Improving Access to Primary Care: The Experience of Türkiye’s Family Medicine Program

The fragmented nature of the American health care system means that more than one-third of people don’t have access to a primary care provider or family medicine specialist. In fact, adults in the United States are the least likely to have a regular care provider when looking across high-income countries. Access to primary care and a regular provider are associated with better health outcomes and lower mortality, as well as more equitable outcomes — a finding that holds true both domestically and internationally.

No country knows this better than Türkiye (formerly Turkey). In 2003, it overhauled its primary care system as a part of a broader effort to achieve universal health care access. In just over 10 years, the government’s family medicine program (FMP) helped most of the nation’s 85 million people gain access to primary care.

Expanding the Primary Care Infrastructure

Prior to 2003, a quarter of Türkiye’s population was uninsured, and there were large gaps in coverage and disparities in health outcomes across the nation’s 81 provinces. The FMP worked to address these inequities by expanding a range of services, including immunizations, child and maternal care, family planning, home visits, and regular annual health checks and made primary care free at the point of care.

Five key policy interventions drove the FMP:

1. Large financial resources dedicated to primary health care, with the government tripling investment between 2002 and 2007.
2. A 10-day training course to certify general practitioners as family medicine providers, meaning they can care for both children and adults.
3. Compensation for newly trained family medicine providers that includes performance-related payments to reward good health outcomes for three child and maternal health indicators and 35 service delivery indicators. Failure to meet targets can result in a 20 percent cut in compensation, and family specialists’ two-year contracts can be terminated if their number of enrolled patients falls below 1,000.
4. A requirement that all Turkish citizens have a family medicine specialist of their choosing, further incentivizing physicians to attract and retain patients.
5. An increase in the number of primary care facilities, and the transformation of some preexisting facilities in underserved rural and poorer areas into more comprehensive family medicine centers.

Huge Improvements, Persistent Disparities

Evidence suggests that Türkiye’s investment in a universal primary care system reduced overall mortality, particularly for infants and the elderly. There were also fewer pregnancies and births among teenagers and women ages 20 to 29, a result of greater access to reproductive health and family planning services. Since 2003, life expectancy has also increased 109 percent, to 78.6 years at birth in 2019 (the COVID-19 pandemic caused a slight drop).

However, income disparities in health care persist, as they do in most countries, including the U.S. In 2019, nearly one in 10 of the poorest 20 percent of people in Türkiye reported unmet needs because of cost or geography, compared to less than half a percent of the wealthiest 20 percent of people. While the FMP succeeded in expanding access to primary care to most of the population, long distances to clinics and a low supply of doctors in rural and other underserved areas often pose barriers. Refugees and undocumented people also struggle to access regular primary care. Only registered refugees or migrants can use the Turkish health system, and only in the city they initially register in. Refugees and migrants seeking care also face discrimination and often struggle to find culturally competent care.

Türkiye has more work to do, but the progress made in just over a decade is undeniable. The country’s investment in primary care infrastructure offers a useful example for the U.S. in its quest to improve health access and outcomes.

The author would like to thank Thomas Hone, Ph.D., M.P.H., for his review of this Insight.