INTEGRATING AN EXPANDED RANGE OF REPRODUCTIVE HEALTH SERVICES IN PRIMARY HEALTH CARE: TURKEY'S EXPERIENCE
Prof. Dr. Ayüse Akin¹, Prof. Dr. Sevkat Bahar Ozvariüs²

Background

Turkey, a Middle Eastern country and bridge between Asia and Europe, had a population of 62.5 million in 1995, 98 percent of whom are Muslim.  Turkey is among the 20 most populous countries of the world and is the most populous country in the Middle East.

It is administratively divided into 80 provinces and has a highly heterogeneous social and cultural structure.  It also has diverse geographical, climatic and economic characteristics prevailing in different parts of the country (Akin and Bertan, 1996; Ministry of Health et al., 1993).  There are sharp contrast between population groups; the "modern" and "traditional" exist side-by-side.  Lifestyles are reminiscent of those in the Western world, especially for those living in metropolitan area, people are more conservative and religious in the rural areas.  Family ties are strong and influence the formation of values, attitudes, aspirations and goals.  However, traditional opposition to modernisation in the country persists in the less developed north and east regions.  Although laws can be considered to be liberal on gender equality, patriarchal ideology still characterises social life.

One of the most striking achievements since the foundation of the Republic in 1923 has been the increase in the literacy rate.  In 1935, only 10 percent of females and 29 percent of males were literate.  In 1990 this percentage increased to 72 and 89 respectively for females and males (population of six years and above).  However, there is a wide gap in literacy among regions and between urban-rural populations (Figure 1).  Until recently, a five-year primary education was compulsory; now compulsory education has increased to eight years (Akin and Bertan, 1996; Ministry of Health et al., 1993).

The Ministry of Health (MOH) was established is 1920 and gave priority to the prevention rather than treatment of diseases.  The current Turkish health sector is a complex one with a large number of government, semi-government and private institutions providing services; for example, the university hospitals, the army hospitals, the state economic enterprises and some non-governmental organisations (NGOs) operate their own hospital/clinic-based health care services to ensure extensive coverage.  However, the MOH is responsible for the overall design and implementation of the country's health policies.  In particular, the preventive health care services are mainly provided by the MOH facilities at the primary health care level (Ministry of Health, 1997a).

Three major legislations have had considerable positive influences on people's health level.

1.  The "Basic Health Law" #224, which was enacted in 1961 and aimed at 1) providing health care services free or partly free of charge; 2) expanding services to make them easily and equitably accessible to the whole population; 3) offering integrated health services at grassroots level by well trained team of service providers; and 4) encouraging community participation (Ministry of Health, 1997a).

2.  The first anti-natalist population law which was enacted in 1965.  Until 1960Õs Turkey followed the pro-natalist policy.  For the period 1955-1960, birth rate, population growth rate and maternal mortality escalated to a very high level.  Many mothers died from complications of unwanted pregnancies and unsafe abortions, one out of five pregnancies was aborted illegally.  According to an official inquiry carried out by Nurset Fisek3 (Akin and Bertan, 1996), in 1959 in 137 villages, about 53 percent of mothers died from unsafe abortion.  In response to this, the government began changing the population policy (Franz, 1994; Akin and Ergšr, 1997b; Huntington and Akin, 1996).  In 1965, the anti-natalist population policy was adopted and Population Planning Law #557 was as well.  This new law legalised the provision of contraceptive services for all kinds of temporary contraceptive methods, including information, education and communication (IEC) services.  Surgical contraceptives and induced abortion were permitted only on eugenic and medical grounds.  However, due to strong oppositions, induced abortion on other grounds remained illegal (Akin and Ergšr, 1997b).

3.  The second anti-natalist Population Planning Law #2827 of 1983.  Prior to this change, a number of operations research studies were carried out by Hacettepe University Public Health Department in collaboration with WHO/HRP, to draw up recommendations for a change in the legislation.  The results of these studies were submitted to the MOH, the medical/academic communities as well as the policy-makers.  Some of the research studies were:

Consequently, some resistance to the proposed legislative changes came from the policy-makers as well as from the medical communities.  To advocate for the acceptance of the new legislation by the related sectors and groups, several meetings were organised by MOH together with the Public Health Department of the Hacettepe University.  As a result, the new Population Planning Law was ratified by the Parliament on May 24, 1983.  Since then Turkey has one of the most compcomprehensive and liberal population planning legislations.

The most striking effects of the new law (1983) was on maternal health.  Before the legislation, many women died due to unsafe abortion.  After the legislation on abortion which permits abortion up to 10 weeks of pregnancy upon request; abortion services became available at public hospitals and the cost of induced abortion at the private sector reduced significantly and the number of women dying from abortion also declined (Ministry of Health, 1997a; Akin and Ergšr, 1997b).  According to available statistics and expert observations during the time when abortion was illegal in Turkey, women in large cities with high socio-economic status had easy access to abortion services which were provided by private Ob/Gyn.  On the other hand, women in the rural areas, due to insufficient financial resources and also non-availability of services, sought self-induced abortion which is hazardous to health/life.  This situation has changed now, and hospital admissions for abortion complications resulting in fatality have reduced (Akin and Bertan, 1996; Akin and Ergšr, 1997b).

Contraceptive use increased over the years, but, until 1993, the proportion using less effective methods had been higher then those using effective methods (Table 1 and Figure 2).  There was a significant increase in IUD acceptance, which doubled in five years after the law was passed and nurse midwives were allowed to insert IUDs.

Table 1  Prevalence of Contraception and Induced Abortion in Turkey by Years (in percentage)

Turkey's Reproductive Health Status

Turkey has a young population as a result of its high fertility and population growth rates in the recent past.  Thirty five percent of the population is under 15 years of age while the population of the elderly is quite low.  Reproductive age women account for 25 percent of the population.  Recent decades have witnessed dramatic declines in fertility rates.  In the early 1970s, the total fertility rate (TFR) was around 5 which declined to 2.7 in 1993 (Figure 3) (Akin and Bertan, 1996; Ministry of Health et al., 1993).  The crude birth rate is estimated to be around 23 per thousand now.  Life expectancy at birth in Turkey is 65.9 years for males and 70.5 years for females (Ministry of Health et al., 1993; Balkan and Akin, 1995; General Directorate on the Status and Problems of Women et al., 1995).  Inter-censal estimates of population growth has been around 20-25 per thousand since 1970 in Turkey but has since decreased to 14 per thousand in 1997 (Ministry of Health, 1997a; Ministry of Health et al., 1995).

The infant mortality rate (IMR) in 1960s was around 200 per thousand live births and  declined to 42 according to most recent estimates (Figure 3). Unfortunately, peri-natal causes are the leading causes of infant deaths, which indicate the need for improvements in maternal health.

The maternal mortality ratio (MMR) was over 200 per one hundred thousand live births in 1974.  Now it is estimated to be 100 per one hundred thousand live births.  The preliminary results of a recent study on maternal mortality carried out in 615 hospitals in the 53 provinces by the MOH, with technical assistance of the WHO and the Hacettepe University Public Health Department in 1997, indicate that MMR is 54 per one hundred thousand live births and two-thirds of the maternal deaths are preventable.  Hemorrhage was found to be the leading cause of maternal deaths followed by toxemia and infection. In the survey it was found that lack of health care services was the cause of half the maternal deaths.  The survey revealed several areas of interventions that can be used for the prevention of maternal mortality in Turkey (Yigitbas, 1998).

During the last five years, the proportion of women receiving ante-natal care increased from 43 percent to 63 percent.  The proportion of safe delivery is 76 percent, 39 percent of the total deliveries took place at home of which the proportion of unsafe deliveries assisted by traditional birth attendants is 24 percent. Distrust (31 percent), traditions (24 percent) and accessibility (21 percent) are the more frequently cited reasons for not using obstetrical services (Akin and Bertan, 1996; Balkan and Akin, 1995; State Institute of Statistics, 1995; Ministry of Health, 1997c; Ministry of Health, 1997b).  Thus, the leading problem is not the access to the health service but social and environmental factors in some regions, such as low social status of families especially of women and/or hard winter conditions which very often create problems for transportation.

Proportion of families who do not want further children is 70 percent. The contraceptive prevalence is 63 percent for families in reproductive age of which 35 percent is for effective methods (Table 1, Figure 4).  Sixty-eight percent of women of reproductive age have at least one of the following risk factors for pregnancy: age under 20 or above 35, having 5 or more pregnancies; having two-year or shorter pregnancy interval (Ministry of Health et al., 1993; Ministry of Health, 1997a; Balkan and Akin, 1995).

Although the statistics related to STDs in Turkey are not very accurate, the latest figures show that there were 279 AIDS cases and 550 HIV carriers in 1997.  The prevalence of Hepatitis B varies between 2-7 percent of the total population (Ministry of Health, 1997a).

Primary Health Care Service Delivery Related to Reproductive Health

Family and mother-child health is secured by the country's main constitutions as one of the basic human rights.  Since the law on socialisation of health services was enacted in 1961, mother child health (MCH) services are being provided as integral parts of PHC services.  Inter-sectorial collaborations are encouraged.

The infrastructure of the National Health Care System is viable enough to provide these services all over the country (Figure 4).  At the grassroot level, there are 11,877 health units where nurse-midwives provide MCH/FP services.  At the primary level there are over 4,987 health centres and 270 MCH/FP centres where a health team, including specialists, general practitioners and nurse-midwives, provide PHC services, including reproductive health care.  All those PHC units are supported by one thousand hospitals in the country.

At the PHC level, the services provided include: counselling, information, education, communication and clinical services for reproductive health (RH) including ante-natal and post-natal care, safe delivery, family planning, screening for STDs, monitoring growth and development of children under 6 years of age, immunisation, family health and early diagnosis and treatment of common infectious diseases.  At the hospital level, in addition to these services, further diagnosis and treatment for risks and complications due to pregnancy, delivery and infancy are provided.  Since the RH care services are accepted as integral components of PHC, the service coverage is not only to meet the needs of women but also for those of adolescents and adult men.

After ICPD (1994) and Beijing Conference (1995), Turkey's programme focus is more on RH rather than only on MCH/FP.  To improve reproductive health and strengthen the RH care services including MCH/FP and to reach the WHO Health For All Targets by the Year 2000, National Targets and Strategies have been defined and are in use now.  The main objective is to provide these services in a more accessible, affordable ways with the highest quality and equality by sharing the responsibility.

Implementing the ICPD Programme of Action in Turkey

Besides the preparation of the National Plan of Actions, several programmes and activities are being carried out to improve RH level in Turkey.  For advocacy, several meetings, publications, media programmes were held to publicise the recommendations of the ICPD and the Fourth World Women Conference.

After the ICPD, the concept of RH has been adopted in a broader sense as it was defined at the ICPD.  Activities related to MCH/FP have been revised and been made more comprehensive to cover all RH care components.  A written "regulation of MCH/FP centres" was prepared, approved and distributed for use throughout the country.  The regulation provides room for expansion of MCH/FP in terms of infrastructure, equipment and services including training.  After the ICPD, the targets and strategies on population and reproductive health have been included into the Seventh National Five-Year Development Plan, which has been in force now since 1995.  The Plan places human resources at the centre of sustainable development.  It also places women and children as sensitive groups and manages the problem of these groups under a separate plan.

Many actions have been taken to expand and strengthen RH service delivery:

1.  The undergraduate curriculum of medical schools and midwifery schools on reproductive health have been revised and improved.  The training centre of the MOH has the capacity to train approximately 1,000 health personnel a year.  The medical schools trained the other thousand thus, doubling the numbers trained per year.

2.  Preparation of the national guidelines on family planning which covers most parts of RH.  This guidelines have been printed and distributed nation-wide and it is in use now.  A mechanism was also established to update information in the guidelines and a third edition is almost ready for use.  A handbook for health care providers on family planning has been prepared, printed and distributed nation-wide.  A resource book on the inter-connectedness of health-environment and development was published officially as a guide for decision-makers and community leaders.  Pilot studies have been carried out to introduce Norplant and injectable contraceptives in order to increase choices of effective contraceptives and help reduce unmet needs in FP.  Since then, two kinds of injectables (monthly and three-monthly) have been introduced into the programme.  Norplant is awaiting registration.

3.  The Safe Motherhood (SM) Programme has been implemented in eight provinces in Turkey which was one of the main recommendations of the ICPD.  Safe motherhood approach is accepted by the MOH as one of the main strategies to improve RH level in the country.  It is planned to expand the SM programme throughout the country.  Under this programme, training modules and methods for the training of health personnel were developed and used.  Community-based health services have been tested with the collaboration of the NGOs.  Also, in-service trainings of the health care providers have been institutionalised by converting the MCH/FP centre as provincial training centres for RH (Ministry of Health, 1997a).

4.  Several special programmes have been carried out to strengthen the IEC component of RH care services.  Under these programmes several IEC materials have been developed and used at the primary health care level as well as secondary level (i.e. various brochures on RH, flipbooks on FP and obstetrical care, several video films on different components of RH etc.).  Under these special programmes three training and communication centres have been established by the MOH for the purpose of production of IEC and promotional materials.

5.  Free standing reproductive health care clinics have been established in a few provinces for pilot testing.  The preliminary results on the clinics were favourable and they will be expanded to other provinces where migrant population is large.  In these clinics, a wide range of RH care are provided.  The clients can easily obtain preventive RH care including surgical contraceptives without being involved in hospital flows.

6.  Special health care programmes are usually provided in the regions or provinces where the needs are greater.  The Second Health Project was implemented in collaboration with the World Bank since 1995 and will continue till 2001.  This project covers east and Southeastern parts of Turkey where the need to improve RH level is greater.  Within the framework of this project all RH programmes are being carried out as an integrated package programme.  It is expected that the health indicators will improve further within a few years (Yigitbas, 1998).

In addition, inter-sectorial collaboration have emphasised on the activities to improve RH.  Collaborations with public and private sectors as well as NGOs have been increased.  The Women Health Advisory Board was used to facilitate collaborations.  The Board also monitors and reports on the progress of the activities and also form a sub-group for detailed evaluation.

More emphasis is also given to improve the status of women in Turkey which is a determinant factor in RH.  In 1990, a special body, the General Directorate of Status of Women and Problems, was established.  This special group collaborates with relevant governments and NGOs to modify the existing legislation that discriminate practices against women.  The "Compulsory Primary Education" has been increased from five years to eight years.  This is expected to have a positive impact on women's health, status, increase in age of marriage and also job opportunities as a result of the higher level of education.

Collaborative activities with international agencies on RH have been expanded to share inter-country experiences.  Establishment of an international training centre for reproductive health has been planned and some preparations have been done.  The main objective of this activity is to share experiences of RH within the countries.  The existing infrastructure and facilities and also accumulated experiences on RH in the country are conducive to setting up such training centre.

NGO Participation in Enhancing RH

NGOs and other grassroot organisations are important contributors to the success of RH programmes because of their comparative advantages over the Government, with their flexible, innovative and responsive programmes and their location within the community.  NGOs participated in the expert group for the preparation of the Seventh Five-Year Development Plan and were also included in the country delegation to ICPD and Fourth World Women Conference.

There are several major NGOs which are active in the field of RH, for example,

Innovations

The main strategy used to provide quality RH services was the improvement and utilisation of existing facilities, which is cost-effective approach.  However, in some circumstances new and innovative projects are needed to upscale the RH programmes, they should be evaluated, to allow necessary decisions for their expansion.

Free Standing Family Health Clinics (FS-FH Clinics)

Under a project initiated in 1995, some MCH/FP centres that are located in crowded, urban squatter areas, having links with hospitals and the peripheral health centres have been converted into Free Standing Family Health Clinics.  The main purpose for this approach is to expand the range of RH services provided at the primary level, to save the clients hospital wait and expenses incurred to clients as well as for the health institutions. As the work load of the primary level is relatively low compared with hospitals, this approach can improve the quality of RH care. Since most of the clients for RH care are healthy individuals, attending clinics for ante-natal, post-natal, family planning, health screening, they usually do not need sophisticated investigations and interventions.  Therefore, if MCH/FP centres are upgraded and some equipment added, they can serve a larger population and provide wider range of RH services with better quality of care.

The FS-FH clinics provide the following RH services in addition to those already provided by MCH/FP centres:

These clinics utilise existing staff to provide services.  However, an anaesthesia technician is required and also a laboratory technician if the former is not available.  Depending on the work load, additional general practitioners and nurse-midwives may be needed.  The clinics allocate one special room for tubal ligations and a recovery/observation room for tubal ligations or pregnancy terminations.  The clinics should have a minimum number of equipment befitting that of the services provided, for example, an ultrasound, operation theatre items and basic laboratory equipment like microscope, haemometer, etc.

Table 3 Activities of the Adana Free-standing Family Health Clinic by Year

One FS-FH clinic was evaluated in 1997.  The results of the evaluation (Table 3) were very favourable and encouraging, indicating that with expanded range of RH services and improved quality of care, the response to these clinical services has strikingly increased. (Akin and Ergšr, 1997a).  The community's appreciation is seen in the attendance rate, which has doubled in this short time.  The service providers are also very satisfied with their work, being able to work in a better-equipped centre with a complete team of care giver.

Community-based Services as a part of the Safe Motherhood Programme

Community-based services (CBSs) have been tested with several NGOs involved in the study.  Male and female volunteers from various communities (rural, urban and squatters) have been trained to provide IEC on RH/FP to their communities, they also motivate the communities to use/consult formal health care facilities centres for any RH problems.  The results of the pilot implementations are encouraging (Table 4).

Involving Men in Reproductive Health Programmes

It is known that women suffer greater health hazards associated with the reproductive system than men.  Sexual health affects men and women differently, but it is more frequently the women who take the initiative to consult the health centres in areas such as fertility regulation and RH.  This is perhaps because men's involvement in RH and services for them such as contraception, has been largely ignored by service programmes as this has been the case in Turkey.  Traditionally, women are targetted.  Nonetheless, one objective of ICPD is to promote gender equality in all spheres of life, including family and community life, and to encourage and enable men to take responsibility for their sexual and reproductive behaviour and their social and family roles (ICPD, 4.25) (United Nations Population Fund, 1996b).

The activities to involve men in RH programmes, especially for STDs and fertility regulations, are particularly important in a male dominant society like Turkey.  Some operational research has shown that when men are targetted using appropriate personnel and IEC materials, contraceptive prevalence is increased.  The needs of men for FP were assessed through a survey and IEC programmes were developed accordingly.  Pamphlets, TV-spots, dramas have also been produced to increase knowledge and awareness of men in RH.

Recently, the Turkish Family Health and Planning Foundation initiated a special programme with the collaboration of the military sector to implement IEC programmes on RH for the soldiers who are men around 20 years of age at the compulsory military services.  The programme is still continuing on a large scale.

Adolescent Reproductive Health Programmes

ICPD can be considered as a turning point for the activities concerning adolescents.  Currently some of the NGOs are conducting IEC activities for university students through a youth-to-youth programme.  The Ministry of Education (MOE) has developed a curriculum for education on the RH and family health for the intermediate school.  In addition, the MoE organised informal IEC programmes on RH which has been attended by over two million adolescent girls.

Although great efforts have been made to provide RH services for adolescents, for involvement of men and for post-menopausal/elderly women in Turkey, achievements of these efforts are far from satisfactory.  A lot more needs to be done for these three groups so that the RH services provided are more comprehensive.  More psycho-social research and innovative programmes are needed for them (…zcebe and Akin, 1995; Akin and Ergšr, 1997a).

Favourable Aspects/Constraints and Obstacles

The ICPD (1994) and the Fourth Women Conference (1995) created a favourable and enabling environment for Turkey to review its current RH situation.  First, it was realised that to provide improved quality of care in RH, resources Ñ staff, machine, money and high technology Ñ must be mobilised and made available.  Second, NGOs and other sectors with the same goals and objectives are enthusiastic to collaborate with the health institutions to promote women's health.  Third, existing mechanisms are effective to facilitate inter-sectoral collaboration and co-operation, one example is the Women's Health Advisory Board.  Fourth, the present PHC system has the capacity to integrate RH components into the service delivery, although traditionally the services that are most available are MCH/FP.

Despite the above conducive aspects, several constraints were also experienced in preparation as well as implementation of the Strategic Plan of Action on the Women's Health and Family Planning Programme:

Looking Ahead

In recent years, all the targets in health has been set for the year 2000.  Now the country is entering into the new century and Turkey is a Member State of the World Health Organization's (WHO) European Region.  Since 1997 activities initiated by the WHO, with the collaboration of the member states including Turkey, is to prepare "Health for All for the 21st Century."  The document, called "Health For All-21" (HFA-21), has been approved by the WHO/Regional Committee in September 1998.  It is now the responsibility of each member states to adapt the HFA-21, which includes targets, strategies and a comprehensive "Plan of Action."  As a follow-up to the HFA-21, a working group was formed with participation from various sectors to prepare the Plan.  As part of the exercise, a sub-group was formed to study the public health profile of Turkey.

Reproductive health will be an important component of the HFA-21 Plan of Action.  Based on previous experiences, strategies and related activities were reviewed, restructured and re-emphasised as follows:

Akin, A., Bertan, M. (1996).  Contraception, Abortion and Maternal Health Services in Turkey: Results of Further Analysis of the 1993 Turkish DHS.  Calverton, Maryland: MOH (Turkey) and Macro International Inc., Ankara.

Akin, A., Ergšr G. (1997a).  "Reproductive Health Transition in Turkey."  Feedback 13(2): 1-4.

Akin, A., Ergšr, G. (1997b).  "Turkish Experiences on Unwanted Pregnancies and Induced Abortion."  Paper submitted and presented at the International Safe Motherhood Technical Consultation Meeting, October 1997, Colombo, Sri Lanka.

Balkan, G., Akin, A. eds. (1995).  Population Issues, Health, Development and Environmental Perspectives in the World and in Turkey.  Ankara: Ministry of Health.

Franz, E. (1994).  Population Policy in Turkey.  Hamburg: Deutsches Orient Institut.

General Directorate on the Status and Problems of Women and the States Institute of Statistics (1995).  Women in Statistics, Turkey 1995.  Ankara: General Directorate on the Status and Problems of Women and the States Institute of Statistics.

Hacettepe University Institute of Population Studies and Macro International Inc. (1997).  "Fertility Trends, Women's Status, and Reproductive Expectations in Turkey."

Huntington, D., Akin, A., et al. (1996).  "The Quality of Abortion Services in Turkey."  Int. J. Gyn.Obs. 53: 41-44.

Ministry of Health (1997a).  Country Health Report 1997.  Ankara: Ministry of Health.

Ministry of Health (1997c).  Main Women Indicators Turkey, 1978-1994.  Ankara: Ministry of Health.

Ministry of Health (1997b).  Health Statistics Yearbook of Turkey 1987-1994.  Ankara: Ministry of Health.

Ministry of Health (Turkey), General Directorate of MCH/FP; Hacettepe University Institute of Population Studies and Macro International Inc. Ankara (1993).  Turkey Demographic and Health Survey.

Ministry of Health, Hacettepe University Institute of Population Studies, DHS Macro International, Ankara (1995).  Trends in Fertility, Family Planning and Childhood Mortality in Turkey.  Ankara: Ministry of Health, Hacettepe University Institute of Population Studies and DHS Macro International.

Ministry of Health-Maternal Child Health/Family Planning General Directorate (1996).  National Strategic Plan on Women's Health and Family Planning.  Ankara: MOH-MCH/FP General Directorate.

zcebe, H., Akin, A. (1995).  "Adolescent: With a Special Reference to Middle East and North Africa Regions."  Rev. Ginecologia & Obstetricia, Sao Paulo, 6(2): 79-88.

State Institute of Statistics (1995).  Women in Statistics 1927-1992.  Ankara: State Institute of Statistics.

United Nations Population Fund (1996a).  "Platform for Action" adopted at the Fourth World Women Conference, Beijing China 4-5 September 1995.

United Nations Population Fund (1996b).  "Programme of Action" adopted at the ICPD, Cairo, 5-13 September 1994.

Yigitbas, S. (1998)  "Survey on the Causes of Maternal Deaths from the Hospital Records."  Thesis submitted to the Hacettepe University Public Health Departments, Ankara, 1998.