Inequalities in the home learning environment during the pandemic: a closer look at Syrian refugee children’s home learning environment in Türkiye prior to COVID-19
Hazal Colak Oz, Meltem Aran, Nazli Aktakke, Emre Üçkardeşler and Yali Hajhassan
The home learning environment of children became critical during the COVID-19 school closures, and already-existing deprivations of children increased inequalities in access to education during the COVID crisis. This study documents the home learning environment for the Turkish host community and Syrian refugee children in the pre-pandemic year. In order to achieve this end, a composite home learning environment (HLEQI) is calculated using the Demographic Health Survey (DHS) in Türkiye, which includes a sample of Syrian children. This study reveals that Syrian children were already burdened with disadvantages regarding their home learning environment quality, with the average HLEQI calculated for Turkish children as 61.7% and Syrian children at 36.5%. Moreover, when examining the individual components of this composite index, our study reveals substantial gaps in the supportive home learning environment for both Turkish and Syrian children, with the latter facing even greater challenges. These gaps span across various dimensions of the composite index, encompassing aspects such as access to remote learning infrastructure, adequate study space at home, and quality interaction with adults. The study underscores the need for targeted interventions to address these disparities and ensure an equitable learning environment for all children, regardless of their background or circumstances.
School Dropout Prediction and Feature Importance Exploration in Malawi Using Household panel Data: Machine Learning Approach
Hazal Colak Oz, Çiçek Güven, and Gonzalo Nápoles
Designing early warning systems through machine learning (ML) models to identify students at risk of dropout can improve targeting mechanisms and lead to efficient social policy interventions in education. School dropout is a culmination of various factors that drive children to leave school, and timely policy responses are most needed to address these underlying factors and improve school retention of children over time. However, applying ML approaches to school dropout prediction is an important challenge, especially in low-income countries, where data collection and management systems are relatively more prone to financial and technical constraints. For this reason, this study suggests using already collected household panel data to predict the probability of school dropout and explore feature importance for primary school children in Malawi through ML models. A rich set of variables is obtained in this study from the household data and used to build Random Forest (RF), least absolute shrinkage and selection operator (LASSO), Ridge and multilayer neural network (MNN) models. The study further explores how performance metrics differ when we embed the training samples' weights representing frequency in sampling design into the cost function of these ML models to discuss the implications of using household data in computational social science. LASSO and MNN models trained with sample weights become more prominent due to their higher recall rates of 80.6% and 78.8%. Compared to the baseline model trained with sample weights, the recall rate gained is roughly 56 percentage points using LASSO and 54 percentage points using MNN. Also, comparing LASSO and MNN trained with and without sample weights reveals that training models with sample weights increase the recall rate roughly by 11 percentage points for LASSO and 12 percentage points for MNN. Lastly, the paper provides a comprehensive and unified approach to better interpret the models using a game-theoretic approach – SHapley Additive exPlanations (SHAP) – to quantify feature importance. As a result, socio-economic characteristics of children, such as working in household farming and father's education level, are among the most important features contributing to the probability of school dropout in ML models. This study argues that the weighted sample structure of household data and its wide range of variables explored through the SHAP method for feature importance can enrich the literature and yield valuable results to harness data science for society.
Cash Transfers: Learning from the EU Programme in Turkey
Meltem A Aran, Nazli Aktakke, Hazal Colak and Gokce Baykal
The EU’s Emergency Social Safety Net (ESSN) programme was introduced in Turkey in November 2016 to provide cash transfers to improve living standards for refugees who do not live in camps. It supports around 1.8 million refugees with a monthly average payment of 155 Turkish Lira (currently around 10.5 euros) per family member and quarterly top-ups depending on family size. The ESSN is the largest humanitarian programme in the history of the EU and is currently planned to continue until early 2023.
Various targeting mechanisms are used for providing cash assistance to refugees globally, including; blanket targeting (that is, provided to all), geographic targeting, community-based targeting, self-targeting (where the programme is designed in such a way that only those who need assistance will choose to participate), proxy means testing (using observable characteristics of the household or its members to estimate their income when other income data are unavailable or unreliable), categorical targeting (selecting individuals belonging to a certain category of people) and using a scorecard approach. Among the humanitarian cash transfer programmes funded by the EU, proxy means testing is used in cash assistance programmes in Iraq and Lebanon, categorical targeting is used in Turkey, and something approaching a blanket targeting approach is used in Greece.
Does Quality Matter in Determining Child Care Prices? Evidence from Private Child Care Provision in Turkey
Didem Pekkurnaz, Meltem A. Aran, Nazli Aktakke
Child care prices are expected to reflect the quality of provision. However, in contexts where there are high information asymmetries between the users of the services and providers, we may expect this link between quality and prices to be weaker. Turkey is selected for the study as it has a highly regulated child care sector where the costs of accreditation and the initial setup are high. However, there is very little on-going supervision and no information provided to users on the quality or ranking of these services. This paper investigates the role of quality in determining private child care prices using a unique provider-level data set collected in five provinces of Turkey. Regression results show that prices are mainly driven by infrastructure quality while human resources and curriculum and materials quality scores that are more likely to have a strong bearing on child development do not have a significant impact on prices.
How to Assess the Child Poverty and Distributional Impact of COVID-19 Using Household Budget Surveys: An Application Using Turkish Data
Meltem A. Aran, Nazli Aktakke, Zehra Sena Kibar, Emre Üçkardeşler
This study presents a methodology to predict the child poverty impact of COVID-19 that can be readily applied in other country contexts where similar household data are available—and illustrates this case using data from Turkey. Using Household Budget Survey 2018, the microsimulation model estimates the impact of labour income loss on household expenditures, considering that some types of jobs/sectors may be more vulnerable than others to the COVID-19 shock. Labour income loss is estimated to lead to reductions in monthly household expenditure using an income elasticity model, and expenditure-based child poverty is found to increase in Turkey by 4.9–9.3 percentage points (depending on shock severity) from a base level of 15.4%. Among the hypothetical cash transfer scenarios considered, the universal child grant for 0–17 years old children was found to have the highest child poverty reduction impact overall, while schemes targeting the bottom 20–30% of households are more cost-effective in terms of poverty reduction. The microsimulation model set out in this paper can be readily replicated in countries where similar Household Budget Surveys are available.
Targeting Humanitarian Aid using Administrative Data: Model Design and Validation
Onur Altındağ, Stephen D.O'Connell, Aytuğ Şaşmaz, Zeynep Balcıoğlu, Paola Cadonie, Matilda Jernecke, Aimee Kunze Foonge
In this study, the performance of an econometric targeting model for a large-scale humanitarian aid program providing unconditional cash and food assistance to refugees in Lebanon was developed and assessed. Regularized linear regression was used to derive a prediction model for household expenditure based on demographic and background characteristics from administrative data that are routinely collected by humanitarian agencies. Standard metrics of prediction accuracy suggest this approach compares favorably to the commonly used "scorecard" Proxy Means Test, which requires a survey of the entire target population. The results in this study are confirmed through a blind validation test performed on a random sample collected after the model derivation.
Quantitative and Qualitative Research Methods Used in Development Projects: A Handbook for Civil Society Organizations
Civil society organizations conduct advocacy activities and implement programs for their constituencies and target groups on various social issues in Turkey. For the effectiveness of the programs and the success of the activities, it is important that the implemented programs are built on a solid research base and that the CSOs can make use of the outcomes of these research studies. The research will provide a clear perspective and understanding of the social problems that the CSOs focus on, and the programs, projects, or policies that are designed by making use of scientific research, and that are based on evidence could give more effective results. This handbook, which we have prepared in this context, is presented to the attention of CSO staff and volunteers as well as policymakers as a reference source on quantitative and qualitative research methods and can be used by all organizations that develop research projects and programs on social issues.
The handbook was prepared within the scope of the project titled “Enhancing Advocacy Capacities of Youth CSOs in Turkey: Guiding CSOs through Research” which is jointly executed by Development Analytics and the Young Guru Academy (YGA). This project is financed within the scope of the second phase of the "Civil Society Support Programme" which is supported by the EU and coordinated by the Ministry of Foreign Affairs, Directorate for EU Affairs.
Can Father Training Programmes Help Reduce Gender-Based Violence: Lessons from a Parenting Intervention in Turkey
Gökçe Baykal, Meltem Aran, Nazlı Aktakke
Globally there is a growing interest in the design and implementation of preventive gender-based violence programs that target men. This article seeks to extend literature on the impact of father training programs on fathers’ attitudes about parenting and gender-based violence, by using a case study from a father-training program in Turkey for men with children of ages 3-6 and 7-11 years old. The paper finds modest improvement in fathers’ approaches and attitudes towards democratic parenting, violence, and gender equality. The evidence of moderate effectiveness of the intervention programme aligns with the subset of other systematic research studies in the literature. Even though the programme impact is limited, the intervention is successful for two reasons (i) in recruiting men for a parenting program, in a country where cultural and social pressures to adhere to the conventional masculinity is a norm, (ii) in learning lessons and evolving the parenting intervention programme by gaining new advocates by conducting corporate-wide projects, seminars on fatherhood and gender equality for keeping fatherhood discussion alive, forming local father networks to sustain learning outcomes after programme implementation, alongside the Father Support Programme.
Building an ex-ante simulation model for estimating the capacity impact, benefit incidence, and cost effectiveness of child care subsidies in Turkey
Meltem A. Aran, Ana Maria Munoz Boudet, Nazli Aktakke
Public financing and subsidization of childcare can allow for more equitable access to childcare in places where public provision and capacity are low. The mechanisms of the delivery of the subsidy matter, however, in terms of who gets the benefits of the subsidy and overall cost-effectiveness, given the initial conditions in the childcare market. This paper sets out an ex-ante simulation model using a supply-side provider level and demand-side household model and combining the two models for estimating the benefit incidence of expanded capacity and enrolments as a result of the childcare subsidies, looking at different mechanisms of the delivery including investment grants to providers, operational monthly grants to childcare providers, combinations of the investment and operational grants and demand-side vouchers to households. The model is applied to empirical data from childcare centres and households in Turkey and results reveal that the choice of the subsidy delivery model is not trivial, and has a strong bearing on both the benefit incidence and cost-effectiveness of the subsidy. In the case of Turkey, where significant supply-side constraints exist in the market, a demand-side voucher system is shown to be the least cost-effectiveness measure of delivery of the subsidy, and while a demand-side voucher can be pro-poor targeted, it is not necessarily the option that reveals the most “pro-poor results” both in terms of newly generated capacity and the impact of the subsidy on household welfare. The simulation model developed here can be applied in other country contexts, with the only data requirements being microdata on costs and pricing structure of childcare providers as well as household data with variables on household welfare and childcare utilization.
Impact Evaluation Methods in Evaluating Development Programmes and Applications from Turkey
Meltem Aran, Güneş Aşık, Gökçe Baykal, İrem Güçeri, Murat Kırdar, Beyza Polat, Nazlı Aktakke.
Our new handbook on quantitative impact evaluation methodologies and their applications in Turkey has now been published. This compilation aims to strengthen the analytical capacities of monitoring and evaluation professionals in the field of development in Turkey and is the first book published in the Turkish language on impact evaluation methodologies.
The handbook was prepared as part of the "Capacity Building in Counterfactual Impact Evaluation Methods for Eastern and South-eastern Anatolia Development Agencies" project. The Project was prepared by the Development Analytics team and implemented by the Institute for Fiscal Studies (IFS) in London, UK, and the Eastern Anatolia Development Agency in Van, Turkey, and was financed through the European Union's Civil Society Dialogue between EU and Turkey - IV Regional Policy and Coordination of Structural Instruments Grant Scheme.
The book explains quantitative and qualitative evaluation methods with applications and gives examples from academic studies conducted in Turkey on these topics. The book is prepared to be used as a handbook by public agencies in the coming years as impact evaluation becomes a more widely used tool for these agencies.
Impact evaluation methods are an important part of evidence-based policy-making processes. These studies which are globally increasing in number and getting a wider reach focus on projects' outcomes and results rather than the projects' inputs. In light of these studies, public policies are revised and are renewed under measurable performance and outcome criteria. Local development programs in Turkey have been managed under project-based financing through Development Agencies since 2006. It is important to measure the impact of these projects in order to use these public funds effectively and efficiently.
Can Regulations Make It More Difficult to Serve the Poor? The Case of Childcare Services in Istanbul, Turkey
Meltem A. Aran, Ana Maria Munoz Boudet, Nazli Aktakke
This paper considers the impact of regulations on private childcare capacity in the context of Turkey's highly regulated childcare market. Using data from a recently fielded survey that sampled 141 private ECEC facilities in Istanbul, Turkey, the paper looks at the impact of fixed regulations on prices and poor children’s access to services. The paper, in particular looks at the outdoor space requirement that was originally imposed on private providers in the 1960s and has over time become more difficult to fulfill in densely populated districts of the city. The paper estimates that controlling for other provider characteristics, in districts where such requirement is more binding, the price of childcare services increases by 376.2 TL per child per month and the percentage of children enrolled coming from "poor" backgrounds is lower by 15.1% points than in districts where this standard proves less challenging.
Benefit Incidence of Fuel Subsidies in Madagascar and Recommendation for Child-Friendly Allocations
Meltem A. Aran, Nazlı Aktakke, Martin C. Evans
Fuel subsidies lead to environmental damage through inefficiencies in energy use, they are a burden for the public budget and moreover, they are regressive, benefiting the already better-off households. Despite these negative qualities, energy subsidies are still implemented throughout the world. Post-tax energy subsidies in the world are estimated to be 5.3 trillion USD while fuel subsidies alone, are estimated to be 1.5 trillion USD, making up 1.8 percent of the global GDP in 2015. Although fuel subsidies are regressive, fuel subsidy reforms impact the poor the hardest. Previous experience with fuel subsidy reforms around the world shows that poverty increases as a result of fuel subsidy removal if it is not mitigated with redistribution efforts like cash transfers.
In Madagascar, the government decided to eliminate fuel subsidies gradually in June 2014. The price control mechanism has not been dropped yet. Given the sharp fall in international oil prices in the last year, a window of opportunity has opened for Madagascar and countries alike to adopt a liberalized pricing system and abolish fuel subsidies.
Using ENSOMD 2012 data set, we show that in Madagascar, fuel subsidies are highly regressive. Gasoline and diesel consumption is very rare in the households in the bottom 60 percent while kerosene is commonly consumed by households from all income groups. We find that poor households are affected the least if kerosene price remains unchanged. Nevertheless, different price increase scenarios including a change in the price of kerosene do not increase poverty by more than 1 percentage point. Instead of reallocating the gains from the fuel subsidy reform to children aged 0-4 or 0-14 uniformly is found to decrease poverty rates between 2.4 to 4.6 percentage points.
Women's Invisible Contribution: Quantifying the Economic Value of Women's Unpaid Care Activities in Turkey and Policy Options to Reduce Women's Care Burden
Meltem A. Aran, Nazlı Aktakke
Women, whether in employment or not, spend a significant amount of time in Turkey occupied in unpaid home-based care activities, providing care for children and the elderly in their families. Among the OECD countries, Turkey ranks second in terms of the amount of time women spend on unpaid household chores and activities. This paper estimates the economic value of time women allocate in Turkey to direct care activities at home by using two main methodologies: (i) the opportunity cost method estimates the value of time using each woman’s potential earnings in the labour market, and (ii) the proxy good method calculates the value of time taking into account a constant fixed value of hourly earnings (either the minimum wage or the average wage of a social worker). The value of direct care, which constitutes a lower-bound for overall care activities of women, is estimated to be around 1.37-3.34 percent of GDP as of 2011. Using the opportunity cost of earnings methodology, the paper estimates the economic value of refocusing the time spent on care activities to employment to be 1.5 billion USD for working women and 4.8 billion USD for non-working women.
Maternal and Child Health in Turkey Through the Health Transformation Program
Meltem A. Aran, Nazlı Aktakke, İpek Gürol, Rıfat Atun
Improving maternal and child health outcomes is a major development objective. Targets related to these outcomes were included in the United Nation’s Millennium Development Goals and they continue to galvanize global support through the Sustainable Development Goals (under Goal 3 health targets). Turkey is among the few successful middle-income countries that have significantly reduced the under-5 mortality rate below the MDG 2015 target levels. This study analyses improved demand-side (health insurance, conditional cash transfers) and supply-side inputs (expanded health services) in Turkey’s health system as part of the Health Transition Program (HTP), as well as contextual improvements (such as improved economic well-being and increased maternal educational attainment), to identify how these input factors have advanced health outcomes. The results show that while demand-side measures, such as universal health coverage through the extension of health insurance to low-income families (Green Card program), improved health utilisation variables, the main impact on maternal and child health was through supply-side improvements which expanded for all women access to free antenatal and midwifery care, regardless of health insurance status.
Socioeconomic Impact of Mining Activity: Effects of Gold Mining on Local Communities in Tanzania and Mali
Beyza Polat, Nazlı Aktakke, Meltem A. Aran, Andrew Dabalen, Punam Chuhan-Pole, Aly Sanoh
The effect of extractive activity on economic growth and development is a long-debated issue in the economics literature. While most of the existing literature focuses on the macroeconomic impacts of natural resource abundance, there is a rather limited but growing strand of literature that studies the local economic impact of extractive activity using microdata. This paper aims to contribute to this literature by providing new evidence on the effects of gold mining in two resource-rich African countries: Tanzania and Mali. We utilize a rich data set collected from various sources and apply a differences-in-differences estimation strategy to see whether individuals/households geographically close to mines are affected differently from the opening of mines. We look at a number of outcome variables including various measures of children’s health indicators, households’ access to facilities, and women's and men’s employment status. The first part of the analysis is at the household/individual level where the data is kept and treatment is defined at. As a second attempt, we aggregate the data up to the district level by using the appropriate poverty mapping techniques and apply Abadie et al. (2010)’s Synthetic Control Group method to study whether mining districts behave differently from non-mining districts after mines start operation. We reach different conclusions for the two case countries. In the case of Tanzania, we show that households in the immediate mining catchment area are negatively affected by extractive activity whereas this effect becomes positive when we consider households that are located in neighbouring and further away catchment areas. In the case of Mali, any significant positive impact of mining activity is on those households that are located closer to the mines. Those households, who are still in the catchment area but further away from the mine, are either not affected or negatively affected by mining activity.
Can Child Care Vouchers Get Turkish Mothers Back to Work? Estimating the Employment and Redistributionary Impact of a Demand Side Child Care Subsidy in Turkey
Meltem A. Aran, Herwig Immervoll, Cristobal Ridao-Cano
Lack of access to affordable and quality childcare is one of the impediments to increasing female labour force participation rates in Turkey. With less than one-third of working-age women active in the labour market, the Turkish government has been considering options for expanding female labour force participation by providing a demand-side subsidy conditional on employment (or activation). To achieve this, utilization of childcare is being considered as a policy option. This paper considers the labour supply impact and cost-effectiveness of such a demand-side subsidy by evaluating the labour supply model of women in Turkey under the current conditions and simulates -- under various targeting scenarios and for different benefit levels of the subsidy - (i) the number of women that would join the labour force or become formally employed; (ii) the budgetary implications and cost-effectiveness of the subsidy; and (iii) the potential benefits accrued by the bottom quintiles of society.
Given the constrained supply of existing services, the paper finds that the immediate employment impact of such a demand-side intervention is likely to be low, and the distribution regressive in the short term. A targeted subsidy based on welfare level and employability of the woman is likely to be most cost-effective in the medium term when supply-side constraints on childcare are addressed and concurrent policies to expand the supply of childcare have been implemented. In the short term, when the subsidy is provided conditional on childcare utilization (and there is no targeting of the poor) the benefits are likely to be highly regressive, with only 3 percent of benefits accruing to the bottom quintile of the population. The formal employment impact of the program is also estimated to below: we find that in the short term the number of women activated through the program would range from 2,800 to 43,000 women (entering formal employment) at a cost varying from 1.4 million TL to 37 million TL per month (not including administrative costs of running the program) if the benefits are fixed at 50 % of the net minimum wage. In the medium term, when the supply of ECEC is assumed to be more flexible and supply of services is not a constraint, the demand side transfer is expected to activate into the formal sector an upper bound estimate of 187,600 women, constituting a less than 1 percentage point change in female labour force participation -- at a cost of about 138 million TL per month.
Early Childhood Health and Education Outcomes and Children's Exposure to Multiple Risks in Turkey
Meltem A. Aran, Cristobal Ridao-Cano
This paper considers changes in children's early health and education opportunities and outcomes in Turkey. The study aims to look at changes in health utilization, nutrition, access to early childhood education, and school enrolment rates for children between 2003 and 2008. The findings suggest that health utilization has improved over time in these years and access to health care has increasingly become delinked from the initial circumstances of children in the household, in parallel to Turkey's expansion of the Health Transformation Program. On the other hand, nutrition outcomes remained correlated with maternal education and household wealth status. Access to early childhood education and care programs also came out to be highly regressive, with only households and children in the top quintile having access to childcare programs outside the home. The paper also considers later educational attainment outcomes for older children, by circumstance groups and finds that while some progress has been made in enrolment in basic education in these years, variables that define gender, mother tongue is spoken at home and parental education remain significant determinants of early dropouts as of 2008. In the final section, the paper investigates the exposure of a certain small group of children in Turkey to multiple risk factors at the same time and evaluates the incidence by circumstance group the probability of facing overlapping risks in early childhood. The paper argues that children in these circumstance groups, and that have exposure to multiple risk factors, should be the primary target of social protection and early childhood intervention programs.
Agricultural Technology Diffusion in a Post-Conflict Setting: Evidence from an Experimental Study in Eastern Turkey
Meltem A. Aran
This paper considers the impact of an agricultural extension program, The Özyeğin Rural Development Program, implemented in eastern Turkey, on rates of agricultural technology adoption. Using a uniquely designed experimental panel survey collected in treatment and control villages before and after program implementation, the paper analyses the heterogeneous impact of this agricultural extension program, on the adoption rates of different groups in the villages. The main results in the paper are consistent with the predictions of the model presented, whereby in the early stages of adoption, the existence of the agricultural extension program increases the adoption rates in the villages significantly for all households: treatment is associated with an increase in the rate of adoption of inoculation of fruit trees by 26.2-31.4 percentage points depending on the empirical specification. The paper also finds evidence for the "inclusiveness'' of the NGOs' efforts by looking at the heterogeneous impact of the program on adoption rates of the "excluded" groups using various economic and political exclusion criteria. the paper also considers the role of social networks in access to information and rates of adoption of new technologies and finds that even in the presence of inclusive policies that reach out to economically or politically vulnerable sub-sections in the villages, those who do not have many social interactions with the rest of the village community may remain excluded from the benefits of the program.
Women and Health: Analysis of the Economic Value of Informal Health Care by Women in Turkey
Ana Langer, Afaf Meleis, Felicia M Knaul, Rifat Atun, Meltem Aran, Héctor Arreola-Ornelas, Zulfiqar A Bhutta, Agnes Binagwaho, Ruth Bonita, Jacquelyn M Caglia, Mariam Claeson, Justine Davies, France A Donnay, Jewel M Gausman, Caroline Glickman, Annie D Kearns, Tamil Kendall, Rafael Lozano, Naomi Seboni, Gita Sen, Siriorn Sindhu, Miriam Temin, Julio Frenk
The study estimated the economic value of the amount of time Turkish women spend on unpaid, informal health care using the Time Use Survey. The estimation was carried out using an opportunity cost method for calculations as well as the proxy good methods. Turkey Survey of Income and Living Conditions (SILC) (2011) and the Time Use Survey (2006) were used as the primary data sources for the study. The findings of the study served as background information to the LANCET Commission Paper on "Women and Health".
Inequality of Opportunity in Access to Basic Services Among Egyptian Children
Meltem A. Aran, Lire Ersado
This paper estimates the inequality of opportunities among Egyptian children over time between the years 2000 and 2008 using Egypt Demographic and Health Surveys. The Human Opportunity Index (HOI) is calculated across four categories of access to services, including health utilization, nutrition, basic infrastructure services, and school enrolment. Over these years, Egypt implemented several policies in the health and education sectors that improved the access of children to services through the nation-wide Family Health Model (FHM), as well as through a social marketing campaign to promote iodized salt. This paper finds improvements in the Human Opportunity Index linked to such policies, with HOI increasing from 38.8 to 67.7 for instance for the probability of blood sample being taken from the mother during pregnancy, and from 37.6 to 63.4 for births taking place in public or private health facilities. Increases in the overall coverage of health services were responsible for improvements in the HOI. However, in terms of malnutrition, indicators have deteriorated during this time period, with HOI for not being stunted decreasing from 78.2 to 74. The decomposition of the HOI finds that the probability of malnutrition among Egyptian children is not closely linked to family circumstances, contrary to what one might expect, calling for more supply-side (and less targeted) efforts to reduce malnutrition for all Egyptian children.
📖 Download our Article "Child Development Indicators in the Egyptian Context"
Universal Health Coverage in Turkey: Enhancement of Equity
Rifat Atun, Sabahattin Aydin, Sarbani Chakraborty, Safir Sumer, Meltem Aran, Ipek Gurol, Serpil Nazlioglu, Senay Ozgulcu, Ulger Aydogan, Banu Ayar, Ugur Dilmen, Recep Akdag
Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003–13, which coincides with the Health Transformation Program (HTP). The HTP rapidly expanded health insurance coverage and access to health-care services for all citizens, especially the poorest population groups, to achieve universal health coverage. We analyse the contextual drivers that shaped the transformations in the health system, explore the design and implementation of the HTP, identify the factors that enabled its success, and investigate its effects. Our findings suggest that the HTP was instrumental in achieving universal health coverage to enhance equity substantially, and led to quantifiable and beneficial effects on all health system goals, with an improved level and distribution of health, greater fairness in financing with better financial protection, and notably increased user satisfaction. After the HTP, five health insurance schemes were consolidated to create a unified General Health Insurance scheme with harmonised and expanded benefits. Insurance coverage for the poorest population groups in Turkey increased from 2·4 million people in 2003 to 10·2 million in 2011. Health service access increased across the country—in particular, access and use of key maternal and child health services improved to help to greatly reduce the maternal mortality ratio, and under-5, infant, and neonatal mortality, especially in socioeconomically disadvantaged groups. Several factors helped to achieve universal health coverage and improve outcomes. These factors include economic growth, political stability, a comprehensive transformation strategy led by a transformation team, rapid policy translation, flexible implementation with continuous learning, and simultaneous improvements in the health system, on both the demand side (increased health insurance coverage, expanded benefits, and reduced cost-sharing) and the supply side (expansion of infrastructure, health human resources, and health services).
Welfare Impact of the Global Economic Crisis of 2008-2009 on Turkish Households: Evidence from a Specialized Monitoring Survey in 7 Provinces
Meltem A. Aran
This paper looks at how the macro shock from the 2008 financial crisis has translated into income and welfare shocks in the form of reduced earnings and consumption at the household level in Turkey. Using a specialized household level Welfare Monitoring Survey implemented in May-June 2009 in 7 provinces of Turkey, the paper estimates the impact of the macro-shock on food, education, and health-related expenditures. The paper first establishes a link between the macro-level shock in the financial sector in the province and the changes in earnings at the household level and then using an instrumental variables strategy, establishes the link between the earnings shock and changes in consumption. The main findings in the paper are that the informally employed workers and those with lower levels of education (lower than university level) were more likely to be hurt by the Crisis in the provinces where the survey was collected. Food expenditures acted as the main adjustment mechanism in the face of the income shock, while education and health expenditures remained relatively stable. The probability of reducing food consumption (and the amount of food provided to children) was highest among the poor that initially had low levels of household assets.
A Methodology Note on the Employment and Welfare Impacts of the 2007-08 Financial Crisis
Mohamed Ihsan Ajwad, Meltem A. Aran, Mehtabul Azam, Jesko Hentschel
The welfare impacts of economic downturns generally have to be estimated using simulation tools because of delays in conducting detailed household surveys. This note documents a methodology with which social impacts of an economic slowdown, through its impact on the sources of household income, can be simulated using a simple partial equilibrium model. The simulated impacts are direct, short-run impacts, and do not take into account general equilibrium effects. The methodology has the advantage that it can be implemented in a relatively short time and the data requirements for the analysis are household surveys, which are now generally available in most countries around the world. The methodology was implemented by The World Bank in Turkey and Latvia in early 2009. The main purpose of the work was to help policymakers estimate the scale of the welfare impact on households. This type of information can be crucial to drawing attention to the “human impact” of an economic slowdown, but also to help simulate the strength of safety nets needed to avert erosion in human capital. This note will focus on the Latvia and Turkey cases to illustrate the ease with which the model can be adapted to estimating the distributional impacts of economic shocks. Simulations show that both countries will experience a sharp rise in poverty, a widening of the poverty gap, and a rise in income inequality. With an 18 percent GDP contraction in 2009 and the above employment projections, poverty will increase from 14.4 percent to 20.2 percent of the population in Latvia. In Turkey, simulations indicate that estimated GDP contractions of 5 percent and 1 percent in 2009 and 2010 respectively, in the absence of policy changes, will increase poverty headcount from a predicted 17.4 percent (2008) to 21.7 percent.
Protection in Good and Bad Times? The Turkish Green Card Health Program
Meltem A. Aran, Jesko Hentschel
This paper evaluates the equity and financial protection implications of the expansion of the Green Card (Yesil Kart) non-contributory health insurance program in Turkey during the growth years from 2003 to 2008. It also considers the program's protective impact during the economic crisis in 2009. The authors find that the rapid expansion of the program between 2003 and 2008 was highly progressive. It led to significant gains in coverage of the poor but offered limited financial protection as out-of-pocket expenditures even before the introduction of the program had been limited. Using a specialized welfare monitoring survey, fielded in 2009, the authors estimate the impact of the program on household-level health care utilization during the first phase of the economic slowdown in Turkey. Using three different estimation techniques, they find that the Green Card program had a significantly positive impact on protecting health care utilization during the crisis.
Recent Trends in Female Labour Force Participation in Turkey
Arzu Uraz, Meltem A. Aran, Müşerref Hüsamoğlu, Dilek Okkalı Şanalmış, Sinem Capar
The female labour force participation level in Turkey is currently very low at 27% compared with the OECD and EU-19 averages of 61 and 64% respectively. This rate has been declining in the last 30 years from a level of 48% in 1980. This paper looks at the most recent trends and profiles of labour force participation of women in Turkey using three different household-level data sources in available Turkey (HBS, LFS and TDHS) for the period 2003-2006. The paper also reports a multivariate analysis on the probability of working for women, controlling for various characteristics.
Poverty and Inequality Changes in Turkey (2003-2006)
Meltem A. Aran, Sırma Demir, Özlem Sarıca, Hakan Yazici
Poverty in Turkey has declined significantly between 2003 and 2006, as a result of rapid poverty reduction in urban areas. In the same time period, the reduction in poverty in rural areas has been slow or non-existent. As a result, the relative risk of poverty has increased in this time period for those employed in the agricultural sector, living in rural areas, and in large households. Inequality in urban areas has decreased as a result of higher growth in the consumption levels of the urban poor compared to richer deciles, while no significant changes to inequality measures have been noted in rural areas. In fact, the consumption levels of the poorest groups in rural Turkey have declined between 2003 and 2006. Child poverty has also been persistent in this time period, with the relative risk of poverty for children (ages 0-19) increasing over time.
Measuring Inequality of Opportunity with Imperfect Data: The Case of Turkey
Francisco H. G. Ferreira, Jeremie Gignoux , Meltem A. Aran
The measurement of inequality of opportunity has hitherto not been attempted in a number of countries because of data limitations. This paper proposes two alternative approaches to circumventing the missing data problems in countries where a demographic and health survey and an ancillary household expenditure survey are available. One method relies only on the demographic and health survey and constructs a wealth index as a measure of economic advantage. The alternative method imputes consumption from the ancillary survey into the demographic and health survey. In both cases, the between-type share of overall inequality is computed as a lower bound estimator of inequality of opportunity. Parametric and non-parametric estimates are calculated for both methods, and the parametric approach is shown to yield preferable lower-bound measures. In an application to the sample of ever-married women aged 30-49 in Turkey, inequality of opportunity accounts for at least 26 percent (31 percent) of overall inequality in imputed consumption (the wealth index).