Financial Burden of Out-of-pocket Health Expenditures in Türki̇ye: Under Covid-19

Background In alignment with the UN Sustainable Development Goal 3.8 on Universal Health Coverage, this study assesses the extent to which Türkiye’s health insurance system protected households from out-of-pocket ( OOP ) health expenditures before and during the Covid-19 pandemic. Despite the implementation of the Health Transformation Program and Universal Health Insurance, concerns remain about financial protection, particularly amid economic downturns and the rapid expansion of private healthcare. Methods Using nationally representative Household Budget Survey data from 2019 (pre-pandemic) and 2022 (pandemic), the study analyzes health expenditure patterns through four models: (1) a logit model predicting any health expenditure, (2) an OLS model estimating the share of health spending in household budgets, (3) a logit model identifying catastrophic health expenditure (CHE), and (4) an OLS model assessing the elasticity of OOP spending. Results Key findings reveal that nominal OOP spending more than doubled from 98.79 TL in 2019 to 245.37 TL in 2022, yet declined slightly in PPP-adjusted USD. The proportion of households facing CHE rose marginally from 4.28% to 4.37%, well below the global average of 13%. However, CHE intensity worsened, with OOP spending among affected households increasing from 19.5% to 21.9% of total consumption. Pharmaceutical, dental, and hospital costs were the main contributors. Insurance coverage slightly increased the likelihood of spending but reduced CHE risk by 13%, indicating partial protection. Income was a strong predictor of both spending and CHE risk, highlighting limitations in the progressivity of health financing. Vulnerable groups—women, households with young children, elderly, or disabled members—faced higher CHE risk. Barriers to access, such as transportation difficulties, also increased financial burden. Conclusions The study concludes that while Türkiye’s health insurance system offers some protection, it remains insufficient for disadvantaged populations, particularly in times of crisis. The absence of 2020–2021 data due to the pandemic limits insights into the immediate effects of Covid-19 but underscores the need for more resilient, equitable health financing mechanisms.