Does the Unification of Health Financing Affect the Distribution Pattern of Out-Of Health Expenses in Turkey?
| dc.contributor.author | Çınaroğlu, Songül | |
| dc.contributor.author | Başer, Onur | |
| dc.date.accessioned | 2019-04-22T12:02:00Z | |
| dc.date.available | 2019-04-22T12:02:00Z | |
| dc.date.issued | 2019 | |
| dc.description.abstract | Turkey has implemented health reforms for over a decade and has taken significant steps toward unifying health financing. This study investigated the financial burden associated with out-of-pocket (OOP) expenditures under universal health coverage, using national 2003–2015 household budget data from the Turkish Statistical Institute. Progress was evaluated using Kakwani–Suits indices and Lorenz concentration curves. The results indicate that overall, more than a decade after its unification, redistribution of wealth in the Turkish health financing system has benefitted the wealthy but not the poor. Both curve and index approaches (Kakwani index 2003 = -0.50; 2015 = -0.44) reveal an increasingly regressive pattern of OOP health expenditures. The effective use of fiscal space and good political leadership are essential for the successful continuation of reforms to combat poverty in Turkey. | |
| dc.description.sponsorship | Turkey established public health insurance and has been developing its capacity for health care service delivery since the late 1940s. Prior to the health reforms, the country experienced inequalities in health financing (Yılmaz, 2013). The following points about inequalities in pre-reform health financing are worth highlighting. Formerly, the public insurance market had a fragmented structure and was stratified by differences in status in Turkey’s labor market (Bugra & Keyder, 2006; Yılmaz, 2013). Inequalities existed between the beneficiaries of public insurance plans and “outsiders” who made informal payments (Tatar & Kanavos, 2006). Before 2006, the level of coverage and quality of care varied among different beneficiaries of the health insurance system, and health benefits were based on employment status. Although the Green Card program provided uninsured people with access to doctors and hospitals within the social security system, it did not cover medicines. Institutional studies have concluded that only a small percentage of the population benefited from medical coverage. HBS data indicate that more than a third of the population still remain without health insurance coverage and have to pay for their health needs themselves. This category also represents Green Card program beneficiaries. Given these circumstances, the government’s health expenditures have been rising. To this end, the government introduced comprehensive “health financing system reform” into its agenda (Bugra & Keyder, 2006). Following changes in the Green Card program, this reform process has provided a new welfare regime for Turkey, aimed at providing universal health coverage and reducing the proportion of the population without health insurance. The Green Card program was established in 1992 as a means-tested mechanism, financed by general taxation, to grant poor people access to health care services as a poverty alleviation strategy. Green Card coverage and benefits expanded between 2003 and 2008. Over the years, the Green Card program’s budget has increased with its number of beneficiaries (Aran & Hentschel, 2012; Bugra & Candas, 2011; Erus et al., 2015). Turkey’s pre-reform health system was comprised of five forms of public insurance: the Social Insurance Organization (Sosyal Sigortalar Kurumu [SSK]), the General Employees Retirement Fund for Civil Servants (Emekli Sandığı [ES]), the Pension Fund for the Self-Employed (Esnaf, Sanatkarlar ve Diğer Bağımsız Çalısanlar Sigortalar Kurumu, Bağ-Kur ), the Active Civil Servants Insurance Fund, and the Green Card program (Akdag, 2011). In 2006, Universal Health Insurance (UHI) was adopted as part of broader social security reform. Reorganization of the health financing system continued in 2008 with the establishment of the SSI for financial pooling and purchasing. With these regulations, the Social Insurance Organization, the Pension Fund for the Self-Employed, and the General Employees Retirement Fund for Civil Servants joined the SSI (Akdag, 2011). These considerable changes reduced the prevalence of informal payments and filled the gap between different occupational statuses in terms of health expenditures (Agartan, 2008, 2012; Wendt, Agartan, & Kaminska, 2013; Yılmaz, 2013). | |
| dc.description.sponsorship | Scientific and Technological Research Council of Turkey (Tubitak) [1059B141500020]; Tubitak | |
| dc.description.sponsorship | fundamental changes to the system were not made until the late 1980s. During 1980–1983, Turkey was governed by military rules, wherein the government’s role in health care was redefined, with structural adjustments and protection for the poor from financial risk becoming primary government goals. Supportive policies began in the early 1980s with private health investments subsidizing private medical care. The military government then announced additional privatization of the health care sector. During the late 1980s, health reforms were supported by international organizations, such as the World Health Organization (WHO) and the World Bank (WB). The first project in 1988 was drafted to develop primary health care in Turkey. After these efforts, with the technical support of WHO experts, Turkey joined an adoption of regional health targets for all European countries in 1989. A National Health Policy (NHP), prepared in 1993, was revised by the Turkish Ministry of Health (MoH), with political support from all parties, which determined the document’s main objectives. The system focused on decentralized health management, family medicine for primary health care services, an autonomous secondary and tertiary health care system, a General Health Insurance (GHI) system, and competition in the health market (OECD & WB, 2008; Yenimahalleli-Yasar, 2011). The sixth, seventh, and eighth five-year development plans (covering 1990–1995, 1996–2000, and 2001–2005, respectively) are coherent with NHP. The seventh plan strengthened the MoH and introduced the GHI system. Scholars suggest that, apart from the Green Card system, the only program accomplished after the NHP document was the promotion of private sector investment (Agartan, 2012; OECD & WB, 2008; Yenimahalleli-Yasar, 2011). Initially set up in 1992, the important Green Card program, which provided social protections, was financed by general revenues. Before 2002, the program’s budget and coverage were small (Yıldırım & Yıldırım, 2011). In 2002, the government launched its Urgent Action Plan through the Health Transformation Program (HTP). The main goals of this program were the reorganization of MoH, coverage of all citizens by GHI, the moving of all health institutions under one umbrella, introduction of a family medicine model, promotion of the private health sector (giving special importance to mother and child care), and effective human resource management. These objectives constituted the main components of HTP, which was launched in 2003. To establish a high-quality and effective health system while considering equity was one of the main targets of this system. On the agenda since the 1980s, Turkey’s health care system has failed to provide universal coverage, due mainly to a high level of informal employment. To address this problem, in the early 1990s a new form of social assistance was introduced, the Green Card program, which offered free inpatient health care services for the very poor and was funded by the general budget. In 2000, Green Card expenditures reached one-fourth of all public expenditures on health care services (MoH, 2004). | |
| dc.description.sponsorship | This article is based on the PhD thesis written by Songul Cinaroglu (2017) entitled The relationship between inequality and equity in health services financing and catastrophic health expenditures, approved by Hacettepe University, Institute of Social Sciences, Department of Health Care Management, Ankara, Turkey. A preliminary version of the study was presented at the International Health Policy Conference (IHPC) at the London School of Economics, February 16-19, 2017. The authors wish to acknowledge the constructive comments from participants at the IHP conference. Our thanks are also extended to the two anonymous reviewers of the study for their careful reading and insightful suggestions for enhancing the study's scientific contribution. The study was financed by The Scientific and Technological Research Council of Turkey (Tubitak), grant number 1059B141500020. The sponsor had no role in the study's design, the collection and analysis of the data, the writing of the report, or its submission for publication. The authors are grateful for the generous funding from Tubitak. | |
| dc.description.sponsorship | World Bank Group, WBG; World Health Organization, WHO; Türkiye Bilimsel ve Teknolojik Araştirma Kurumu, TÜBITAK, (1059B141500020) | |
| dc.identifier.citation | Cinaroglu, S., & Baser, O. (April 07, 2019). Does the unification of health financing affect the distribution pattern of out-of-pocket health expenses in Turkey?. International Journal of Social Welfare. pp. 1-14. | |
| dc.identifier.doi | 10.1111/ijsw.12389 | |
| dc.identifier.issn | 1369-6866 | |
| dc.identifier.issn | 1468-2397 | |
| dc.identifier.scopus | 2-s2.0-85063986457 | |
| dc.identifier.uri | https://hdl.handle.net/20.500.11779/1054 | |
| dc.identifier.uri | https://doi.org/10.1111/ijsw.12389 | |
| dc.language.iso | en | |
| dc.publisher | Wiley | |
| dc.relation.ispartof | International Journal of Social Welfare | |
| dc.rights | info:eu-repo/semantics/closedAccess | |
| dc.subject | Out-of-Pocket Health Expenditures | |
| dc.subject | Turkey | |
| dc.subject | Unification of Health Financing System | |
| dc.subject | Poverty Alleviation | |
| dc.subject | Health Reform | |
| dc.subject | Poverty | |
| dc.subject | Health Care | |
| dc.title | Does the Unification of Health Financing Affect the Distribution Pattern of Out-Of Health Expenses in Turkey? | |
| dc.type | Article | |
| dspace.entity.type | Publication | |
| gdc.author.id | Cinaroglu, Songul/0000-0001-5699-8402 | |
| gdc.author.institutional | Başer, Onur | |
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| gdc.author.wosid | Baser, Onur/PGA-2243-2026 | |
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| gdc.description.department | İİSBF, Ekonomi Bölümü | |
| gdc.description.departmenttemp | [Cinaroglu, Songul] Hacettepe Univ, Dept Hlth Care Management, FEAS, TR-06800 Ankara, Turkey; [Baser, Onur] MEF Univ, Dept Econ, Istanbul, Turkey; [Baser, Onur] Univ Michigan, Internal Med, Ann Arbor, MI 48109 USA | |
| gdc.description.endpage | 14 | |
| gdc.description.issue | 3 | |
| gdc.description.publicationcategory | Makale - Uluslararası Hakemli Dergi - Kurum Öğretim Elemanı | |
| gdc.description.scopusquality | Q2 | |
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| gdc.description.volume | 28 | |
| gdc.description.woscitationindex | Social Science Citation Index | |
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| gdc.oaire.keywords | Social Work | |
| gdc.oaire.keywords | Turkey | |
| gdc.oaire.keywords | poverty | |
| gdc.oaire.keywords | Social Sciences | |
| gdc.oaire.keywords | out‐of‐pocket health expenditures | |
| gdc.oaire.keywords | health reform | |
| gdc.oaire.keywords | health care | |
| gdc.oaire.keywords | poverty alleviation | |
| gdc.oaire.keywords | unification of health financing system | |
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| gdc.publishedmonth | Nisan | |
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| gdc.virtual.author | Başer, Onur | |
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| gdc.wos.collaboration | Uluslararası işbirliği ile yapılan - EVET | |
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| gdc.wos.indexdate | 2019 | |
| gdc.wos.publishedmonth | Nisan | |
| gdc.yokperiod | YÖK - 2018-19 | |
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