Abstract
Family medicine is a specialty with its own research topics, training curriculum and clinical functioning. The first step toward the implementation of the expected field trainings was taken in 2014, and training family health centers started to be established.
The regulation has been revised in order to solve problems encountered in practice, to protect the public interest, to meet service needs and to encourage educational family health centers. In addition, it was considered necessary to expand the use of educational family health centers where family medicine specialty students are trained in the field. These regulations have been harmonized with the changes in family medicine legislation. As a result, the “Regulation on Training Family Health Centers” was published in the Official Gazette dated 28.04.2023 and numbered 32174 and entered into force. The aim of this article is to provide an overview of educational family health centers and to evaluate the revised regulation.
Keywords: education, general practice, legislation, regulation
Introduction
Definition of family medicine and the specialization process
Family medicine is a primary health care service provided by specialist physicians who provide continuous and comprehensive care to everyone in need of medical care, regardless of the patient’s age, gender and disease, without discrimination; provide services in accordance with the family, society and culture of individuals; advocate for health; respect their personalities; observe ethical values; and demonstrate an attitude in accordance with the principles of the discipline of family medicine. The World Organization of Family Doctors (WONCA) has identified six core competencies and twelve essential skills that every family physician should master, regardless of the health systems in which they practice. Primary care management, person-centered care, specific problem-solving skills, comprehensive approaches, community orientation and holistic modeling are the basic competencies that form the framework of the family medicine discipline.[1]
In our legislation, a family physician is defined as a family medicine specialist who is obliged to provide preventive health services and primary diagnosis, treatment and rehabilitative health services to each person comprehensively and continuously in a specific place without discrimination of age, gender and disease; who provides mobile health services to the extent necessary and works on a full-time basis; or who is a specialist physician or physician who receives the training required by the authority.[2]
In Türkiye, family medicine specialization was first included in the Medical Specialization Regulation in 1983. In 1985, specialty training started in training and research hospitals in Ankara, Izmir and Istanbul, and in 1993, the Department of Family Medicine was established at Trakya University and started residency training.[3]
Content of family medicine specialty training
Family medicine is a specialty with its own research topics, training curriculum and clinical functioning. The Curriculum Creation and Standard Setting Commission of the Board of Medical Specialization has set out the aim of family medicine specialty education as providing appropriate opportunities for the development of clinical knowledge, skills, attitudes and behaviors as well as the ability to provide health education, research and management qualities in line with the basic principles within the definition of family medicine.[4] Family medicine training differs from the training of other specialties in many aspects. During the education process, it is necessary to adapt to disciplines in a short period of time through the rotation of many different departments. While other specialties train specialists to provide health services in secondary and tertiary care, family medicine specialization graduates specialists to provide primary health care services. The duration of education varies from country to country, but in Türkiye, it is 3 years. Until 2009, family medicine residency training consisted entirely of rotations; however, the Medical Specialty Committee shortened this period to 18 months and included Educational Family Health Centers (EFHC) among the places where the remaining 18 months would be spent.
The EFHCs have been considered by family medicine clinicians to be the most appropriate training environment for on-the-job, structured clinical training supported by evaluation and feedback, where the trainer can be a role model, where reflection and case discussions can be held, and where public education, management and inter-institutional cooperation can be learned.[5]
Historical process of regulating education in family health centers
In Türkiye, family medicine practices started as a pilot in Düzce Province in 2005 and were implemented in all provinces in 2010. The “Law on Family Medicine”, which is the main basis for implementing regulations, was published in 2004 (OG: 09.12.2004--25665).[6] After three years spent in the family medicine outpatient clinics of universities and training and research hospitals providing specialty training and in the necessary rotations, the graduating specialty students took a long time to adapt to primary care when they started working in the field and found themselves in situations they encountered for the first time in many ways. The first step toward the implementation of the expected field trainings was the abrogated “Regulation on Payment and Contracts for Educational Family Health Centers” published in 2014 (OG: 26.09.2014--29131).[7]
Following the entry into force of the regulation, EFHCs began to be established by various educational institutions, and by March 2019, twenty-five EFHCs had been opened by a total of seventeen different educational institutions.[8] A number of negative circumstances, such as technical problems and problems in correcting them, difficulties in assigning personnel, and legislative impasses in the use of the money transferred by the ministry to the educational institution, have caused educational institutions and provincial health directorates to approach the issue of opening an EFCH with hesitation.[5]
For reasons such as solving the problems encountered in practice, the public interest, service needs and encouraging the opening of educational family health centers and expanding the training that family health centers where family medicine assistants/research assistants receive field training and updating the regulation by making it compatible with the regulations made in family medicine legislation, it has become necessary to revise and reorganize the regulation. At the same time, the “Regulation on Educational Family Health Centers”, which was created by gathering together the provisions on educational family health centers, which were found in pieces in other family medicine legislation, entered into force after being published in the official gazette dated 28.04.2023 and numbered 32174.[9]
Examination of the regulation of educational family health centers
The purpose of this regulation, which has been prepared on the basis of the ninth paragraph of Article 3 of the Law on Family Medicine and Articles 352, 361 and 508 of Presidential Decree No. 1, is to determine the principles of contract and payments to be made to trainers, assistants, family health personnel and training institutions who take part in the provision of family medicine services in training family health centers or training family medicine units by signing an institutional contract.
The first notable change in the regulation is the addition of city hospitals, which are hospitals providing services through the public-private partnership model, to the definitions in Article 4. This paved the way for city hospitals to provide specialty training to open educational family health centers.
The eighth section of the Family Medicine Implementation Regulation was completely removed and included in the Regulation on Educational Family Health Centers as Article 5, with significant changes. Important changes and additions have been made here, and there is no longer a need for a contract between the ministry-affiliated hospitals and the institution, and educational family health centers can now be opened directly by the ministry. Moreover, in terms of establishing service venues, the new regulation adds that provincial health directorates can also establish venues and that they can be operated by the directorate. While the previous regulation stated that available family medicine units would be evaluated upon the request of the institution, the new regulation obliges provincial health directorates to first offer vacant or newly opened units to the training institution. Thus, it aims to prevent the problems experienced by educational institutions in keeping track of new units opened or vacant within the province.
The difficulties in collecting data from the registered population have led to the closure of many units. To prevent this situation, Article 5, Paragraph 15 of the regulation stated, “In accordance with the first sentence of the first paragraph of Article 5 of the Law on Family Medicine, provided that the right of individuals to change their family physicians is reserved, individual or collective family medicine person registration or registration changes can be made to training family medicine units on the basis of the proposal of the directorate and the approval of the Ministry in accordance with the health service planning.” In this process, collective person transfers can now be made with the approval of the ministry.
In the event that there are no assistants to work in the unit, the unit can continue to serve for eight months with the assignment by the directorate, but if there are still no assistants at the end of eight months, the rights arising from the institutional contract terminate.
Payments to the educational institution
The payments to the institution to be made by the Ministry are regulated in Article 7 of the last regulation. A notable innovation here is the mention of the payment to foundation universities. For EFHCs provided by foundation universities, no payments are made to instructors, assistants or family health personnel.
The money to be transferred to the institution by the ministry will be transferred to a subaccount in the revolving fund enterprises of the educational institution to be used only for this purpose. The first aim here is to prevent revolving fund deductions, and the second aim is to prevent the money transferred to the hospitals’ revolving fund pools. This provision, which seems wise and logical in theory, has led to a number of problems in practice. The defensive attitude of the trustees and hospital revolving fund enterprises because they are not aware of or afraid of how to use this money has caused disruptions in meeting the needs of service units. In the same article, the fact that educational family health centers are a unit of educational institution providing field services seems to be a regulation that increases institutional ownership and responsibility.
In the payments to be made for assistants and family health personnel, it is also stated in this article that the salary and base supplementary payment will be made by the institution, whereas the encouragement payment will not be made. For instructors, encouragement payments are also made by the institution, taking into account the duration of their employment.
The use of fixed figures for the payments to the educational institution specified in the first paragraph of Article 7 of the regulation is contrary to the logic of the legislation. Indeed, it is clear that the figures will remain very low and insufficient in the coming years owing to inflation and the cost of living. Although these amounts are increased every 6 months by the ministry and deposited into the institutions’ accounts, it would be more accurate to calculate this amount by indexing it to the ceiling wage, as in the Family Medicine Contract and Payment Regulation.
Payments to instructors, assistants and family health personnel
Within the scope of the white reform, new arrangements were made in the payments of physicians and health workers, and changes in payment methods led to the need for revision in this regulation; as a result, significant changes were made. The most marked change regarding the payments regulated in Article 8 of the regulation is that the disease management platform (DMP) has been made applicable to educational family health centers. Thus, the intermediate score for payment can now be increased up to one and a half times if residents perform certain screenings and follow-ups of patients registered in their units, and the score for payment is calculated in this way. Another important change is that the limit of 2800 people for the first eight months, after which up to 4000 people were included in the calculation, has been reduced to 2800, making it an encouraging incentive for the DMP.
Conclusion
As a result, with amendments and positive changes, as of December 2024, there are a total of 63 EFHCs and 195 educational family medicine units. However, the desired number of EFHCs has not yet been reached for reasons such as the hesitancy of the directorates and the lack of adoption of EFHCs by educational institutions. It is essential to take measures to facilitate the establishment and operation of EFHCs, which are the undeniable reality of the field training of family medicine specialty training, and to open new units. Each EFHC or new unit to be opened will contribute to the reduction of ceiling populations in terms of increasing the quality of health services provided to citizens, reduce the burden on secondary and tertiary hospitals and prevent overcrowding, and ensure that family medicine assistants are ready to enter the field by understanding the operational structure of the family health centers where they will work after graduation and the profile of the patients or population they will encounter.
Source of funding
The authors declare the study received no funding.
Conflict of interest
The authors declare that there is no conflict of interest.
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Copyright and license
Copyright © 2025 The Author(s). This is an open access article distributed under the Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.
