Equity and Healthcare Reform in Developing Economies

The Case of Turkey

Songül Ç?naro?lu

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000214635
• Edition: 1
• Topic: Commerce
• Subtopic: Industrie pharmaceutique, biotechnologique et de la santé

Ensuring equity in healthcare is the main concern of health policymakers in order to provide a sustainable health system. This concern is more prominent in developing countries due to the scarcity of resources. This book provides a comprehensive analysis and discussion on the distributive pattern of out-of-pocket pharmaceutical expenditures under the health reforms in Turkey and makes comparisons with pharmerging countries.

Turkey's health reforms began in 2003 to address shortcomings related to financial protection and to improve health outcomes and the quality of healthcare services. The primary motivation was to ensure equity in the distribution of health resources, and this transformation process led to profound changes in how these resources were used, and in health financing in general. However, there is a lack of knowledge regarding the long-term effect of health reforms on the distribution patterns of health expenditures and health service use. This book offers a thorough equity analysis of the health financing system, affected by this health transformation program. Index and curve approaches are used in the equity analysis of pharmaceutical expenditures. The book examines the long-term effects of health system regulations on the health spending characteristics of households and improves the current understanding of equity in this context. It includes extensive international comparisons of healthcare services across a range of developing countries and highlights the significance of ensuring equity for emerging economies.

The author explores the existing evidence as well as future research directions and provides policy and planning advice for health policymakers to contribute to establishing a more equal health system design. Additionally, the book will be of interest to scholars and professionals in the fields of health economics, public health management and health financing.

Chapter 1

Equity in healthcare services

Healthcare is one of the essential policymaking sectors of the government in any country (Purnell et al., 2016). Financial resource constraints, increasing needs and expectations of health consumers, and high competition in health market necessitates considering “equity” in healthcare (Hall and Jacobson, 2018). Ensuring equity in the distribution of health resources is crucial for ensuring health system sustainability (Baum and Fisher, 2010). Lack of awareness of health policymakers regarding the health expenses of households, in areas with high cost, such as on pharmaceutical products, can affect the financially weaker sections of the society (Gemmill et al., 2008). Thus, health policymakers need to be aware of the importance of equity and should consider income-level differences when healthcare services are distributed (Khaled et al., 2018). Turkey is a developing country wherein the greatest proportion of healthcare expenditures come from public resources (Acemoglu and Ucer, 2015). As in most of the countries in the Organization for Economic Co-operation and Development (OECD), one of the primary out-of-pocket (OOP) healthcare expenditures in Turkey is medicine, and public and private expenditure on pharmaceuticals is high (Yardim et al., 2014; Ozgen-Narci et al., 2015)

After 2001, the Turkish government was able to promote stabilization as a result of reform in the public sector, and money was allocated to facilitate the increase in expenditure on healthcare and education and to improve socially inclusive growth (World Bank, 2014). Turkey’s Health Transformation Program (HTP) began in 2003 and has continued since then under the auspices of the Adalet ve Kalkınma Partisi (Justice and Development Party). This program is comprehensive and includes structural reforms in the areas of organization and financing of healthcare services.

Public healthcare expenditures in Turkey have increased, especially from 2003 to 2008. This increase coincided with the establishment of the HTP and a period of sustained economic growth, followed by increased public sector investment (Atun et al., 2013; Yardim et al., 2014). During this period, members of poor households were much less likely to seek healthcare than those of nonpoor households because of concerns regarding affordability (Brown et al., 2014). Before HTP, Turkey had a fragmented structure in the health insurance market. In 2006, as part of the unification of the health financing system, the General Health Insurance Law unified the five health insurance funds within the Sosyal Güvenlik Kurumu (Social Insurance Institution); (Akdağ, 2003). Moreover, all public hospitals formerly owned by social security funds came under the jurisdiction of the Ministry of Health.

The unification of the health financing system, including the Green Card scheme, to protect poor populations is a significant component of this reorganization process to decrease poverty and address consumer expectations. Clearly, the success of healthcare transition programs depends on incorporating patient expectations into the system and considering demographic and welfare state indicators (Meng et al., 2015). The degree of satisfaction with the healthcare services in Turkey increased from 39% in 2003 to 72.3% in 2015 (Ministry of Health, 2015). The Turkish populace view healthcare as the government’s most developed policy area (Agartan, 2015), and the successful healthcare reforms reflect the popularity of the Adalet ve Kalkınma Partisi (Onis, 2015). Despite the fact that healthcare is a dynamic area of research and pharmaceutical expenditures are costly, the distributional analysis of pharmaceutical expenditures in Turkey has not been analyzed extensively. To fill this void, we analyze the level of progressivity in the distribution of pharmaceutical expenditures, using Turkey as a case study.

The objective of this chapter is to provide a closer look at the meaning of equity and health system differences regarding the consideration of equity in the light of health trends and socially inclusive policies. Therefore, in this chapter, the meaning of equity is explained first. After that, globalization and the increasing concern to ensure equity is explained. Next, healthcare system differences are indicated according to the level of primary concern to ensure equity in healthcare. Subsequently, the interrelationships between health trends and socially inclusive policies in health with equity are examined.

The meaning and key concepts of equity in healthcare

Equity has always been the primary concern for health policymakers (Purnell et al., 2016), and the primary goal in developing inclusive and equitable health policies (Atun et al., 2016). Despite the existence of significant differences in the definitions, measurements, interpretations, and determinants of equity, this issue should be the principal aim of every healthcare system (Liu et al., 2002). Health inequity is defined as the differences in health among groups of people who are avoidable, unfair, and unjust (Whitehead, 1992). Equity is characterized by social justice and fairness, and it is an ethical concept based on principles of distributive justice (Beauchamp and Childress, 1994). Equity in health can be defined as the absence of unjust and unfair health disparities in a society (Braveman and Gruskin, 2003). The terms “equality” and “equity” are often used interchangeably; however, they are different concepts. Health equity focuses on the distribution of resources and other processes. Not all disparities are unfair (Anand, 2002; Evans et al., 2001); for example, young adults in general are expected to be healthier than elderly people. Moreover, newborn girls tend to have lower birth weights on average than newborn boys (Braveman and Gruskin, 2003).

Differences in nutrition and immunizations coverage, racial/ethnic differences, and income disparities are the primary focus areas of equity research (Fiscella et al., 2000). Equity in health means that all people have an equal opportunity to be healthy. This is accomplished by the distribution and design of healthcare resources and programs, many of which are shaping and transforming the healthcare sector (Braveman and Gruskin, 2003). Indicators of health equity that have been described in the literature include education, economic status, place of residence (rural and urban), and child’s sex (where applicable) (Hosseinpoor et al., 2015). Additionally, equity analysis can be applied in several contexts, such as health outcomes, specific diseases, malnutrition, maternal care, newborn and child health, accessibility of care, utilizations of healthcare services, delivery of healthcare services, financing of healthcare, insurance coverage, operations of healthcare services, and distribution of healthcare technologies (WHO, 2013a).

In this regard, equity is a multidisciplinary concept and closely related to poverty issues. Poverty is a dynamic phenomenon, and poverty-alleviation strategies have been on top of the agenda of policymakers and practitioners in healthcare (Atun et al., 2016; Deaton, 2003). Closing the gaps in healthcare disparities, interventions, and research are the primary motivations in achieving health equity (Purnell et al., 2016) and ensuring health system sustainability. In addition, globalization has created increasing economic inequality and uncertainty, which has led to a major debate on the sustainability of healthcare financing (Liaropoulos and Goranitis, 2015).

Core distributional concern in most health systems is to achieve egalitarian goals and ensure that the equity standards are met and equal treatment is provided. However, it is difficult to specify the distribution of relational egalitarian ideals of healthcare and examine what policies would best implement them (van Doorslaer et al., 1992). Egalitarians with a specific interest in health are the primary links between health; health-relevant factors; socially relevant factors; and the distribution of healthcare, public health programs, and health research (van Doorslaer et al., 1992). The motivation behind egalitarianism is to promote equal standards and establish equal standing of people to cut across different dimensions of well-being (Moss, 2007). Developing a strong economy and implementing poverty-alleviation strategies are necessary to fight against poverty. Because of the existence of a close relationship between economy and health systems, an effective health system is essential for developing a strong economy (Leach-Kemon et al., 2012). Pursuing equity in healthcare means alleviating disparities between poor and wealthy people through government action in favor of the poor (Smith and Weinstock, 2019). Continuous monitoring of the level of equity in healthcare provides an opportunity for further policy advocacy at the national and regional levels (Bambas Nolen et al., 2005)

Moreover, simultaneous poverty-alleviation strategies supported by effective health and economic policies have helped in reducing poverty and improving health status (Atun et al., 2016). The primary objective of these policies is ensuring healthcare services for everyone (Evans et al., 2013). One of the elements of these policies is insurance coverage enhancement for citizens. However, improving medical care services and establishing affordable healthcare for the financially weaker population are the main strategies of improving the quality of healthcare systems (Levey et al., 2012). Today, under the effect of increasing chronic diseases, the OOP health expenditure, which refers to the payments made at the point of health services (Terrelonge, 2014), has increased in several countries. Additionally, pharmaceutical expenditure constitutes a significant part of OOP health expenditure (Xu et al., 2003).

The healthcare reforms that took place during the past decade to achieve equity in healthcare have led to an improvement in health outcomes and helped in creating an equitable financing system (Wagstaff, 2002). HTPs have been implemented to control and reduce OOP (Piroozi et al., 2017). Moreover, government investments and income distribution are two well-known critical factors in the health reforms that help reduce the share of OOP in total health expenditure and disposable personal income (WHO, 2013).

The principal concern of health policymakers is to devise policies to extend insurance coverage of vulnerable people so that they have continued access to healthcare services. The primary reason for the increased interest in medical insurance is to make it an incentivizing factor and to help improve the health status (Atun et al., 2016). Even though ensuring equity is the main motivation of health policymakers, every health system has its own dynamics. Therefore, it is necessary to consider globalization and personalized medicine dynamics to better understand health system differences and equity in the health system.

Globalization, personalized medicines, and an increasing concern for equity in healthcare

The progressive integration of national economies into the world economy, which is known as “globalizations,” has changed the way of thinking in healthcare policymaking (Ottersen et al., 2014). Increasing evidence has shown that health inequalities exist between and within countries, and emphasis has been placed on eliminating global health inequalities (Cash-Gibson et al., 2018). Policymakers, donors, and nongovernmental organizations are increasingly concerned about equity in healthcare for several reasons. Increased demand is one reason; in the 1980s, governments preferred to use cost containment and efficiency to promote equity in health. The reason for this preference was the belief that “inequalities” are ideologically unacceptable (O’Donnell et al., 2008). Researchers further familiarized themselves with the concept of equity in the 1990s. The number of policies and programs related to health equity increased during that decade (Evans et al., 2001). Other reasons for the increasing popularity of equity research in healthcare are as follows: household datasets are available and comparable for developed and developing countries; national governments are continuously monitoring international comparability of household surveys and are increasing the availability of data for researchers; and the use of computers is expanding. After the introduction of personal computers at the end of the 1980s, analysis of household datasets became easy, quick, and cheaper. Increase in usage of analytic techniques to quantify health inequalities is another reason for the increasing interest in analysis of equity in healthcare (van Doorslaer et al., 2004; Wagstaff and van Doorslaer, 2000).

Health equity is a priority in the post-2015 sustainable development agenda and other major health initiatives. The World Health Organization (WHO) has a long history of actions to achieve equity in health, including efforts to encourage monitoring and curtailing of health inequalities. In 1948, the WHO endorsed health as a right for all, regardless of age, race, religion, and political opinion. The WHO prioritizes the improvement of the health status of vulnerable groups. In 1978, the Declaration of Alma-Ata, advocating action to improve the health of all the people of the world, emphasized the need to reduce inequalities within and between countries (WHO, 1978; WHO Social Determinants of Health, 2015). In 1981, the Global Strategy for Health for All was adopted by the World Health Assembly. In the report of this strategy, the WHO (1981) stated that the achievement of equity depended on how healthcare resources are distributed. Recently, the Commission on Social Determinants of Health (CSDH) was established by the WHO to promote global movement to achieve health equity (CSDH, 2008).

In view of the emerging post-2015 sustainable development goals (SDGs), the importance of equity is gaining attention as a cross-cutting theme for all development-related spheres, including health (SDGs, 2014). CSDH provides evidence to inform effective action and to indicate “avoidable” health inequalities (Graham, 2004). CSDH’s approach focuses on the Social Determinants of Health (SDH) perspective (WHO, 2016). The WHO offers a broad, multidimensional definition of these determinants, describing them as “the conditions in which people are born, grow, live, work, and age” (SDH, 2008). Although th...