Development Analytics Research Paper Series # 151 Maternal and Child Health in Turkey through the Health Transformation Program (23-28) Meltem A. Aran Nazli Aktakke Ipek Gürol Rıfat Atun Development Analytics Research Department www.developmentanalytics.org research@developmentanalytics.org December 215 Electronic copy available at: http://ssrn.com/abstract=271839
Summary Improving maternal and child health outcomes has been a major development objective of the United Nation s Millennium Development Goals (MDGs), designed to address global inequality in the year 2. To reach this goal, significant effort has gone into assessing the best practices for improving health care utilization through antenatal, delivery and postpartum care to reduce infant, child and maternal mortality. The fourth Millennium Development Goal as outlined by the United Nations focuses on reducing the under-5 (U-5) mortality rate by two-thirds from the 199 level by 215. This paper considers the case of Turkey, which has been among the few successful countries in significantly reducing the U-5 mortality rate below the MDGs 215 target levels doing so even ahead of the MDG target schedule. This study attempts to unpack the bundle of demandand supply-side inputs in Turkey s health care system, as well as contextual improvements (such as improved economic wellbeing and increased maternal educational attainment), to identify the input factors that have had the greatest push in bringing about improvements in health outcomes. The results show that while demand-side measures such as universal health insurance helped improve some of the health utilization output variables, the main impact of the Health Transition Program (HTP) on maternal and child health was through improvements on the supply side. This is also a function of the fact that all women had access to free antenatal and midwifery care, regardless of health insurance status, and as such demand-side benefits such as the Green Card program did not have a further impact on these output variables. The conditional cash transfer program (CCT), on the other hand, which provided extra benefits to poor women who utilized antenatal care services and delivered at hospitals, consistently had a significant and positive impact on these utilization variables. Keywords: Health Insurance, Maternal and Child Health Outcomes, Health Utilization, Social Protection, Green Card, Turkey JEL Classification Numbers: J13, I13, I14, I15, I38 1 Electronic copy available at: http://ssrn.com/abstract=271839
Acknowledgments The authors would like to thank Dr. Sarbani Chakraborty, for bringing together the work program and facilitating data collection; Dr. Uğur Dilmen, Dr. Banu Ayar, Dr. Volkan Cetinkaya from the Ministry of Health for providing the data and their helpful feedback on the analysis and Isabel Hunter for editing support. 1
2
3
4
5
y i = β + δ year 28 i + β 1 greencard i + δ 1 year 28 greencard i + β 2 x i + u i 6
% output p = β + (β 1 % input p ) + u p % output p = β + (β 1 % input p,supply ) + (β 2 % input p,d ) + (β 3 % context p )+ u p 7
8
9
1
11
12
13
14
15
16
1 15 % Change by province in antenatal care (23-28) van mus agri 1 15 % Change by province in antenatal care (23-28) van mus agri 5 diyarbakir manisa ordu elazigadiyaman afyon kars kayserik. maras içel yozgat bitlis konya kirsehir nevsehirantalya istanbul balikesir erzurum zonguldak malatya samsun osmaniye kocaeli sivasgaziantep hatay trabzon adana eskisehir izmirtekirdag ankara Çanakkale igdir sakarya bursa erzincan giresun aksaray sanliurfa siirt 5 diyarbakir adiyaman afyon kars manisa ordu elazig k. maras kayseri içel yozgat bitlis osmaniye kirsehir sivas samsun zonguldak malatya konya kocaeli hatay gaziantep siirt balikesir antalya nevsehir erzurum eskisehir Çanakkale trabzon izmir adana tekirdag ankara sakarya igdir istanbul bursa giresun erzincan aksaray sanliurfa 5 1 15 2 5 1 15 2 % change in total number of physicians % change in total number of nurses and midwives Source data: Turkey DHS 23-28 limited sample Source data: Turkey DHS 23-28 limited sample 1 15 % Change by province in antenatal care (23-28) mus van agri 1 15 van mus agri % Change by province in antenatal care (23-28) 5 sanliurfa diyarbakir afyon kars adiyaman kayseri ordu elazig manisa k. maras yozgat içel bitlis kirsehir zonguldak samsun konya sivas osmaniye malatya hatay kocaeligaziantep siirt trabzon nevsehir balikesir ankara eskisehir istanbul erzurum izmir adana Çanakkale antalya tekirdag sakarya igdir bursa erzincan giresun aksaray -5 5 1 15 % change in total number of hospital beds 5 sanliurfa diyarbakir afyon kars elazig adiyaman kayseri manisa ordu k. maras yozgat içel bitlis konya samsun osmaniye balikesir eskisehir trabzon hatay malatya kocaeli sivas gaziantep kirsehir sakarya antalya erzurum nevsehir zonguldak siirt Çanakkale bursa ankara izmir istanbul adana tekirdag igdir giresun aksaray erzincan 5 1 15 2 % change in province level mean for green card coverage Source data: Turkey DHS 23-28 limited sample Source data: Turkey DHS 23-28 limited sample 1 2 3 4 % Change by province in receiving iron tablets during pregnancy (23-28) van yozgat diyarbakir nevsehir erzurum k. maras manisa adiyaman kars giresun konya ordu kayseri elazig kirsehir antalya içel istanbul eskisehir zonguldak malatya osmaniye sivas afyon samsun kocaeli gaziantep bitlis adana erzincan balikesir trabzon izmir ankara hatay tekirdag Çanakkale igdir aksaray sakarya bursa mus siirt sanliurfa 5 1 15 2 % change in total number of physicians Source data: Turkey DHS 23-28 limited sample agri 1 2 3 4 % Change by province in receiving iron tablets during pregnancy (23-28) van yozgat diyarbakir nevsehir erzurum k. maras manisa adiyaman kars giresun osmaniye sivas ordu elazig afyon konya kayseri içel antalya eskisehir kirsehir samsun zonguldak izmir ankara malatya kocaeli hatay gaziantep bitlis balikesiradana erzincan Çanakkale tekirdag trabzon istanbul siirt sakarya igdir bursa aksaray mus sanliurfa 5 1 15 2 % change in total number of nurses and midwives Source data: Turkey DHS 23-28 limited sample agri 1 2 3 4 % Change by province in receiving iron tablets during pregnancy (23-28) erzincan mus van yozgat diyarbakir sanliurfa nevsehirerzurum k. maras adiyaman kars giresun kayseri ordu manisa konya sivas osmaniye afyon elazig bitlis kirsehir ankara zonguldak eskisehir samsun trabzon istanbul izmir içel balikesir adana Çanakkale antalya malatya hatay kocaeligaziantep siirt tekirdag sakarya igdir bursa aksaray -5 5 1 15 % change in total number of hospital beds Source data: Turkey DHS 23-28 limited sample agri 1 2 3 4 % Change by province in receiving iron tablets during pregnancy (23-28) agri mus van sanliurfa diyarbakir yozgat erzurum k. maras nevsehir manisa kars adiyaman kayseri giresun konya afyon elazig ordu eskisehir samsun hatay malatya balikesir trabzon antalya ankara osmaniye sivas kocaeli izmir içel gaziantep bitlis istanbul kirsehirzonguldak sakarya Çanakkale bursa adana tekirdag aksaray igdir erzincan 5 1 15 2 % change in province level mean for green card coverage Source data: Turkey DHS 23-28 limited sample siirt
-2 2 4 6 8 % Change by province in trained delivery (23-28) manisa kirsehir nevsehir içel yozgat konya kayseri zonguldak adanaerzurum istanbul balikesir malatya izmir samsun tekirdag sivas gaziantep diyarbakir kars antalya aksaraytrabzon osmaniye kocaeli k. hatay maras ankara adiyaman erzincan giresun bursa bitlis Çanakkale sakarya igdir eskisehir ordu elazig afyon van mus siirt sanliurfa 5 1 15 % change in total number of physicians -2 2 4 6 8 % Change by province in trained delivery (23-28) ordu elazig manisa afyon van kirsehir içel nevsehir zonguldak yozgat kars konya kayseri balikesir sivas adana erzurum diyarbakir samsun izmir tekirdag k. maras malatya hatay gaziantep osmaniye antalya adiyaman kocaeli istanbul trabzon ankara aksaray siirt giresun erzincan bursa bitlis Çanakkalesakarya igdir eskisehir sanliurfa mus 5 1 15 2 % change in total number of nurses and midwives agri Source data: Turkey DHS 23-28 limited sample Source data: Turkey DHS 23-28 limited sample -2 2 4 6 8 % Change by province in trained delivery (23-28) erzincan ordu kirsehir kayseri yozgat zonguldak nevsehir diyarbakir konya mus içel kars sivas erzurum samsun balikesir adana istanbul izmir malatya hatay gaziantep tekirdag k. ankara trabzon osmaniye adiyaman kocaeli maras antalya aksaray siirt giresun bitlis bursa Çanakkale sakarya igdir eskisehir elazig manisa afyon sanliurfa van -5 5 1 % change in total number of hospital beds -2 2 4 6 8 ordu elazig manisa afyon sanliurfa van agri kirsehir kayseri konya kars erzurum nevsehir diyarbakir mus yozgat içel zonguldak balikesir hatay samsun malatya izmir k. maras sivas adana gaziantep trabzon antalya ankara osmaniye adiyaman kocaeli istanbul tekirdag aksaray giresun bursa bitlis sakarya Çanakkale eskisehir % Change by province in trained delivery (23-28) igdir erzincan 5 1 15 2 % change in province level mean for green card coverage siirt Source data: Turkey DHS 23-28 limited sample Source data: Turkey DHS 23-28 limited sample 1 15 % Change by province in delivery in a health facilit (23-28) 1 15 % Change by province in delivery in a health facil (23-28) 5 nevsehir ordu van kirsehir manisa adana yozgat konya elazig osmaniye gaziantep içel antalya balikesir erzurum zonguldak malatya aksaray istanbul kayseri erzincan giresun eskisehir trabzon izmirtekirdag samsun kocaeli sivas ankara adiyaman k. hatay sakarya maras bursa afyon diyarbakir kars bitlis Çanakkale igdir mus sanliurfa siirt a 5 nevsehir ordu van osmaniye balikesir içelkirsehir manisa adana yozgat elazig konya zonguldak antalya adiyaman erzurum k. afyon kars maras giresun erzincan eskisehir Çanakkale sivas samsun izmir tekirdag trabzon ankara sakarya malatya aksaray kayseri diyarbakir kocaeli istanbul bursa hatay gaziantep siirt bitlis igdir sanliurfa mus -5-5 5 1 15 5 1 15 % change in total number of physicians % change in total number of nurses and midwives Source data: Turkey DHS 23-28 limited sample Source data: Turkey DHS 23-28 limited sample 1 15 % Change by province in delivery in a health facilit (23-28) 1 15 % Change by province in delivery in a health facil (23-28) 5 erzincan nevsehir ordu van osmaniye mus sanliurfa kirsehir yozgat konya zonguldak ankara trabzon giresun eskisehir samsun kayseri diyarbakir balikesir içel afyon kars manisa elazig adana sivas istanbul adiyaman erzurum izmir antalya malatya hatay gaziantep tekirdag sakarya k. maras bitlis bursa Çanakkale kocaeli aksaray siirt igdir 5 sanliurfa ordu van nevsehir agri konya manisa elazig osmaniye mus balikesir kayseri sakarya afyon hatay adana yozgat gaziantep antalya erzurum kars malatya bursa giresun eskisehir trabzon samsun ankara adiyaman k. diyarbakir maras içel kirsehir bitlis zonguldak Çanakkale izmir kocaeli aksaray istanbul sivastekirdag igdir erzincan -5-5 -5 5 1 5 1 15 % change in total number of hospital beds % change in province level mean for green card coverage Source data: Turkey DHS 23-28 limited sample Source data: Turkey DHS 23-28 limited sample 1
1
2