UNICEF Global     TR

* Infant and under-five mortality has continued to decline rapidly in Turkey but a gap remains between Turkey and the most successful countries, mostly due to higher mortality rates in less developed regions. Turkey can now aim to close this gap.

* Child nutrition has improved, but serious problems remain. 10% of Turkey’s children – mainly in underdeveloped regions - are stunted, meaning that they are of low height for their age and at risk of further health and development problems. This unacceptable situation reflects the persistence of poverty, inadequate care in the family and gaps in public services. Micronutrient deficiencies are also significant.

* As part of a transformation of the health sector, Turkey has introduced free health insurance for children. With respect to public health, a more holistic service can be envisaged, focusing not only on infant survival, immunization or breastfeeding but widening its goals towards the ultimate objective of safer and healthier lives for all. This will require further refinement of the family medicine system and careful monitoring and assessment of impacts for all children everywhere.

* Many infants and young children face some kind of disability or developmental delay which needs to be detected and responded to as early as possible. While Turkey has pioneered Development Paediatric Units, much more investment needs to be made to change attitudes to developmental delays and disability within the health system, to ensure correct screening and diagnostics of all children, and to provide early intervention, special education and rehabilitation in line with best international practice.

4.1 Survival: Infant and under-five mortality has fallen dramatically in recent years (albeit from a high level) as a result of social trends, including higher incomes, better education of mothers, urbanisation and safer fertility practices, combined with improvements in the coverage and/or quality of various aspects of health services such as ante-natal care and monitoring, birth attendance, knowledge of key personnel and availability of intensive care units. The UN puts under-5 and infant (0-12) mortality in Turkey at 18 per 1,000 live births and 14 per 1,000 live births respectively. These figures compare to rates of 57 and 40 for the World, 41 and 31 for the Middle East and North Africa, 23 and 19 for the Central and Eastern Europe/Community of Independent states region, and 6 and 5 for the industrialised countries (UNICEF: State of the World Children’s Report, 2012). Health officials in Turkey are confident that single figures will be achieved very soon. The story of the recent rapid progress in reducing child mortality rates is told in the publication “Decline in the Under-5 Mortality Rate (U5MR) in Turkey: A Case Study” (http://www.unicef.org.tr/en/knowledge/detail/1035/decline-in-the-under-5-mortality-rate-u5mr-in-turkey-a-case-study, or in Turkish: http://www.unicef.org.tr/tr/knowledge/detail/1034/turkiye-de-5-yasindan-kucukler-olum-hizinda-5ykoh-azalma-bir-durum-arastirmasi).

Achieving the low under-five and infant mortality rates recorded in the most developed countries will require a focus on risky cases (premature babies, low birthweight…) and on the first few weeks of life, when most of the babies are lost. Disparities between regions and social groups are also significant. The 2008 Demographic and Health Survey (DHS) put under-5 mortality for the ten years preceding the survey at 43 in rural areas, 50 in the “East” region and 52 among mothers from the lowest wealth quintile compared to a national average of 33. Besides variations in socioeconomic circumstances, educational levels, fertility practices and geographical distances between homes and health facilities, these disparities may reflect geographical variations in the provision of infrastructure and services, and high turnover of health staff. The same survey showed that only 79% of mothers received medical guidance and care before birth in the East, which was thirteen percentage points below the national average, that only 74% of births in the East were assisted – seventeen percentage points below the national average - and that only 33% of mothers in the East receive assistance from a doctor (rather than a nurse or midwife) during birth. Similar disparities were identified between rural and urban areas. In its Concluding Observations in June 2012, the UN Committee on the Rights of the Child encouraged Turkey to “eradicate regional disparities and address maternal and infant mortality targeting the Eastern regions of the country”. The next DHS survey, to be conducted in 2013, may well confirm that the geographical disparities in infant and child mortality and in access to and take-up of mother-and-child health services have diminished with the aid of policy initiatives like conditional cash transfers linked to regular health checks and hospital delivery, the provision of transport and accommodation for women from remote areas when giving birth, and home-visiting. However, recent mortality data from the Turkish Statistical Institute (Turkstat) suggests that infant mortality in eastern regions remained significantly above the national average in 2010.

Infant mortality by age of death, 2010

 

no. of deaths

% of total

0 days

2,172

14.4

1-6 days

4,796

31.9

7-29 days

2,638

17.5

1-4 months

3,451

22.9

5-8 months

1,349

9.0

9-11 months

643

4.3

Total

15,049

100.0

Source: Turkish Statistical Institute (Turkstat) as of March 31, 2012

Infant mortality by region, 2010

 

no. of deaths

Mortality rate (‰)

TR1 Istanbul

2,048

9.7

TR2 West Marmara

372

10.4

TR3 Aegean

1,464

11.6

TR4 East Marmara

998

10.0

TR5 West Anatolia

1,232

11.6

TR6 Mediterranean

2,003

12.2

TR7 Central Anatolia

693

11.0

TR8 West Black Sea

689

11.3

TR9 East Black Sea

362

10.7

TRA Northeast Anatolia

688

14.0

TRB Central East Anatolia

1,205

14.5

TRC Southeast Anatolia

3,295

16.0

All regions

15,049

12.1

Source: Turkish Statistical Institute (Turkstat) as of March 31, 2012

Deaths of children due to childhood diseases and other communicable diseases are low in Turkey, in keeping with geographical and climatic conditions, the development of the economy, education and infrastructure, urbanisation and the expansion of health services including basic public health interventions. Turkey has been polio-free since 2002, and a National Measles Vaccination Campaign carried out in 2003-2005 resulted in 95 per cent coverage, according to the Ministry of Health, putting measles vaccination coverage on a par with the industrialized countries, and making the Millennium Development Goal target of 100 per cent infant immunization look achievable. The scope of routine immunisation policies has been widened. The 2008 DHS found that 74% of children aged 12-23 months had been fully immunised (at the time, indicating one dose of BCG, 3 doses of polio and one dose of measles), compared to only 54% in 2003. However, full immunisation among two year-olds was only 60 per cent in rural areas and in the East, and this may indicate geographical variations in service provision and staff as well as demand-side factors.

According to Turkstat, 920 5-9 year-olds, 798 10-14 year-olds, 1,399 15-19 year-olds and 1,710 20-24 year-olds died in 2010. Three-fifths of the deaths among 5-19 year-olds and two thirds of the deaths among 20-24 year-olds came among males. A variety of causes are cited. The figures need to be treated with caution as it is not possible to attribute causes to all deaths.

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4.2 Nutrition:  The nutritional status of Turkey’s children has improved as a result of economic development, urbanisation, smaller family size and social change, as well as official policies favouring breastfeeding and salt iodisation. Nevertheless, a significant percentage of children in Turkey are malnourished or experience health conditions or risks related to deficiencies of micronutrients like iron, iodine and vitamins. This situation reflects the extent of child poverty, the inability of social protection systems and social services to compensate, and in some cases the ignorance or negligence of parents and caregivers with respect to diet and feeding. The results of a national nutrition survey conducted in 2011 have not yet been published, and statistical information about micronutrient deficiencies is limited. However, the 2008 Demographic and Health Survey (DHS) showed that 10.3% of children under the age of five were stunted – down from 16.0% in 1998 and 12.2% in 2003 – and 3.2% severely stunted. Stunted children are short for their age, a sign of chronic malnutrition. Just under 1% of Turkey’s under-fives were wasted, meaning that their bodyweight was low relative to their height, a sign of acute malnutrition.

Malnutrition affects not only life chances, physical health and stature but also cognitive development. It has been described as a hidden global emergency. It persists in middle income countries as well as poor countries. WHO data cited in UNICEF’s State of the World’s Children report 2012 puts stunting at 29% for Egypt, 17% for Malaysia and 16% for Mexico but only 8% for Jordan and 7% for Brazil.

In Turkey, malnutrition shows substantial variations between regions, and between urban and rural areas, which is unsurprising given the distribution of poverty in the country. The 2008 DHS, dividing Turkey into five main regions, showed that 20.9% of children in the “East” region were stunted, compared to 7.6% in the “West” region. For specific provinces or districts, the ratio may be still higher. Separately, the survey put the percentage of households using iodised salt in the East at 61 percent - twenty-four points below the national average. In its Concluding Observations in June 2012, the UN Committee on the Rights of the Child recommended that Turkey “continue its efforts to eradicate malnutrition, especially stunting, as well as improve neonatal care with special emphasis on the Eastern regions”.Efforts to improve health and nutrition outcomes in difficult locations will be much more meaningful if they are made in the context of policies designed to overcome the wider economic and socioeconomic disadvantages of the population.

Breastfeeding: Almost every child in Turkey is breastfed at some time in infancy, increasing his or her chances of survival, good health and strong emotional and cognitive development. The 2008 DHS put this ratio at 98.5 percent. Ideally, however, babies should be exclusively breast-fed for six months – and the proportion of under-6s who are exclusively breast-fed was put at just 41.6%. This was in spite of improvements brought about by the Baby-Friendly Hospitals initiative and other related efforts carried out by the Ministry of Health and supported by UNICEF. In terms of exclusive breastfeeding, Turkey’s performance appears to be above the World average of 37% given in UNICEF’s State of the World’s Children report for 2012. Nevertheless, many babies younger than two months are fed with ready-made formula (one-fifth according to the DHS), and few babies (less than a quarter according to the DHS) are still being exclusively breastfed at 4-5 months. Although the 2013 DHS may confirm some more progress, mothers of more than half of 0-6 year-olds in all parts of the country are feeding them unsuitably. Moreover, a code on the marketing of breast-milk substitutes first drafted in 2002, in line with the International Code of Marketing of Breast-Milk Substitutes has still not been adopted due to issues of EU-compatibility, lobbying by formula manufacturers and the indecisiveness of the government. In its Concluding Observations in June 2012, the UN Committee on the Rights of the Child recommended that Turkey “continue strengthening its efforts to promote breast-feeding and fully enforce the International Code of Marketing of Breast-milk Substitutes”.

4.3 Trends in health services for children: Public health policy for children has been dominated by large-scale programmes in specific service areas, such as prenatal care, immunization or breastfeeding. Correspondingly, the health of Turkey’s children has been measured by collecting data on the anticipated results of these programmes – such as reduced infant mortality or the elimination of measles. These programmes have been successful, and are to some extent institutionalised and sustainable. Without underestimating the importance of continuing with this kind of work - especially in poorer regions and among disadvantaged social groups – national health policy now needs to take a more holistic approach to children, to widen its goals towards the ultimate objective of healthier lives for all, and to adopt appropriate new indicators. Priorities for intervention may need to change as the importance of old challenges subsides, hitherto-neglected issues (such as child injuries and accidents) rise to the surface and new problems emerge, such as childhood cancers and lifestyle-related conditions like obesity (School canteen menus are now subject to anti-obesity rules). With respect to nutrition, complementary feeding and dietics in general may take on more importance, alongside breastfeeding and individual micronutrients.

A series of changes have been taking place in the health system which have the potential to contribute to a more comprehensive health service for children, reaching all children regardless of geographical or social background, but which also entail some risks. Most recently, in 2012, the Ministry of Health was reorganised ending the division between the general directorates of Mother and Child Health and Primary Health Care and creating new units like the Turkey Public Health Institute. In 2010, the roll-out of a system of family doctors to all parts of the country was completed, effectively setting up a new primary health care network. This was part of a structural “transformation” of the health care system, partly influenced by the World Bank, which has been going on since the early 2000s.

Assessing and monitoring the health system

According to the Government’s Annual Programme for 2012, the health service “transformation” policy has contributed to important improvements in provision of services, access to services, basic health indicators and satisfaction with health services. However, the Programme acknowledges that there are still significant disparities in the distribution of physical infrastructure and health personnel between urban and rural areas and among regions. It also notes that issues related to the financial sustainability of health services persist. Health spending has increased, reaching 5.0% of GDP in 2009, a year when GDP shrank, the Programme says, but the Government is expecting to cut costs and increase revenues in future.

Other reports which make broadly similar but more detailed assessments of the health system include the following:

--OECD/World Bank: Review of the Turkish Health System, 2008 (http://www.worldbank.org.tr/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/TURKEYEXTN/0,,contentMDK:22081093~

pagePK:1497618~piPK:217854~theSitePK:361712,00.html )

--World Bank: Health Workforce Policy in Turkey: Recent Reforms and Issues for the Future (http://www.worldbank.org.tr

/external/default/mainpagePK=64193027&piPK=64187937&theSitePK=361712&menuPK=64187510&searc

hMenuPK=64187282&theSitePK=361712&entityID=000333037

_20090717003257&searchMen

uPK=64187282&theSitePK=361712 )

--Economic Policy Research Foundation of Turkey (TEPAV): Genel Sağlık Sigortasının Mali Sürdürülebilirlik Açısından Analizi – 2009’da ne oldu? [Analysis of General Health Insurance from the Angle of Financial Sustainability - what happened in 2009?], 2009 at http://www.tepav.org.tr/upload/files/1271313500r1067.Saglik_Harcamalari_Genel_Saglik_Sigortasinin_Mali_

Surdurulebilirlik_Acisindan_Analizi.pdf.)

While there is a widespread belief that health services in general improved in the 2000s, there is also a lack of independent monitoring of the performance of the public health and health care systems, in terms of coverage/access and quality, particularly with respect to children, and with respect to disadvantaged groups. The establishment of think-tanks in this area and the dissemination and analysis of more of the data which is available to the Ministry of Health would be beneficial.

Family medicine: Family medicine doctors are expected to conduct an integrated mother-child monitoring service throughout pregnancy and early childhood, collecting information from mothers and children regularly, and closely tracking the cognitive and psycho-social development of the child will be followed closely. All this will not only make it possible for individual girls and boys to receive the timely treatments which they need but will also generate data to guide the conduct of public health policies and education. Moreover, the family medicine system can serve as a conduit for the education of parents and hence of society as a whole. Key factors for success include the provision of adequate compensation, training and support for family medicine practitioners, maintaining public confidence in the system, and the development of effective procedures for the collection and processing of data. For a more efficient/sustainable and equitable health system, preventive services should be prioritized, and greater use should be made of nurses and of child development specialists who can contribute to the early childhood development efforts of families and public agencies (According to the Government’s Annual Programme for 2012, Turkey has 16.9 doctors and only 15.7 nurses per head of population compared to 33 and 82.4 in the EU).  

Access to health care: A single, public, compulsory, contributory general health insurance scheme is replacing both the previous fragmented contributory health insurance schemes, which covered those in regular work - or retired - and their dependents, and the “green cards” providing access to the health system for most of the uninsured. The government meets the cost of general health insurance contributions for the very poor, subject to means-testing, and for all under-eighteens and some students above eighteen. Differentiated user fees have been introduced to orient people initially towards primary health care institutions and to use the referral system. There are private, state and university hospitals; some state hospitals may be privatised. It remains to be seen what quality of service can be provided on a long-term basis and in all parts of the country. Issues include the content of the basic health insurance package, user fee levels, the use of global budgets aimed at cutting costs, paying for emergency services and the question of whether treatments and medicines will be priced so as to ensure their availability everywhere as market forces come to dominate provision. Despite free health insurance for children, access to health services for children requiring certain types of treatment may be complicated by “hidden” costs such as transport and care-givers’ time.

4.4 Beyond survival: developmental delays and disability: While fewer and fewer infants and young children are dying, a significant proportion are faced with some kind of disability or developmental delay which needs to be detected and responded to as early as possible in order to eliminate or minimise the consequences for the individual in terms of morbidity and physical, cognitive, emotional and social development, and to ease the resulting burden on families and society. In all countries, at least one child out of ten has a developmental difficulty that includes or places them at risk for disabilities. These children often come from disadvantaged groups such as low-income families. In Turkey, diagnosis has improved as a result of increased access to and use of health services and more screening programmes. However, the screening programmes address only limited preventable causes of developmental difficulties and disability and are neither comprehensive nor coordinated. In addition, the methods used for detecting children at risk may not be up-to-date, and there may be long waiting lists for diagnoses, particularly for cognitive and mental health problems. Health care staff are not routinely trained for developmental surveillance and do not know how to manage the cases that are identified.

Turkey has been a pioneer in its region in the development of specialised Developmental Paediatric Units (DPUs), in order to support young children with developmental delays or difficulties and their families. In  cooperation with Ankara University, the Association of Developmental Paediatrics and UNICEF, the Ministry of Health has so far established DPUs with trained staff for detecting and responding early to developmental difficulties in twelve of the most important hospitals for children across the country. These innovative units served 10,000 children in 2011 alone. The DPU model supports health care providers and community workers with the monitoring of developmental delays and the counseling of caregivers on how to enhance their child’s development. It also promotes child development interventions within the health care system including the use of inclusive Growth Monitoring Child Development support cards, and provides pre-service training for pediatricians and medical students. In April 2011, Turkey held its First National Developmental-Behavioural Paediatrics Congress, and Developmental Paediatrics became an officially recognized sub-specialty within the health system.

There is still work to be done to expand the DPU model, and to change attitudes to developmental delays and disability within the health system. The family medicine system has great potential for monitoring children’s development if staff - nurses as well as doctors - are suitably trained. With respect to support for disabled children within the health care system, the numbers of trained staff for early intervention, special education and rehabilitation need to be increased and the content and quality of training improved in line with contemporary approaches. Simultaneously, the current centre-based, directive teaching and behavioural teaching-oriented framework needs to give way to a community-based, home-based, holistic approach. In addition, major revisions are needed to the criteria for the issue of Disability Reports, upon which access to services depends, so as to make them functional and reliable and appropriate for young children.

UNICEF Turkey Country Office, Yukarı Dikmen Mah. Alexsander Dubçek Cd. 7/106, 06450 Çankaya/Ankara. Telephone: +90 312 454 1000 Fax: +90 312 496 1461 E-mail: ankara@unicef.org