In this study, we examine whether and to what extent the health insurance system in Turkey provided adequate protection against high out of pocket expenditures in the period prior to "The Health Transformation Programme". Furthermore, we examine the distribution of out of pocket expenditures by demographic characteristics, poverty status, health service type, access to health care and self-reported health status. We employ the 2002/03 National Household Health Expenditure Survey data to analyze financial burden of health care expenditure. Following the literature, we define high burdens as expenses above 10 and 20% of income. We find that 19% of the nonelderly population were living in families spending more than 10% of family income and that 14% of the nonelderly population were living in families spending more than 20% of family income on health care. Furthermore, the poor and those living in economically less developed regions had the greatest risk of high out of pocket burdens. The risk of high financial burdens varied by the type of insurance among the insured due to differences in benefits among the five separate public schemes that provided health insurance in the pre-reform period. Our results are robust to three alternative specifications of the burden measure and including elderly adults in the sample population. We see that prior to the reforms there were not adequate protection against high health expenditures. Our study provides a baseline against which policymakers can measure the success of the health care reform in terms of providing financial protection.
Keywords: Out of Pocket expenditures, Financial burden, Health care reform, Turkey
In 2001, Turkey initiated a series of reforms to align its health care system with the health regulations of the European Union and the OECD countries. The "Health Transformation Program" (HTP) was launched in 2003 (1, 2). The Universal Health Insurance (UHI) system was implemented in October, 2008. Prior to the UHI, health insurance was provided by five different public schemes each with separate provider networks. UHI will provide health services under one scheme. Providing financial protection is one of the main goals of the Turkish health care reform.
However, to date there is only one study that examines the size of out-of-pocket (OOP) health expenditures for public insurees prior to HTP reforms: Erus and Aktakke (3). They consider the OOP health expenditures concerning the insurance schemes and some demographic characteristics of the insurees by using the 2003 Household Budget Survey. But, their study does not provide the information regarding the distribution of OOP expenditures by health service type, access to health care and self reported health status. Therefore, there is still a need of baseline criteria to evaluate the performance of the reforms in terms of providing adequate financial protection. Our paper fills this gap by examining the distribution of health care expenditure burdens for the period prior to the UHI implemented in 2008. We employ the National Household Health and Expenditure Survey 2002-2003 which has been conducted as part of Turkish Ministry of Heath's effort to develop and implement 'National Health Accounts' that are in line with the standards of European Union and OECD Health Accounts System. The survey is specifically designed to collect health related expenditures as well as detailed information on health utilization, health status and socio-demographic variables.
We examine the risk of high financial burden due to out of pocket health spending for the non elderly population by insurance status. Furthermore, we examine the distribution of out of pocket expenditures by service type, access to care and self-reported health status. Indeed we provide robustness check considering the three alternative specifications of the burden measure, using total expenditures instead of income to define capacity to pay, adding imputed rent to income for homeowners, and including elderly adults in the sample population. …