This document presents research on access to healthcare, utilization, and health outcomes in Turkey. It aims to analyze regional inequality in Turkey's healthcare system following reforms in 2003. The study uses data from 2009-2014 at the province level to examine potential accessibility, utilization, and health outcomes. It finds sizable regional disparities and increasing spatial dependence and concentration over time. Spatial econometric models show that both accessibility and utilization significantly impact regional health outcomes. The study aims to better understand equity in Turkey's healthcare system from a regional perspective.

1. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
Access to Healthcare, Utilization and Health
Outcomes in Turkey
Can Karahasan
Piri Reis University
Firat Bilgel
Okan University
ERF Workshop
The Economics of Healthcare in the ERF Region
MENA Health Policy Forum
Cairo, Egypt
22 May 2016
1 / 30

2. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
MOTIVATION
Consolidation of the healthcare system in Turkey (post 2003 reform)
Developments in the healthcare system has sizable effects among
different segments of the society
Current focus is on the access to healthcare system originating from
macro questions:
2 / 30

3. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
MOTIVATION
Consolidation of the healthcare system in Turkey (post 2003 reform)
Developments in the healthcare system has sizable effects among
different segments of the society
Current focus is on the access to healthcare system originating from
macro questions:
size of the Ministry of Health budget
deficit of the healthcare system in Turkey
coverage of the system
Equity among different income groups and among individuals
within and outside the coverage of the system
2 / 30

4. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
MOTIVATION
Consolidation of the healthcare system in Turkey (post 2003 reform)
Developments in the healthcare system has sizable effects among
different segments of the society
Current focus is on the access to healthcare system originating from
macro questions:
size of the Ministry of Health budget
deficit of the healthcare system in Turkey
coverage of the system
Equity among different income groups and among individuals
within and outside the coverage of the system
Our knowledge on the equity issue from regional perspective is
limited
2 / 30

5. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
RESEARCH QUESTION(S)
Given the extent of regional disparities in Turkey and given sizable
measures to transform the healthcare system during the last decade:
What is the extent of regional healthcare inequality in Turkey?
Focus is on the accessibility and outcome
3 / 30

6. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
RESEARCH QUESTION(S)
Given the extent of regional disparities in Turkey and given sizable
measures to transform the healthcare system during the last decade:
What is the extent of regional healthcare inequality in Turkey?
Focus is on the accessibility and outcome
How do we define access to healthcare system?
Potential vs. revealed accessibility
Is it possible to offer an alternative way to measures inequalities?
Spatial Analysis of healthcare system
What is the extent of spatial dependence, heterogeneity and
persistence of regional differences?
Spatiotemporal patterns
How do we incorporate geography to introduce a geographical
accessibility measure?
What is the relationship between access to healthcare system and
health outcomes of Turkish regions?
3 / 30

7. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
HUMAN CAPITAL DEVELOPMENT:
HEALTH AND EQUITY
Gallup and Sachs (2001) and Barro (2013) indicate the impact of
health based human capital development in order to understand
cross country income differences.
Lopez-Casasnovas et al. (2005), Frohlich et al. (2006), Fang et
al. (2010) put forward the regional dimension by examining intra
country variation of healthcare development
4 / 30

8. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DATA AND SAMPLE
Description
Data Source: TurkStat, Ministry of Health Care Statistical Yearbooks
Level of disaggregation: NUTS 3 (81 Province)
Time Dimension: 2009-2014
5 / 30

9. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DATA AND SAMPLE
Description
Data Source: TurkStat, Ministry of Health Care Statistical Yearbooks
Level of disaggregation: NUTS 3 (81 Province)
Time Dimension: 2009-2014
Categorization
Potential healthcare accessibility
Healthcare utilization (revealed accessibility)
Healthcare outcome
5 / 30

10. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
HEALTHCARE VARIABLES
6 / 30

11. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
HEALTHCARE VARIABLES
Potential healthcare accessibility
practitioners per 100K population (gptp)
specialists per 100K population (specptp)
6 / 30

12. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
HEALTHCARE VARIABLES
Potential healthcare accessibility
practitioners per 100K population (gptp)
specialists per 100K population (specptp)
Healthcare utilization (revealed accessibility)
primary healthcare visits (phcvpc )
secondary healthcare visits (sthcvpc)
6 / 30

13. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
HEALTHCARE VARIABLES
Potential healthcare accessibility
practitioners per 100K population (gptp)
specialists per 100K population (specptp)
Healthcare utilization (revealed accessibility)
primary healthcare visits (phcvpc )
secondary healthcare visits (sthcvpc)
Healthcare outcomes
infant mortality (imr1)
under five mortality rates (imr5)
crude death rate in hospitals per 1K population (crudehosp)
6 / 30

14. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
HOW TO DEFINE INEQUALITY?
Usual suspects
Theil Decomposition
T =
n
i=1
yilog
yi
xi
+
n
g=1
YgTg (1)
Spatial Concentration - Autocorrelation
Moran’s I and Geary’s C
I =
n
s
i wij(xi − ¯x)(xj − ¯x)
z2
i
(2)
C =
(n − 1)( i j wij(xi − xj)
2( i j wij)(xi − xj)2
(3)
7 / 30

15. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
WEIGHT MATRIX CONSTRUCTION
Contiguity Weight Matrix
wi,j =



w = 0 if i=j
w = 0 if i,j non-neighbor
w = 1 if i,j neighbor



(4)
Inverse Distance Weight Matrix
wi,j =
1
dn
i,j
(5)
k-th Nearest Weight Matrix
wi,j =



w = 0 if i = j
w = 0 if di,j > Di(k)
w = 1 if di,j ≤ Di(k)



(6)
8 / 30

16. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSING SPATIAL SPILLOVERS
Local Indicator of Spatial Association (LISA), Anselin (1995)
Ii = (xi − ¯x)
j
wij(xj − ¯x) (7)
4 different Spatial Regimes are identified
9 / 30

17. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSING SPATIAL SPILLOVERS
Local Indicator of Spatial Association (LISA), Anselin (1995)
Ii = (xi − ¯x)
j
wij(xj − ¯x) (7)
4 different Spatial Regimes are identified
H-H: High-High Cluster
L-L: Low-Low Cluster
L-H: Low-High Outliers
H-L: High-Low Outliers
9 / 30

18. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
PERSISTENCE OF SPATIAL DEPENDENCE:
MOBILITY VS. STABILITY
Distributional dynamics approach of Quah (1993, 1996) is later
augmented by Rey (2001; 2014)
Given each spatial regime represents a state within the distribution, it
would be possible to trace how regions move among these regions in
order to identify the extent of the stability/mobility of the distribution
10 / 30

19. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
SPATIAL MARKOV CHAIN ANALYSIS
Low-Low Low-High High-Low High-High
Low-Low 0 II I IIIA
Low-High II 0 IIIB I
High-Low I IIIB 0 II
High-High IIIA I II 0
Source: Rey (2001)
F0,t, FI,t, FII,t, FIIIA,t, FIIIB,t
n = F0,t + FI,t + FII,t + FIIIA,t + FIIIB,t
Cohesion index:
Ct =
FIIIA,t
n
(8)
Augmented cohesion index:
C∗
t =
FIIIA,t + F0,t
n
(9)
11 / 30

20. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
INCORPORATING THE IMPACT OF GEOGRAPHY:
GEOGRAPHIC ACCESSIBILITY
NEG framework to define market access / potential - Redding
and Schott (2003); Redding and Venables (2004)
Harris (1954) market potential index is defined to control for the
demand and supply based potential of Turkish provinces
HAi =
Hi
Dij
(10)
H measures the province based healthcare indicator
(demand/supply in NEG framework, accessibility/utilization in
the current framework) of any region, D represents the physical
distance between any pair of province.
12 / 30

21. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DESCRIPTIVE FIGURES
Mean Std. Dev. CoV Min-Max
2009 2014 2009 2014 2009 2014 2009 2014
gpptp 52.10 55.48 7.58 7.78 0.15 0.14 0.48 0.41
specptp 62.82 76.64 24.59 27.35 0.39 0.36 0.17 0.19
phcvpc 2.94 2.79 0.92 0.78 0.31 0.28 0.09 0.15
sthcvpc 4.23 5.38 0.70 0.81 0.16 0.15 0.46 0.44
imr1 13.77 10.99 3.27 3.40 0.24 0.31 0.38 0.20
imr5 17.49 13.18 4.83 4.09 0.28 0.31 0.30 0.25
crudehosp 10.87 15.80 4.34 5.88 0.40 0.37 0.08 0.08
Notes: For the phcvpc variable we use the 2012 data for 2009
13 / 30

22. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSITION OF INEQUALITIES
2009 2014
Theil Within Between Theil Within Between
Index (%) (%) Index (%) (%)
gpptp 0.011 30.26 69.83 0.010 57.51 42.49
specptp 0.064 35.79 64.21 0.059 40.41 59.59
phcvpc 0.053 20.33 79.65 0.043 21.39 78.61
sthcvpc 0.013 48.46 51.54 0.011 55.83 44.17
imr1 0.028 44.72 55.28 0.044 29.86 70.16
imr5 0.036 30.95 69.05 0.045 25.18 74.84
crudehosp 0.084 28.66 71.34 0.073 43.19 56.80
Notes: For the phcvpc variable we use the 2012 data for 2009
14 / 30

23. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
SPATIAL CONCENTRATION
15 / 30

24. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
SPATIAL CONCENTRATION: A SUMMARY
Existence of sizable spatial dependence
For primary healthcare access spatial dependence is decreasing,
while for primary healthcare utilization we detected rising spatial
auto-correlation
For all of the healthcare outcome indicators we do observe rising
spatial dependence.
16 / 30

25. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
SPATIAL CONCENTRATION: A SUMMARY
Existence of sizable spatial dependence
For primary healthcare access spatial dependence is decreasing,
while for primary healthcare utilization we detected rising spatial
auto-correlation
For all of the healthcare outcome indicators we do observe rising
spatial dependence.
Revisiting Combes et al. (2008) this validates the concerns on the
link between rising spatial concentration and inequalities, giving
clues on the existing level of regional healthcare heterogeneities.
16 / 30

26. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSITION OF SPATIAL CONCENTRATION
LISA Analysis of Infant Mortality Rates (2009)
Not Significant
Low−Low
High−Low
High−High
17 / 30

27. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSITION OF SPATIAL CONCENTRATION
LISA Analysis of Infant Mortality Rates (2014)
Not Significant
Low−Low
Low−High
High−Low
High−High
18 / 30

28. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSITION OF SPATIAL CONCENTRATION
LISA Analysis of Crude Death Rates at Hospital (2009)
Not Significant
Low−Low
Low−High
High−Low
High−High
19 / 30

29. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
DECOMPOSITION OF SPATIAL CONCENTRATION
LISA Analysis of Crude Death Rates at Hospital (2014)
Not Significant
Low−Low
Low−High
High−Low
High−High
20 / 30

30. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
PERSISTENCE OF SPATIAL DEPENDENCE: MOBILITY
BETWEEN SPATIAL REGIMES
Low-Low Low-High High-Low High-High
Low-Low 0 II I IIIA
Low-High II 0 IIIB I
High-Low I IIIB 0 II
High-High IIIA I II 0
Source: Rey (2001)
Type 0 Type I Type II Type IIIA Type IIIB Cohesion Flux
gpptp 0.595 0.123 0.227 0.044 0.010 0.640 0.360
specptp 0.938 0.047 0.015 0.000 0.000 0.938 0.062
phcvpc 0.932 0.043 0.025 0.000 0.000 0.932 0.068
sthcvpc 0.807 0.111 0.074 0.005 0.002 0.812 0.188
imr1 0.763 0.183 0.074 0.005 0.012 0.768 0.232
imr5 0.805 0.158 0.030 0.007 0.000 0.812 0.188
crudehosp 0.820 0.131 0.044 0.005 0.000 0.825 0.175
21 / 30

31. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
ECONOMETRIC SPECIFICATION
Non-Spatial Models: Cross Section and Panel Fixed Effects
Spatial Models: Panel Fixed Effects (Spatial Lag and Error
Models)
Spatial Lag Procedure: Spatal Auto Regressive Models (SAR)
HOi,t = a + bHi,t + ρWHOi,t + εi,t (11)
Spatial Error Models (SEM)
HOi,t = a + bHi,t + Wλεi,t (12)
22 / 30

32. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
RESULTS: CROSS SECTION MODELS
23 / 30

33. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
RESULTS: PANEL MODELS
24 / 30

34. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
RESULTS: SPATIAL PANEL MODELS: SAR
25 / 30

35. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
RESULTS: SPATIAL PANEL MODELS: SEM
26 / 30

36. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
SUMMARY OF ECONOMETRIC MODELS
Cross section and panel models underline the significant impact
of access and utilization on understanding regional health
outcome differences
Controlling for spatial networks via lag and error procedures
depresses the impact of access and utilization
Note that no regional controls are used so far
Geographical access is interestingly influencing our results:
impact of access and utilization is reloaded
27 / 30

37. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
TO CONCLUDE...
Inequalities matter for healthcare development
Outcome of healthcare services is spatially more concentrated,
more heterogeneous and less mobile within the distribution
Modelling outcome shows that even access and utilization
matters, this impact is not robust as incorporating spatial
networks weakens the impact of access and utilization.
Using the geographical access as distance weighted access and
utilization measures reloads the impact of the two.
28 / 30

38. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
TO DO LIST...
Discussion on the literature for health and development.
Similarly theoretical discussions are going to be reviewed in
order to formalize the background of the central research
question.
Analysis of the spatial varying relationship by estimating the
GWR models.
Augment all set of models by using some other regional control
variables.
Discussing the policy issues on healthcare system in conjunction
with the regional development paradigm.
Central focus will be diverted to the one size fits approach of
both healthcare and regional policies.
29 / 30

39. Introduction Theoretical Background Research Design Analysis Modelling Strategy Conclusion Future work
Thank you, Q/A
30 / 30