Equity in access to care in the era of health system reforms in Turkey

Medical oncologists' dance with international guidelines and national reimbursement: insights from a survey in Türkiye

BACKGROUND

This study explores Turkish medical oncologists' perceptions of integrating international treatment guidelines with national reimbursement policies, considering local legal, economic, and healthcare constraints.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey was conducted from March 24-31, 2024, targeting all 1,096 active oncologists registered with the Turkish Medical Oncology Association, as these specialists are exclusively authorized to prescribe anticancer drugs under national regulations. The survey included 25 questions on demographics, perceptions of guidelines, and integration preferences. Statistical analyses, including chi-square tests and logistic regression, identified factors influencing guideline preferences.

RESULTS

Among 337 respondents (31%), 94% found international guidelines essential, but 62% noted a lack of clear real-world algorithms. Significant predictors for preferring national guidelines included working in public institutions (OR: 3.90, p < 0.001), concerns about pharmaceutical industry influence (OR: 4.38, p = 0.017), legal challenges (OR: 5.89, p < 0.001), and variability among clinical research centers (OR: 2.95, p = 0.019). Despite these challenges, 57% favored national guidelines for their compatibility with local healthcare policies.

CONCLUSIONS

The findings highlight the need for hybrid models that merge the evidence-based rigor of international frameworks with local healthcare priorities. Such models can enhance equitable and effective cancer care in Türkiye by addressing both global standards and national realities.

How enabling factors determine unmet healthcare needs? A panel data approach for countries

Health service need refers to the essential care required to achieve optimal health outcomes within resource constraints. When necessary services to address identified health issues are not received, unmet needs arise. This research focuses on the determinants of unmet healthcare needs across the 34 countries within the European region from 2011 to 2019, focusing on Andersen's Behavioral Model's enabling factors. We employed a static and robust panel regression model using Stata 14.0 software. Key determinants analyzed include GDP per capita, urbanization rate, and physicians per capita. Findings reveal that lower GDP per capita and lower urbanization rates are significantly correlated with higher levels of unmet healthcare needs, highlighting income level and geographical accessibility as critical factors. Additionally, a higher number of physicians per capita is associated with reduced unmet healthcare needs, indicating the importance of healthcare resources in addressing healthcare access gaps. These findings underscore the importance of targeted healthcare policies that address income level, improve healthcare accessibility, and enhance healthcare resource allocation to reduce unmet healthcare needs effectively. These findings equip policymakers and administrators with empirically grounded insights to comprehend the factors contributing to unmet healthcare needs and to develop policies aimed at addressing this challenge.

Diagnostic process of cancer in a health system without gatekeeping: a single centre survey analysis

INTRODUCTION

It is essential to increase the rates of early diagnosis in cancer control, and the diagnostic process needs to be improved to achieve this goal. Previous studies showed that in countries where there is a gatekeeping system, there might be a delay in cancer diagnosis. Our aim is to examine the process of cancer diagnosis in a healthcare system without gatekeeping.

METHOD

A quantitative descriptive study has been conducted in various outpatient clinics of Pendik Training and Research Hospital, between 1 February and 31 May 2019, with individuals aged over 18 and diagnosed with cancer in the last six months. The data was collected through a questionnaire filled in by face-to-face interview method. Patient's socio-economic characteristics, their symptoms at the time of the diagnosis and the diagnosis process were questioned.

RESULT

The median diagnostic interval was 30 days (min-max 1-365), and the median patient interval was 60 (1-600) days. Patients pointed out that the diagnostic tests, especially the pathology reporting process, caused the diagnostic interval to be prolonged. Of the patients, 84% (n 135) stated that they did not consider their symptoms as a sign of serious illness. The patient interval was shortest with symptoms of haematuria and haematochezia and longest with dysuria and change in bladder habit.

DISCUSSION

The study examined the diagnosis process in our health system, where patients can apply for health services at any stage. The results showed that there were no superior outcomes to those observed in primary care-led health systems. Patients reported that waiting times for medical tests led to prolongation of the diagnosis time. Cancer awareness of patients should also be increased to shorten patient admission times.

Gender differences in cost-related unmet healthcare needs: a national study in Turkiye

BACKGROUND

Unmet healthcare needs are a complex and multifaceted issue, influenced by individual, socioeconomic, and healthcare system factors. This study aimed to investigate the determinants influencing cost-related unmet healthcare needs within the Turkish population, emphasizing a comprehensive analysis of gender disparities in accessing healthcare services.

METHODS

This secondary analysis scrutinizes the 2019 Turkiye Health Survey data of 16,976 individuals aged 15 and older. The dependent variables included cost-related unmet medical, dental, and prescribed medication, and mental services. The independent variables were considered under a three-domain approach for the determination of health service utilization, developed by Andersen. Logistic regression models with predisposing, enabling, and need factors were run for any self-perceived cost-related unmet need for each sex and overall population. Another six regression models for both sexes were run for each subgroup of indivuals with unmet healthcare needs.

RESULTS

The study revealed that 15.4% of individuals cannot access healthcare due to financial constraints, with 16.8% for women and 13.5% for men. The highest level of unmet needs is associated with accessing dental care services for both sexes. According to multivariate analyses, the unmet need for both sexes decreases with older age and higher education level, and it is greater for those who have difficulties communicating in Turkish. By adding enabling and needs factors, the odds ratios of education decreased for men, while education became nonsignificant for women. Having chronic disease impacts unmet needs for both sexes. However, the inability to perform daily activities due to health problems was not a significant factor for men. Poorer household income increases overall unmet needs. Education is a determinant of both medical and mental care needs.

CONCLUSIONS

This pioneering study illuminates the multifaceted gender disparities in cost-related unmet healthcare needs across Turkiye, reflecting the intertwined issues of access influenced by a complex interplay of factors. Our findings underscore the significance of adopting an intersectional approach to address health inequalities.

The Relationship Between the Health Transformation Program and Health Expenditures: Evidence From an Autoregressive Distributed Lag Testing Approach

OBJECTIVES

As health expenditure increases every year, countries try to provide accessible health services to society and try to protect individuals from the expenses they cannot overcome by investigating the reason for this increase. Especially with the arrangements made in the health systems in developing countries such as Turkey, it has been tried to take the control of dramatic increases in health expenditure. Based on this issue, in this study, we aimed to evaluate the effect of income per capita, annual inflation, and health reform called as Health Transformation Program on the health expenditure per capita in Turkey.

METHODS

This study reflected the effects of income, inflation, and the reform on the total health expenditure through the autoregressive distributed lag. This study covered the years between 1985 and 2016 for Turkey.

RESULTS

As a result of this study, there was a positive relationship between health expenditure and income and a negative relationship with the reform (P < .05).

CONCLUSION

According to the results of this study, it is suggested that health expenditures can be kept under control with improvements such as encouraging individuals to use more primary healthcare services than curative health services and increasing the quality of service without compromising the equity in financing.

Identifying the Group Vulnerable to Unmet Medical Needs Due to Food Security: According to Children in the Household

OBJECTIVE

Adults may experience unmet medical needs for various reasons. The purpose of this study was to examine the effect of food security on unmet medical needs according to the presence of children in the household of adults, as well as to identify the medically vulnerable group considering individual and household characteristics.

METHODS

This study was conducted using data from the National Health and Nutrition Examination Survey for 2013-2015 and 2019-2020. The subjects of the study were 23,069 adults 19 years of age or older, and were divided into two groups according to whether or not children were included in the household. In order to observe the association between food security and unmet medical needs, multiple logistic regression analysis was performed. In addition, a subgroup analysis was performed in consideration of individual and household characteristics.

RESULTS

When food security was unstable for households with children, or without children, there was a high correlation with unmet medical needs. Considering individual and household characteristics, in groups with lower age and household income level, or higher number of members in household and subjective health status, food security was strongly correlated with unmet medical needs in households with children. Contrarily, households without children showed a high correlation in the opposite characteristics of households with children, excluding household income level.

CONCLUSION

Food security was highly correlation with unmet medical needs regardless of whether or not children were included in the household. However, according to the individual and household characteristics of households with and without children, the relationship between food security and unmet medical needs was found to be different. Therefore, it is necessary to prepare a health policy that can increase access to medical services in consideration of food security and individual and household characteristics depending on whether or not children are included in the household.

Equity of national publicly funded health insurance schemes under the universal health coverage agenda: a systematic review of studies conducted in Africa

BACKGROUND

The implementation of publicly funded health insurance schemes (PFHIS) is the major strategy to drive progress and achievement of universal health coverage (UHC) by 2030. We appraised evidence on the equity of insurance schemes across Africa.

METHODS

We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Seven databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalized the PROGRESS-Plus (place of residence; race/ethnicity/culture/language; occupation; gender/sex religion; education; socioeconomic status; social capital) equity framework to assess equity areas.

RESULTS

Forty-five studies met the inclusion criteria and were included in the study, in which 90% assessed equity by socioeconomic status. Evidence showed that rural residents, those self-employed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely to be covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilization by disadvantaged groups, however, the same groups were less likely to benefit from health services.

CONCLUSIONS

Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilization of essential health services in Africa.

Determinants of Turkish households' out-of-pocket expenditures on three categories of health care services: A multivariate probit approach

This study identifies the driving forces that contribute to the probabilities of incidence of out-of-pocket (OOP) expenditures by households in Turkey. Factors affecting the probability of OOP expenditures on medical products/devices/supplies (MP), outpatient services (OTS), and inpatient services (ITS) are examined using the Household Budget Survey data gathered by the Turkish Statistical Institute in 2018. The study applies the multivariate probit model. The incidence of OOP spending varied with 48.9% of the households reporting OOP expenditure on MP, 22.4% on OTS, and 25.4% on ITS. The largest probability changes were associated with household disposable annual income, household type and size, age category, and having private health insurance. Gender and marital status also influenced expenditures in some categories. Lifestyle choices had small and mixed effects, with smoking and alcohol consumption lowering the probability of OOP spending. From a policy standpoint, households with the lowest incomes, large households, and those where the household head was 'others' (retiree, student, housewife, not actively working, etc.) or had a condition preventing employment seemed to report OOP expenditures less frequently and may have chosen not to receive healthcare services, leading to the need for more healthcare services later.

Occupational class and educational level inequalities in major cardiovascular risk factors in Turkey: 2008-2016

BACKGROUND

We aimed to investigate the magnitude of occupational class (OC) and educational level (EL) inequalities in cardiovascular risk factors in Turkey from 2008 to 2016 and compare these inequalities with neighbouring European countries.

METHODS

We used the Turkey Health Survey among a representative sample of the Turkish population. We estimated relative index of inequality (RII) for four cardiovascular risk factors (obesity/overweight, hypertension, diabetes, smoking) by OC/EL with an interaction term for survey year and compared selected results with neighbouring countries.

RESULTS

Men with lower OC and EL smoked more (e.g. RII for EL = 1.40 [1.26-1.55]); however, the remaining risk factors were mostly lower in these groups. Women in lower socio-economic groups smoked less (e.g. RII for EL = 0.36 [0.29-0.44]), however, had higher prevalence of the remaining risk factors. Significant interactions with survey year were only found in a few cases. The pattern of inequalities in Turkey is largely similar to neighbouring countries.

CONCLUSIONS

Inequalities in cardiovascular risk factors are less systematic in Turkey than in most high-income countries, but ongoing trends suggest that this may change in the future.

Investigating unmet need for healthcare using the European Health Interview Survey: a cross-sectional survey study of Luxembourg

OBJECTIVES

We investigate the prevalence of unmet need arising from wait times, distance/transportation and financial affordability using the European Health Interview Survey. We explore associations between individual characteristics and the probability of reporting unmet need.

DESIGN

Cross-sectional survey conducted between February and December 2014.

SETTING AND PARTICIPANTS

4004 members of the resident population in private households registered with the health insurance fund in Luxembourg aged 15 years and over.

OUTCOME MEASURES

Six binary variables that measured unmet need arising from wait time, distance/transportation and affordability of medical, dental and mental healthcare and prescribed medicines among those who reported a need for care.

RESULTS

The most common barrier to access arose from wait times (32%) and the least common from distance/transportation (4%). Dental care (12%) was most often reported as unaffordable, followed by prescribed medicines (6%), medical (5%) and mental health (5%) care. Respondents who reported bad/very bad health were associated with a higher risk of unmet need compared with those with good/very good health (wait: OR 2.41, 95% CI 1.53 to 3.80, distance/transportation: OR 7.12, 95% CI 2.91 to 17.44, afford medical care: OR 5.35, 95% CI 2.39 to 11.95, afford dental care: OR 3.26, 95% CI 1.86 to 5.71, afford prescribed medicines: OR 2.22, 95% CI 1.04 to 4.71, afford mental healthcare: OR 3.58, 95% CI 1.25 to 10.30). Income between the fourth and fifth quintiles was associated with a lower risk of unmet need for dental care (OR 0.29, 95% CI 0.16 to 0.53), prescribed medicines (OR 0.38, 95% CI 0.17 to 0.82) and mental healthcare (OR 0.17, 95% CI 0.05 to 0.61) compared with income between the first and second quintiles.

CONCLUSIONS

Recent and planned reforms to address waiting times and financial barriers to accessing healthcare may help to address unmet need. In addition, policy-makers should consider additional policies targeted at high-risk groups with poor health and low incomes.

The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study

BACKGROUND

Fragmentation in health insurance system may lead to inequity in financial access to and utilization of health care services. One possible option to overcome this challenge is merging the existing health insurance funds together. This article aims to review and compare the experience of South Korea, Turkey, Thailand and Indonesia regarding merging their health insurance funds.

METHODS

This was a cross-country comparative study. The countries of the study were selected purposefully based on the availability of data to review their experience regarding merging health insurance funds. To find the most relevant documents about the subject, different sources of information including books, scientific papers, dissertations, reports, and policy documents were studied. Research databases including PubMed, Scopus, Google Scholar, Science Direct and ProQuest were used to find relevant articles. Documents released by international organizations such as WHO and World Bank were analyzed as well. The content of documents was analyzed using a data-driven conventional content analysis approach and all details regarding the subject were extracted. The extracted information was reviewed by all authors several times and nine themes emerged.

RESULTS

The findings show that improving equity in health financing and access to health care services among different groups of population was one of the main triggers to merge health insurance funds. Resistance by groups enjoying better benefit package and concerns of workers and employers about increasing the contribution rates were among challenges ahead of merging health insurance funds. Improving equity in the health care financing; reducing inequity in access to and utilization of health care services; boosting risk pooling; reducing administrative costs; higher chance to control total health care expenditures; and enhancing strategic purchasing were the main advantages of merging health insurance funds. The experience of these countries also emphasizes that political commitment and experiencing a reliable economic growth to enhance benefit package and support the single national insurance scheme financially after merging are required to facilitate implementation of merging health insurance funds.

CONCLUSIONS

Other contributing health reforms should be implemented simultaneously or sequentially in both supply side and demand side of the health system if merging is going to pave the way reaching universal health coverage.

Poverty effects of public health reforms in Turkey: A focus on out-of-pocket payments

RATIONALE, AIMS, AND OBJECTIVES

Expanded financial coverage is critical to fight against poverty through public health reforms in developing countries. This study explores inequity in public health financing reforms in Turkey between 2003 and 2015.

METHODS

This paper has two parts. The first part examines inequity in health care financing in Turkey between 2003 and 2015. Gini, entropy (Theil and mean logarithmic deviation), and Atkinson indexes were calculated. In the second part of the paper, we investigated the degree of progressivity by using Kakwani index and Lorenz and concentration curves.

RESULTS

We found a decreasing trend in terms of inequity. After major public health reforms and unification of the health financing system, it is seen that the distribution of out-of-pocket expenditure on health stands on the shoulders of vulnerable groups.

CONCLUSIONS

Study results provide a deep understanding of the effects of poverty on public health financing reforms on households in Turkey. To reduce out-of-pocket health spending inequities and to protect vulnerable groups from increasing the level of health expenditures, we suggest that the government enlarges health insurance coverage for the poor.

Inherited eye diseases in Turkey: Current approaches and future directions

The aim of this review is to reveal Turkey's current status of medical practice in inherited eye diseases and the necessary steps to improve healthcare services and research activities in this area. Since consanguinity rate is high, disease burden is estimated to be high in Turkey. Universal health insurance system, easily accessible medical specialists, increasing genetic test, and counseling opportunities are the key advantages of Turkey's healthcare system. However, specialized clinics for inherited eye diseases, low-vision rehabilitation services, training of ophthalmologists about the recent developments in ocular genetics, and multidisciplinary translational research are the main headlines needed to be focused for better health services and successful research in Turkey.

Prevalence of upper respiratory tract infections and associated factors among children in Turkey

PURPOSE

Upper respiratory tract infections (URIs) are the most common diseases observed in children aged 0-6 years in Turkey. This study was conducted to investigate URIs in 0-6 year-old children in Turkey.

DESIGN AND METHODS

Data of children aged 0-6 years who were included in the 2014 Turkey Health Survey conducted by the Turkish Statistical Institute were collected from their parents.

RESULTS

In total, 1,293 and 1,732 children with and without URIs, respectively, were identified. The weighted point prevalence of URIs was 42.23%. Compared with the uninsured and female children belonging to high-income families, insured male children belonging to low-income families were more likely to develop URIs (p < .001). Moreover, comorbidities such as communicable diseases, anemia and diarrhea, and factors like health services utilization were associated with URIs. Analysis of health services utilization highlights that URIs were reported more among the children who had not visited a hospital than among those who had visited a hospital, with an odds ratio of 1.23.

CONCLUSIONS

The results of this study provide a deeper understanding of sociodemographic, comorbid, and health services utilization factors associated with URIs. These results provide useful insights for pediatric nursing professionals to improve the quality and efficiency of pediatric respiratory nursing services.

PRACTICE IMPLICATIONS

Collaborative networks with other health professionals, parents, and public health policy-makers are essential to decrease the prevalence of URIs in Turkey. These study results provide several insights for health professionals to improve pediatric action plans for ultimately improving child health status.

Nonclinical predictors of caesarean section: a path analytic approach

The objective of this study was to explore nonclinical predictors of cesarean sections (CS) and how they interact with each other, specifically in Turkey. Data was gathered from official statistical records for the year 2017 from the 81 different provinces throughout Turkey. A path analytic model was constructed to examine the interrelationships between socioeconomic factors, utilization of health services, patient satisfaction, and number of CS procedures. The overall performance of the final path model was quite good (GFI = 0.98, AGFI = 0.93, and CFI = 0.96). The study results emphasize the substantial impact of an increase in the number of hospital admissions on the increase in the rate of CS procedures (PC = 0.70). Additionally, the increase in the number of hospital admissions mediates the interrelationship between geographic region, high education, and CS. The findings demonstrate the significant interrelationships among the several major nonclinical predictors of CS in Turkey.Impact StatementWhat is already known on this subject? There has been a considerable increase in the rate of CS in Turkey and the current study examined the nonclinical predictors of CS, and how they interact with each other, specifically in Turkey. The insights developed by this study are due to its scope and topicality. Although of course clinical factors associated with CS are reflected in the literature, this study focused on nonclinical predictors of CS.What the results of this study add? This study empirically clarifies the causal interrelationships among nonclinical predictors of CS, using data from Turkey where CS rates are very high, causing great concern by health professionals and decision-makers. The results of this study provide a stronger understanding of how nonclinical factors relate to CS in Turkey. Significant factors include the connective role of geographic region, the increasingly high level of education being received by women, and the total number of hospital admissions.What the implications are of these findings for clinical practice and/or further research? Study results empirically prove interconnection among geographic region, education, health services utilisation and the number of CS. Health decision makers need to consider the important indirect effects of region, education and number of hospital admissions on the demand for CS procedures.

Unmet needs across Europe: Disclosing knowledge beyond the ordinary measure

Unmet healthcare needs (or foregone healthcare) is a widely used intermediate indicator to evaluate healthcare systems attainment since it relates to health outcomes, financial risk protection, improved efficiency and responsiveness to the individuals' legitimate expectations. This paper discusses the ordinary measure of this indicator used so far, prevalence of unmet needs in the whole population, based on the level of healthcare needs among the population. The prevalence of needs and the prevalence of unmet needs among those in need are key aspects that have not yet been fully explored when it comes to foregone healthcare. We break down the ordinary measure into prevalence of needs and prevalence of unmet needs among those in need based on data taken from the European Social Survey 2014. Afterwards, we analyse these different measures in a cross-country perspective. We also discuss the link between them and the implicit relative assessment of healthcare systems considering the whole population and the sub-group of the population aged 65 or more. Comparisons across countries show different attainment levels unveiling varying challenges across European countries, depending on the combination of levels of need and levels of unmet needs for those in need.

Politics and health outcomes: A path analytic approach

Social and health policies and political participation are associated with each political tradition related to public health outcomes. However, there is a lack of evidence for the relationship between policy and outcomes. This study seeks to determine the relationship between politics, labour and welfare state indicators, economic inequality, and health outcome indicators. Data to test the model was obtained from the Turkish Statistical Institute (TurkStat) that belongs to the 81 provinces of Turkey. Path analysis was used to model the associations between policy, labour and welfare states, economic inequality, and health outcomes. To test the goodness of fit of the model, multiple criteria of model fit indices were utilised. The fit of the respecified path analytic model data is good (normed fit index [NFI] is 0.91, comparative fit index [CFI] is 0.92, goodness of fit index [GFI] is 0.91, and adjusted goodness of fit index [AGFI] is 0.93). Study results illustrate a strong relationship between voter partisanship, employment rate, satisfaction from both social security and health services, and life expectancy at birth and mortality. These results represent an important step towards understanding the elusive relationship between policy and health outcomes. Designing socially inclusive policies, considering labour market opportunities, and enhancing the population's well-being are advisable strategies for policymakers who wish to optimise public health outcomes.