Obligatory service requirement and physician distribution in Turkey

1
Obligatory service requirement and physician
distribution in Turkey

• Burcay Erus and Ayca Bilir
• Bogazici University,
• Istanbul, Turkey
• 28/3/2008

2
Motivation

• Unequal distribution of physicians is a major
  problem in both developing and developed
  countries
• In Turkey per capita physician numbers vary
  considerably across regions
• 1990 2000
• MoH Others MoH Others
• Lowest 10 0.62 2.88 0.99 5.55
• Highest 10 6.34 15.04 13.62 24.58

3
Incentive Schemes

• Monetary compensation
• Roemer (1987)
• Hurley (1990)
• Bolduc et al. (1996)
• Obligatory Service
• Cavender and Alban (1998)

4
Objective

• In this work obligatory service requirement
  policy in Turkey is analyzed. A change in policy
  in 1995 is used to measure its impact on the
  distribution of specialists at MoH hospitals
• Initial Observations Change in physician per
  capita
• Obligatory service In
  place Cancelled
• (1990-1995) (1995-2000)
• MoH Others MoH Others
• Lowest 10 1.26 -0.07 1.42 0.43
• Highest 10 2.83 3.69 6.70 3.59

5
Obligatory service requirement in Turkey

• Obligatory service law was put into practice
  between 1981 and 1995.
• From 1995 until 2005 graduates were immediately
  appointed to their place of employment.

6
Career following obligatory service

• After the obligatory service, specialists can
  work in
• private sector (one fifth of physicians in 2000)
• public sector
• MoH (one third of specialists)
• SSK, University and other public hospitals
• Location decision in MoH hospitals
• MoH constrained by availability of outside option
  for specialists
• rotation systems in place
• specialists do sometime retire or quit the job if
  assigned to backward locations
• permission to work part-time in private practice
  makes quitting MoH easier

7
Methodology

• Dependent variable
• change in physician per capita from 1990 to
  1995 and
• change in physician per capita from 1995 to
  2000
• Physician per capita in 63 cities
• Major cities Istanbul, Izmir, Ankara
• Cities affected by the 1999 earthquake
• Cities divided during the period from 1990 to
  2000
• are excluded
• Seemingly Unrelated Regressions

8
Independent Variables Socio-Economic Development

• A socio-economic development index
• Expected to be more important after 1995
• Calculated in 1996 and 2003
• Combines a large number of indicators using PCA

9
Independent Variables Number of Hospital Beds in
MoH Hospitals

• Number of hospital beds in MoH hospitals
• Might signal the intentions of MoH
• Both levels and change

10
Empirical Specification
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Conclusion

• Obligatory service requirement is an effective
  tool
• the impact of socio-economic development in
  specialist distribution in MoH hospitals is
  reduced
• No similar pattern in other hospitals
• Economic and human costs should be evaluated for
  a full assessment
• No evidence on productivity of physicians

15
Work in progress

• Extension of the analysis to the periods
  1985-1990 and 2000-2005is there a satiation
  point for the private market
• Assessment of the costs by comparing the
  admissions to Medical School in those periodsno
  evidence from raw data
• Assessment of specialist performance using the
  number of inpatient and outpatient cases in the
  two periodsdifficulties in finding measures of
  performance