Distr.
GENERAL
CES/PAU/1998/25
9 November 1998
English only
Regional Population Meeting
Budapest (Hungary), 7-9 December 1998
NATIONAL REPORT
Submitted by the Government of Turkey
Unedited version prepared by the Government of Turkey for the Regional Population Meeting (Budapest, 7-9 December 1998). The views expressed and the designations employed in the paper are those of the Government of Turkey and do not imply the expression of any opinion whatsoever on the part of the Government of Hungary, the United Nations Economic Commission for Europe, or the United Nations Population Fund.
1- PERCEPTION AND POLICY RELATED TO THE FAMILY, FERTILITY AND REPRODUCTIVE HEALTH
Turkish population policy gives special importance to family in Turkey. Article 41 of the Turkish Constitution states that the State takes the necessary measures and establishes the organizational network for securing peace and welfare of the family, especially the protection of the mother and the children and of education and implementation of the family planning methods.
Accordingly, in the Seventh Five Year Development Plan (1996-2000) a special emphasis was placed on the measures to be taken to ensure that families have income continuity, basic health services and social security. It was also expressed that a system shall be developed for meeting the requirements and solving the problems of the family in cases of crisis and families shall be trained and supported with respect to child raising and care of the elderly and disabled members of the family.
Structural changes had been taking place within the Turkish families in recent decades. Mean household size declined from 5.5 to 4.5 during the period between 1968 and 1993. The biggest drop was observed in the developed Western region while in the least developed region of the country, the East, there was no change in the mean household size except a rise in 1983. The other regions all experienced similar amount of decreases in mean sizes.
Nuclear families have always been the dominant type of family in Turkey and their proportion have an increasing trend. The latest figure from the 1993 survey also revealed that two-thirds of the households (62.2 %) in Turkey are living in a nuclear form (husband, wife, and children, if any).
Family formation and sustainability of the families had been tradionally very strong in Turkey. Consequently, divorce rates have been low and almost constant with less than one in ten thousand during the recent history. Percantage of divorced population for age 12 and over was around 0.7 percent in 1997. It was 0.45 percent for males and 0.95 percent for females. Age at first marriage is around 22 for females and 26 for males. Because of social norms, sexual relationship and extra-marital births are very rare in Turkey. However, they have been increasing in urban areas; still this is not a discernable problem.
In accordance with the ICPD Programme of Action, more emphasis is given to improve the status of women in Turkey, which is a crucial determinant of women’s and children’s well being. In 1990, as a national mechanism for the enhanchement of women’s satus the General Directorate of Women’s Status and Problems was established. It functions within the Ministry of State responsible for Women and Family Affairs. The General Directorate has been working with a number of NGOs, donor agencies and voluntary organizations to strengthen the network of women’s organization and to collaborate towards the aim of increasing the awareness level of decision makers and the public at large on the cocerns of women. Some NGOs have ongoing activities geared to increase the level of participation of women in decision making processes as well. But there are a small number of initiatives which have the potential to became nation-wide movement. Turkish Civil Code has been revised to eliminate certain articles contradictory to gender equality (ie.retaining maidens name after marriage, ownership on acquired propert after marrige). Revised Civil Code is waiting for the approval of the Turkish Grand National Assembly.
In addition, Social Structure and Women’s Statistics Department was established in State Institute of Statistics in 1993 in order to identify the status and problems of women and started to generate and make available gender-specific data. Universities established centers for women studies. They developed graduate programmes aiming to contribute to efforts towords the improvement of the status of women. For the time being, twelve of the leading universities have women studies center.
After the ICPD, NGOs are more actively involved in advocacy and IEC on issues concerning women.
With respect to government policies concerning the compatibility between paid employment and familial responsibilities, a variety of incentives are granted to secure family unity under the Turkish legislation. One of these is the posting of the state employee husband and wife to the same settlement area. Women working in the public sector are eligible for maternal leave three weeks before and six weeks following delivery. The women are granted a leave of one and a half hours per day for breast-feeding, for six months after the birth.. If requested, the male civil servant is granted a three day paternity leave after his wife’s delivery. Women workers under the social insurance program are granted six weeks of leave for both post and prenatal periods. In addition, the mother may be given an unpaid leave of absence for up to six months following the normal postnatal leaves. This period has been increased to 12 months for civil servants recently. Those workers who belong to trade unions recive a small monetary assistance at the time of child birth, and compensation is added to the worker’s wages for each child until 18 years of age. If the child proceeds with education through the university, compensation payment continues till graduation. Similar kinds of contribution exist for civil servants as well. Children whose parent(s) are covered any type of social security schemes become entitled to use of health services free of charge at least until the age of 18.
With regard to child care, labour laws states that establishment employing 100-300 women should have nursing rooms and those employing more than 300 should provide nurseries. However, in practise, the employers keep the number of their women employees below these limits and thus constrain work opportunities for women. New measures are planned to overcome this problem. For instance, criteria for having nursing room and nurseries will be the total number of workers instead of women workers only.
In the process of urbanization and modernization child costs are increasing for families in Turkey. Direct cost associated with delivery, housing, clothing, education, food, health and opportunity costs like earnings of the mother foregone when giving birth, and the lost income of students who might otherwise be working to earn money are getting more public awareness in Turkey. Since the state has the responsibility to provide basic health and education to its citizens, a substantial amount of the costs are being paid by the society instead of families.
Intervention of the state in the field of education and health in other words in basic social services delivery remains, as it’s fundamental role in Turkey. Investments targeted to the advancement of the women, children and the poor are being accepted as tools for bringing improvements in human development. Unfurtanetely it has been observed that the total national expenditure on health services gradually decreased in percenatge points of GNP from 4.4 in 1993 to 4.0 in 1997 which is the lowest among OECD countries.
The proportion of population with medical coverage under the social security schemes and private insurance increased to 67.1 percent in 1997 from 52 percent in 1989. The uninsured patients rely largely on their own funding and benefit from subsidized medical services provided by government hospitals and health senters. The green card implementation has been started as a step toward ensuring equity in the distribution of state subsidies to the needy citizens for health services.
As for families with limited resources, families are provided social aid from several institution among which Social Aid Fund, which functions under the Prime Ministry, is the major aid provider for those who are in need. But, because of its inadequate structuring, aids are not allocated in a systematic and even manner. Seventh Five Year Development Plan put forward the arrangement, institutionalization and effective use of all types of social aid and services undertaken by the public. New measures regarding the issue are being dealt with under the Social Security Reform Project.
2- PERCEPTION AND POLICY CONCERNING MORTALITY AND HEALTH
Sharp declines in infant and child mortality have been observed during the recent decades. In the early 1980s, the infant mortality (IMR) rate was as high as 109 per 1000 live births; the 1993 Turkish Demographic and Health Survey (TDHS) estimated the IMR at 53 per 1000 live births. Estimates for 1998 and 2000 are 37.9 and 34.8 respectively. The TDHS also revealed that the proportion of neonatal deaths among all infant deaths had exceeded that of postnatal deaths, reaching 56 percent, and indicating a reversal of the pattern observed in the 1978 Turkish Fertility Survey. Such results imply that perinatal couses of death are the leading causes of infant mortality.
Reduction in infant and child mortality have played a major role in raising the average expectation of life at birth. A large percentage of improvements in the increase of survivors were attributable to the impact of special programs aiming improvements in child health including programs of immunization, control of diarrhoeal diseases, and acute respiratory infections.
Recent mortality analysis have shown the expectation of life at birth has increased from 59 years during 1980-85 to 65 years during 1985-90. Estimates of life expectancy at birth for the 1990-95 period is 67.3 and 69.3 for the year 2000.
Diarrhoeal diseases are still among the important causes of childhood morbidity and mortality. These are most frequently seen among children under age of five. Also acute respiratory infections such as pneumonia is the second most common cause of deaths among children under 5 years age. As the rates of morbidity and mortality due to infectious diseases are decreasing in Turkey, deaths from hereditary metabolic diseases, other genetic diseases and the malignancies of childhood are becoming more visible. The program for Screening Phenylketonuria, The program for Iodising the Consumed Alimentary Salt (for the prevention of endemic goitre) an the program for fluorine (for the prevention periodontal diseases and tooth decay especially among 0-14 age group children) have been initiated recently in Turkey.
HIV infections and AIDS is not among the main problems of Turkey yet. Large proportion of HIV/AIDS cases due to heterosexual transmission, mother to child transmission is 1% of the cases, according to the June-1998 statistics of Ministry of Health (MoH), number of HIV positive carriers are 540 and the number of AIDS cases are 273.
Cancer was the fourth greatest death reason 20 years ago but it has risen to the second place among deaths whose reason is known, following cardiovascular diseases.
Chronic disease including hypertansion and other circulatory diseases gained more importance, because the life expectancy has been prolonged. In order to decrease the mortality and morbidity due to them, to improve the quality of life and to prolong the life expectancy were planned activities in hormony with the targets. Implementations of these activities began in October 1997. According to the research done by Turkish Heart Foundation between 1991-96, there were about 1.2 million patients who have coronary heart diseases in Turkey and 130 thousand of them died in a year.
Smoking is a very widespread habit in Turkey. In order to prevent the destruction of tobacco consumption, the law (4207, 7 November 1996) was accepted. Under the this law, in all closed public areas cigarette smoking is prohibited.
Drugs related health problems could be accepted as it’s early stages. In Turkey AMATEM (Alcohol, substance, research and rehabilitation centre) features to be the only official institution specialised in services regarding substance dependence. Since 1983, there have been rapid increased in enrolments regarding AMATEM services.
Health services in Turkey are provided mainly by the Ministry of Health, SSK (Social Insurance Organization), Universities, the Ministry of Defense, and private physicians, dentists, and pharmacists, nurses and other health professionals. The Ministry of Health is the major provider of primary and secondary health care and the only provider of preventive health services. At the central level, the MoH is responsible for the country's health policy and health services. At the provincial level, through provincial health directorates health services is also provided by the MoH.
The basic health care units are health centres and health posts at the village level. According to the current legislation health posts staffed by a midwife serve a population of 2,500–3,000 in rural areas. Health centres serve a population of 5,000–10,000 and are staffed by a team consisting of physician, nurse, midwife, health technician, and medical secretary. The main functions of health centres are the prevention and treatment of communicable diseases; immunisation; maternal and child health services, family planning; public health education; environmental health; patient care; and the collection of statistical data concerning health.
The MoH, the Ministry of Defense, the Ministry of Labor and Social Security, some State Economic Enterprises, Universities, and the private sector provide secondary and tertiary health care services. Of the total of 1,129 hospitals, the MoH runs 705. These provide 50.0 percent of the hospital beds in the country, with an average occupancy rate of 55 percent.
SSK provides mainly curative services to its members in 115 hospitals with 25,934 beds (16.1 percent) and an occupancy rate of around 65 percent. The 38 university hospitals provide health services with 23,503 beds (14.6 percent) with an average occupancy rate of 61.7 percent.
The Ministry of Health is the largest health services provider in Turkey, employing about 195,000 staff: it operates 705 hospitals (including specialty hospitals) with 80.737 bed capacity. Number of hospital beds per 100,000 population in Turkey is 257 beds in 1997.
The health indicators in Turkey are not satisfactory given its level of socioeconomic development. The most common causes of mortality are preventable or controllable. The scope and cost of curative services are increasing, the technology is advancing, countries are trying to decrease the costs of curative services by protecting and improving their citizens’ health and are also exploring a system in which they can use their resources more effectively.
The reforms are intended to provide people with better health services according to their needs by extending social insurance coverage to whole population through principles of equity, efficiency and effectiveness.
The objectives of health care reform in Turkey are:
- Improve the health status of the Turkish population by covering the whole population under the social health insurance scheme,
- Equity in health services,
- Emphasis on preventive services, health promotion and primary curative care ,
- Efficiency in service provision,
- Separating service purchaser- provider,
- Establishing competition between service providers,
- Appropriate use of technology,
- Strengthening multi-sectoral cooperation for health services,
- Collection of effective, timely and accurate information to improve information based decision making,
- Appropriate usage of human resources according to skill, duration, number and combination,
- Delegation of decision making authority to the individual service units.
Since the implementation of reforms requires changes in legislation, three major draft laws (health Financing Institution Law, Hospitals and Health Enterprises Law, and Primary care and Family Physician Services Law) have been prepared by the MoH, Health Project Coordination Unit with contribution from all interested parties and have been made ready to be submitted to the Parliament.
According to the results of a survey conducted in 1974, the maternal mortality rate (MMR) was estimated as 207 per 100,000 live births (LBs). Another study conducted in 1989 by the State Institute of Statistics using sisterhood method and estimated MMR as 132 per 100,000 LBs for the year 1981. However, since the latter estimation the maternal mortality rate seems more likely to be about 100 per 100,000 LBs. In 1996 a prospective hospital based study was designed by MoH in collaboration with WHO (World Health Organisation), UNFPA (United Nations Population Fund) and Hacettepe University , Public Health Department on maternal mortality and its causes. According to the intermediate evaluation of this study, the maternal mortality rate was estimated as 54.2 per 100,000 live births and the main causes of maternal deaths was found as toxaemia(28.2 %), haemorrhage (5.6%) and infections (5.6 %) . The study is continuing and the results with more accurate data on maternal mortality for Turkey will be available at the end of the year of 1998.
Turkey has a young population as a result of high fertility and growth rates in the recent past. A third of the population is under 15 years of age while the population of the elderly is quite low. The 54% of the women population of Turkey is in reproductive age .
Since the reproductive health care services are accepted as integral components of primary health care, the service coverage is not only to meet the needs of women but also for those of adolescents and adult men.
Since 1961, reproductive health, family planning and STD services are being provided as integral parts of primary health care ( PHC) services. The infrastructure of National Health Care System is quite favourable to provide these services in all over the country.
At the primary health care level, the given reproductive health services include: Family planning counselling, information, education, communication and clinical services for temporary contraceptive methods; education, communication and services for prenatal care, safe delivery and post-natal care ( infant and women’s health care and breastfeeding), STD counselling, information, education, communication and early diagnosis and treatment of common gynaecological and obstetrical disorders and diseases.
At the hospital level, besides these services permanent contraceptive methods, prevention and appropriate treatment of infertility, termination of pregnancy and management of complications of abortion; treatment of STDs and other reproductive health issues; further diagnosis and treatment for risks and complications of pregnancy, delivery, new-born, breast cancer and cancers of reproductive system are provided.
The first anti-natalist Population Planning Law was enacted in 1965. In 1983, the law was revised and a more liberal and comprehensive one was accepted. This new law legalised abortion up to 10 th week of pregnancy and voluntary surgical contraception. In addition, trained nurses and midwives were authorised to provide effective methods like IUD insertion. In this law, inter-sectorial collaboration was also emphasised for the success of family planning services.
To secure conformity to human rights, and to ethical and professional standards in the delivery of family planning and related reproductive health services aimed at ensuring responsible, voluntary and informed consent and also regarding service provision the Population Planning Advisory Committee (PPAC) is established. In 1993 Women Health Advisory Board was established under the
PPAC.Ministries, international organisations, NGOs, State Planning Organisation, State Institute of Statistics, Hacettepe Institute of Population Studies, Higher Education Council are being represented at PPAC.
According to the TDH (1993), 80% of currently married women have used a family planning method at some time in their life. Overall, 63 percent of currently married women are using a contraceptive method. The majority of these women are modern method users (35%) but substantial proportion use of traditional methods (28%), particularly withdrawal. Considering specific methods, The IUD is the most commonly used modern method (19%), the condom (7%) and the pill (5%) are the second and third most popular modern methods. Current use of the IUD has increased markedly and that of female sterilisation has increased slightly.
To improve reproductive health and strengthen the RH care services including MCH/FP services to reach the WHO Health For All Targets by the year 2000 and also implement the recommendations of ICPD National Targets and Strategies, Women’s Health and Family Planning Strategic Plan was prepared in 1995, to help couples and individuals meet their reproductive goals in a framework that promotes optimum health, responsibility and family well-being and respects the dignity of all persons and their right to access qualified reproductive health services.
3- PERCEPTION AND POLICY RELATED TO POPULATION AGEING, INCLUDING CHANGE IN POPULATION AGE STRUCTURE
In order to focus attention on a small but important number of changes in population structure, three age groups of the population are taken into consideration: First group is child which includes individuals from birth up to age 15. Second group is the population in working ages which is from age 15 to age 64. The last group is elderly, defined as aged 65 and over.
Proportion of children in total population was 35 percent in 1990. It is 31 percent in 1998 and expected to decrease 26 percent in the year 2010. Size of the child population has been almost constant with 6.5 million since 1990.
Proportion of the population in working ages is around 64 percent in 1998 and expected to increase to 68 percent in 2010. Yearly rate of increase for this group has been rising and reached 2.1 percent in 1998. It is expected to decrease 1.5 percent in 2010.
Proportion of elder population in total was 4 percent in 1990. It is around 5 percent in 1998 and expected to increase to 6 percent in 2010. The growth rate of elder population is two times higher than the growth rate of total population.
Age dependency ratio is 55.8 in 1998 and expected to continue to decrease 50 in the year 2010. Child dependency ratio and elderly dependency ratio are 47.9 and 7.9 respectively. They are expected to be 38.4 and 11.2 in the year 2010.
The elderly begin to appear important some time around the 1980s also, and than grow continuously in the future at a rapid rate. The 1990s present an entirely new structural situation with trends that will completely change Turkey’s population situations during the immediate future and for decades after that. The changes in prospect are basically unavoidable. They are the consequences of changes in past mortality and fertility that have already taken place.
The Turkish government places importance for ageing population for the near future and started to make preperations for new policies regarding the ageing population. In addition to the existing social services provided to the elderly, such as counselling, old people homes, nursing homes, social and
cultural programs for the elderly by public, private and NGO, new programmes are being generated. Furthermore, Social Security Reform Project which is yet negotiated by the concerning parties gives special importance to the pension system.
With regard to the health of ageing population, programs for elderly related with the chronic diseases including hypertansion and other circulatory diseases and diabetes were planned and implementing some selected cities as a pilot. At the some time among the reproductive health programme activities , some special activities have been planning. Newly the primary health care activities include menapousal period. Activities have been implementing in four provinces mainly include preventive care like osteoporosis.
There are three main social security funds in Turkey, each vith a specific target population. Together, the three funds insured 9.5 million people in 1997-almost one half of total employment. Once the 4.8 million current beneficiaries of pensions are taken into account as well as dependants of those insured, around 45 million people (two thirds of the population) have some sort of coverage. In addition to pensions, all three funds provide health, disability, and death beneficiaries. Each fund functions on pay-as-you-earn basis, and as a result, has relatively few investment assets.
The Turkish government has produced a set of draft laws that introduce very modest changes in the benefits structure and retirement age of the funds to improve their financial situation. These proposals would be short-run provisional solutions. Given the severity of the situation, a set of substantial measures needs to be applied to the present system to immediately stem the accelerating deficits and provide breathing room for more fundemantal reforms. The key element in such a reform would be the imposition of a minimum retirement age of 60/58 years for existing workers with a short transition arrangement, a sharp increase in the minimum contribution period, and indexation of pensions to yhe Consumer Prices Index. A major effort to improve administration of the system also need to be undertaken.
4- PERCEPTION AND POLICY CONCERNING INTERNATIONAL MIGRATION
The population of Turkey has undergone a structural change with regard to urbanization especially starting from 1950. 1970 census indicated that about one-third of the population (32.3 %) were living in settlements which are considered as urban(with a population of 20.000 or more). This percentage increased to 51.4 in 1990. 1997 population count found two-third of the population (65.03%) living in province, district, an sub-district centers.
Rapid urbanization has led to considerable bottlenecks in urban sevices, to the evolution of problem burden centers as a result of its unplanned nature and the emergencies of Gecekondus where sub-culture groups not yet assimilated to the urban way of life blossoms. The process of rapid urbanization accelerated the growth of environmental problems.
International migration is a phenomenon which still exerts considerable influence on the social, economic and demographic structure of the country. Intensive population movements abroad had started back in early 60s. Up to 1973 this outward movement took the shape in which Turkish citizens moved abroad for employment. Starting from 1974 and till the end of the 80s this movement sloved down considerably, then turned out to be mostly for the reunification of families. Today, emigartion is possible mainly through marriages.
After change of the rgime in Iran and particularly during the Iraq-Iran war, approximately five million Iranians are believed to have entered Tuırkey. At the end of May 1989, ethnic Turks began to leave Bulgaria for Turkey in large numbers and undere severe hardship. In less than three months, about 320.000 ethnic Turks from Bulgaria arrived in Turkey. Around 140.000 of them have since returned tu
Bulgaria, but the rest remained in Turkey, most of them being granted Turkish citizenship. Several measures have been taken by the Turkish authorities for their resettlement, vocational education and placement in jobs relevant to their training background.
Movement of Asylum seekers of Iraqi origin towards Turkey have occurred on three major occasions in the years 1981-91. The first one occurred in the aftermath of the Iran-Iraq war. In August 1988 more than 50.000 Iraqis fled to Turkey. The second movement began with the Iraqi occupation of Kuwait in August 1991. However this movement took place as small groups. The third and most important mass movement occurred as a result of military action by the Iraqi government against civilian groups in Northern Iraq at the end of the Gulf war. Almost over night 446.000 Iraqis fled to Turkey in order to save their lives. This was, since the World War II, the largest asylum movement in such a short time. In cooperation with the UN and other international governmental and non-governmental organizations, their return to Iraq has been arranged , with only a few thousands still remaining in Turkey. Each of these movements of asylum seekers have affected Turkey politically, economically and socially.
5- PERCEPTION AND POLICY OF GOVERNMENT RELATED TO POPULATION GROWTH
Since the founding of the Republic in 1923, Turkey has experienced substantial changes in its demographic structure, particularly over the past few decades. The general structure over the last twenty (or fifteen) years was characterized by a rapid decline in fertility, following that of mortality which is continuing to improve and a high population growth in urban areas.
The population of Turkey was around 13 million in 1923. The population reached maximum growth rate of 2.8 percent during 1950s. Total fertility rate recovered to a high level, fluctuating between 6.5 and 7.0 children before 1950s. Fertility level started to decline during the 1950s, but a rapid decline was not seen until after about 1970. During the years from 1970 to 1998 there was a very rapid decline from about 5.6 to 2.4 children.
The death rate declined continuously except for a temporary setback during the second world war. During the years from 1950, when infant mortality was about 250 deaths per thousand births, to 1998 when it reached around 38 deaths per thousand births. The improvement was especially rapid during 1980s, which is generally credited to lower fertility, improved living conditions, education, health services and special immunization campaigns. Infant mortality rate is expected to decrease 23 per thousand births by the year 2010.
The improvements in infant and early childhood survival have made a large contribution to raising the general expectation of life at birth, which was increased from 55 years to 69 years between 1970 and 1998. It is expected to reach 71 years in the year 2010.
The population of Turkey has been increased almost five times since 1923. In 1998, the population of Turkey is around 63.5 million. It is expected to reach around 74 million by 2010.
6- PERCEPTION OF THE GOVERNMENT REGARDING THE NEED FOR POLICY-RELATED COLLECTION OF DATA AND RESEARCH
Turkey has a series of censuses and surveys used for implementation, monitoring and evaluation of government program. However vital registration system is needed to be improved in order to collect timely and completed data.
One of the most important characteristics of Turkey is the high population growth rate in urban areas due to the internal migration. Turkey plans to carry out migration surveys in metropolitan areas. These researches will improve regional data within the country.
Turkey needs to improve data on health statistics, ageing population, living standards and environmental data to analyze interrelationship between population and environment.
Turkey has been implementing some projects in cooperation with international organization on international migration, ageing population, tourism, trade, national account, transportation, etc. The purposes of the projects are to produce internationally comparable data and analyze them.
Turkey has also give technical support to the countries of the Central Asia and Macedonia, in the field of analysis of demographic data, population projections, international migration.
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