Hospital Choice: Survey Evidence from Istanbul

Abstract

This study analyzes patient characteristics that affect the choice between public and private healthcare providers in Istanbul. In addition to socioeconomic variables often considered, this study focuses on another factor that might determine the ease of access to hospital services in developing countries: the availability of social networks. The analysis is based on data from a household survey conducted in Istanbul. The econometric results provide some evidence that potential social ties play an important role in choosing public healthcare centers over private ones for minor health problems. This finding indicates that households with higher‐level social networks might be using them in easing access to public facilities.

Acknowledgements

The authors greatly appreciate the financial support provided by the Boğaziçi University Research Fund (ref no. 06C101). They would also like to thank Frekans Research Company, which conducted the fieldwork for the study, as well as two anonymous referees for helpful comments. The usual caveat applies.

Notes

1. http://www.tuik.gov.tr.

2. The Green Card program covers healthcare expenditures of those earning less than one‐third of the minimum wage. The card is given after a thorough investigation and is renewed every year. In 1992, when the program was initiated, it covered only inpatient healthcare expenditures. In 2004, outpatient expenditures and drug expenses were also included in the coverage. As of 2008, the number of Green Card holders was about 9 million.

3. The number of people covered by these institutions is not very clear. According to SIO statistics, active and retired civil servants make about 15 percent of population, while SIO and BK cover 50 percent and 23 percent of the population, respectively.

4. Ministry of Health, Yataklı Tedavi Kurumları İstatistik Yıllığı 2006 [Inpatient Treatment Centers Statistical Annual 2006] (Ankara: T.C. Sağlık Bakanlığı, 2007).

5. World Bank, Turkey: Country Economic Memorandum‐Structural Reforms for Sustainable Growth, World Bank Report No. 20029‐TU, 2001.

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7. See, for rural patients, Wan‐Tzu Connie Tai, Frank W. Porell and E.Kathleen Adams, “Hospital Choice or Rural Medicare Beneficiaries: Patient, Hospital Attributes, and the Patient‐Physician Relationship,” Health Services Research, Vol. 39, No. 6 (2004), pp. 1903–22.

8. See, for various surgical procedures, Harold S. Luft, Deborah W. Garnick, David H. Mark, Deborah J. Peltzman, Claran S. Phibbs, Erik Lichtenberg and Stephen J. McPhee, “Does Quality Influence Choice of Hospital?” Journal of the American Medical Association, Vol. 263, No. 21 (1990), pp.2899–906.

9. Claran S. Phibbs, David H. Mark, Harold S. Luft, Deborah J. Peltzman‐Rennie, Deborah W. Garnick, Erik Lichtenberg and Stephen J. McPhee, “Choice Of Hospital For Delivery: A Comparison Of High‐Risk And Low‐Risk Women,” Health Services Research, Vol. 28, No. 2 (1993), pp.201–22.

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15. For more on the definition of social capital being incoherent and unclear, see Kenneth. Arrow, “Observations on Social Capital,” in Partha Dasgupta and Ismail Serageldin (eds.), Social Capital: A Multifaceted Perspective (Washington, DC: World Bank, 2000), pp.3–5; Partha Dasgupta, “Economic Progress and the Idea of Social Capital,” in Partha Dasgupta and Ismail Serageldin (eds.), Social Capital: A Multifaceted Perspective (Washington, DC: World Bank, 2000), pp.325–424; Steven N. Durlauf and Marcel Fafchamps, “Social Capital,” in Philippe Aghion and Steven N. Durlauf (eds.), Handbook of Economic Growth, Vol. 1B (Amsterdam: North Holland, 2005), pp.1639–700. For an introduction to social capital, see James S. Coleman, “Social Capital in the Creation of Human Capital,” American Journal of Sociology, Vol. 94, (1988), pp.95–121.

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25. Richard Rose, “Getting Things Done in an Antimodern Society: Social Capital Networks in Russia,” in Partha Dasgupta and Ismail Serageldin (eds.), Social Capital: A Multifaceted Perspective (Washington, DC: World Bank, 2000), pp.147–171.

26. Mark E. Warren, “The Nature and Logic of Bad Social Capital,” in D. Castiglione and J. Van Deth (eds.), The Oxford Handbook of Social Capital (New York, NY: Oxford University Press, 2008), pp.122–149.

27. Michael E. Foley, Bob Edwards and Mario Diani, “Social Capital Reconsidered,” in Bob Edwards, Michael E. Foley and Mario Diani (eds.), Beyond Tocqueville. Civil Society and the Social Capital Debate in Comparative Perspective (Hanover, NH: Tufts University, 2001), pp.266–80.

28. Fikret Adaman and Ali Çarkoğlu, “Social Capital and Corruption During Times of Crises: A Look at Turkish Firms in Economic Crisis of 2001,” Turkish Studies, Vol. 4, No.2 (2003), pp.120–45; Fikret Adaman, Ali Çarkoğlu and Burhan Şenatalar, Toplumun Kamu Yönetimine, Kamu Hizmetlerine ve Reforma Bakışı [Public Administration, Public Services and Reforms from the Perspective of the Public] (Istanbul: TESEV, 2005).

29. Fikret Adaman and Çağrı Yoltar, “Health and Living Conditions Network in the Observatory on Social Situation: Turkey,” entry for the report Health Status and Living Conditions in an Enlarged Europe prepared for European Commission, 2005.

30. With this reduction in sample size, the city is represented at household level within a 95 percent confidence range with a margin of ±0.05.

31. Weighted household size is computed according to Eurostat methodology as follows: any household member older than 14 is counted as an adult. The first adult member gets a weight of 1, the other adult members receive a weight of 0.5, and each child receives a weight of 0.3. For example, a household composed of a husband and a wife with two children aged younger than 14 has a weighted household size of 1+0.5+0.3+0.3=2.1.

32. In our econometric analyses, we include either the socioeconomic status variable or the three dimensions that form it separately. In fact, when we do the latter, we find that income per capita and education per capita exhibit poor statistical performance.

33. Fikret Adaman and Oya Pınar Ardıç, “Social Exclusion in the Slum Areas of Large Cities in Turkey,” New Perspectives on Turkey, Vol. 38 (2008), pp.29–65.

34. Note that it is possible to use all these measures separately as identifiers of potential social networks. However, in our econometric analyses, we uncovered that those measures, when used one‐by‐one, do not have a significant impact on the outcome while, when combined, they play a significant role. This might indicate that although some of the variation in these variables is not relevant for our purposes, once the appropriate portion is extracted, it becomes possible to observe the effects of the potentiality of networks.

35. Here the implicit assumption is that every member of the household is treated equally when faced with a health problem. In reality, however, it may well be the case that because of the existence of power inequalities (arising from, inter alia, gender, age, education differences) in a given household, certain members may receive preferential treatment. Investigation of this important factor was not possible within the budgetary limit of our fieldwork, as this would mean interviewing all members of a given household in order to be able to cross‐check the answers. We are thankful to an anonymous referee who drew our attention to this point.

36. Estimated logit coefficients are given in the Appendix, Table A‐2.

37. See Table A‐3 in the Appendix for logit coefficients.

38. See Table A‐4 in the Appendix for logit coefficients.