Work

The political economy of health reforms and out-of-pocket spending in Türkiye: evidence from household microdata, 2014–2023

Year: 2026

Type: article

Abstract: BACKGROUND: Out-of-pocket (OOP) health spending remains a major challenge to financial protection and health equity in many middle-income countries, even in contexts where insurance coverage has expanded. Türkiye represents a salient case, as large-scale health reforms over the past two decades have coincided with persistent OOP burdens and increasing macroeconomic volatility. METHODS: This study analyzes nationally representative microdata from the Turkish Household Budget Survey covering the period 2014-2023. Log-linear regression models were used to examine the socio-demographic determinants of individual-level out-of-pocket (OOP) health expenditures. To assess equity and financial protection, both the OOP-to-income ratio and a World Health Organization-referenced 10% threshold were employed as descriptive benchmarks, rather than to estimate full population-level catastrophic health expenditure incidence. RESULTS: OOP health expenditures increased over the study period and remained above OECD averages. While higher-income groups incurred greater absolute spending, the relative financial burden was disproportionately concentrated among lower-income households. After 2018, the concentration of high OOP-to-income burdens increased, particularly among disadvantaged groups, suggesting a weakening of financial protection during periods of economic turbulence and structural reform. CONCLUSIONS: The findings indicate that health reforms in Türkiye expanded access to services but did not prevent the unequal distribution of financial risk across income groups. From a health equity perspective, modernization strategies that rely on public-private partnerships and digital expansion may unintentionally shift cost pressures onto households. Strengthening financial protection mechanisms and systematically monitoring distributional effects are essential for advancing equity-oriented health reform.

Source: International Journal for Equity in Health

DOI: 10.1186/s12939-026-02929-5

Authors: Sinem Cece, Abuzer Pınar, Lamiha Öztürk, Dilara Şenay

Institutions: Ankara Medipol Üniversitesi, Ankara University

Language: English

Topic: Healthcare Systems and Reforms

Subfield: Finance

Field: Economics, Econometrics and Finance

Domain: Social Sciences

SDGs: Good health and well-being, Reduced inequalities, No poverty

Open Access status: gold

Estimated APC paid: $3,690