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Turkey
Primary care and the Turkish Medical Association

 

Dr. Unal Ertugrul ,TMA General Practitioners section  

Health services in Turkey are organised by the law of 'socialisation of health services' which came into effect in the early 1960s. By this law the Ministry of Health is responsible for maintaining free primary care services fully covering the population.In 1994 total health expenses (per capita) were US$1 53 and only $70 of that was public expenses (to make 3.5 per cent of public expenses).After a central MCQ exam, medical education is taught in 38 medical schools. Of the six years, the last is for internship. More then 5,000 new students are accepted and graduate each year. After another MCQ exam, half of this number are accepted for vocational training programmes for specialisation. Most of the rest are employed by the Ministry of Health mainly at primary care centres (4,431), emergency care services of hospitals and mother/child care/family planning centres (262).Primary care centre teams consist of one to ten practitioners, nurses, midwives, environmental health and administrative staff, possibly a driver and a few others. The composition and number of the team members are regulated on population basis.The average annual consultation with a physician is 2.4, but despite the law, less than half of the consultations take place at primary care centres and so practitioners do not function as gatekeepers. The service quality, professional satisfaction and income is relatively low and most of the practitioners make great efforts to enter a specialisation programme. There is no recertification for physicians and continuing medical education (CME) in primary care is poor.By the end of 1995 there will be 71,000 physicians in Turkey;30,000 specialist, 6,000 resident for specialisation, 35,000 practitioner. About 20 million of the population (out of 63) is not covered by public social insurance (usually they have no insurance at all), and 12,000 physicians (of which only 1,000 are practitioners) are also active in private practice.The annual income of a practitioner employed by the Ministry is $4,500 and most of them either have or look for a second job, but rarely can double this income. Posts in primary and secondary care are almost fully occupied and by the year 2000, eight to 10,000 doctors (mostly new graduates) are going to be unemployed.Both physicians and patients are complaining about the present position of the health sector. Health indicators don't show enough progress (UEMO 95/053). The Government's solution mentioned in 'the health reform programme' is liberation/marketing of the sector and reducing the responsibilities of the State. On the other hand, theTMA's main proposals are:

more public influence, co-operation and full consultation of the profession while producing and carrying out health policies;

stressing preventive medicine, primary care by financial and educational means;

replacing the current ineffective, hospital-oriented family physicians vocational training programme which promotes curative medicine, with a new programme which should include education in practice, general practitioner (GP) trainers, specific curriculum, an autonomous institution to lead/authorise general practice.

 

Turkish Medical Association

The Turkish Medical Association (TMA) is the voice of organised medicine in Turkey. It is a voluntary organisation which has been established in 1953. Only physicians can be a member ofTMA which is primarily financed by membership fees. While TMA cooperates with government in many areas, it receives no financial support from government. TMA consists of Local Chambers, Central Executive Council and House of Delegates. On behalf of its members, the TMA exists to:

protect and improve the general health of people of Turkey by promoting high-quality, cost-effective healthcare that is accessible to everyone;

preserve a high level of professional ethics;

maintain the excellent standards of medical care;

present the profession's views as effectively as possible both to government and to the public;

promote interests of the profession.

 

Membership
Membership ofTMA is obligatory only for doctors in private practice.

46,000 doctors out of 66,000 (by the end of 1994) are members ofTMA.

18,000 of the members are practitioners and 15,000 of them are active in national primary care service.

Annual membership payment to local chambers: $12 (the legal level is 1.7)

A quarter of the membership payments are transferred to TMA to make the Association's main source of income.

 

Structure
There are 52 local Chambers and a Central Council. The doctors can only become members of the local chambers of medicine. A chamber of doctors can be established in every province that has a minimum of 200 doctors. The local chambers execute their activities independent from the Central Council.The Central Council oftheTMA is formed of seven physicians who are elected by Congress (House of Delegates) which is held every two years. The Central Council is responsible for coordinating the activities oftheTMA, executing the decisions taken by the Congress and representing the Association.The general policies and activity plans oftheTMAare determined by the Congress each year and followed by the Central Council.

 

Activities
The Central Council oftheTMA, technical divisions and the local chambers perform the following activities:

dealing with all sorts of matters regarding the rights of the doctors, mainly wages and working conditions;

determination of minimum wages, with which the private doctors and health institutes have to be in compliance;

to assign the physicians for private jobs;

preserve a high level of professional ethics;

promote a high-quality medical education;

establish a continuing education system for physicians in the country;

ensure that qualified, cost-effective healthcare is accessible to everyone;

fighting against all kinds of human rights violations, torture and working for a democratic society;

promote research on public health issues in various fields;

execute courses for the education of the doctors, such as tourism, sports and health;

co-operate with various international institutions, such as the World Medical Association, the European Union of General Practitioners (UEMO), the European Union of Medical Specialists (UEMS).

 

The activities that have been stated above are executed by the following divisions:

Medical Education Division;

Occupational Health Division;

General Practitioners' Division;

Tourism and Medicine;

Public Health;

Basic Sciences in Medicine;

Sports Medicine;

Law Office;

Medical Students' Division;

Human Rights Division Ethical Committee;

Board of Creditation.

Six periodicals and 13 books (mainly on health policy, medical education and occupational health) are published and distributed by the Central Council as well as the bulletins published by each local chamber.

 

General practitioners' division

Foundation: 1989

Approval by TMA Congress: 1990

Structure: Co-ordinational centre

Term President, Vice-President, Secretary-General (from Ankara)

Executive council (eight members from six cities)

Local commissions: Active in approximately 30 medical chambers out of 52 Decision taking and election of presidency: at general meetings of commissions held three times a year. Members of the Executive Council are nominated by six commissions which have bee predominantly active in the recent year.

 

Activities

(A) Local commissions:

regular meetings for commission members;

visits to health centres where practitioners are employed;

producing written material on first level healthcare and prac titioners' problems for the periodic of the chamber and pres:

organising educational and social activities for GPs;

being in dialogue with people and institutions for the promc tion of general practice and first level healthcare;

advisory help for the chamber administration on subject dealing with general practice.

(B) Central:

organising periodic general meetings and following the dec sions taken;

representing the practitioners and their sub-organisation (I) i the Association (II) to governmental or civil institutions (II press and international partners;

producing documents/policies on general practice for th TMA's use;

organisation of national congresses on general practice (1990, 92,94);

harmonisation of the activities held in local commissions;

preliminary work for the future GP Association, Academy Society.


 

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