Improving health care services in Northern Cyprus: a call for research and action

Introduction

The island of Cyprus is divided in two parts. The Greek side is internationally recognized as the Republic of Cyprus, but the Turkish side, known as the Turkish Republic of Northern Cyprus, is not recognized by any nation other than Turkey. While the Republic of Cyprus has prospered, becoming a member of the European Union in 2004, Northern Cyprus has remained under economic sanctions and has been left relatively isolated from the rest of the world for nearly 40 years.

The unique political context of Northern Cyprus has had important implications for public health and the health care system. In this brief commentary, we describe how the Northern Cyprus population accesses health care services, highlight the inadequacy of health data and call for an expanded research and action agenda.

Accessing health care

Northern Cyprus is home to approximately 300 000 people. An estimated 70% of the population is of Turkish Cypriot origin, 27% are from Turkey and the remaining 3% are from other nations. The population has grown by 11.2% since 2006 (preliminary results from the 2011 Population and Housing Unit Census). According to the 2006 census, 96% of the population is literate and 87% has at least completed primary school.¹

Individuals living in Northern Cyprus are able to access health care through four potential care pathways. The first is via the public health care system. Care in the public system is provided at greatly discounted rates to those who have social security insurance, which is mandatory for everyone in the workforce, whether employed by the government, private sector or self-employed. Subsidized public health care services are also available for the partners and for children aged <18 years of those with social security insurance. Care in accident and emergency departments is free of charge to everyone. It is thought that only a small percentage of Turkish Cypriots use the public health system; however, no official estimates exist.

Many people in North Cyprus seek care from the private sector. In addition to the recent emergence of private hospitals, the past decade has seen an increase in private “polyclinics”, which provide a wide range of outpatient services, although treatments offered in these settings are generally basic. In recent years, individuals have started purchasing voluntary health insurance; however, it is not yet widespread. Consequently, high out-of-pocket health care expenditures are extremely common.

A third alternative is accessing public services in Turkey. The Northern Cyprus government has a formal scheme, sending individuals free of charge to Turkey for specialist health care if the required services are not available specifically within the public sector. Therefore, some patients who are diagnosed in the private sector with a condition that requires costly specialized care may visit public hospitals to receive a duplicate diagnosis and become entitled for free public services in Turkey. In this regard, the private and public health systems work in parallel with a considerable lack of coordination, resulting in waste and duplication. A total of 2023 patients were sent to Turkey in 2010, most commonly for cardiovascular disease (22%) and cancer treatment (16%).

The fourth care pathway is by crossing the border and receiving public services in the Republic of Cyprus. Turkish Cypriots are eligible for Republic of Cyprus citizenship, and thus benefit from health care coverage provided to all its citizens. Although its public services are perceived to be of higher quality than in Northern Cyprus, only a small percentage of the Turkish Cypriot community is thought to use public health services in the Republic of Cyprus (<10% of the population). According to the Republic of Cyprus Ministry of Health, 24 420 Turkish Cypriots received public health care between April 2003 and December 2004.²

Potential for health reform in the North

There are striking similarities in terms of health care sector issues between the two sides of the island, despite no formal linkages between 1974 and 2003. The health care system in the Republic of Cyprus comprises comparably sized public and private sectors, which exist in parallel. This fragmentation and lack of coordination leads to duplication of services, a lack of cost control and poor capacity planning. In an attempt to address these issues, the Republic of Cyprus has worked towards implementation of a national health insurance scheme, which is designed to provide universal coverage by introducing competition between the public and private sectors, adding a social insurance component to financing (in addition to taxes) and changing the way providers are paid. Despite years of delay, the plan is expected to come into effect in 2016; data collection has already begun in select facilities.^3,4

Northern Cyprus would also benefit from health system reforms similar to those on the other side of the island. One of the critical components of rational and objective policymaking is the accurate and systematic collection and dissemination of data. Yet such efforts in Northern Cyprus are in their infancy; the prevalence of diseases has been reported only since 2002, and only for governmental hospitals. Most commonly reported conditions are cardiovascular disease, cancer, neurodegenerative disease, diabetes and asthma. The most prevalent reported cancer among the general population is skin cancer; the most commonly reported cancer among women is breast cancer; and colorectal cancer is most often reported in men.⁵ Because the majority of the population receives private health care, the information collected from government hospitals is not representative of the general population. As a result, simple yet extremely important indicators, such as causes of morbidity and mortality, are not available at the population level.

A call for action: a health services research agenda for Northern Cyprus

Without information on the health needs and behaviours of the Northern Cyprus population, there is little hope for protecting public health and reforming the health system. One example of a successful data collection and evidence-based treatment program in North Cyprus is the well-established thalassemia prevention program (TPP).⁶ This multifaceted programme began in 1976 and comprised population screening to identify those with, or at risk of developing, thalassemia. Coupled with an effective treatment strategy, TPP has led to a reduction in the incidence of children born with this hereditary blood disease, from 1 out of every 158 births to 0.

We call for development of a national population-level data-collection program in Northern Cyprus. We urge policymakers to invest in health information systems that will lay the foundation for evidence-based medicine by identifying risk factors for disease, help set targets for policymaking and enable formal program evaluation strategies. Better information on health care use and expenditure patterns is also needed. Improved data collection will allow for an informed policymaking agenda, continuing dialogue regarding gaps in health care provision and an assessment of whether reforms similar to those in the Republic of Cyprus can be implemented by the Turkish Cypriot government.

Funding

None.

Conflicts of interest: None declared.

References