TURKEY Performance-Based Contracting Scheme in Family Medicine – Design and Achievements February 15, 2013 Human Development Sector Unit Europe and Central Asia Region WORLD BANK Report No: 77029-TR Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 1 Report No: 77029-TR TURKEY Performance-Based Contracting Scheme in Family Medicine – Design and Achievements February 15, 2013 Human Development Sector Unit Europe and Central Asia Region WORLD BANK 2 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements Copyright @ 2013 The International Bank for Reconstruction and Development The World Bank 1818 H Street, NW Washington, DC 20433, USA All rights reserved The World Bank enjoys copyright under protocol 2 of the Universal Copyright Convention. This material may nonetheless be copied for research, educational or scholarly purposes only in the member countries of The World Bank. Material in this report is sublect to revision. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 3 Currency Equivalents (Exchange Rate Effective February 15, 2013) Currency Unit = TL (Turkish Lira) US$ 1 = 1.77 TL Acronyms ANC Antenatal Care BCG Bacille Calmette-Guerin CHC Community Health Center CRMS Core Resource Management System CVD Cardiovascular Disease DHS Demographic and Health Survey DPT Diphtheria, Pertussis and Tetanus FM Family Medicine FMIS Family Medicine Information System FMP Family Medicine Practice HepB Hepatitis B Hib3 Haemophilus Influenza type b HTP Health Transformation Program IMR Infant Mortality Rate M&E Monitoring and Evaluation MCH Maternal and Child Health MDG Millennium Development Goals MoH Ministry of Health NCD Non-Communicable Disease OECD Organization for Economic Cooperation and Development PBC Performance Based Contracting PHD Provincial Health Directorate Pol3 Third dose of Polio Vaccine SSI Social Security Institution TL Turkish Lira WDI World Development Indicators WHO World Health Organization Vice President : Philippe H. Le Houerou Country Director : Martin Raiser Sector Director : Ana Revenga Task Team Leader : Rekha Menon 4 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements Acknowledgements This report was prepared by the World Bank with the support of the Public Health Institution of the Ministry of Health, Turkey. The team would like to express their special thanks and appreciation to Asst.Prof. Dr. Mustafa Aksoy, President, Public Health Institution and his team for their continuous support during the preparation of the report. On the Public Health Institution side, the report received support and benefitted from the discussions with Dr. Halil Ekinci(Vice President). Dr. Osman Öztürk, and Dr. Adem Kucur, Kıvanç Yılmaz, İlhami Akkuş, Dr. Aslıhan Kahraman Koçan, and Dr. Mehmet Çelen provi- ded valuable contributions to the report. The General Directorate of Health Research and the Strategy Development Presidency provided important assistance and input. The World Bank team was led by Rekha Menon (Sr. Economist, ECSH1) and composed of Son Nam Nguyen (Sr. Health Specialist, ECHS1), Aneesa Arur (Health Specialist, ECHS1), Ahmet Levent Yener (Sr. Human Development Specialist, ECSH4), and Iryna Postolovska (Consultant). The team received guidance of Martin Raiser (Country Director, Turkey) and Daniel Dulitzky (Sector Manager, Health, Nutrition and Population, Europe and Central Asia Region). The peer reviewers were Rama Lakshminarayanan (Sr. Health Specialist, AFTH1), Prof. Rifat Atun (Professor of International Health Management, Imperial College London) and Cheryl Cashin (Senior Fellow, Results for Development Institute). Solange P. Van Veld- huizen (Program Assistant, ECSHD), and Elif Y. Yükseker (Program Assistant, ECCU6) pro- vided valuable support at all stages. A report based on the focus group discussions prepared by Francoise Cluzeau, Associate Director, NICE International was a background study for this report. The team would also like to thank Isil Oral (Junior Program Associate, ECSH4) for her inputs at early stages of the report. The team would also like to thank the managers and staff of Ankara, Düzce, Erzurum, Istan- bul, Izmir, and Manisa Provincial Health Directorates (Public Health Directorates) and the family medicine personnel of these provinces for their help, support and useful insights du- ring the field visits. The team would also like to thank the personnel of the Provincial Health Directorate (Public Health Directorate) and family medicine personnel of Ankara, Eskişehir, Rize, Istanbul, Gaziantep, Manisa, Konya, Siirt for their participation in focus group discussi- ons and useful insights. The team would also like to thank Prof. Dr. Sabahattin Aydin, Rector, Medipol University for his useful insights on the family medicine program. The team would also like to thank Ahmet Celalettin Tarhan, Project Director, Project Management Support Unit and his team for their support in the development of this study. The team would also like to acknowledge the financial support provided by the Health Results Based Financing Trust Fund in the conduct of the study. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 5 Table of Contents Executive Summary v Introduction 1 The Family Medicine Performance Based Contracting Scheme – How does it work? 6 Contractual Arrangements and Pay 7 Performance Incentives and How They Work 9 Measuring and Managing Performance 10 Performance Verification - Audits 11 Appeals and Grievance Resolution 11 Assessing the Design 12 Appropriateness of Design 12 Governance and Accountability Mechanisms 14 Monitoring and Verifying Performance 16 Conclusion 17 From Design to Achievements 18 Antenatal Care 19 Immunization Rates 20 Health Care Utilization 24 Human Resources 25 Financing 26 Responsiveness to Users of Health Services 27 Responsiveness to Providers 28 Conclusion 29 The Way Forward 30 References 33 Appendix Tables 34 6 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements Figures Figure 1 : Global comparisons of infant mortality rates (2002) and maternal mortality ratios (2000) versus income and total health spending, 2002 7 Figure 2 : Performance Based Contracting Scheme 12 Figure 3 : Average number of antenatal visits, 2003-2010 26 Figure 4 : Global Comparisons of Immunization Coverage versus Income and Total Health Spending, 2003 and 2010 27 Figure 5 : Vaccination Coverage, Turkey and Upper-Middle Income Countries 28 Figure 6 : Immunization coverage, 2003-2010 29 Figure 7 : Box Plot of Immunization Coverage Rates, 2003 and 2010 30 Figure 8 : Primary Health Care Visits per Capita, 2005-2009 31 Figure 9 : Remuneration of General Practitioners and Nurses, 2000-2010 32 Figure 10 : Total remuneration of physicians and health officers in family medicine relative to that of GPs and nurses in hospitals 32 Figure 11 : Total Remuneration (Monthly, Salary + Additional Payments) by Type, 2007-2010 32 Figure 12 : Spending on Family Medicine in Million TL, 2005-2011 33 Figure 13 : Health Care Employee Satisfaction by Profession, 2010 35 Tables Table 1 : Infant mortality rates per 1,000 live births, 2003 8 Table 2 : Immunization rates – by lowest and highest province in 2003 8 Table 3 : Rural-Urban difference in antenatal care visits, 2003 9 Table 4 : Average Number of Antenatal Care Visits, Selected Provinces, 2003 9 Table 5 : Auditing and monitoring practices reported by provinces 23 Table 6 : Infant mortality rates per 1,000 live births, 2010 24 Table 7 : Vaccine Antigens, 2002, 2010 and 2012 25 Table 8 : Average Number of Antenatal Care Visits, selected provinces, 2010 26 Table 9 : Number of Infectious Diseases Cases 28 Table 10 : Share of provinces reporting 99-100 percent coverage, 2005-2010 30 Table 11 : Share of FM/non-FM provinces reporting 99-100 percent coverage, 2005-2010 30 Table 12 : Number of Health Personnel per 1,000 Population, 2003-2010 31 Table 13 : Distribution of personnel per 1,000 population, 2007 and 2010 31 Table 14 : Patient Satisfaction EUROPEP Scale, 2008 and 2011 34 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 7 v Executive Summary 1. Prior to 2003, health outcomes in Turkey, specialty and service delivery approach, including Maternal and Child Health bringing family physician salaries up to and (MCH) outcomes lagged behind the OECD exceeding those of specialists, promoting and middle income comparators. Rural- the use of clinical guidelines, implementing urban and regional disparities meant that well-functioning health information and some provinces lagged even further behind. decision support systems and designing A number of health systems concerns properly aligned financial incentives. underlay this situation. Access to primary This model of primary care, the family health services, driven in large part by medicine program was initially introduced disparities in the distribution of health as a pilot in 2005, but now operates personnel, varied considerably. Delivery nationwide. Here, individual doctors and of care was fragmented and continuity other clinical staff are contracted using of care limited creating service delivery performance based contracts. Under this inefficiencies. A combination of low salaries contracting mechanism, up to 20 percent and a lack of performance incentives of the providers’ payments are withheld if prompted staff absenteeism and public performance targets for Maternal and Child perceptions of poor quality at primary care Health (MCH) including vaccinations are facilities fueled dissatisfaction and patients not met. It covers 72.0 million people (as of by-passed primary care facilities to access December 31, 2011) and includes a total of care at hospitals instead. 20,243 FM doctors and 20,243 FM health personnel who work in 6,463 Family Health 2. These concerns set the stage for the Turkish Centers in 81 provinces. Ministry of Health’s wide-ranging reform agenda to improve access, efficiency and 3. Although this innovative performance quality in the Turkish health sector through based contracting scheme is drawing the Health Transformation Program increasing attention internationally, there (HTP). A key element of the MoH’s is limited information on the mechanics of response was the reform of primary care the scheme. Further there is no systematic through the creation of a new primary care review of its achievements. This report 8 vi Performance-Based Contracting Scheme in Family Medicine – Design and Achievements seeks to fill this gap by: targets i.e., if immunization, antenatal care and follow-up of registered babies and - Describing the scheme children drops below 99 percent among - Assessing whether the scheme’s design, their registered population. Performance is institutional, and monitoring & assessed on a sliding scale for each FM unit evaluation and verification arrangements as a whole and applied to individual unit FM are (i) aligned to reform priorities at the staff. Contracts could even be terminated time, and (ii) facilitate the functioning for poor performance, though this rarely of the Performance Based Contracting appears to be the case. In addition, a scheme system of warning or admonition points for - Analyzing results achieved violations of service delivery governance conditions, structural measures of quality Finally, the report seeks to identify and even for failure to meet MCH service potential areas and options for coverage targets is also included in the further refining the Family Medicine contract. Compliance with governance Performance Based Contracting scheme and quality service delivery conditions to meet outstanding current and future is assessed at least once every 6 months challenges. through facility visits by the staff of the Community Health Centers. In addition, Family Medicine doctors are randomly How Does it Work? selected for audit each month and service 4. Under the Performance Based Contracting delivery is verified for a 10 percent sample Scheme, the Provincial Health Directorate1 of the users of their services. in each province enters into performance- 6. Two information systems, the Family based contracts with individual doctors Medicine Information System and the Core and other FM staff to deliver an integrated Resource Management System (CRMS) package of preventive, promotive and are the informational pivot on which the curative services to the population PBC scheme functions. Payments for registered to them. Family Medicine each provider are calculated using data in doctors are also contractually responsible the FMIS and CRMS. The FMIS includes for managing health facilities and meeting comprehensive electronic patient records service standards. Providers are paid and offer providers decision-support monthly and a capitation formula, which features to help with patient management assigns higher payments weights to and follow-up. It is also a source of pregnant women and children, is used performance management and oversight to calculate providers’ base payments. In data for the PHD and MOH. addition, a ‘service fee’, or monthly location bonus payment – which can be as high as 40 percent of the base payment -- is offered Appropriateness of the Design, to providers who work in under-served and Institutional and Verification areas. Further doctors receive additional & Monitoring Arrangements payments and reimbursements to cover health facility operating costs, including for 7. The design of the Performance Based delivering mobile health services. Contracting scheme is well-aligned to the main identified priorities for reform, and 5. Here, providers risk up to 20 percent of their the implementation arrangements appear base salary for failing to meet performance to facilitate its effective functioning. 1 With the Decree Law dated November 3, 2011, the Ministry of Health has been restructured; and the provincial unit has been divided into three as: Provincial Health Directorate, Provincial Public Health Directorate and Provincial Public Hospitals Union General Secretariat. This study reflects the organization structure before the restructuring. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 9 vii 8. Incentives introduced under the scheme responsive to the users of health services focus on key priority areas. Contracted since payments are based on enrollments providers are incentivized to focus on and the population has the option of voting Maternal and Child Health (MCH) with their feet and changing providers. The including immunizations, a key health scheme also includes a toll-free national sector priority under MDG 4 and 5, through hotline. By all accounts, complaints made three main performance levers: on this hotline are taken seriously and • up to 20 percent of base salary payments investigated independently of providers. are ‘at risk’ conditional on meeting The scheme encourages coordination of 12. MCH coverage targets. This is arguably care. The Family Medicine model, by its substantial enough to motivate providers. design, emphasizes integrated delivery • provider contracts could potentially be of preventive, promotive and curative terminated for repeated failure to meet primary care services. The PBC scheme MCH performance targets. assesses performance for the FM unit as a whole, rather than for individual providers • the capitation formula assigns the highest which incentivize FM providers in a unit to payment weights to pregnant women and collaborate to improve MCH coverage and children under five, therefore creating quality. incentives to enroll people in these groups. Information systems support timely 13. reporting and verification mechanisms 9. Disparities in the distribution of health keep performance reporting honest. The personnel across the country have declined FMIS facilitates providers’ management and since the scheme was introduced. Although patient follow-up and makes performance the scheme penalizes providers for poor data available in real time without performance – rather than offering bonuses making onerous demands on providers. for good performance – it does not appear It also greatly facilitates Provincial Health to have deterred voluntary participation. In Directorates’ oversight of performance fact, the distribution of health personnel and improves the transparency of the under the program has improved since the system by allowing providers to view scheme was implemented. Large overall their payments enabling them to lodge an increases in pay as well as incentives for appeal if necessary. Provider self-report of working in rural areas under the FM performance is verified through a system of scheme may help to explain this. random audit of a sub-sample of users by the Admonition points and institutional 10. CHC. Sanctions for falsifying data include arrangements foster improved contract termination and audits help to accountability. The admonition points and keep performance reporting honest while performance points (salary deductions) facilitating rapid performance assessments systems hold providers formally for monthly payments. accountable to provincial authorities for service delivery quality and governance and for their MCH performance. Separation Achieving Results of purchaser and provider and delegating Turkey’s experience of successfully 14. contract management to the provincial level strengthening primary care over a period has helped to create a more manageable of less than 10 years has yielded significant span of control and to hold providers results. Provider performance has accountable to provincial managers. improved, as have health outcomes. This has 11. Incentives encourage health service user- been achieved through a carefully designed centeredness. In addition, the capitation combination of measures including mechanism incentivizes providers to be properly aligned financial incentives. 10 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements viii Using incentives and performance targets Finally, both patient satisfaction and 18. to focus provider efforts and hold them provider satisfaction improved over time. accountable, through the family medicine Surveys conducted in 2008 and 2011, performance based contracting scheme show patient satisfaction with primary reinforced this strategy. As a result Turkey care services improving as provinces join has seen considerable improvements in family medicine system. Further, in terms immunization and antenatal care coverage, of provider satisfaction, job satisfaction, postnatal care coverage, infant follow- motivation and commitment is seen to be up, utilization of primary care services, highest among family medicine providers distribution of health personnel, and compared with other health professionals patient and provider satisfaction. in Turkey. 15. Improving maternal and child health was the overarching policy objective driving The Way Forward both the HTP as a whole and the FM PBC scheme specifically. Infant mortality rates Moving forward, the study recommends 19. and immunization and service coverage that as progress is made towards the have improved considerably since the original challenges that framed the introduction of the FM PBC scheme. Infant Performance Based Contracting scheme mortality fell from 28.5 per 1,000 live births in Family Medicine, incentives should be in 2003 to 10.1 per 1,000 in 2010. Average aligned to the most important current national immunization coverage rates rose challenges. There is also scope for fine- from 70 percent in 2003 to 97 percent in tuning the institutional arrangements for 2010. implementation. Generally speaking, an elaborate and functioning monitoring and Analyses of trends in outpatient visits 16. evaluation system is in place to form the per capita to primary care facilities basis for performance-based payments. show that utilization of primary care It has shown to be effective in preventing facilities increased substantially and was doctors from gaming the system as well as significantly higher at 2.9 visits per capita improving accountability of FM providers. in FM provinces than in non-FM provinces However, there are still a few areas in which which had 2.1 visits per capita on average. it is desirable to further strengthen the A fixed effects regression controlling for system. These include: both province and year shows that the introduction of FM was associated with a 14 20. Re-orienting performance contracts to percent increase in per capita consultations. include quality of care indicators: The This may reflect improvements in access, quality improvement program in primary and also possibly, perceived improvements health care is already ongoing. As providers in quality that prompt users who would now performs very well with regard otherwise have visited hospitals to use their to existing MCH indicators, this study family medicine provider instead. recommends that it may be time to include quality of MCH indicators in performance 17. Significant improvements are also evident contracts, with a focus on clinical processes in the distribution of health personnel, a key to support the ongoing quality improvement constraint to improving access to care. In efforts. For example, quality indicators fact, as a result of increases in base salaries related to clinical processes in antenatal of family medicine providers and incentives care that could be included in performance to work in rural areas, the gap between the contracts: highest and lowest provinces fell from 0.6 general practitioners per 1,000 population • pregnant women screened for in 2007 to 0.36 per 1,000 population by hypertension in each antenatal visit 2010. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 11 ix • pregnant women screened for proteinuria on outstanding challenges, in each antenatal visit • Add new performance indicators and • pregnant women screened for glycosuria retire the original performance indicators in each antenatal visit in a phased manner, or • pregnant women given a hemoglobin test • Introduce new indicators while retaining in the first trimester the original indicators and weight these indicators differentially so that a larger • pregnant women given a platelet count in portion of payment is linked to the most the third trimester important policy concern. Computerized medical records are being Each option holds different risks and used to monitor some of these indicators, benefits. Retiring indicators carries the risk especially those related to proteinuria that providers will redirect their efforts away screening and hemoglobin tests at the in favor of the new incentives. Increasing facility level. It should be noted however, the number of performance indicators that for payment purposes, measuring could potentially increase administrative quality of care is more complex than burden. It is therefore prudent to introduce measuring quantity of care but it could be new indicators on a pilot basis with careful the natural next step. evaluation prior to scaling up. 21. Re-orienting performance indicators 23. A need for combined demand side focus to to address NCDs: Given the increasing reach the ‘last mile’: Given the current high burden of non-communicable diseases, level of achievements, reaching the ‘last Turkey rightly plans to implement mile’ in improving MCH coverage could positive incentives for FM providers in the necessitate a demand-side focus to overcome prevention control of non-communicable constraints that especially hard-to-reach diseases (NCDs). Care however should be health service users face in obtaining such taken to continue to maintain the simplicity services. In this context, leveraging the of the system. Potential performance benefits of existing demand-side schemes indicators could be: such as the conditional cash transfers2 may • Screening adults for common further amplify family medicine providers’ cardiovascular risks (hypertension, high ability to improve coverage. In addition, cholesterol, obesity) such interventions could have an important • Successful management of NCDs role in the control of NCD risk factors such (control of blood pressure in as obesity, smoking, hypertension and high hypertensive patients, control of blood cholesterol. sugar in diabetic patients (HbA1c or 24. Standardizing monitoring of FM providers: glycated hemoglobin test) Significant variations among provinces • Screening of common cancers were found to exist in the procedures to monitor FM providers and verify their With regards to the introduction of the 22. results for payments during the conduct new indicators, the MOH has the option to of the study. Recognizing the importance either: of standardization, the Ministry of Health • Retire those performance indicators has recently introduced standardized where targets have been achieved and monitoring forms and guidelines for its use. introduce new indicators that are focused 25. Introducing constructive feedback 2 The conditional cash transfer scheme offers the poorest women a monthly allowance of 17 TL on condition that they continue their required health check-ups during pregnancy and infant check-ups after birth, and an additional 35 TL for giving birth in a health facility. 12 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements x mechanisms to and from FM providers settings. Turkey has taken advantage of the at the local level to improve performance: availability of good internet connectivity While annual meetings are held between in most provinces which presents a cheap MoH and Family Practitioners Association and potentially effective option and has to resolve issues and grievances, currently, created internet-based “open platform� for no standard guidelines on feedbacks peer to peer learning. This can be a good between providers and provincial health mechanism for training forums and other departments exist. Standardizing these modes of peer to peer learning. strategies across provinces could make 27. Conducting rigorous impact evaluations an important contribution to further of new incentives: Now that the original improving the performance of Family scheme has been applied nationwide and Medicine providers. the MOH plans to introduce new additions to the scheme in the form of positive 26. Improving use of existing peer to peer incentives for prevention and control learning networks for quality improvement: of NCDs, it is important that a rigorous Peer-to-peer learning networks for quality impact evaluation is envisioned from the improvement are used as a provider-driven very beginning so that the future success of tool to improve quality in many health care such changes in the PBC can be confirmed with solid evidence. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 1 Introduction 1. Prior to 2003, health outcomes in Turkey, levels, Turkey performed below average with including maternal and child health outcomes, respect to infant and maternal mortality lagged behind those of OECD countries and relative to other countries with similar per of those in other middle income countries. In capita income and health spending (Figure 1). 2002, the infant mortality rate was 28.5 deaths 2. Furthermore, within Turkey there were clear per 1000 live births compared to the OECD regional and rural-urban disparities. In 2003, average of 5 deaths per 1000 live births. Life the infant mortality rate (IMR) was 70 percent expectancy at 71.9 years was significantly higher in rural areas than in urban areas (39 lower than the OECD average of 78.6 years. and 23 deaths per 1,000 live births, respectively) The maternal mortality ratio in 2000 was more (Table 1). Large regional disparities persisted than 5 times the OECD average: 61 deaths per with infant mortality rates being higher than 100,000 live births in Turkey compared to the the national average of 29 deaths per 1000 live OECD average of 11.8 deaths per 100,000 live births in the North and East regions. Istanbul births. For its health spending and income had the lowest rate (19 per 1000 live births) FIGURE 1 Global comparisons of infant mortality rates (2002) and maternal mortality ratios (2000) versus income and total health spending, 2002 Infant Mortality (2002) Maternal Mortality (2000) Source: World Development Indicators and WHO, 2011 Note: Both axes log scale 2 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements Ankara and Tekirdağ had the highest coverage TABLE 1 Infant mortality rates per 1,000 live births, 2003 rates for measles (88 percent). Infant mortality rate 4. Health service utilization was low. The Residence average number of visits per capita to primary Urban 23 care facilities was 0.9 visits in 2002 (MoH, Rural 39 2011c). Over 18 percent of women did not Region seek antenatal care during their pregnancy, West 22 and this indicator was significantly higher in South 29 rural areas, where 34.2 percent of women did Central 21 not receive any antenatal care (Table 3). More North 34 than 23 percent of women first sought care East 41 after the first trimester (Turkey DHS, 2003). In Selected NUTS 1 Regions addition, while the national average number of Istanbul 19 antenatal care visits was 3.8, nineteen provinces Southeast Anatolia 38 had an average of less than three visits, and one province (Kilis) had an average of less than two Source: Turkey DHS, 2003 visits per pregnant woman (Table 4). 5. A number of health systems performance while Southeast Anatolia had the highest (38 concerns underlay this situation (MoH, per 1000 live births) (Turkey DHS, 2003). 2006). First, access to primary health services 3. National coverage rates for immunization varied considerably across the country both rates masked significant variation across between rural and urban areas, and also provinces. In 2003, the national coverage among provinces. These inequities were to rate was around 70 percent for BCG (Bacille a large extent driven by uneven distribution Calmette-Guerin), DPT3 (Diptheria, Pertussis of health personnel. In 2002, population per and Tetanus), measles, and HepB3 (Hepatitis general practitioner varied between 875:1 B3) vaccines (Table 2). In Şırnak province, and 7,571:1 among provinces (Vujicic et al., coverage rates were as low as 29 percent 2009). Further governance concerns existed for BCG and 31 percent for measles. In at the service delivery level. A combination of comparison, Tekirdağ and Gaziantep provinces low salaries and the absence of performance had 100 percent coverage rates for BCG, while incentives prompted coping strategies like staff TABLE 2 Immunization rates – by lowest and highest province in 2003 .. Source: Ministry of Health, 2012 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 3 TABLE 3 Rural-Urban difference in antenatal care visits, 2003 Source: Turkey DHS, 2003 absenteeism. This had ripple effects for higher level facilities as patients responded to perceived TABLE 4 Average Number of Antenatal Care Visits, Selected Provinces, 2003 poor quality at the primary care by by-passing primary care facilities and increasing patient Average Number of loads at secondary and tertiary facilities. Only Selected Provinces Antenatal Care Visits 38 percent of the population in 2002 chose to National Average 3.8 utilize outpatient care at the primary care level Kilis 1.4 (MoH, 2011c). Bingöl 2.0 6. Fragmentation in health service delivery, Batman 2.1 with several agencies providing care to Gaziantep 2.1 different parts of the population meant Denizli 6.0 limited emphasis on preventive health in the Malatya 6.7 absence of a single point of responsibility for coordinating care and well-being across levels Şırnak 7.7 of the health system, leaving significant gaps Source: FMIS, 2012 across the system. Centralized administration of service delivery from Ankara made it difficult to effectively manage for results while the Health Transformation Program (HTP) distracting the Ministry of Health from paying in 2003 aimed at improving access to health full attention to its role as steward of the health services, expanding coverage (particularly sector. Public dissatisfaction with the health to low-income groups eligible under the system was growing as a result of governance Green Card program), narrowing regional concerns and perceptions of poor quality. disparities, and improving health outcomes of the population. This was to be done by making 7. The 2002 elections provided political the Turkish health system more effective by impetus to health systems reform as the newly improving governance, efficiency and long- elected government perceived a clear mandate term fiscal sustainability. Strengthening to improve social services. Responding to this primary care, with specific emphasis on situation, the Government of Turkey launched maternal and child health, was an important 4 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements pillar in the reform agenda. work in. In addition, the government also covers operational costs for maintenance and 8. A key element of these reforms was the operation of the facilities, costs of outreach introduction of family medicine within a services and costs of laboratory tests and performance-based contracting framework. medical supplies. Established as a family medicine practice (FMP) pilot scheme under the “Law on piloting 11. In order to focus provider efforts on above of Family Medicine� (Number 5258), it was mentioned policy priorities, and increase initially implemented in Düzce province in accountability, a performance-based payment September 2005 and then rolled out nationwide scheme was introduced along with family starting in 2006. By December 2010 all 81 medicine. The performance based payment provinces in Turkey had been included in the scheme was not supplemental to the payment scheme (Appendix 1: Table 1) and in November for providers as is commonly seen in other 2011 the scheme was designated a permanent OECD countries but designed within the salary program of the Government.3 envelop. Two changes were made to the scheme during its rollout. In 2006, an “administrative 9. As of end 2011, the FMP scheme covered the component� which now has 35 indicators for entire 72.0 million population of Turkey. At further improvement of service delivery quality the time of preparation of the study a total of was added. In 2007, the scheme was expanded 20,243 Family Medicine Practice doctors and beyond doctors to include all family medicine 20,243 Family Health Personnel (mainly nurses personnel in health centers. and midwives) worked in 6,463 family health centers.4 They provide “integrated health 12. A mandatory referral system from primary services5� covering a wide range of primary care to hospitals was initially included in the care services with an increasing emphasis on performance-based payment scheme whereby prevention of chronic diseases. Services (such payments to FM staff were deducted if referrals as vaccination, antenatal care, and infant exceeded 15 percent. However this created follow-up), which were previously delivered severe bottlenecks in the system and placed primarily by midwives prior to the roll out of a high burden on FM physicians. The system the family medicine scheme, are now delivered was removed by a constitutional court order in jointly by family medicine teams. In addition, 2009. at the time of study preparation, there was 13. It is widely believed that the family 13,476 staff working in 960 Community Health medicine program is working well and Centers (CHCs), 2,349 of whom are physicians. reinforced by performance-based contracting, On average 3,500 patients were registered for has contributed to the improvement of primary each FMP doctor but the number of registered health care services and patient satisfaction. patients per physician can be as high as 4,500. Individual studies do exist that focus on various The Ministry of Health (MOH) goal is to reduce aspects of the family medicine program such this number to 2,000 by 2023. as patient and provider satisfaction. However, there has been no systematic description and 10. Under the FMP, doctors interested in being comprehensive review of the performance- family medicine providers can voluntarily based contracting scheme. join the program and are contracted for a period of two years, and payment is made on 14. This report aims to add to this body the basis of capitation adjusted by the socio- of evidence through the conduct of a economic development level of the region they comprehensive review of the scheme within 3 Decree in Force of Law no. 663 on the Organization and Duties of the Ministry of Health and Its Affiliates. 4 A Family Health Centre is defined as a health care organization which provides family health care services through one or more doctor (family physician) and at least an equal number of family health personnel (midwives/nurses) 5 Integrated health care is defined as the health care service designed for performing primary health care services intensively at locations designated by the Ministry, where preventive health care services, emergency health care services, examination, treatment and rehabilitation services, maternity, maternal and infant health, outpatient or inpatient medical or surgical intervention and environmental health, forensic medicine and oral and dental health services are given within its structure. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 5 the context of the overall family medicine FMP health personnel and division chiefs (or program. It describes and assesses Turkey’s deputies) from the provincial administration/ performance based payment scheme Community Health Centers (CHC) to obtain in family medicine with regard to design, their views about the performance-based institutional arrangements, governance, contracting scheme and to complement the monitoring and evaluation, implementation, information gathered from other sources. Each results and financial implications. Potential focus group comprised 10 participants, each areas for improvement are identified and participant representing a different province. further refinements of the current system are Efforts were made to cover as wide as possible a suggested. The report will also contribute to the geographical and urban/rural spread as well as current body of knowledge on the experience the range of dates when the provinces entered with pay for performance in primary care for the scheme. the interest of other countries. 17. The focus groups were conducted 15. The study methodology uses both separately for each of the three professional quantitative and qualitative approaches. groups to encourage participants to speak Further as the scheme was rolled out among freely and openly about their experience and Turkey’s provinces gradually, the quantitative lasted for four hours. The discussions were assessment uses before-and-after comparisons translated simultaneously and transcribed. for providers/provinces in the scheme as Four key topics were discussed, in line with well as comparison of providers/provinces the objectives of the review, focusing on the in the scheme and outside the scheme where design, contractual agreements, reporting feasible. The quantitative assessment is based and monitoring and effect on service delivery. on review of existing literature and Ministry of Open ended questions were asked followed Health reports, analysis of data from the health by prompts and probes to focus on specific information system, relevant surveys and aspects. financial data. The qualitative analysis relied 18. The report is organized as follows. The next on key Informant interviews and focus group two sections briefly describe the scheme and discussions (with regulators/purchasers and assess the design, institutional arrangements providers) to get their views on what works, and governance and monitoring and evaluation what does not work and why. It should be framework of the scheme. Section four noted, however, that as the scheme was merely outlines the achievements based on available one aspect of an integrated approach to primary recent data. Section five concludes with care, it did not allow for a rigorous evaluation lessons learned and implications for future of the impact of the scheme. interventions such as expanding the scheme 16. Three focus groups were conducted with to cover positive incentives for prevention and Family Medicine Practice (FMP) doctors, control of non-communicable diseases. 6 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements The Family Medicine Performance Based Contracting Scheme – How does it work? 19. Performance Based Contracting is an established negative incentives if targets were integral part of Family Medicine Practice not met rather than positive incentives for model in Turkey and is set as a sub-legislation rewarding greater effort. In addition this system to the “Law on piloting of Family Medicine� was perceived to be more affordable as it set a (Number 5258). The policy concern driving ceiling for maximum payment to providers thus the introduction of the scheme was that Turkey controlling health expenditures. was lagging behind other European countries in achieving Millennium Development Goals 20. This section describes the family medicine (MDG) 4 and 5, thus leading to an emphasis on performance-based contracting scheme maternal and child health indicators in selecting in terms of the contractual arrangements, performance targets. The scheme sought payment terms, monitoring and evaluation to take a zero tolerance approach to failure and governance mechanisms. Figure 2 is a to meet performance targets and therefore schematic of the scheme. FIGURE 2 Performance Based Contracting Scheme Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 7 Contractual Arrangements and preventive care services to a roster of registered Pay patients. In addition, they are responsible for providing mobile services in hard-to-reach rural areas and also, since 2010, for providing 21. The family medicine scheme is funded home-based care to their bedridden patients. In through general revenues within the budget of contrast to other family medicine staff, family the Ministry of Health. The main stakeholders physicians are also contractually responsible in the family medicine performance-based for managing health facilities7 so that services contracting scheme are: meet contractually specified standards and that health information reporting and record • Ministry of Health (MOH): who are the keeping is in line with protocols. All individuals stewards of the scheme are assigned to a specific family physician, who • Provincial Health Directorate (PHD): is expected, to act as the custodian of the health who are delegated the responsibility of and well-being of his or her patients. Patients managing and monitoring performance- do have the option of changing their family based contracts under the scheme, and of physician if an alternative is available. supporting contracted family medicine 24. The contractual approach provides staff considerable flexibility to family medicine • Community Health Centers (CHC): personnel in how to improve service delivery provide logistical and technical assistance while holding them accountable for meeting to family medicine units and supervise and standards and performance targets. Family monitor the FMP on behalf of the PHD physicians and other family medicine staff • Individual family medicine staff, including are not permitted to practice at other health family physicians, nurses and other staff facilities or take up any other occupation. All who work in a family medicine unit. Family family medicine staff is held to administrative medicine staff members are individually standards related to service delivery quality, contracted by provinces to deliver a and also for meeting performance targets package of services under the scheme. focused on maternal and child health. Failure to meet administrative standards can result 22. Here, under the scheme, each Provincial in contract termination and failure to meet Health Directorate, on behalf of the Ministry performance targets can result in payment cuts of Health, enters into contracts with individual and also contract termination for both family family physicians and other family medicine physicians and other family medicine staff in staff. The maximum duration of each contract their unit. is 2 fiscal years.6 In principle, the Governor of the province is responsible for entering into 25. The day-to-day responsibility for managing and canceling contracts but this responsibility and monitoring contracts is assigned to the is typically delegated to the Provincial Health Provincial Health Directorate (PHD) in each Director or Deputy Provincial Health Director. province. The PHD, in turn, is supported Doctors and other clinical staff who are by Community Health Centers (CHCs) in government employees can opt to take a leave verification and supervision. A team from the of absence from their government jobs to join CHC visits family medicine health centers the family medicine scheme as individually at least once every six months to assess their contracted family medicine personnel. level of compliance with service conditions to verify FMU groupings. In addition, the CHC 23. Family physicians and ancillary family also selects doctors for a performance audit medicine staff function as a single family each month and verifies service delivery for a medicine unit to deliver an integrated package sub-sample of patients through a combination of primary diagnostic, therapeutic and of phone calls and home visits as needed. The 6 In practice this means that an individual contract can be a maximum of 2 calendar years and could be less depending on when the contract is signed. 7 Family physicians’ management role includes managing expenses for emergency care and first aid drugs, equipment and supplies that are not provided in kind, for securing and maintaining the clinic itself and other operational expenses. 8 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements PHD, in turn, uses the information generated serving in less developed districts with a by the CHC to release payments to family shortage of medical personnel receive an medicine providers. additional payment “service credit� on a sliding scale that is linked to the socio- 26. The payment for family medicine staff has economic development index of the five components: district. At its maximum, this increment A. Capitation based payment. The monthly can be as high as TL 1,384 for family base payment for family physicians is physicians in the most disadvantaged defined with a capitation-linked formula, areas. This amounts to close to 40 percent i.e., in proportion to the number of of the maximum base payment. people registered to the family physician. C. Operational costs and other The monthly base payment for each reimbursements: registered person varies depending on the potential resource intensiveness of (i) Family physicians are paid a lump providing health care for that category of sum each month to cover equipment and persons. Pregnant women have the highest operational expenses including rent (where payment coefficient (adjustment factor needed), electricity, fuel, water, telephone, of 3), followed by prisoners (adjustment internet, data processing, cleaning, office factor of 2.25), children under 4 years and supplies, small repairs, secretarial and the elderly over 65 years (adjustment factor medical consumables. This lump sum of 1.6) and finally the general population payment is calculated as 50 percent of the which does not fall into any of these maximum monthly base payment. categories (adjustment factor of 0.79). (ii) The range of services and quality Payments are calculated by computing the standards to be satisfied vary by the total number of points by multiplying the category of the family medicine unit. number of patients in each category by the Depending on the category of the family adjustment factor points for that category medicine unit, family physicians are paid and summing up across categories. Family an additional lump sum payment that medicine specialist doctors are paid at the ranges from 10 percent of the maximum rate of TL 3.139 per point for the first 1,000 monthly base capitation payment for points for a maximum of TL 3,139. Non- category D family medicine units to 50 specialist physicians are paid at the rate of percent of the maximum monthly base TL 2.4 per point for the first 1,000 points capitation payment for category A family for a corresponding total of TL 2,400. medicine units. The purpose of this The balance of points over a 1,000 are monthly lump sum payment is to ensure multiplied by an adjustment factor of 1.44 that family physicians have the additional to calculate the total underlying capitation resources needed to meet the mandated payments up to a maximum of 2,400 points service delivery conditions. for integrated health centers and up to 4,000 points for all other family medicine D. Reimbursements for expenditures on facilities. Over and above this, doctors laboratory tests and consumables. working in integrated health service E. Ambulatory health care service fees. centers are paid an additional 65 percent To meet mobile health care service on this capitation base. Similarly, doctors expenditures, family physicians receive working in designated sparsely populated an additional lump sum payment of 1.6% areas are paid an additional 100 percent of the maximum base capitation payment on their capitation base if the number of for every 100 persons who receive mobile patients registered to them is below 1,350. services. If the mobile health service is B. Capitation adjusted for socio-economic carried out by using a vehicle provided level of area. The monthly base payment by the PHD; then the payment for related is adjusted for the socio-economic cost that is normally paid to the family development of the area in which the family physician, is funneled to the revolving physician practices. Family physicians fund of PHD. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 9 27. Although family physicians and other family a single contract period (i.e., a maximum of 2 medicine staff are contracted individually, they years), his or her contract is terminated and are expected to function as a unit under the he or she is debarred from applying for a new overall guidance and management of the family contract for a year. physician. The total monthly payment for all 29. In terms of salary deduction, deductions family medicine staff in the family medicine are made from the total monthly base payment unit is calculated using the above approach. of family physicians based on the gap between the target level for each indicator, which is set at 98% for all indicators and applied uniformly across all practices, and the coverage level Performance Incentives and How attained: They Work • A deduction of 2% if the monthly coverage rate is 97% to 98% 28. The performance aspect of the family • A deduction of 4% if the monthly coverage medicine contracting scheme includes two rate is 95% to 96% components: • A deduction of 6% if the monthly coverage A salary deduction system (Performance rate is 90% to 94% point system) focusing on three performance • A deduction of 8% if the monthly coverage indicators and targets which applies to FMP rate is 85% to 89%, and physicians and to FMP health staff as well as to FMP managers. The three performance • A deduction of 10% if the monthly coverage indicators in the salary reduction scheme also rate is lower than 85% included as criteria in contract cancellation. The maximum total deduction for Here, the contracting framework links performance is capped at 20 percent. payments to individual family medicine staff to their verified performance on the following 30. For the administrative system, the maternal and child health service coverage conditions are a mix of indicators that relate indicators: to governance at the service delivery level, structural measures of quality and service • Immunization coverage rate of registered coverage targets. In fact, repeated failure to children for each target vaccination (BCG, meet targets for key maternal and child health DPT3, Pol3, measles, HepB3, Hib3) indicators could result in contract termination • Registered pregnant women with a for all the family medicine staff in the unit, minimum of 4 antenatal care visits in addition to the payment deductions levied according to schedule for each indicator falling below the desired performance target. Furthermore, it is also • Follow-up visits of registered babies & clear that the family medicine contracting children according to the schedule scheme is very concerned about the quality of An administrative system comprising reporting and patient privacy. Incorrect (‘non- 35 indicators which form the basis for factual’) reporting or failure to keep patient written admonitions or contract cancellation records secure can result in 50 warning points (Appendix 1: Table 2). These include among respectively, implying that two violations over other indicators for abiding with working two years would result in contract termination. hours and duties as per contract regulations, 31. In practice, the actual penalty amounts for maintenance and security of health records, the performance points system are relatively ensuring patient confidentiality and low as most of the provincial authorities prefer maintenance of property and equipment. Each resolving current problems and increasing violation is linked to a pre-specified number of patient satisfaction rather than penalizing points defined with reference to the severity of responsible personnel, so FM doctors’ concerns the violation. If a family medicine staff member are primarily about the administrative warning accumulates 100 or more warning points over points system. 10 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 32. Further, the contracts of family medicine an electronic health record for each person staff may be terminated without warning if they registered to the family physician. Family fail to meet specific administrative conditions medicine staff – doctors and nurses – updates of service, including: patient records with health data for their registered population into the FMIS. The FMIS • If the number of people registered to the therefore includes a comprehensive record of family physician in question falls below patient characteristics and services received, 1,000 for two continuous months including Maternal and Child Health services • If the family medicine staff member is that are specifically targeted by performance absent from duty without excuse for 10 incentives in the family medicine scheme, consecutive days other services provided by the family medicine • If the family medicine staff member is unit and referrals. Diagnostic test results from unable to carry out his or her duties for laboratories to which patients are referred, more than 180 days for health reason for instance, are scanned and available via the FMIS to the referring family physician. The • Any falsification of records or documents FMIS provides decision support to family • Absence from duty for 8 weeks or more medicine staff by generating reminders and because he or she was arrested lists of persons who need to be followed up (for instance, by providing lists of those who need follow-up for specific immunizations or antenatal check-ups), and allowing family medicine providers to track their progress with Measuring and Managing attaining performance targets for indicators Performance that are linked to payment deductions. 36. FMIS data can be accessed from multiple 33. The family medicine scheme is supported geographic locations. Family medicine staff by two main information systems that are can enter data offline if necessary. When they used to track performance on technical and connect to the internet, these data are updated managerial/ budgetary parameters namely the on a central server. Therefore, regularly Core Health Resource Management System updated data can be accessed by authorized and the Family Medicine Information System. staff in the PHD and by the Ministry of Health. The FMIS enables the PHD and MOH 34. The Core Resource Management System to assess each individual family medicine (CRMS) is a Ministry of Health wide unit’s performance on targeted performance information system that is used to track indicators by calculating service coverage rates budgets and expenditures. It includes data on among eligible population registered to each parameters that determine payments to family family medicine unit. medicine staff: including socio-economic development coefficients for each district, 37. The information generated through these expenditures on lab tests, staffing, expenditures information streams are used by Provincial on mobile services etc. Not all districts were Health Directorates (PHD) to assess the level initially covered by the CRMS, however and of payments to be made to individual family some did not input data correctly in the medicine staff, compliance with standards past. The Provincial Health Directorate also and to identify whether contracts should be manually tracks these data in the provinces to terminated. The exact payment due to each ensure data validity. provider is calculated in the CRMS. The PHD, in turn, uses data from the FMIS, CRMS and the 35. The Family Medicine Information System CHC’s reports on performance audit findings (FMIS) was developed and introduced in to release payments to providers by the 15th 2005 in conjunction with the family medicine of each month. Providers are also informed scheme to track health-related indicators that of their calculated payments, and of possible are relevant to family medicine services and as deductions, each month through the FMIS by a decision-support system for health providers. the 13th of each month. The FMIS provides The provider interface of the FMIS includes Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 11 a source of oversight data for the Ministry of performance. Any discrepancies identified Health who oversee the performance of the during routine visits can trigger a more in- scheme and release advance funds to each PHD depth audit of individual family medicine staff. assuming satisfactory performance. Mobile services are audited directly by the PHD. 41. If FM practices fail to meet the conditions of service for a particular quality standard the Performance Verification - Audits audit report will include the date when failure started. Following the approval of the audit report by the MOH Primary Health Care 38. Mechanisms for data verification and Directorate, payment is revised downward counter-verification are crucial to the success of accordingly and the over payments are covered a performance-based system. This is of utmost with interest at around 9 percent per year from importance in the case of the Turkey model as the date the failing was identified. performance indicators in the FMIS are entered into the information system by family medicine staff themselves and are therefore self-reported data. To ensure accurate reporting, family medicine staff are contractually obliged to Appeals and Grievance report on a regular basis, and falsification of Resolution data carries heavy penalties with 50 warning points per violation. If within a contract period, 42. FM physicians who have had their contract a FM provider falsifies data twice, it can result terminated can appeal against the contract in contract termination. decision to the provincial discipline committee 39. The PHD is responsible for verifying that within 7 days of the notification date. The these self-reported data on service coverage appeals committee has 30 days to investigate are accurate. Every month, approximately 10 the appeal and provide information on the percent of family physicians are selected for data decision back to FM physicians. verification by the CHC. Staff from the CHC 43. FM doctors and FM health staff can complain conducts a performance audit of the selected to the provincial Performance Objection doctor through a combination of patient Commission to contest deductions either records review, phone calls or home visits. before or after the payment has been made. Approximately 10 percent of the patients for In addition, appeals can be lodged against an audited doctor are selected for participation the audit report prepared by the audit team in this audit. Findings from regular audits can within five work days. Appeals are made to the trigger a more in-depth audit or investigation of FM directorate at the MOH and are evaluated the FM physician in question. However, except within 10 working days, on the basis of under exceptional circumstances, no doctor is documents provided by the PHDs. In practice, audited in two consecutive months. grievances against payment deductions have 40. The CHC is also responsible for auditing seldom been contested. Grievances have been compliance with the standards and conditions mostly about heavy workload. of service delivery, and assigning warning 44. In addition, PHDs have a complaints points when necessary. CHC staff visit each mechanism whereby patients can send family medicine practice a minimum of once complaint letters or use a hot line SABIM every six months to assess compliance with (Hello 184) for oral complaints. A commission standards and identify any violations. These of 7-8 people within the PHD makes the data are also used to verify that the family final decision. There is no set process for this, medicine unit satisfies the conditions associated but most of the provinces apply the current with its service classification (A-E). In 2011, investigation/inspection practices of the the Ministry of Health introduced a standard Ministry of Health. checklist that all provinces now use to assess 12 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements Assessing the Design 45. This chapter presents an assessment of Appropriateness of Design the Family Medicine Performance-Based Contracting scheme from a programmatic perspective. The discussion in this chapter is 47. As noted earlier, the scheme incentivizes framed around the following guiding questions: primary care providers to focus on key priority reforms areas for the Ministry of Health a. Is the design of the Performance-Based under the Health Transformation Program. Contracting incentives appropriate, and At the time of design, Turkey’s maternal and are the indicators used to measure the child health outcomes were lagging behind performance of contracted providers those of OECD countries and other middle appropriate? income countries. Regional and rural-urban b. Are the institutional arrangements for disparities in outcomes prevailed fueled governing and managing the Performance- largely by disparities in the distribution of Based Contracting scheme appropriate? health personnel. Also, most service delivery c. Are the methods for measuring and was hospital focused – patients bypassed low verifying the performance of contracted quality primary care services to seek care at Family Medicine providers appropriate? higher levels of care. Further fragmentation of service delivery led to inadequate coordination 46. The question of appropriateness is of care. The design of the Performance-based discussed with reference to whether the design, Contracting framework clearly reflects these institutional arrangements and methods for concerns. measuring and verifying performance are aligned to the main challenges highlighted by 48. First, the design includes a number of the Ministry of Health for the health sector and mechanisms to incentivize providers to focus for primary care, and how they may facilitate their efforts on reaching pregnant women the functioning of the Performance Based and children through the following three Contracting scheme. performance levers: 49. Payments held ‘at risk’ conditional on Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 13 performance: The contracting framework for issuance of warning points. The complete family medicine staff specifies that a portion list of reasons for the issuance of admonition of their individual salaries may be deducted points is presented in Appendix Table 2. if critical MCH performance targets (targets 51. Incentives created by the capitation-based relate to coverage of BCG, DPT3, polio, formula used to calculate Family Medicine measles, Hepatitis B and HiB (Haemophilus provider salaries: The base capitation payment Influenza type b)vaccines, the proportion assigns higher weights to enrolling pregnant of pregnant women who receive 4 or more women and children to motivate providers to antenatal care visits and follow-up visits to improve access to care among these categories pregnant mothers and children under 4 years) of the population. Pregnant women have a are not met by the Family Medicine unit. In all payment coefficient of 3 while under-fives cases, the minimum performance threshold have a payment coefficient of 1.6. Both these below which deductions apply is 98 percent. payment coefficients are considerably higher Salary deductions are made on a sliding scale than the coefficient of 0.79 for the general in inverse proportion to the coverage achieved (non-prison) population. In effect this means and capped at 20 percent of each contracted that family medicine providers are paid more provider’s salary. This creates strong incentives per pregnant woman and child under five. to focus on immunizations, ensuring that This incentivizes family medicine personnel to antenatal care services are delivered and proactively seek out pregnancies and register mothers and children are followed up. children under five therefore improving access 50. Performance conditions linked to contract to care among these population groups. termination: Contracts can be terminated if a 52. Second, recognizing that unevenness in the family medicine provider accumulates 100 or geographic distribution of health personnel more admonition points over a single contract was a critical deterrent to improving access in period (i.e., a maximum of two years). Failure poorly served area, extra payments “service to maintain vaccination rates, follow-ups of credits� (see paragraph 24) are provided pregnant women and infant and child follow- to family medicine providers for working ups at 90% or higher results in 10, 20 and 20 in such areas. Pre-HTP, approximately 50 warning points per violation respectively so that percent of the variation in the distribution of five failures to meet performance targets could, general providers and specialist doctors was in principle, result in contract termination. correlated with provincial levels of economic Furthermore, a survey of 38 provinces that had development.8 With the implementation of implemented PBC for 3 or more years found the FM PBC scheme differences in distribution that failure to meet performance targets was the among provinces appear to have lessened most frequent reason for assigning admonition and the gap between the best and worst-off points in the first year of family medicine in provinces has narrowed (Table 13). 47.8 percent of family medicine provinces. This risk has incentivized providers to focus their 53. Third, uniform absolute performance efforts on improving maternal and child health targets – rather than targets that are relative services. By 2011, significant improvements had to baseline – reflect the Ministry of Health’s been achieved in MCH services and the share policy objective of closing geographic gaps of provinces citing failure to meet performance in performance. Performance targets for targets as the most frequent reason for assigning Maternal and Child Health indicators in admonition/warning points decreased to 29.2 the Family Medicine Performance Based percent. The second most common reason Contracting scheme are set at an absolute level for the issuance of admonition points in the and are uniform for all provinces and providers first year of implementation was the failure to irrespective of their starting point. In effect, comply with working hours (13%). By 2011, they incentivize family medicine providers in it has become the most common reason for areas with lagging performance to work harder 8 Ministry of Health 2007 as cited in Vujicic, M., Sparkes, S. & Mollahaliloglu, S. 2009. Health Workforce Policy in Turkey: Recent Reforms and Issues for the Future. HNP Discussion Paper. The World Bank. July 2009 14 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements to prevent salary deductions for failure to meet Penalties can, in principle, deter participation these performance thresholds. if it is voluntary as is the case in the FM PBC scheme. However, there is little evidence that 54. Fourth, to reduce fragmentation and performance penalties have adversely affected improve accountability, performance is participation in the Turkish context, and in fact, assessed for the family medicine unit as a the distribution of health personnel appears whole thus improving co-ordination of care. to have improved because of other incentives Although family medicine staff are contracted built into the family medicine program such as individually and performance sanctions bonus payments for working in under-served applied to each individual, the performance areas. Further, the large overall increase in of the team is assessed as a unit to incentivize payment for FM personnel may have strongly co-operation and co-ordination within the encouraged voluntary participation in the FM team. Family physicians and ancillary staff are PBC scheme. responsible for delivering an integrated package of primary level preventive and curative health services to a roster of registered patients, and   the family physician is expected to co-ordinate care of his or her patients across levels of the Governance and Accountability health system therefore creating a single point Mechanisms of responsibility for primary care services and reducing the fragmentation in service delivery at the primary care level. 58. Governance concerns at the service delivery level prior to the launch of the HTP meant that 55. Further to elevate the status of family improving accountability was a key health physicians and attract doctors to family systems objective. The admonition points and medicine under the FM PBC scheme, salaries performance points system aimed to achieve for family medicine general providers were this objective as seen below: made attractive enough to induce them to leave government positions and join as a contracted 59. Admonition points system in the contracting family medicine physician. In fact, family framework are a mechanism for the provincial medicine doctors are now paid as almost the health authorities to hold family medicine same as specialists working in hospitals on providers accountable for maintaining basic average. service standards that relate to structural aspects of quality and also to maintain expected 56. A common driver of the performance standards of behavior for health professionals. based payment mechanism is the size of the Supervisors from Community Health Centers performance risk transferred to the provider. visit family medicine units to assess whether In Turkey, as we see the payment risk borne warning points must be awarded. This by family medicine providers is arguably high direct link between independently assessed enough to incentivize performance. Under the performance along pre-determined parameters performance points system, family medicine and contract termination is an important providers risk an increasing proportion of mechanism in the scheme for improving their salary as the gap between the target and accountability, for ensuring that services meet achieved coverage increases. A maximum of basic quality standards and for improving 20 percent of providers’ base salary payments service delivery governance. In reality however, (around 915 TL) is at risk, which is substantial contract termination is a rare event – only given it amounts to around 16 percent of total 1.4 percent and 1.6 percent of contracts were take home pay, to motivate providers to reach terminated in 2011 and 2012 respectively (see targets. Appendix Table 15). 57. As noted above, the performance-based 60. Performance points that result in salary contracting scheme includes both positive and deductions for failing to meet Maternal and negative incentives. As the positive incentives Child health service coverage standards are are related to locating in underserved areas, it a mechanism to improve accountability for can be said that service delivery performance results to provincial health authorities. Warning is mainly framed in terms of penalties. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 15 points are also assigned if providers fail to meet management to the provincial level improves 90 percent coverage targets for vaccinations, provider accountability and facilitates the follow-up of pregnant women and follow-up of Ministry of Health’s stewardship of family infants and children under five years of age (see medicine results. Although funding originates Page 11 for details). from the Ministry of Health, the purchaser and contract manager for all practical 61. High levels of public dissatisfaction with purposes is the Provincial Health Directorate health services due to perceptions of poor (PHD). Delegating contract management and quality and staff absenteeism before family monitoring responsibilities to the provincial medicine was introduced meant that improving level creates a more manageable span of service deliveries to meet user expectations was control which allows PHDs to play a more an important reform objective for the Turkish active role in monitoring, supervising and Ministry of Health. Under the FM-PBC scheme managing providers and to respond quickly the population has the option of voting with to any concerns. Furthermore, the purchaser- their feet and choosing their family physician provider split also facilitates a more objective if dissatisfied with the one assigned to them. and independent assessment of providers’ Since family medicine providers are paid based performance by the Provincial Health on the number of people registered with them, Directorate. This institutional arrangement this creates incentives for responsiveness to has also liberated the Ministry of Health from their registered population. the responsibility of day-to-day monitoring of 62. Grievance mechanisms too are an important providers or managing contracts and enables feature of user responsiveness. The Ministry the Ministry to focus on overseeing the PBC of Health has a national toll-free hotline that scheme and the health sector as a whole. people can call to lodge their grievances. 65. A focus on results with management SABIM hotline complaints are investigated flexibility to attain them gives providers and by the Provincial Health Directorate and the PHDs the space to achieve results. The PBC Community Health Center, independently of scheme holds family medicine providers the family medicine providers, and can trigger in a unit jointly accountable for achieving an audit. The separation of purchaser and contractually specified results while giving provider created by the contracting framework providers management autonomy. To illustrate, helps to maintain the independence of while contracts specify service standards that provincial-level authorities who are effectively must be met, providers are given flexibility responsible for holding family medicine in organizing their work hours, in recruiting providers accountable to the requirements non-clinical support staff or in maintaining of the contracting agreement. Findings from physical premises of their facilities (for which key informant interviews with provincial they receive a lump sum payment). In effect, regulators and contracted providers suggest the contracting mechanism has given family that investigations based on complaints are medicine providers managerial responsibilities taken seriously. in terms of facility and performance 63. Performance payments are frequent management for their own unit. enough to lend visibility to the link 66. Similarly, PHDs have the autonomy to between performance on contract-specified exercise their contract management role parameters and payments. Payments under within the guidelines specified by the Ministry the Performance Based Contracting scheme of Health. Key informant interviews with are made by the 15th of each month for the provincial health officials and family medicine preceding month. Performance is monitored providers showed that provinces showed largely through self-reported data by family considerable initiative and diversity in their medicine providers, and verified independently strategies to supervise and support family through a combination of facility visits, patient medicine providers. For instance, the PHD record review, patient phone calls and home in Düzce province organizes weekly meetings visits. The reporting and verification system is with all the FM providers. The meetings agile enough to enable monthly payments. are used as a platform to provide additional 64. Delegating contract monitoring and information and feedback to FM providers and 16 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements get their feedback on the types of support and effectively. Similarly, the Ministry of Health is information they need from the PHDs to work able to monitor the overall performance of the more effectively. FM PBC scheme.   70. Facilitating rapid and credible performance assessment: This is enabled by self-reporting of performance combined with independent Monitoring and Verifying audits of service delivery. Self-reporting, backed Performance up by a solid family medicine information system, is adequately structured to trigger monthly performance-based payments. Given 67. Crucial to the success of any performance the large number of FM providers who need based payment system is an information system to be paid monthly, it makes sense to rely on that (i) supports providers in the management self-reporting by providers as the mechanism and follow-up of patients and (ii) facilitates the to trigger performance-based payments. This is rapid and transparent performance reporting also the experience of most performance-based and payment administration. incentive schemes for FM in other OECD 68. Facilitating health service user management countries such as the UK, Australia and New by provider. The Turkey FMIS has a cutting- Zealand (Cashin, 2011; Cashin and Chi, 2011). edge patient records management system that 71. Rigorous random audits also help prevent facilitates health service user management providers from gaming the system. As by providers. It helps to maintain a complete performance reporting to trigger payments electronic history of everyone registered in and is primarily through self-report, independent using services in the family medicine system. verification of results is vital to deter over- Patient medical records enable providers to reporting by providers and trigger sanctions if easily maintain and update the medical and over reporting is found. The monthly random service provision history of all their registered audit covers 10 percent of doctors. For each population. It also incorporates a decision audited doctor, 10% of patients are selected for support feature that reminds providers of a random audit. Since FM has been scaled up people that require follow-up, for instance in the whole country, around 110,000 infants infants who need to be immunized. None of under 11 months and 90,000 mothers are the contracted providers interviewed by the checked annually for the MCH services they assessment team suggested that the data entry received. This mechanism is both cost-effective is onerous or excessively time consuming. and a deterrent to inaccurate self-reporting by 69. Facilitating rapid and transparent FM providers. reporting of performance and administration 72. During the conduct of the study it was of payments. Providers’ reporting of their own seen that despite existing central guidelines on performance via the FMIS is the start point for monitoring and supervising family medicine performance reporting in the PBC scheme. providers, there appeared to be a high degree of Providers’ performance data sourced from the diversity in the practices followed by individual FMIS provide a vital input for the automatic provinces. A survey of provincial officials in 38 calculation of providers’ payments in the provinces where the family medicine scheme Ministry-wide Core Resource Management has been implemented for 3 or more years also System. The ability to share information showed that important differences between with multiple parties both facilitates the provinces in how providers are selected for administration of payments and improves the performance audits, whether visits to family transparency of the PBC system. Providers can medicine units to verify service conditions view the payments due to them in the FMIS and, and assess warning points are announced if necessary, lodge an appeal against deductions or not, and on guidelines for supervisors so that deductions may be reversed if necessary (Table 5). Furthermore, the provincial survey, before the payment is made. At the same time, key informant interviews and focus group data from the FMIS enable the PHD to track discussions with Provincial Health Directorate provider performance and manage contracts staff and Family Medicine providers too Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 17 TABLE 5 Auditing and monitoring practices reported by provinces Audit and monitoring practice reported % of provinces highlighted the importance of reducing priorities and support the smooth functioning ambiguities in interpretation of when warning of the PBC scheme. Further, the monitoring and points may be awarded. Recognizing this, the evaluation system in FM appears to facilitate Ministry of Health has recently introduced performance tracking and accountability for standardized monitoring forms with guidelines results. for its use throughout the country. 74. However, as many of the original challenges that framed the introduction of the FM PBC scheme have been achieved, the FM PBC scheme faces the task of addressing Conclusion outstanding as well as new challenges that emerge as the scheme evolves. The experience with implementing FM PBC in Turkey has 73. As can be seen, the design of incentives is also yielded many insights about some options aligned to the main challenges in the health for further refining its design, institutional sector at the time of initiation. The institutional arrangements and performance monitoring arrangements for implementation too appear and verification mechanisms. These are to be appropriate in the context of sectoral discussed in the final section. 18 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements From Design to Achievements 75. Turkey has seen significant improvements in key health outcomes in the period surrounding TABLE 6 Infant mortality rates per 1,000 the introduction of the family medicine live births, 2010 program. The infant mortality rate fell from 28.5 per 1,000 live births in 2003 to 10.1 deaths per 1,000 live births by 2010 at the national level with substantial narrowing of regional disparities (Table 6). The maternal mortality ratio fell from 61 deaths per 100,000 live births in 2003 to 16.4 in 2010. The averagenational vaccination coverage rates for DPT3 rose to approximately 96 percent in 2008 and to 97 percent in 2010 from 68 percent in 2003, while regional disparities narrowed. In addition, more and more pregnant women have at least four antenatal care visits in line with WHO standards. Source: MOH (2011a). 76. It should be noted that in addition to the and standards set of minimum number and Family Medicine program roll out in 2005, a timing of antenatal and postnatal care visits. myriad of other measures were initiated since Beginning 2005, free iron supplements are 2003 to reduce infant and maternal mortality, distributed to infants and pregnant women improve immunization coverage, and increase as part of the Iron-Like Turkey and Iron the number of antenatal and postnatal visits. Supplement for Pregnant Women programs. In order to inform family planning decisions and detect pregnancies at an early stage, 77. Several improvements have also been made women 15-49 years old are now followed-up in the immunization schedule and delivery. twice a year by primary health care and family Prior to the introduction of the HTP, children medicine providers. Prenatal and postnatal care were immunized against seven diseases management guidelines have been developed (diphtheria, pertussis, tetanus, polio, hepatitis Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 19 TABLE 7 Vaccine Antigens, 2002, 2010 and 2012 (7 antigens, 9 injections) (11 antigens, 13 injections) (13 antigens, 16 injections) Source: MOH (2011), HTP Evaluation Report (2003-2010) B, and tuberculosis). In 2006, haemophilus not seek care during the first trimester of their influenza type b (Hib), rubella and mumps pregnancy. To address this important service were also included in the program. Table 7 gap, service standards for care of pregnant shows the changes over the period 2002 to women were set to ensure at least four antenatal 2012. Spending on vaccination too increased care visits during pregnancy; following the more than nineteen-fold from 20 million TL in schedule of at least 1 visit in the first trimester, 2002 (in 2010 prices) to 397 million TL in 2010. 2 in the second and 1 in the third. To further emphasize the importance of these standards, 78. Recognizing that performance based these were included as performance targets. contracting was merely one aspect of an integrated approach to primary care supported 80. As a result, the national average number under the HTP, this section analyzes the trends of antenatal care visits increased from 3.8 in health outcomes in terms of key performance visits in 2003 to 4.6 visits in 2010. By 2010, indicators which the scheme reinforces such twenty provinces had an average of less than as vaccination coverage, access and utilization four antenatal care visits and only two had an of services such as antenatal care services, average of less than three visits compared with resource allocation – human and financial and fifty provinces with less than four antenatal consumer and provider satisfaction. It assesses care visits and twenty with less than three visits trends, pre-HTP and currently through in 2003 respectively. Istanbul at 1.9 visits per international benchmarking and comparisons pregnant woman had the lowest average. The over time relative to other upper middle- number of consultations in Istanbul, however, income countries. appears to be underreported, as most women seek care at private facilities. According to estimations from the Demographic Health Survey (2008) conducted by Hacettepe University, 51 percent of women in Istanbul Antenatal Care sought antenatal care from private clinics and 25.7 percent from a mix of public and private 79. Prior to 2003, there were significant facilities. Only 23.3 percent sought antenatal variations in antenatal care visits across the care solely from public facilities. regions and in many cases pregnant women did 81. Figure 3 displays the average number of 20 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 8 Average Number of Antenatal Care Visits, selected provinces, 2010 Average Number of Antenatal Care Visits National Average 4.6 İstanbul 1.9 Erzincan 2.5 Giresun 3.0 Yozgat 6.8 Muğla 6.9 Aydın 7.5 Source: FMIS (2012). antenatal care visits for all provinces according Immunization Rates to their year of entry into the Family Medicine program. This indicator also follows an upward trend, with most provinces having reached the 82. As noted in the earlier section, vaccination target rate of at least four antenatal care visits. coverage for six vaccinations (BCG, DPT3, As can be seen, prior to the implementation of Polio 3, Measles, Hepatitis B3, Hib3) very family medicine, there were large variations key priority area of focus in the reform of in the average number of antenatal visits. By primary care in Turkey and formed part of 2010 the gap has narrowed with all provinces the Performance Based Contracting Scheme converging to the set target of at least four visits. in the Family Medicine Practice. These are included as performance indicators linked to salary payment reduction and also among the 35 criteria for the contract cancellation component. Salary deductions incur if FIGURE 3 Average Number of Antenatal Care Visits, 2003 - 2010 providers fail to achieve 99-100 percent coverage rates. In addition, the number of “admonition/warning points� for failing to 6.0 achieve the 90% target is 10 points for each 5.5 target vaccine. 5.0 83. In 2003, Turkey’s immunization coverage 4.5 rates were well below average for comparable 4.0 health spending and income level countries for 3.5 the five vaccines (BCG, DPT3, Polio 3, Measles, 3.0 and Hepatitis B3). Significant improvements 2003 2004 2005 2006 2007 2008 2009 2010 in immunization service including a focused 2006 FM 2007 FM 2008 FM approach in family medicine have yielded results. By 2010, Turkey performed well above A 2009 FM 2010 FM Turkey Average average relative to comparator health spending and income level countries in all five cases Source: Primary Care Statistic Module (2012). (Figure 4). Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 21 FIGURE 4 Global Comparisons of Immunization Coverage versus Income and Total Health Spending, 2003 and 2010 Source: WHO and WDI, 2012 84. Further this increase in immunization middle income countries in 1986,9 by 2009 coverage rates was achieved in a relatively short Turkey had surpassed the average vaccination time frame compared with other upper-middle coverage rates for upper-middle income income countries. As shown in Figure 5, despite countries for all four vaccines and continues starting at much lower levels than upper- to see high growth rates. Between 2006 and 9 Hepatitis B3 data is alone available starting 2000. 22 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements FIGURE 5 Vaccination Coverage, Turkey and Upper-Middle Income Countries Source: WHO and OECD (2012) 2007, Turkey’s immunization coverage for BCG TABLE 9 Number of Infectious Diseases Cases rose from 88 percent to 94 percent. Upper- middle income countries required four years (1992-1996) to achieve the same improvement. Measles Turkey’s Hepatitis B3 coverage increased from Tetanus 82 percent in 2006 to 96 percent in 2007, while Neonatal upper-middle income countries required seven Tetanus years to improve their coverage from 83.6 Pertussis percent to 93.5 percent between 2000 and 2007. Hepatitis B Diphtheria 85. These high vaccination coverage rates have resulted in reducing the prevalence of vaccine preventable infectious diseases. The most Source: Health Statistics Yearbook, 2010 notable decrease is seen in measles, which *Note: 2008 - 1 imported case and 3 import-related cases. No local cases were reported. 2009 - 3 im- dropped from 7810 cases in 2002 to 7 in 2010. ported cases out of 4 and 1 import-related case. No local cases were reported. 2010 - All of 7 imported cases. No local cases. All of the 7 cases are either imported or related Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 23 FIGURE 6 Immunization coverage, 2003-2010 Source: Ministry of Health (2012). to imported cases. were implemented during the same time period targeted at improving immunization rates thus 86. Analysis of trends in coverage rates for it is difficult to separate out the effect of the four of the six vaccines of interest, i.e., BCG, Family Medicine program. DPT3, measles, and HepB3 show an upward trend (Figure 6). Despite the upward trend 87. As can be seen from Figure 6, while the in vaccination coverage for the four target average vaccination coverage rates for provinces diseases, (perhaps with the exception of that joined FM in 2010 were lowest in 2003, HepB3) between 2003 and 2010, the greatest by 2006 they had converged to the national increase (gain) occurred before 2006 and average and in 2010 had surpassed it. Thus, therefore before the family medicine scheme the success of the improvement in vaccination was introduced. As a result, no significant coverage rates cannot be attributed solely to the difference in coverage rates based on the year implementation of the FMP, as a number of the Family Medicine program was implemented other activities were being implemented since is noticed. As explained earlier, other programs 2003 to increase immunization coverage rates. 24 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements (Table 11). TABLE 10 Share of provinces reporting 99-100 percent coverage, 2005-2010 89. In addition to increases in the national coverage rates, between 2003 and 2010 regional gaps too narrowed significantly (Figure 7). By 2010, only eight provinces had coverage rates lower than 90 percent with only one province falling below 80 percent (Batman reported 78 percent for measles immunization coverage). Of the eight provinces that fell below 90 percent coverage, six joined the Family Medicine program in 2010. Source: Ministry of Health (2012). TABLE 11 Share of FM/non-FM provinces reporting 99-100 percent coverage, 2005-2010 Health Care Utilization 90. The number of primary health care consultation increased with the implementation of family medicine. Utilization increased substantially, rising from 1.9 visits per capita in 2005 to 2.8 visits per capita in 2009. As shown in Figure 8, in 2009, the number of visits per capita to primary health *Provinces that implemented FM in 2010 are treated as non-FM provinces in 2010. facilities was significantly higher in provinces Source: Ministry of Health (2012). that had implemented family medicine – 2.9 visits per capita compared to 2.1 visits per 88. While initially a larger share of FM provinces capita in non-FM provinces. In fact, a fixed- had achieved 99-100 percent vaccination effects regression controlling for both province coverage; by 2010, this was no longer the case. and year shows that the introduction of family By 2010, a larger share of non-FM provinces medicine is associated with an increase in per had 99-100 percent coverage rates for DPT3 capita consultations by 0.28, a 14% increase (43 percent) and Hepatitis B3 (33 percent) in visits over this short time span. Further, compared to FM provinces (37 percent and 31 the share of population that chose to utilize percent, respectively). In all by 2010, over 30 outpatient services at the primary care level percent of provinces had reached the 99-100 rose from 38 percent in 2002 to 51 percent in percent target rate for immunization coverage 2010 (MoH, 2011c). FIGURE 7 Box Plot of Immunization Coverage Rates, 2003 and 2010 Source: Ministry of Health. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 25 Human Resources FIGURE 8 Primary Health Care Visits per Capita, 2005-2009 91. Distribution. While Turkey’s level of health workers per capita remains lower than the OECD average, Turkey has made significant improvements between 2003 and 2010 in scaling up its health workforce. The number of physicians per 1,000 population increased from 1.29 in 2003 to 1.68 in 2010 (of which family physicians represent 17 percent). In line with the increased focus on primary care and family medicine, the number of general practitioners (including family physicians) per 1,000 population increased from 0.43 in 2003 to 0.53 in 2010 (Table 12: Number of Health Personnel per 1,000 Population, 2003-2010). Source: Primary Care Statistics Module (2012 and FMIS(2012)). 92. Significant improvements have been made in narrowing regional differences in distribution of health personnel. As can be TABLE 12 Number of Health Personnel per 1,000 Population, 2003- seen in Table 13, inequality in the distribution 2010 of general practitioners decreased with the gap between the highest and lowest provinces falling from 0.6 per 1,000 population in 2007 to 0.36 per 1,000 population in 2010. Such a shift indicates that given the focus on primary care, particularly family medicine, and the relatively low levels of physicians in some provinces, concerted efforts are being made to relocate Source: MOH (2012). physicians to fill the regional needs. 93. Remuneration. Prior to the nationwide TABLE 13 Distribution of personnel per 1,000 population, 2007 and implementation of the family medicine scheme, 2010 remuneration for general practitioners10 and nurses was substantially higher in hospitals than in primary care settings due to the more rapid increase in additional payments11 in hospitals. A change in the trend, however, can be seen since 2009. In 2007, the monthly base salary for general practitioners in hospitals and primary care settings was roughly the same – TL 1,272 and TL 1,265, respectively. Monthly additional payments, however, were almost 2.7 times higher in hospitals than in primary Source: MOH (2012) care – TL 2,680 in hospitals compared with TL 997 in primary care. As a result, in 2007, additional payments for general practitioners GPs in hospitals received a total monthly in hospitals were only 1.3 times higher than for remuneration of TL 3,952 and GPs in primary those in primary care –TL 1,991 and TL 1,496, care settings received TL 2,262. By 2010, the respectively (Figure 9). gap in additional paid to GPs in hospitals and primary care narrowed significantly as did the 94. Remuneration for family physicians appears gap in total remuneration. In 2010, monthly sufficiently high to attract general practitioners 10 GPs in primary care include family medicine providers. 11 Additional payments are incentive payments. 26 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements FIGURE 9 Remuneration of General Practitioners and Nurses, 2000-2010 Source: Ministry of Health, 2012 into the family medicine program. Total gross FIGURE 10 Total remuneration of physicians and health officers in monthly remuneration for family physicians family medicine relative to that of GPs and nurses in as a share of total monthly remuneration of hospitals general practitioners in hospitals rose from 131 percent in 2008 to 158 percent in 2010, while family health officers are paid approximately as much as nurses in hospitals (Figure 10). 95. As shown in Figure 11, in 2010, family physicians report a gross monthly income of TL 5,679 – 1.6 times higher than the average gross monthly income of general practitioners in hospitals, 1.9 times higher than the average gross monthly income of general practitioners in primary care, and on par with the average gross monthly income of specialists. Given the previous emphasis on curative care and Source: Ministry of Health, 2012 Note: Family health officers include nurses, midwives, and health officers high levels of specialization among physicians, the high remuneration levels for family FIGURE 11 Total Remuneration (Monthly, Salary + Additional physicians are expected to further encourage Payments) by Type, 2007-2010 new graduates to specialize as family medicine practitioners. Financing 96. In 2009, Turkey’s total health spending as a share of GDP and in per capita terms was about average relative to comparable income countries. Over the past decade, the relatively high economic growth and continued Source: Ministry of Health. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 27 prioritization of health in total government spending has resulted in increased resources FIGURE 12 Spending on Family Medicine in Million TL, 2005-2011 for health in all aspects – hospital care, primary care, pharmaceuticals and medical supplies. In terms of primary care, spending almost doubled between 2002 and 2010, rising from 2,169 million TL (in 2010 prices) in 2002 to 4,136 million TL in 2010. Spending on primary care as a share of public health spending rose from 4.9 percent in 2002 to 7.4 percent in 2010. Latest available figures for 2011 indicate a further increase to 6,424 million TL, roughly 11.4 percent of public health spending. 97. In 2011, spending on family medicine constituted 3,137 million TL. Family medicine expenditures comprised 48.8 percent of primary care spending and 5.6 percent of public health spending. Figure 12 shows the rise in family Source: Ministry of Health, 2012 medicine expenditures as provinces joined the scheme. we also break down the provinces into those that implemented FM in 2006 and those Responsiveness to Users of that implemented FM in 2010. As can be Health Services seen, in 2011 patient satisfaction rates are slightly higher among old reformers - 92.1 percent compared to 90.2 percent among new 98. An important dimension health reformers, however these differences are not system performance is health service user statistically significant (p=0.4071). Between responsiveness. This has been studied very 2008 and 2011, satisfaction rates among new closely in Turkey in the implementation of reformers rise from 80.8 percent to 90.2 percent. family medicine. In 2008 and 2011, patient If we look at 2006 FM provinces and 2010 FM satisfaction surveys were conducted to ascertain provinces, we see larger differences in patient satisfaction rates with different aspects of satisfaction – 94.7 percent compared to 89.6 primary care using the EUROPEP scale (Table percent, respectively and these are statistically 14). In 2008, satisfaction rates were compared significant (p=0.0048). between provinces that had implemented the 100. A key area of improvement in patient FM program and those that had yet to do so satisfaction between FM and non-FM and were found to be significantly higher in FM provinces (old reformer versus new reformer provinces (p=0.000). provinces) is related patient confidentiality 99. Since by 2011, all provinces had joined (as highlighted in line 6 in Table 14). Patient the FM program, here in column 3 and 4 confidentiality is included in the warning point respectively, the provinces are broken down system (see Appendix 1 Table 2). Thus higher into “old� reformers (those that joined the satisfaction for this indicator among patients program prior to 2008) and “new� reformers in FM provinces suggests that the warning (those that have joined the program in 2008 points have had a positive impact in improving and later). In addition, in columns 5 and 6, confidentiality of patient records and data. 28 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 14 Patient Satisfaction EUROPEP Scale, 2008 and 2011 What is your opinion of the general practitioner and/or general practice over the last 12 months with respect to... Total 80.8 90.9 92.1 90.2 94.7 89.6 Source: MOH (2008, 2011). Responsiveness to Providers 102. In 2008, a health care employee satisfaction survey was conducted in public health facilities and university hospitals to 101. Health providers are important evaluate providers’ views on job satisfaction, stakeholders in any health reform effort. motivation and commitment. Further, Managing provider expectations and providers were also asked a series of questions supporting provider performance by regarding their views on elements of the responding to their legitimate needs is essential Health Transformation Program, such as to ensure that health reform yields good results. performance based payments, family medicine Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 29 practice, and patient satisfaction (MoH, 2010). Providers were asked to rate their responses on FIGURE 13 Health Care Employee Satisfaction by Profession, 2010 a scale ranging from 1 being the most favorable option to 6 being the least favorable option. Family physicians ranked most favorable on most of the questions asked. 103. Job satisfaction was highest among family physicians (average score of 2.32 compared to an average score of 2.64 among specialists). Motivation and commitment were also highest among family physicians – 2.86 and 2.60, respectively, compared to 3.25 and 2.90 among specialists (Figure 13). 104. Views regarding family medicine were most positive among family doctors themselves (2.44) and most negative among specialists (3.54) and assistants (3.57). Family physicians Source: MoH, 2010, Healthcare Employee Satisfaction Survey. also had the second most positive views about patient satisfaction after managers - 2.32 and 2.11, respectively, compared to 2.91 among specialists and 3.09 among assistants. how maternal and child health services are delivered in Turkey has resulted in significant improvements both on health outcomes and service delivery. In addition, gaps narrowed Conclusion between the various regions and the success was achieved in a very short period of time. Resources allocated both in terms of human 105. As can be seen while it is difficult to and financial resources increased in support disentangle the impact of the family medicine of the reforms. Higher remuneration for performance-based payment system given the family physicians have attracted much needed significant investments in the sector that were personnel to join family medicine practices. undertaken just prior to its implementation, As a result, both user and provider satisfaction it is evident that a comprehensive reform of improved significantly. 30 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements The Way Forward 106. Within a relatively short time, Turkey during implementation as needed. Any successfully introduced and rolled out changes could be reflected in the contract with nationwide family medicine model of which FM providers in the next contracting cycle. performance-based contracting is an integral Possible areas for fine-tuning in the Turkey’s component. As discussed in the earlier chapters, scheme can include: in combination with other interventions, 108. Re-orienting performance contracts maternal and child health indicators have to introduce quality of care indicators in significantly improved. Performance- MCH: The admonition or warning points based contracting was appropriate to system includes a number of indicators which meet the priority needs of the sector at the primarily capture structural aspects of quality time of implementation. The institutional of care such as expired drugs or failure to arrangements, accountability structures as adhere to cold chain rules - basic minimum well as M&E systems are fully functional at all pre-requisites for service delivery. However, the levels - national, provincial and provider and performance-based contracting scheme does adequate in the context of sectoral priorities not incentivize the clinical process dimension and support the smooth functioning of the in quality of care. For example, the ANC performance based contracting scheme. indicator concerns with the coverage with 4th 107. Based on these findings, the study finds ANC visits but the clinical content of such that there is now an opportunity to fine-tune visits are not an area of focus. It can therefore the scheme and scale up its success. While be said that the performance-based contracting the “rules of the game� should not change too scheme in Turkey started out with a mostly often to confuse providers and supervisors of “pay for quantity� approach for MCH. the scheme, it should also not remain static as 109. Turkey already has quality checks as over time this could reduce the benefits. Rather, an integral part of its quality improvement performance indicators and targets, size of program in primary health care. As providers incentives, methods and sample size for counter now perform very well with regard to verification of results, sanction measures, etc. existing MCH quantity indicators, this study need to be periodically reviewed and modified Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 31 recommends that it may be time to include • Screening adults for common quality of MCH indicators in performance cardiovascular risks (hypertension, high contracts, with a focus on clinical processes cholesterol, obesity) to support the ongoing quality improvement • Successful management of NCDs (control efforts. For example, quality indicators related of blood pressure in hypertensive patients, to clinical processes in antenatal care that could control of blood sugar in diabetic patients be included in performance contracts are: (HbA1c or glycated hemoglobin test)) • pregnant women screened for hypertension • Screening of common cancers in each antenatal visit 112. With regards to the introduction of the • pregnant women screened for proteinuria new indicators, the MOH could: in each antenatal visit • Retire those performance indicators where • pregnant women screened for glycosuria targets have been achieved and introduce in each antenatal visit new indicators that are focused on • pregnant women given a hemoglobin test outstanding challenges, in the first trimester • Add new performance indicators and • pregnant women given a platelet count in retire the original performance indicators the third trimester in a phased manner, or 110. The monitoring of these indicators would • Introduce new indicators while retaining depend on the computerized medical records the original indicators and weight these as part of the FMIS. Some of the above indicators differentially so that a larger indicators such as proteinuria screening and portion of payment is linked to the most hemogloboin tests are already being monitored important policy concern. at the facility level. FMIS record of such tests Each option holds different risks and for pregnant women could form the basis for benefits. Retiring performance indicators the achievement of the target by the provider. carry the risk that providers will redirect their Audit methods can include comparing of efforts away in favor of the new indicators laboratory records with medical records, that are incentivized and undermine existing as well as interviewing a random sample of achievements. Increasing the number patients to see if urine and blood samples of performance indicators increases the were taken from them during ANC visits. For administrative burden of the system. It should payment purposes, measuring quality of care be noted that moving to new performance is more complex than measuring quantity of indicators such as those mentioned above care but it would be the natural next step for could be an enormous challenge, as the the scheme. The introduction of such complex current performance indicator definitions are indicators should be conducted on a pilot basis widely accepted, relatively easy to measure, with rigorous evaluations prior to scaling up. and to a significant extent within the control 111. Re-orienting performance indicators to of providers. There is very little international address NCDs Given the increasing burden evidence that points to the effectiveness of of non-communicable diseases (NCD), tying incentives to complex performance it is encouraging that Turkey now plans indicators. It would therefore be prudent to to implement positive incentives for FM introduce new indicators on a pilot basis with providers in the prevention control of NCD. careful assessment before scaling up. This also Care however should be taken to continue underscores the importance of stewardship to maintain the simplicity of the system. A and the Ministry of Health’s role in periodically scheme with both negative incentives for reviewing patterns of performance for certain indicators and positive incentives for indicators linked to payments and those that others could potentially complicate matters for are not to assess the need for further changes. both providers and supervisors of the scheme. 113. A need for combined demand side focus For NCD, possible performance indicators can to reach the ‘last mile’: The incentives in the be: 32 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements PBC scheme are primarily on the supply-side, Standardizing these strategies across provinces i.e., they motivate family medicine providers could make an important contribution to to increase their effort in favor of services further improving the performance of Family that are captured in either the performance Medicine providers. Obtaining feedbacks from points or admonition/ warning points system. Family Medicine providers is also important to Reaching the ‘last mile’ in coverage of MCH ensure that the PBC scheme remains responsive interventions may, however, necessitate a to the legitimate expectations of providers demand-side focus to overcome constraints and does not undermine their intrinsic that especially hard-to-reach population motivation to perform well in the interest of face in obtaining maternal and child health their registered population. Finally, provider services. In this context, leveraging the benefits feedback can help provincial officials to tailor of existing demand-side schemes such as training or technical assistance to providers’ the conditional cash transfers12 may further needs.It is important that the “random audit� amplify family medicine providers’ ability to “twice a year� visits and the accompanying improve coverage. In addition, demand side feedbacks are conducted in a constructive interventions can have an important role in manner to motivate family medicine providers. disease control especially with regards to As discussed above, guidelines and supervision NCDs. This is particularly relevant to address formats to standardize the process and training NCD risk factors such as obesity, smoking, for supervisors that have recently been hypertension, high cholesterol for which the introduced would help address this issue. patients might not seek care from their FM providers. 116. Improving use of peer to peer learning networks for quality improvement: Peer-to- 114. Standardizing monitoring of FM providers: peer learning networks for quality improvement As Table 5 shows, the study revealed significant are used as a provider-driven tool to improve variations among provinces in the procedures quality in many health care settings. Key used to monitor FM providers and verify their results for payments (e.g. the methodologies informant interviews with Family Medicine to audit 10% of doctors, conduct twice-a-year providers highlighted their continued interest evaluation of FM units and assess the warning in using the existing open platform as a forum points). To reduce such variations, the Ministry for sharing common operational problems and of Health has recently introduced standard solutions to these problems. This could be monitoring forms and guidelines for its use. further strengthened. 115. Introducing constructive feedback 117. Conducting rigorous impact evaluation mechanisms to and from FM providers at the for the new incentive scheme: It is a challenge to local level to improve performance: Ministry ascertain the success of the current PBC scheme of Health conducts annual meetings with the as a rigorous impact evaluation was not built in Family Practitioner Association to understand when it was rolled out. Now that the original and resolve issues and grievances. However, scheme has been applied nationwide and MOH currently, there are no standard guidelines plans to introduce new additions to the scheme, on regular feedbacks between providers and it is important that an impact evaluation is provincial health departments. Some provinces envisioned from the very beginning so that the are, on their own initiative, implementing future success of such changes in the PBC can meetings to provide and elicit feedback. be confirmed with solid evidence. 12 The conditional cash transfer scheme offers the poorest women a monthly allowance of 17 TL on condition that they continue their required health check-ups during pregnancy and infant check-ups after birth, and an additional 35 TL for giving birth in a health facility. Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 33 References Akdag, R. (2008), Health Transformation Ministry of Health (2006), Family Medicine: Program in Turkey and Primary Health The Turkish Model, Ankara Care Services: November 2002-2008, Ministry of Health (2009), Patient Satisfaction Ankara with Primary Health Care Services, Ankara Akdeniz, M., Ungan, M., and H. 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Health Sector for Improved Access and Roland (2006), “Pay-for-Performance Efficiency, Washington, D.C., World Bank Programs in Family Practices in the United Kingdom,� The New England Journal of World Bank (2010), Implementation Medicine Vol. 355(4) Completion and Results Report: Turkey Hacettepe University (2004), Turkey Health Transition Project, Washington, Demographic and Health Survey 2003, D.C., World Bank Ankara World Health Organization (2008), Evaluation Hacettepe University (2009), Turkey of the Organizational Model of Primary Demographic and Health Survey 2008, Care in Turkey: A Survey-Based Pilot Ankara Project in 2 Provinces of Turkey 34 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements Appendix Tables TABLE 1 Roll out of Family Medicine in Turkey (as of December 31, 2011) Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 35 DATE OF FMDS (Family Family Doctors Family Health Community NAME OF PROVINCE INTRODUCTION Medicine Data System) Centers Health POPULATION Centers 18.01.2010 213.365 63 24 9 12.04.2010 185.317 47 21 4 12.04.2010 120.108 35 14 4 10.05.2010 332.008 97 45 6 14.06.2010 415.687 119 33 16 14.06.2010 331.540 94 42 8 14.06.2010 1.995.263 550 189 31 05.07.2010 253.712 73 29 8 05.07.2010 1.627.819 441 117 13 05.07.2010 449.482 125 41 14 12.07.2010 472.417 131 51 12 12.07.2010 735.809 203 73 14 12.07.2010 375.297 103 51 7 15.07.2010 4.681.202 1257 317 25 09.08.2010 583.197 164 64 12 09.08.2010 99.622 30 13 6 09.08.2010 496.049 140 39 6 09.08.2010 797.735 219 80 9 09.08.2010 271.529 84 32 8 13.09.2010 678.666 187 62 19 13.09.2010 313.069 87 31 7 13.09.2010 606.894 173 63 6 13.09.2010 373.793 112 46 6 20.09.2010 598.462 170 53 17 11.10.2010 492.103 147 51 8 11.10.2010 672.100 193 98 18 11.10.2010 1.111.127 313 110 19 18.10.2010 955.009 271 77 12 18.10.2010 221.502 63 19 4 30.10.2010 12.782.635 3540 883 39 09.11.2010 282.364 77 27 7 15.11.2010 691.449 190 61 10 15.11.2010 1.449.892 414 131 17 15.11.2010 1.528.665 420 137 12 06.12.2010 394.866 112 49 7 13.12.2010 1.637.725 456 117 11 13.12.2010 1.928.179 545 180 19 13.12.2010 1.670.383 452 119 9 13.12.2010 1.429.701 399 168 12 13.12.2010 1.009.117 290 102 10 13.12.2010 801.072 228 105 12 13.12.2010 953.249 280 113 17 71.923.589 20.243 6.463 960 36 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 2 Admonition or warning points Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 37 TABLE 3 Vaccination Coverage Rates, 2003-2010 38 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 4 Immunization Rates by Province, 2003 and 2010 2003 2010 BCG DPT3 Measles HepB3 BCG DPT3 Measles HepB3 85 79 83 70 100 97 97 96 74 72 76 71 95 96 96 95 75 72 76 69 98 100 98 100 31 31 35 25 100 100 96 94 77 66 74 70 100 100 91 100 78 61 71 70 100 98 96 98 96 72 88 81 98 93 96 94 89 81 86 81 97 97 97 97 47 54 55 52 100 100 100 100 74 75 79 66 93 100 100 100 77 70 80 76 98 97 98 96 76 66 74 72 98 98 98 98 77 72 79 79 100 100 99 99 54 58 61 48 100 84 78 82 67 73 76 73 100 100 100 98 81 77 81 82 100 100 99 100 58 51 56 43 89 93 87 89 55 43 46 36 95 97 97 95 75 72 79 77 100 99 99 99 74 66 70 69 100 97 98 98 90 81 83 82 95 97 97 97 77 72 76 75 100 100 99 100 70 70 77 76 93 95 92 95 72 67 75 70 95 99 97 99 79 75 80 79 94 96 97 95 62 48 61 37 96 95 94 93 76 76 85 84 95 97 97 97 73 65 70 67 96 97 97 97 85 67 79 74 98 99 100 99 78 75 79 77 96 100 94 100 63 76 84 72 95 99 98 98 77 73 76 75 92 93 95 93 100 73 82 68 95 94 95 95 97 64 69 63 91 100 100 96 83 74 85 78 83 90 92 89 33 50 51 25 83 95 93 97 85 74 76 72 99 98 98 98 78 71 73 69 98 100 98 99 54 62 57 52 96 100 96 99 76 63 75 74 99 98 100 98 73 64 77 66 98 98 99 98 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 39 2003 2010 BCG DPT3 Measles HepB3 BCG DPT3 Measles HepB3 79 68 75 74 96 97 98 97 91 74 87 77 97 97 96 95 83 76 70 78 100 100 100 100 73 66 74 74 98 97 100 97 42 63 74 55 99 100 100 98 76 74 76 77 99 100 99 100 83 76 82 80 100 100 100 100 62 67 82 74 99 100 97 100 81 74 82 78 97 97 98 96 77 74 85 76 97 99 98 98 65 69 72 73 100 100 100 100 89 74 87 82 96 96 97 95 81 78 82 80 97 98 93 98 80 72 77 75 99 99 97 99 77 78 81 79 100 99 99 99 75 69 74 74 91 92 88 93 60 59 71 49 95 94 94 92 84 71 81 80 98 100 97 99 37 54 60 41 100 100 98 100 73 66 74 74 100 100 100 100 67 70 73 74 100 100 100 100 73 72 78 73 95 97 98 96 75 75 79 77 97 96 97 96 82 72 85 84 100 100 100 100 84 80 87 86 97 98 98 97 71 67 72 69 97 98 100 98 56 53 54 42 93 90 88 89 61 68 69 60 97 100 96 95 72 68 70 67 93 96 99 97 68 68 72 71 95 97 98 97 29 38 31 26 91 95 95 85 100 75 88 86 95 95 97 95 59 64 71 68 90 97 95 96 81 78 82 79 97 98 99 98 59 70 71 68 100 100 100 100 69 68 75 72 96 97 95 97 42 48 63 41 91 93 95 89 80 75 84 79 100 98 100 97 60 68 67 69 92 94 92 94 79 71 80 76 98 98 98 98 40 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 5 Average Number of Antenatal Care Visits by Province, 2003 and 2010 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 41 TABLE 6 Top 3 Most Common Reasons for the Issuance of Warning Points in the First Year of Implementation of Family Medicine in the Province 42 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 7 Top 3 Most Common Reasons for the Issuance of Warning Points in 2011 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 43 44 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 8 Remuneration of Specialists in Hospitals by MoH Service Regions, 2000-2010 TABLE 9 Remuneration of General Practitioners in Hospitals by MoH Service Regions, 2000-2010 TABLE 10 Remuneration of Nurses in Hospitals by MoH Service Regions, 2000-2010 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 45 TABLE 11 Remuneration of General Practitioners in Primary Care by MoH Service Regions, 2000-2010 Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Turkey Total Total Monthly Annually (Salary (Salary Basic Additional Basic Additional Basic Additional Basic Additional Basic Additional Basic Additional Basic Additional +Additional ) +Additional ) Year Salary Payment Salary Payment Salary Payment Salary Payment Salary Payment Salary Payment Salary Payment 2000 351 313 308 305 360 363 333 0 333 4000 2001 474 443 424 459 515 541 476 0 476 5712 2002 668 74 665 134 649 85 656 173 743 142 766 145 691 126 817 9803 2003 838 214 794 270 807 213 817 257 926 263 893 166 846 231 1077 12918 2004 922 339 916 370 885 353 940 370 1018 277 1044 214 954 321 1275 15299 2005 1006 716 1035 646 1020 896 1035 657 1118 829 1214 486 1071 705 1776 21316 2006 1104 1090 1103 988 1086 950 1114 988 1205 728 1318 741 1155 914 2069 24829 2007 1219 1287 1218 1117 1217 1070 1249 827 1348 772 1337 907 1265 997 2262 27139 2008 1316 1335 1292 1255 1309 976 1381 976 1428 1021 1757 1220 1414 1130 2544 30529 2009 1549 1314 1322 1322 1451 949 1460 718 1670 1091 1762 1120 1536 1086 2621 31457 2010 1617 1201 1406 1728 1529 1076 1462 1574 1635 2280 1627 1117 1546 1496 3042 36505 TABLE 12 Remuneration of Nurses, Midwives, and Health Officers in Primary Care by MoH Service Regions, 2000-2010 TABLE 13 Remuneration of Family Practitioners by MoH Service Regions, 2008-2010 TABLE 14 Remuneration of Family Health Officers* by MoH Service Regions, 2008-2010 *Includes nurses, midwives, health officers TABLE 15 Remuneration of Community Health Center Practitioners by MoH Service Regions, 2008-2010 Source: Ministry of Health, 2012 46 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements TABLE 16 Contracts terminated and Warnings issued in 2011 and 2012 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements 47 Source: CRMS 2012. 48 Performance-Based Contracting Scheme in Family Medicine – Design and Achievements