World Applied Sciences Journal 17 (8): 976-985, 2012 ISSN 1818-4952 IDOSI Publications, 2012

Level of Patients Satisfaction Toward National Health Insurance in Istanbul City (Turkey)
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Saad Ahmed Ali Jadoo, 1Sharifa Ezat Wan Puteh, 2Zafar Ahmed and 1Ammar Jawdat Department of Community Health, Faculty of Medicine, National University of Malaysia, UKMMC, Malaysia 2 International Training Centre for Case mix and Clinical Coding, National University of Malaysia, UKMMC, Malaysia
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Abstract: A cross sectional study was carried out in July-October 2011 in Istanbul city, Turkey to determine the level of patients satisfaction and factors influencing satisfaction toward newly reformed national health insurance. A total of 345 heads of houshold have been selected by using simple random sampling selection method. Data was collected via households structured questionnaire and Patients' Satisfaction Questionnaire version II. The response rate was (89%) and data was analyzed by using SPSS version 16.0. Age of respondents was around 20 to 70 years old with the mean age of 41.97 13.87 years. Majority of clients' are educated till tertiary education (54.5%) and most of them are currently employed (87.2%). Among the respondents, more than half were satisfied toward national health insurance (53.3%). Respondents were satisfied with domains of access to care (66.7%); availability of resources (52.2%); technical quality (56.5%); overall satisfaction (55.9%); continuity of care (68.7%) and humaneness (53.6%). In bivariate chi-square analysis, result of this study indicated that there were eight factors significantly associated with level of satisfaction i.e. age, gender, marital status, education, occupation, self perceived health status, area of residency and type of households plan. Further analysis, by using multiple logistic regression showed that the eight factors also significant predictors to the level of satisfaction. Higher patients satisfaction was associated with improved access to care and continuity of care. However, light must be shed on availability of resources, technical quality and humaneness to improve overall patients satisfaction. Key words: Accessibility Availability Technical Quality Continuity of Care Humaneness

INTRODUCTION Patient satisfaction is one of the barometers that reflect how well a health care system is working [1]. In recent years patients have increasingly been considered as consumers or customers by the health care system [2]. It has become increasingly important for health care professionals to systematically measure patients satisfaction with their care. Measuring patient satisfaction involves evaluating patients perceptions and determining whether they felt that their needs were adequately met [2,3]. Healthcare staff awareness about the needs and wants of their patients, [4] as well as physician-patient interaction significanlty affect the patients satisfaction [5].

Turkey is one of the developing countries. It is a high- middle income OECD member, with about 71,517,000 total populations. Growth Rate is (5.9%), total expenditure on health (6.1% of GDP). Public expenditure on health was 73% of total health expenditure, health expenditure per capita, (624 USD) in 2008. Out-of-pocket health expenditure was (17.4%) to total health expenditure [6]. Aran 2008, showed that health insurance system inTurkey was composed of contributory and non contributory systems [7] Social security system is considered as a conributory system and it can be categorized into three different social security organizations, each one with its service network and they vary in the offered benifits [7,8]. They are as follows:

Corresponding Author: Sharifa Ezat Wan Puteh, Department of Community Health, Faculty of Medicine, National University of Malay, UKMMC, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +60 193217468.

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The Social Insurance Organization (SSK), it was offering services to private sector employees, blue collar civil servants and their families. About 46.26 % of the Turkeys population had been supported by this organization in the year 2008. Its members get treated by SSKs hospitals only. The financial source of this organization is a compulsaray deduction from the salaries of the employees which is done by the employers. Its calculated as 5% cut from employees and 6% cut from employers [8,9]. Bag-kur, the social insurance program established for serving traders, artists and self own business, in 2008 they have supported 20.4% of Turkeys population. Since they didnt establish their own health centers, they utilized the SSK hospitals and signed contracts with some other private health providers. The members choose the amount of premium they pay. Primium rates for the members starting from 1 to 24, where 1 representing the least premium rate [8,9]. The Government Employees Retirement Fund (GERF), it was an insurance scheme specialized in offering services to the working and retired civil servants and their supported families. In 2008 they have supported 13.22% of Turkeys population. They have benifited from the governmental hospitals. A compulsaray premium rate calculated as 11% of salary cut from employees and 18% of salary cut from employers [8,9]. For all the above mentioned social insurance organizations (The SSK, GERF and Bag-Kur), the cost of medicines is paid jointly by employees and employers 10% for retired members and 20% for the active members and their supported family. Also these organizations can obtain a governmental support if their expenses surpasses their income [7-9]. In Turkey the social assistance system subdivided into main four programs: elder-hood/disability benefits, in-kind transfer, family and childrens benefits and non-contributory health insurance scheme (Green Card). The green card scheme have been established in 1992 in order to provide free heath assistance to the people with income levels less than the incomes threshold and who do not have social security assistance [10]. The scheme is wholly financed by the state. A survey in 2006 showed that there are 10.2 million Green Card holders, which means 14.1 % of the Turkeys population [8] They are benefited from the states hospitals and the states university hospitals [9]. The scheme covers all the expensed of the offered treatments and medicines and all the expenses of a new born child (not more than three 977

months age) and their mothers. In the year 2007, the green card scheme allotted about 85% of the social assistant budget which made it the biggest non-contributory program [10]. Historically, Turkey has used many reform approches to rectify their centeralized and fragmented healthcare systems [11]. In the year 2003 Turkey started Health Transformation Programme (HTP) [12] for the sake of pairing its health care system with the health regulations of the E.U and OECD countries [7]. Turkeys Health Transformation Programme has been able to ensure universal health coverage for essential care and significantly improve health outcomes [13]. The three social security institutions (SSK, Bag-Kur and GERF, in addition to Green Card Programme) were unified under one umbrella; the unified government-provided mandatory; the Social Security Institution (SSI). The purchaser and provider functions of the Ministry of Health hospitals as well as the insurance organizations were separated [14]. Health information system has been upgraded. In 2004, Ministry of health also started a new Performance-based System (P4P) in all its hospitals and healthcare providers which led to improved hospital efficiency [15] . The implementation of the "Social Security and Universal Health Insurance Law" in October 2008 extended the insurance coverage to the whole population [15,16]. OECD Reviews of Turkey's health care system (OECD 2008) shows that health status has improved rapidly in Turkey in recent decades, partly as a result of higher health spending. Infant mortality rate in Turkey decreased from 78 per 1000 live births in 1993 to 21 per 1000 live births in 2007, as well as the Maternal Death rate decreased from 70 per 100.000 live births to 28.5 per 100,000 lived birth in 2005. Betterment of the life expectancy for both men and women increased from 70.9 in 2003; to 71.9 years old in 2007 [17,18]. The aim of this research is to study the level of patients' satisfaction with national health insurance recently applied in Turkey. This will indicate whether clients are satisfied or not with health services and coverage offered? Does the health insurance provide good coverage and protection for her people? Methodology: The cross sectional study was conducted in Istanbul city (Turkey) from July to October 2011. Sample size was calculated based on the calculation from Lwanga and Lemeshow [19], with confidence interval of 95%, prevalence of satisfaction from the previous study 70% [20] and precision is 10%; the minimum sample size would be 345 patients. We managed to recruit 345 patients

World Appl. Sci. J., 17 (8): 976-985, 2012

using simple random sellection method. Data was collected by households survey using Patient Satisfaction Questionnaire version II. The questionnaire contain 38 items which related to six dimensions of the patients satisfaction such as access to care, availability of resoueces, technical quality, overall satisfaction, continuity of care and humaneness. Likert Scale was used to score the satisfaction questionnaire with five response categories (excellent,very good, good, fair and poor). Scaling decision for the questionnaire is by using the median score as the cut of point. Data was analyzed using Statistical Package for Social Science (SPSS) programme version 16.0. Normality tests were done and all of the quantitative data were found to be normally distributed. Therefore, statistical analysis which used in this study were parametric tests such as Pearson Correlation and Chi square test. In further analysis, multiple logistic regression was done to predict the factors that influence the level of satisfaction. RESULTS The response rate in this study was 89.0% (345 out of 388). As high as 53.3 % of the respondents were satisfied comparing with 46.7% who was dissatisfied. Respondents socio-demographic characteristics studied are age, sex, marital status, educational status, occupational sector, households income, self perceived health status, area of residency and type of households plan. Respondents' age ranged from 20-70 years old but the mean age was 41.9713.87 years. From the 345 included in the study they were 192 males (55.7%) compared with153 females (44.3%). More than half were married; 50.7% compared to 49.3% were single (unmarried, divorce and widows). In term of age, division of age into two categories saw that the highest response rate at 64.9% were the age of 41 years old and above and this was followed by respondents who were considered as young i.e. less than 41 years old and below at 29.4%. As for educational backgrounds, 54.5% of the respondents had completed their academic education and considered as highly educated (with university certificate and above) compared with 45.5% who completed their primary and secondary education (considered as low level education). In term of households occupational status, 27.2% of them who worked in the governmental sector; 42.6% who worked in the private sector; 17.4% were self employed, while 12.8% were unemployed at all. The households 978

median annual income was (USD 10,000) and interquartile range (IQR) 937. Depending on the median value; as much as 40.0% of the respondents were from lower income group compared to 60.0% were of higher income. For the self perceived health status; 60.3% perceived themselves as healthy compared to 39.7% perceived themselves as unhealthy. In term of distribution of respondents according to urbanization locality, there were 29.9% respondents from rural area and 70.1% from urban area. In term of type of households health insurance plan; 54.5% of the respondents were under coverage of SSK; 17.1% of the respondents were under coverage of Bag-Kur; 12.8% of the respondents were under coverage of GERF and 15.7% of the respondents were under coverage of Green Card scheme. Table 1 showed the demographic characteristics of respondents. Level of Satisfaction: Table 2 showed that the most of the patients were satisfied with access to care (66.7%), availability of resources 180 (52.2%), technical quality of providers 195 (56.5%), overall satisfaction 193 (55.9%), continuity of care 237 (68.7%) and humaneness 185 (53.6%). By overall, more than half of the patients were satisfied with services that they received (53.3 %), while others were not satisfied (46.7%). Level of Satisfaction by Socio-Demographic Factor: Table 3 showed the chi-square tests for characteristic of patients and level of satisfaction. The result found that there was a significant relationship between gender, marital status, education level, occupation and self perceived health status, area of residency and type of households plan with level of satisfaction (p value >0.05). In this study, the female were more satisfied with 67.5%. Married respondents were more satisfied (62.9%) than singles 43.5%. Comparing between the levels of satisfaction with education, low educated group (68.6%) was more satisfied than high educated group (40.7%). In term of occupation, working respondents were more satisfied (56.5%) comparing to the unemployed (31.8%). Healthy respondents perceived higher satisfaction (63.9%) than those who perceived themselves as unhealthy (37.2%). Comparing between the levels of satisfaction with area of residency, urban respondents were more satisfied (64.0%) than rural area (28.2%). Comparing between the level of satisfaction with type of households plan, Green Card holders were more satisfied (88.9%) comparing to the other three groups SSK (46.3%), Bag-Kur (55.9%) and GERF (36.4%).

World Appl. Sci. J., 17 (8): 976-985, 2012

Table 1: Frequency Distribution of Socio - demographic of Respondents (n=345) Patients Characteristics Age 20-29 years 30-39 years 40-49 years 50-59 years = > 60 Median IQR 41 21 Gender Male Female Marital Status Single married Highest Level of Education Primary education Secondary education Tertiary education Households Occuaption Private Own business Government Not working General Health Status Healthy Unhealthy Area of Residencey Rural Urban Type of Households Plan SSK Bag-Kur GERF Green Card Households Annual Income (USD) Mean sd 11865 74.6 Freq. 105 81 65 52 42 Mean sd 41.97 192 153 170 175 47 110 188 147 60 94 44 208 137 103 242 188 59 44 54 Median 10,000 (%) (30.4) (23.5) (18.8) (15.1) (12.2) 13.37 (55.7) (44.3) (49.3) (50.7) (13.6) (31.9) (54.5) (42.6) (17.4) (27.2) (12.8) (60.3) (39.7) (29.9) (70.1) (54.4) (17.1) (12.8) (15.7) IQR 937

Table 2: Frequency Distribution of Level of Satisfaction toward Six Dimensions (n=345) Poor satisfaction -----------------------------------Level of satisfaction Mean Sd Freq. % Access to care 24.32 6.05 115 (33.3) Availability of resources 14.18 4.02 165 (47.8) Technical quality 24.85 6.59 150 (43.5) Overall satisfaction 12.25 3.82 152 (44.1) Continuity of care 11.40 4.21 108 (31.3) Humaneness 21.36 5.99 160 (46.4) By Overall 108.35 21.42 161 (46.7) Table 3: Association between Socio Demographic Factors and Level of Satisfaction Level of Satisfaction Poor Satisfaction Good Satisfaction ---------------------------------------------Factors f. (%) f. (%) Gender Male 111 (58.1) 80 (41.9) Female 50 (32.5) 104 (67.5) Marital Status Single 96 (56.5) 74 (43.5) Married 65 (37.1) 110 (62.9) Education Low education 49 (31.4) 107 (68.6) High education 112 (59.3) 77 (40.7) Occupation Working 131 (43.5) 170 (56.5) Not working 30 (68.2) 14 (31.2) Health Status Healthy 75 (36.1) 133 (63.9)

Good satisfaction ---------------------------------------Freq. % 230 (66.7) 180 (52.2) 195 (56.5) 193 (55.9) 237 (68.7) 185 (53.6) 184 (53.3)

*p 0.000

POR 2.89

95% Confidence Interval ------------------L. U. 1.85-4.50

22.53

12.94

0.000

2.20

1.43-3.38

26.63

0.000

0.32

0.20-0.49

9.38

0.002

0.36

0.18-0.70

23.69

0.000

0.33

0.21-0.52

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Table 3: Continue Level of Satisfaction Poor Satisfaction ---------------------f. (%) 86 74 87 101 26 28 6 (62.8) (71.8) (36.0) (53.7) (44.1) (63.6) (11.1) Good Satisfaction ------------------------f. (%) 51 29 155 87 33 16 48 (37.2) (28.2) (64.0) (46.3) (55.9) (36.4) (88.9) 37.40 0.000 4.55 2.75-7.52 95% Confidence Interval ------------------L. U.

Factors Unhealthy Residency Rural Urban Type of plan SSK Bag-Kur GERF Green Card

*p

POR

36.44

0.000

*P value significant at > 0.05, Chi square test Table 4: Association between Age, Income and level of satisfaction Factors Age Households annual Income *Correlation is significant at the 0.01 level (2-tailed) Table 5: Plan Type Comparisons for Level of Satisfaction (ANOVA analysis, n= 345) Type of Households Health Insurance Plan SSK Bag-kur GERF Green Card *p value significant > 0.05 Table 6: Association of Type of plan, Age, Income factors with level of satisfaction Level of Satisfaction Poor Satisfaction ----------------------f. (%) 155 6 109 52 67 94 (53.3) (11.1) (64.9) (29.4) (48.6) (45.4) Good Satisfaction -------------------------f. (%) 136 48 59 125 71 113 (46.7) (88.9) (35.1) (70.6) (51.4) (54.6) 95% Confidence Interval --------------------------------------POR L. U. 9.12 4.44 3.78-21.97 2.82-6.98 Level of Satisfaction ------------------------------------------------------------------------------------------------------------------------------------------------------n mean sd F. *p 188 59 44 54 104.46 113.00 102.59 121.48 23.45 15.25 14.93 17.98 11.833 0.000 Pearson Correlation 0.238 0.079 P value* 0.000 0.143

Factors Type of plan Non-contributory Contributory Age = > 41 years < 41 years Income Low income High income

*p 0.000 0.000

32.52 43.65

0.33

0.576

1.13

0.74-1.75

Table 7: Level of Association of Dichotomous Variables with Level of Satisfaction Variables Age Gender Marital Status Level of Education Households occupation Self Perceived Health Status Type of Households plan Area of Residency Income Scores 76.839 22.533 66.106 33.767 28.380 23.687 32.518 37.401 0.328 df 1 1 1 1 1 1 1 1 1 Sig. 0.000 0.000 0.000 0.000 0.002 0.000 0.000 0.000 0.567

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Table 8: Binary Logistic Regression of level of Satisafction (backward LR) 95.0% C.I.for EXP(B) ---------------------------L. U. 1.84- 6.78

Variables Age < 41 years old > 41 years old Gender Female Male Marital Status Married Single Education Low education High education Health Status Healthy Unhealthy Occupation Working Not working Type of health plan Non contributory Contributory Area of Residency Urban Rural Income High income Low income Constant

B 1.262 Reference Group 1.226 Reference Group 1.590 Reference Group -1.273 Reference Group -1.431 Reference Group -2.534 Reference Group 2.431 Reference Group 1.983 Reference Group 0.501 Reference Group -2.220

S.E. 0.332

Wald 14.427

df 1

Sig. 0.000

POR 3.53

0.337

13.194

0.000

3.40

1.76- 6.60

0.333

22.757

.0000

4.90

2.56 -9.42

0.350

13.235

0.000

0.28

0.14-0.56

0.351

16.628

0.000

0.24

0.12-0.48

0.604

17.569

0.000

0.08

0.02-0.26

0.733

10.996

0.001

11.37

2.70-47.88

0.389

26.038

0.000

7.26

3.39-15.56

0.350 0.553

2.052 16.120

1 1

0.152 0.000

1.65 .109

0.83-3.27

Table 4 showed that there was a fair correlation between age and the level of satisfaction, Pearson correlation coefficient value was 0.238 and significant at p>0.01, but there was no correlation between households income and the level of satisfaction (r= 0.079; p< 0.01). Association Between Type of Households Health Insurance Plan and Level of Satisfaction: One-way ANOVA between-groups analysis of variance was conducted to explore the impact of households type of health insurance on level of patients satisfaction toward national health insurance, as measured by PSQ II. Subjects were divided into four groups according to the type of households health insurance plan (group 1: SSK; group 2: Bag-Kur; group 3: GERF; group 4: Green Card Holders). Table 5 showed that there was a statistically significant difference in the level of satisfaction among the four groups of social health insurance (F = 11,833, p <0.0001). Post-hoc comparisons using Tukey HSD test indicated that the mean score for the Green Card group (mean = 121.48, s.d. = 17.98) was significantly difference 981

from SSK group (mean = 104.46, s.d. = 23.45) and GERF group (mean = 102.59, sd = 14.93). Also the mean score for SSK group was significantly different from Bag-kur group (mean = 113.00, sd = 15.25). Multivariate Analysis Significant Binary Variables for Binary Regression Analysis: In this study, Binary Regression analysis has been done for predicting effect of socio demographic factors. Tables 6 and 7 showed the results to determine the significant dichotomous variables. Independent variables have been divided into binary variables as follows: age (> 41 years old, =< 41 years old based on mean); gender (male, female); marital status (single, married); education level (low for primary and secondary, high for tertiary); households occupation (working for private, own business and government, not working); self perceived health status (healthy, unhealthy); income ( > USD 10,000 and =< USD 10,000 based on median income); type of households plan (contributory, non-contributory based on the premium payment); area of residency (rural, urban based on geographical distribution).

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From these variables, eight variables had significant association with level of satisfaction from bivariate analysis results. These factors were age, gender, marital status, level of education, households occupation, self perceived health status, type of households plan, area of residency. Binary Logistic Regression: In order to determine which of the study variables best explain the variation in level of satisfaction; multiple logistic regressions was done (backward LR technique). The significant predictors of level of satisfaction in this model after control of confounders were age (p<0.0001), gender (p< 0.0001), marital status (p<0.0001), education (p<0.0001), occupation (p< 0.0001), self perceived health status (p< 0.0001 ), households type of plan (p <0.001 ), area of residency (p< 0.000) Table 8. The Hosmer and Lemeshow test indicated a good fit (p = 0.815). The total model was significant (p<0.0001) and accounted for 65.2% of the variance (Nagelkerke R Square = 0.652). That means 65.2% of level of satisfaction was explained by this model. DISCUSSION This study showed that the level of satisfaction with national health insurance and its components are good. More than half of the participants were satisfied (53.3%), while (46.7%) of them were dissatisfied. On one hand, these results are in line with the findings of health system satisfaction survey carried out by Turkish statistical institute in 2005 showed that (55.2%) of respondents were satisfied with health care services [21]. Furthermore, these results could be considered usual as Turkish health system is undergoing a radical reform process since 2003[18]. On the other hand these outcomes are concordance with international literature, where many surveys stated high levels of patients satisfaction [3], as high as 86.4 points on a scale of 0-100 in Slovenia [22]. However, some other countries in transition showed similar results, such as Romania with 78% satisfaction with the health care system in general, while 21% were dissatisfied [23]. Taiwan national health insurance received 70% public satisfaction rate [20]. In South Korea, Minister of Strategy and Finance survey in 2006 showed the overall patient satisfaction rate was 63.3% [1]. Many satisfaction studies have tried to relate patients demographic characteristics to the level of satisfaction. While others considered accessibility and quality as an 982

important aspects in orgainzing, financing and offering services in the health system studies [24]. Most of satisfaction studies showed variable determinants of satisfaction, which revealed that satisfaction is multi-factorial and no one factor could be claimed to be the only contributor to satisfaction or dissatisfaction [25]. Margolis et al. [26] concluded that overall satisfaction was not statistically significantly related to any of the measured demographic characteristics. There is a greater tendency of research studies to focus on old age patients [27]. It seems to be based on the presumption that old people are the major recipients of health care services. As in previous studies [28], we showed that older patients tended to have higher satisfaction scores in all areas of our questionnaire [29]. There was a weak correlation between age and the level of satisfaction, Pearson correlation 0.238 and p value > 0.01, but when we categorized the age factor (> 41 years old, =< 41 years old based on median) the chi square test was highly significant 43.649 and p value is > 0.05.The older age group (70.6%) was more satisfied than younger age group (35.1%). In this study, despite of females component (55.3%) was less than males (55.7%), but thier level of satisfaction (67.5%) was more than men (41.9). There was a siginficant association between gender and level of satifaction, Chi square test 22.533 and p value (> 0.05). These findings can be supported by study done by Bara et al [30] showed that the highest level of satisfaction was among female (women were 1.5 times more likely to be extremely satisfied compared to their male counterparts). In this study married group was more satisfied (62.9%) than single group (unmarried, divorce and widows) (43.5%). Al-doghaither [31] indicated that married females having high rate of satisfaction and could be consider as an important predictors. The more educated people are, the more likely they tend to be critical, while the less educated people are, the more likely tend to be satisfied, as they are less demanding [30,32]. This can be explained as higher educational level will result in higher expectation of service receives and consequently causing increased in the gaps between expectation and perception. Our findings, nonetheless have shown that a low education (68.6%) was significantly associated with high level of satisfaction. And there was a significant association between the eduction status and level of satisfaction. Chi square test 26.631 and p value (> 0.05).

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There was a significant association between occupation and level of satisfaction. Chi square test 9.38, p value (> 0.05). In this study working group was more satisfied (56.5%) than non working group (31.2%). This can be also explained as workingrespondents have higher expectation of service received compared to not working respondents as they are more exposed to external environment. Al - doghaither [31] indicated that that gender, marital status, occupation and income are the most important predictors for level of satisfaction. Level of satisfaction is found to be high in patients who perceived better overall health status [29,33], with the exception of patients with long lasting illness [34]. In this study, there was a significant association between self perceived health status and level of satisfaction. Chi square test 23.687, p value (> 0.05). In this study healthy group was more satisfied (63.9%) than unhealthy group (37.2%). In our study, there was a significant association between area of residency and level of satisfaction. Chi square test 37.401, p value (> 0.05). In this study urban residents were more satisfied (64.0%) than rural residents (28.2%). Sharifa Ezat et al [35] found that rural community was more satisfied with Posyandu (rural health services by the community) services in Sumatera compared with its urbanites. In this study, there was no correlation between level of satisfaction and Households Annual Income. Pearson correlation 0.079 and p value< 0.01. Theodosopoulou et al [36] indicated that patients income correlated negativley with patients global satisfaction. In this study, the level of satisfaction among Green Card Holders (88.9%) was significantly more than other three groups; bag-kur (55.9), SSK (46.4%) and GERF (36.4%). Similar study done by Mummalaneni and Gopalakrishna [37], as well as Davis et al. [38] in U.S, they found that satisfaction was significantly different based on plan type. The Green Card is the largest non-contributory program, accounting for 1.91% of total Government Spending in a year 2007 [7]. Angel-Urdinola [10] illustrated that Green Card beneficiaries do not have copayments for in-patient and out-patient care, while beneficiaries from the contributory health system do have to pay co-payments. Also there is no time limit for enjoying Green Card benefits. Green Card beneficiaries utilize more health services than non-beneficiaries, conditional on being poor. Green Card beneficiaries display slightly higher doctor/hospital utilization than non-beneficiaries, conditional on being poor. 983

CONCLUSION This study showed that most of the respondents were satisfied with the national health insurance. Higher patients satisfaction was associated with improved access to care and continuity of care. However, light must be shed on availability of resources, technical quality and humaneness to improve overall patients satisfaction. REFERENCES Chun, C.B., S.Y. Kim, J.Y. Lee and S.Y. Lee, 2009. Republic of Korea: Health system review. Health Systems in Transition: World Health Organization on behalf of the European Observatory on Health Systems and Policies, 11: 1-184. 2. Kleeberg, U.R., P. Feyer, W. Gunther and M. Behrens, 2008. Patient satisfaction in outpatient cancer care: a prospective survey using The PASQOC(R) questionnaire. Support. Care. Cancer, 16: 947-954. 3. Williams, B. and G. Grant, 1998. Defining "peoplecentredness": making the implicit explicit. Health and Social Care in the Community, 6: 84-94. 4. Rad, N.F., A.P. Mat Som and Y. Zainuddin, 2010. Service Quality and Patients Satisfaction in Medical Tourism.World Applied Sciences J., 10: 24-30. 5. Ranjbarian, B., A. Emami and P. Ranjbarian, 2012. Dentists' Socio-Emotional, Informational Behaviors and Theirpatient's Satisfaction: A Case Study from Iran. Middle-East J. Scientific Res., 11: 318-323. 6. Turkish Statistical Institute, Tuksat. Available from: http://www. turkstat. gov. tr/PreTablo. do?tb_id=39 and ust_id=11 http://www. turkstat. gov. tr/AltKategori. do?ust_id=1 http://www. t u r k s t a t . g o v . tr/Gosterge.do?metod=IlgiliGostergeandid=3507 [Accessed February 2, 2012]. 7. Aran, M., 2008. Social Protection in Turkey. Mimeo. World Bank. Washington, D.C. 8. Akhmedjonov, A., Y. G and F. Akinci, 2011. Healthcare financing: how does Turkey compare? Taylor and Francis Online, 89: 59-68. 9. Savas, B.S., . Karahan and R.. Saka, 2002. Health Care Systems in Transition, Turkey, European Observatory on Health Systems, Brussels. 10. Angel-Urdinola, D., 2009. Informality in Turkey: wage analysis using 2006 HBD data. Mimeo. World Bank, Washington D.C. 1.

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Abbreviations: (SSK); The Social Insurance Organization (SPSS); Statistical Package for Social Science (Bag-kur); the social insurance program established for serving traders, artists and self own business (GERF); the Government Employees Retirement Fund (HTP); Health Transformation Programme (SSI); Social Security Institution (OECD); Organization for Economic Co-operation and Development (GDP); Gross Domestic Product (USD); United State Dollar

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