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Turkey
Primary care and the Turkish Medical Association
Dr. Unal Ertugrul
,TMA
General Practitioners section
Health services in Turkey are organised by the law of 'socialisation
of health services' which came into effect in the early 1960s. By
this law the Ministry of Health is responsible for maintaining free
primary care services fully covering the population.In 1994 total
health expenses (per capita) were US$1 53 and only $70 of that was
public expenses (to make 3.5 per cent of public expenses).After a
central MCQ exam, medical education is taught in 38 medical schools.
Of the six years, the last is for internship. More then 5,000 new
students are accepted and graduate each year. After another MCQ exam,
half of this number are accepted for vocational training programmes
for specialisation. Most of the rest are employed by the Ministry of
Health mainly at primary care centres (4,431), emergency care
services of hospitals and mother/child care/family planning centres
(262).Primary care centre teams consist of one to ten practitioners,
nurses, midwives, environmental health and administrative staff,
possibly a driver and a few others. The composition and number of
the team members are regulated on population basis.The average
annual consultation with a physician is 2.4, but despite the law,
less than half of the consultations take place at primary care
centres and so practitioners do not function as gatekeepers. The
service quality, professional satisfaction and income is relatively
low and most of the practitioners make great efforts to enter a
specialisation programme. There is no recertification for physicians
and continuing medical education (CME) in primary care is poor.By
the end of 1995 there will be 71,000 physicians in Turkey;30,000
specialist, 6,000 resident for specialisation, 35,000 practitioner.
About 20 million of the population (out of 63) is not covered by
public social insurance (usually they have no insurance at all), and
12,000 physicians (of which only 1,000 are practitioners) are also
active in private practice.The annual income of a practitioner
employed by the Ministry is $4,500 and most of them either have or
look for a second job, but rarely can double this income. Posts in
primary and secondary care are almost fully occupied and by the year
2000, eight to 10,000 doctors (mostly new graduates) are going to be
unemployed.Both physicians and patients are complaining about the
present position of the health sector. Health indicators don't show
enough progress (UEMO 95/053). The Government's solution mentioned
in 'the health reform programme' is liberation/marketing of the
sector and reducing the responsibilities of the State. On the other
hand, theTMA's main proposals are:
• more public influence, co-operation and full consultation of
the profession while producing and carrying out health policies;
• stressing preventive medicine, primary care by financial and
educational means;
• replacing the current ineffective, hospital-oriented family
physicians vocational training programme which promotes curative
medicine, with a new programme which should include education in
practice, general practitioner (GP) trainers, specific curriculum,
an autonomous institution to lead/authorise general practice.
Turkish Medical Association
The Turkish Medical Association (TMA) is the voice of organised
medicine in Turkey. It is a voluntary organisation which has been
established in 1953. Only physicians can be a member ofTMA which is
primarily financed by membership fees. While TMA cooperates with
government in many areas, it receives no financial support from
government. TMA consists of Local Chambers, Central Executive
Council and House of Delegates. On behalf of its members, the TMA
exists to:
• protect and improve the general health of people of
Turkey by promoting high-quality, cost-effective healthcare that
is accessible to everyone;
• preserve a high level of professional ethics;
• maintain the excellent standards of medical care;
• present the profession's views as effectively as possible
both to government and to the public;
• promote interests of the profession.
Membership
Membership ofTMA is obligatory only for doctors in private practice.
• 46,000 doctors out of 66,000 (by the end of 1994) are
members ofTMA.
• 18,000 of the members are practitioners and 15,000 of
them are active in national primary care service.
• Annual membership payment to local chambers: $12 (the
legal level is 1.7)
• A quarter of the membership payments are transferred to
TMA to make the Association's main source of income.
Structure
There are 52 local Chambers and a Central Council. The doctors
can only become members of the local chambers of medicine. A chamber
of doctors can be established in every province that has a minimum
of 200 doctors. The local chambers execute their activities
independent from the Central Council.The Central Council oftheTMA is
formed of seven physicians who are elected by Congress (House of
Delegates) which is held every two years. The Central Council is
responsible for coordinating the activities oftheTMA, executing the
decisions taken by the Congress and representing the Association.The
general policies and activity plans oftheTMAare determined by the
Congress each year and followed by the Central Council.
Activities
The Central Council oftheTMA, technical divisions and the local
chambers perform the following activities:
• dealing with all sorts of matters regarding the rights of the
doctors, mainly wages and working conditions;
• determination of minimum wages, with which the private
doctors and health institutes have to be in compliance;
• to assign the physicians for private jobs;
• preserve a high level of professional ethics;
• promote a high-quality medical education;
• establish a continuing education system for physicians in the
country;
• ensure that qualified, cost-effective healthcare is
accessible to everyone;
• fighting against all kinds of human rights violations,
torture and working for a democratic society;
• promote research on public health issues in various fields;
• execute courses for the education of the doctors, such as
tourism, sports and health;
• co-operate with various international institutions, such as
the World Medical Association, the European Union of General
Practitioners (UEMO), the European Union of Medical Specialists (UEMS).
The activities that have been stated above are executed by
the following divisions:
• Medical Education Division;
• Occupational Health Division;
• General Practitioners' Division;
• Tourism and Medicine;
• Public Health;
• Basic Sciences in Medicine;
• Sports Medicine;
• Law Office;
• Medical Students' Division;
• Human Rights Division Ethical Committee;
• Board of Creditation.
Six periodicals and 13 books (mainly on health policy, medical
education and occupational health) are published and distributed by
the Central Council as well as the bulletins published by each local
chamber.
General practitioners' division
Foundation: 1989
Approval by TMA Congress: 1990
Structure: Co-ordinational centre
Term President, Vice-President, Secretary-General (from Ankara)
Executive council (eight members from six cities)
Local commissions: Active in approximately 30 medical chambers
out of 52 Decision taking and election of presidency: at general
meetings of commissions held three times a year. Members of the
Executive Council are nominated by six commissions which have bee
predominantly active in the recent year.
Activities
(A) Local commissions:
• regular meetings for commission members;
• visits to health centres where practitioners are employed;
• producing written material on first level healthcare and
prac titioners' problems for the periodic of the chamber and
pres:
• organising educational and social activities for GPs;
• being in dialogue with people and institutions for the
promc tion of general practice and first level healthcare;
• advisory help for the chamber administration on subject
dealing with general practice.
(B) Central:
• organising periodic general meetings and following the
dec sions taken;
• representing the practitioners and their sub-organisation
(I) i the Association (II) to governmental or civil institutions
(II press and international partners;
• producing documents/policies on general practice for th
TMA's use;
• organisation of national congresses on general
practice (1990, 92,94);
• harmonisation of the activities held in local commissions;
• preliminary work for the future GP Association,
Academy Society.
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