Predictors of informal health payments: the example from Turkey.

Little is known about the factors that can affect informal health payments in Turkey, which is pertinent given that Turkey has been undergoing and considering a series of reforms in the health sector. This paper aims to examine the predictors of informal payments in Turkey. The study surveyed a random sample of 3,727 people in a medium-sized city, of whom 706 received medical care for illness and/or non-illness related reasons, using a Turkey-specific version of a model questionnaire focused exclusively on informal out-of-pocket payments. Using multivariable logistic model, household health expenditure, health insurance, service type and provider ownership were found to be statistically significant predictors of informal payment. The findings suggest the supply side factors as the main drivers of informal payments and thus a need for radical changes in the supply side as well as actions to rebuild lost confidence in the health care system of Turkey.

Measurement of efficiency of the dialysis sector in Turkey using data envelopment analysis.

OBJECTIVES: Limited prior work exists on the efficiency of the dialysis sector characterized by steady increase in the dialysis population, providers, and dialysis expenditures in Turkey. The study aimed to examine technical efficiency among producers of dialysis treatment in Turkey. METHODS: Cross-sectional data were used from the 2008 Turkish Statistical Yearbook of Dialysis for total 830 dialysis facilities. Efficiency was measured using data envelopment analysis technique. RESULTS: Results drawn from an input-oriented variable-returns-to-scale model showed technical efficiency from only 3% of facilities, as well as 50% reduction in inputs. Mean efficiency score was found higher among facilities that were freestanding, private, affiliated with international chains, older, and located in Istanbul. CONCLUSION: Efficiency enhancement in dialysis production in Turkey should be placed on the priority agenda, along with careful evaluation of impact of the already-inserted changes on efficiency.

Informal payments in the health sector: a case study from Turkey.

The practice of making informal payments in the health sector is common in a number of countries. It has become an important policy issue around the world. These payments can jeopardize governments' attempts to improve equity and access to care and policies targeted to the poor. It is widely believed that a considerable amount of out-of-pocket payment in the health sector in Turkey is informal. To examine this issue, we used a questionnaire adopted from a wider international study. We concluded that informal payments in Turkey are significant and have important implications for health care reform.

Does chain affiliation make a difference in efficiency of dialysis providers in the USA.

There has been an accelerated movement in the USA dialysis market towards affiliation with chain organizations. But little is known about the impact of this strategy of consolidation on provider performance of efficiency. This paper examines whether affiliation with multi-center dialysis chains creates a difference in technical efficiency. Data were obtained from 1994 to 2000 Independent Renal Facility Cost Report Data files of the Centers for Medicare and Medicaid Studies. Using multiple time series design with a comparison group, technical efficiency was examined through an intertemporal data envelopment analysis. The results showed that mean efficiency scores of chain-affiliated facilities in both pre- and post-affiliation periods are slightly higher than those of their independent counterparts, but the difference was not statistically significant. Members of the first and second largest chains did not appear to gain benefit from affiliation. In conclusion, greater technical efficiency of affiliated facilities is not the result of system engagement but rather the result of organizational maturation, or organizational learning. Engagement with the two largest systems does not provide members with its theoretical premises to achieve technically efficient production of dialysis treatments in multiple product markets.

Longitudinal analysis of efficiency in multiple output dialysis markets.

Provider efficiency in the dialysis industry in the U.S.A. has been of great interest for a variety of parties mainly because of the continuing growth in the number of such patients and providers and in the industry's costs. This study examined technical efficiency longitudinally among the multiple-output producers of freestanding facilities, as the dominant group of providers, using the DEA-based Malmquist index. Nationally representative data were obtained from Independent Renal Facility Cost Report Data Files for the years 1994 through 2000. The resulting sample comprised 140 facilities that had operated throughout the seven study years and jointly produced all dialysis outputs with nonzero inputs. The results show that over the period 1994-2000, on average multi-output, freestanding dialysis facilities did not achieve improvement in productivity. Decomposition of the Malmquist productivity indices showed improvement in technical efficiency but at the same time regress in technologies with potential to improve their quality of care. Negative change in technology was the major source of negative movement in productivity. The study concludes that under the fixed-price payment policy, multiple dialysis outputs are produced efficiently, but it may be that the quality of care is being sacrificed.

A national study of efficiency for dialysis centers: an examination of market competition and facility characteristics for production of multiple dialysis outputs.

OBJECTIVE: To examine market competition and facility characteristics that can be related to technical efficiency in the production of multiple dialysis outputs from the perspective of the industrial organization model. STUDY SETTING: Freestanding dialysis facilities that operated in 1997 submitted cost report fonns to the Health Care Financing Administration (HCFA), and offered all three outputs--outpatient dialysis, dialysis training, and home program dialysis. DATA SOURCES: The Independent Renal Facility Cost Report Data file (IRFCRD) from HCFA was utilized to obtain information on output and input variables and market and facility features for 791 multiple-output facilities. Information regarding population characteristics was obtained from the Area Resources File. STUDY DESIGN: Cross-sectional data for the year 1997 were utilized to obtain facility-specific technical efficiency scores estimated through Data Envelopment Analysis (DEA). A binary variable of efficiency status was then regressed against its market and facility characteristics and control factors in a multivariate logistic regression analysis. PRINCIPAL FINDINGS: The majority of the facilities in the sample are functioning technically inefficiently. Neither the intensity of market competition nor a policy of dialyzer reuse has a significant effect on the facilities' efficiency. Technical efficiency is significantly associated, however, with type of ownership, with the interaction between the market concentration of for-profits and ownership type, and with affiliations with chains of different sizes. Nonprofit and government-owned Facilities are more likely than their for-profit counterparts to become inefficient producers of renal dialysis outputs. On the other hand, that relationship between ownership form and efficiency is reversed as the market concentration of for-profits in a given market increases. Facilities that are members of large chains are more likely to be technically inefficient. CONCLUSIONS: Facilities do not appear to benefit from joint production of a variety of dialysis outputs, which may explain the ongoing tendency toward single-output production. Ownership form does make a positive difference in production efficiency, but only in local markets where competition exists between nonprofit and for-profit facilities. The increasing inefficiency associated with membership in large chains suggests that the growing consolidation in the dialysis industry may not, in fact, be the strategy for attaining more technical efficiency in the production of multiple dialysis outputs.