How primary care reforms influenced health indicators in Manisa district in Turkey: Lessons for general practitioners

Figures & data

Table 1. Main elements of primary care reforms, outcomes and conceptual framework of the study.

Main elements of HC period (before primary care reforms)	Main elements of FP period (after primary care reforms)	Outcomes or variables linked to primary care reforms	Measures	Conceptual framework (themes of the study)
Broad team with 8–10 members (mainly home visits and follow-ups)	Narrow team with two members (mainly examination in the family physician office, limited home visits)	Follow-ups  - Infant (0–11 months)  - Children (1–4 years)  - Pregnant women  - Women (15–49 years) Vaccinations  - Measles  - BCG  - HBV III  - DPT III Mortality rates  - Infant death rate  - Postneonatal infant death rate  - Under five years mortality rate  - Crude death rate	Mean (per infant/per year) Mean (per child/per four years) Mean (per pregnant women) Mean (per women/per year) per cent per cent per cent per cent per thousand per thousand per thousand per thousand	Preventive health services
No selection of FP	Free selection of FP	Average number of outpatient services Non-communicable diseases  - Hypertension	Mean (per person/per year) Prevalence (per ten thousand)	Healthcare utilization
Integrated health services (HCs for primary care and public health services)	Very weak or no integration (Family HCs for primary care; community HCs for public health services)	Communicable diseases  - Rabies suspected animal bites  - Acute haemorrhagic gastroenteritis	Incidence (per ten thousand) Incidence (per ten thousand)	Integration of health services
No extra payment or penalty	Pay for performance system (negative performance system for infant follow-ups, pregnant women follow-ups and infant vaccinations, but no penalty for women and children follow-ups) Extra payment for people who registered on FP’s list (per capita payment)	Follow-ups  - Infant (0–11 months)  - Children (1–4 years)  - Pregnant women  - Women (15–49 years) Vaccinations  - Measles  - BCG  - HBV III  - DPT III Average number of outpatient services	Limits Six times, per infant/per year Four times, per child/per four years Four times, per pregnant women Twice per woman/per year 90% 90% 90% 90% Mean (per person/per year)	Performance system

HC: health centre; FP: family physician; BCG: Bacillus Calmette–Guérin vaccine; HBV III: hepatitis B vaccine third dose; DPT III: diphtheria, pertussis (whooping cough), and tetanus vaccines third dose.

Figure 1. Pregnant women mean follow-up visits (per person/per year), intersection points and trends comparing health centre and family physician periods.

Table 2. Follow-up visits, trends and differences comparing health centre and family physician periods.

	Mean follow-up visits (per people/per year)				Trends
Indicators	HC period (95%CI)	FP period (95% CI)	Difference	P	HC period (95% CI)	FP period (95% CI)	Difference	P
Infant (0−11 months)	10.5 (10.0−11.02)	6.76 (5.88−7.64)	−3.83 (−2.83−4.82)	.001	0.06 (0.04−0.07)	0.03 (0.01−0.05)	−0.03 (−0.06, −0.01)	.001
Children (1−4 years)	2.11 (1.71−2.50)	1.16 (0.41−1.91)	−0.95 (−0.91−1.80)	.030	0.002 (−0.008, 0.013)	0.03 (−0.02,0.03)	0.003 (−0.023,0.029)	.812
Pregnant women	6.60 (6.31−6.82)	5.64 (5.14−6.14)	−0.97 (−1.56−0.38)	.001	0.04 (0.03−0.05)	−0.01 (−0.02, 0.001)	−0.05 (−0.07, −0,04)	.001
Women (15−49 years)	1.76 (1.29−2.21)	0.96 (0.81−1.20)	−0.81 (−1.35−0.26)	.004	0.005 (−0.01,0.02)	−0.002 (−0.01−0.004)	−0.01 (−0.02,0.01)	.321

Table 3. Vaccination rates, trends and differences comparing health centre and family physician periods.

	Vaccinations (%)				Trends
Indicators	HC period (95% CI)	FP period (95% CI)	Difference	P	HC period (95% CI)	FP period (95% CI)	Difference	P
BCG (Percent)	101.95 (95.47-108.44)	115.28 (105.82-124.74)	13.29 (0.66, 25.92)	.039	0.04 (−0.17−0.25)	−0.27 (−0.54−0.007)	−0.31 (−0.63, −0.01)	.042
Measles (%)	86.42 (71.19−101.64)	118.46 (104.77−132.16)	32.27 (11.68, 52.84)	.002	−0.23 (−0.66, 0.21)	−0.38 (−0.75−0.002)	−0.16 (−0.73,0.41)	.580
HBV III (%)	103.80 (92.38−115.23)	117.14 (108.89−125.39)	13.23 (−1.36, 27.82)	.075	0.11 (−0.17, 0.39)	−0.30 (−0.52, −0.09)	−0.41 (−0.76, −0,06)	.021
DPT III (%)	100.51 (95.31−105.70)	100.09 (82.68−117.50)	−0.43 (−18.65, 17.80)	.963	0.089 (−0.41, 0.59)	0.096 (−0.34, 0.53)	−0.089 (−0.41, 0.59)	.725

Figure 2. Average number of outpatient services (per person/per year), intersection points and trends comparing health centre and family physician periods.

Table 4. Morbidity rates, trends and differences comparing health centre and family physician periods.

	Average number of outpatient services and disease rates				Trends
Indicators	HC period (95% CI)	FP period (95% CI)	Difference	P	HC period (95% CI)	FP period (95% CI)	Difference	P
Average number of outpatient services (Mean, per person, per year)	2.84 (2.69, 2.99)	3.25 (2.97, 3.52)	0.379 (0.059, 0.697)	.020	0.029 (0.025, 0.034)	–0.024 (0.012, 0.007)	–0.032 (–0.042, –0.022)	<.001
Hypertension (per ten thousand)	31.29 (28.83, 33.74)	26.05 (18.33, 33.78)	–6.34 (–14.87, 2.21)	.144	1.10 (0.940, 1.271)	0.416 (0.157, 0.674)	–0.69 (–0.99, –0.39	.001
Rabies suspected animal bites (per ten thousand)	31.89 (26.77, 37.01)	36.94 (26.12, 47.77)	4.53 (–6.63, 15.69)	.422	0.519 (0.279, 0.759)	–0.171 (–0.486, 0.145)	–0.69 (–1.11, –0.264)	.002
Acute haemorrhagic gastroenteritis (per ten thousand)	3.98 (3.13, 4.83)	1.79 (1.45, 2.13)	–2.24 (–2.99, –1.49)	<.001	0.052 (0.033, 0.0719)	–0.011 (–0.020, –0.002)	–0.063 (–0.09, –0.04)	<.001

Table 5. Mortality rates, trends and differences comparing health centre and family physician periods.

	Mortality rates				Trends
Indicators	HC period (95% CI)	FP period (95% CI)	Difference	P	HC period (95% CI)	FP period (95% CI)	Difference	P
Infant mortality rate (per thousand)	9.21 (7.83−10.60)	14.51 (12.81−16.20)	5.37 (3.13−7.61)	<.001	−0.08 (−0.13, −0.38)	−0.119 (−0.16, −0.074)	−0.04 (−0.01, 0.03)	.261
Postneonatal infant mortality rate (per thousand)	3.32 (2.20−4.44)	5.02 (3.92−6.21)	1.78 (0.16,3.41)	.032	−0.042 (−0.08, −0.01)	−0.0359 (−0.066, −0.0053)	0.01 (−0.41, 0.05)	.812
Under 5 years mortality rate (per thousand)	11.09 (9.61−12.57)	15.06 (13.85−17.34)	4.60 (2.25−6.94)	.001	−0.09 (−0.14, −0.04)	−0.131 (−0.176, −0.084)	−0.04 (−0.11, 0.03)	.256
Crude death rate (per thousand)	3.71 (2.72−4.69)	2.05 (0.54−3.55)	−1.67 (−3.47, 0.13)	.069	0.01 (−0.27, 0.04)	0.06 (0.02−0.10)	0.054 (−0.003, 0.111)	.065