of theoretical framework adapted is presented between these two health systems. The paper concludes with critical comparative components of contextual factors of change in implementation of reform programmes in health services.
Contextualist Approach to Change
Contextualist understanding of change refers to examining processes of change within a historical and organisational context (Johnson, 1993, p.58). As stated by Clark et. al. (1988) this approach is often multidisciplinary. It draws on a range of perspectives and methods such as the business historian, the corporate strategist and organisation theorist (Whipp et. al., 1987). It is also concerned with a detailed examination of the process of organisational transition (Child & Smith, 1987). In a study of strategic change and competitiveness, Whipp et al. (1987) argue that it is important to examine content of a chosen strategy, the process of change and the context in which it occurs.
Pettigrew also draws attention to the difference between context and environment. He argues that; any view which considers the workplace as operating in a business environment as opposed to operating within a larger society, or context, is of little use either academically or practically. Because in this way, it would fail to capture the complex relationship between constraints, and the choice between continuity and change. He argues that the notion of environment is a much less dynamic phenomenon than the notion of context. Therefore, in understanding change management in large organisations, environment effects as opposed to contextually sensitive effects would miss many of the key dynamics of organisations and changing. Pettigrew also puts a great deal of emphasis on theory. Theory, according to him, is the engine, which drives our understanding of change. We should endeavour to deploy theoretical models, which can embrace the ideas of contextualism and processualism. He (1987) further clarifies the contextualism with the need for vertical and horizontal levels of analysis. The vertical levels of analysis are taken to outer (i.e. environment) and inner (i.e. interest group behaviour) contextual factors. The horizontal level refers to the temporal interconnectedness between future expectations, present events, and historical accounts. Research which is able to combine a processual analysis of change with an inner and outer organisational analysis of context is defined as contextualist: "An approach that offers both multilevel and horizontal analysis is said to be contextualist in character" (Pettigrew, 1987: 656).
The theoretical framework of Pettigrew et al. (1992) study lies in the interdependent exploration of content, process and contexts. In their three dimensional model context refers to the ‘why’ and ‘when’ of change. This also covers the influences from both the outer context like economic, social and/or political events and the inner context of specific organisations. Content is the ‘what’ of change and process is the ‘how’ of change. Process involves examination of how, and by whom change is formulated and managed, and what patterning occurs in this activity. All these three dimensions are also linked closely to the time dimension which brings a dynamic and changeable potential to this structure itself. The inner and outer context of change is the main focus in order to see the patterns in the way that strategic change occurs. A good focus for this analysis necessitates a distinction between receptive and non-receptive contexts for change. By the term ‘receptive context' they refer to the features of context (and also management action) that seem to be favourably associated with forward movement. The nonreceptive contexts are associated with blocks on change. They also state that there is no social science research explaining rates and pace of change by using the language of receptivity and non-receptivity. However, they also say that there is an emerging literature which not only seeks to connect features of context and action to rates of adoption and change, but then posits a relationship between capabilities to change by learning from differences in competitive performance of firms (Smith and Grimm, 1987; Pettigrew and Whipp, 1991).
Pettigrew et al. (1992) mentioned that there is not a strong social science tradition of theorising about receptive contexts for change. There are not either many empirical studies in organisations seeking to describe different aspects or comparisons about contexts of change. Their study concentrates on why the health districts in UK facing similar environmental and policy pressures behave at times similarly and at times differently in achieving outcomes.
In this paper, we compare these three dimensions of change, namely content, process and context in two countries change programmes in managing health services. We anticipated that there will be similarities and differences in both contextual factors and organisational approaches to change programmes. Our aim is to highlight areas of critical importance for future empirical comparative studies.
Performance management related changes in Turkish health care system
Turkey used to run a nationalised health system so-called “socialisation of health services” with holistic approach during the five decades. The system tried to establish community-oriented, accessible, comprehensive, longitudinal and multi-disciplinary team based primary care services. It was also contemporary, flexible, and open to be updated and was supported strongly by health professional organisations, the universities and the people. However it was faced with serious problems due to the lack of interest of the health authorities and politicians for the resources and facilities to be adapted to the needs of the rapidly changing and urbanising community. Thus, Turkish health system entered to the eighties with various problems (Aksakoglu, 2011; Yavuz, 2011).
The coup d’état in 1980 introduced structural adjustment and market-oriented reform policies for Turkey. Turkish health care system has been experiencing neo-liberal transformation since then. Reform proposals of the 1990s focused on the introduction of a general health insurance (GHI) system, decentralisation, introduction of a family medicine scheme, purchaser-provider split, contracting out, quasi-markets, and improvement of management information systems (Ministry of Health – MoH, 1993).
Subsequent attempts to realize these reform proposals have been made by the conservative Justice and Development Party (JDP) with the announcement of its “Health Transformation Programme” (HTP) policy document in 2003. The HTP announced the central objective of the reform as ‘establishing a high-quality and effective health system which everybody can access’. The main principles are as follows: human centrism, sustainability, continuous quality improvement, participation of all stakeholders, reconcilement, volunteerism, division of power, decentralization and competition in service (MoH, 2003). According to the Organization for Economic Co-operation and Development (OECD) and the World Bank (WB), the HTP is designed to address long-standing problems in the Turkish health sector, namely: i) lagging health outcomes as compared to other OECD and middle-income countries, ii) inequities in access to health care; iii) fragmentation in financing and delivery of health services, which contributes to inefficiency and undermining of financial sustainability; and iv) poor quality of care and limited patient responsiveness (OECD-WB, 2008: 44).
The HTP aims to achieve a transformation in the framework of eleven themes:
1. MoH as planner and supervisor,
2. GHI gathering all people under a single umbrella,
3. Widespread, easily accessible and friendly health system,
a) Strengthened primary health care services,
b) Effective and graduated chain of referral,
c) Administratively and financially autonomous health enterprises,
4. Knowledge and skills-equipped and highly-motivated health service personnel,
5. System-supporting educational and scientific bodies,
6. Quality and accreditation for qualified and effective health care services,
7. Institutional structuring in rational drug use and material management,
a) National Pharmaceuticals Agency,
b) Medical Devices Agency,
8. Access to effective information in decision-making: Health Information System (MoH, 2007a:277).
9. Health promotion for a better future and healthy life programmes,
10. Multi-dimensional health responsibility for mobilizing parties and inter-sectoral collaboration,
11. Cross-border health services to increase the country’s power in the international arena (Akdag, 2009).
Assessments of the HTP show that despite some improvements, the HTP remains far from reaching its ultimate goals; defined as improvement in health status, financial risk protection and satisfaction with health care fully. Therefore, Turkish people continue to face low health status and a low level of financial risk protection (Yenimahalleli Yasar, 2010). In addition assessments according to the intermediate performance characteristics/goals such as efficiency and quality which can serve as guides for evaluating performance (Roberts et all, 2004) also show that performance of the HTP is very poor (BSB, 2011).
In line with the fourth component of HTP namely ‘knowledge and skills-equipped and highly-motivated health service personnel’, a performance-based supplementary payment (PBSP) system was introduced in MoH hospitals in 2004. It was initially piloted in ten hospitals in 2003 and subsequently expended to all MoH health facilities including primary health care. Currently, all 850 MoH hospitals and primary health care facilities have in place the PBSP system (OECD-WB, 2008:49). In 2008 there were 1.350 hospitals; 847 of which MoH hospitals, 57 of which university hospitals, 400 of which private hospitals and 46 of which other hospitals in Turkey. There has been a rapid increase in the number of private hospitals during the HTP period. Between the 2002 and 2008 the number of private hospitals increased 48%, rising from 270 to 400 (MoH, 2010:43), between the 2002 and 2011, 81% rising from 270 to 490 (Sonmez, 2011:73).
Social Security Institution (SSI) has been contracting with private facilities for the delivery of outpatient and inpatient health services. Despite the rapid increase in private sector provision there is very limited regulation of the market. For example the payment mechanism for private hospitals has not been defined yet. Moreover the Social Insurance and General Insurance Law allows “extra billing”, which are to be paid by patients on an out-of-pocket-payments, by private providers, whereby, based on detailed criteria adopted by the Council of Ministers, private providers were allowed to charge up to 100% above the price paid by the SSI. Recently SSI has limited this amount up to 30% above the price paid by SSI. It is very difficult to have a control over prices charged in the private sector although the Reimbursement Commission established in 2004 determined a regulated price list for all health service clinical activities reimbursed by SSI. The calculation of list prices is performed annually by a Reimbursement Committee at the SSI. It is then published and distributed via Health Budget Law but the process of calculation is not public information (OECD-WB, 53).
It will be useful to have a look briefly the reforms of MoH hospitals in Turkey before starting discussions on PBSP system.
Reforming MoH hospitals in Turkey
The third component of the HTP aims to create administratively and financially autonomous health enterprises. In line with this component all public facilities (with exception of university hospitals and health facilities belonging to the Ministry of Defence) have been integrated under the MoH in 2005 before the establishment of autonomous hospitals. Accordingly the Social Insurance Institution (SII) hospitals transferred to the MoH in 2005 in order to harmonize management and payment mechanisms across all public hospitals and to pave the way towards autonomy for hospitals. A pilot hospital autonomy law was drafted in 2007 setting out the principles of hospital governance based on a public enterprise model, whereby hospitals joining the pilot project would be managed by boards, but remain affiliated to the MoH. The law offers the possibility of the creation of a joint hospital union at the regional level. The hospital union would be a network of hospitals that would jointly undertake programme planning, budgeting and implementation. Pilot hospital unions would have greater autonomy and flexibility over hiring health personnel, who would no longer be classified as public employees with the right to life-long employment, and resource allocation decisions. The MoH would be responsible for guaranteeing quality of care and adherence to MoH standards in hospital unions (Yenimahalleli Yasar, 2010).