Social Determinants of Out-of-Pocket Health Expenditures for the Older Adults in Turkey: An Econometric Analysis Using TURKSTAT 2023 Data

Öz

The rise in the older-aged population due to the demographic transition increases healthcare needs, creating a substantial Out-of-Pocket expenditure burden that is structurally determined not just by medical necessity but also by critical social and socioeconomic factors. This study aimed to analyze the social and socioeconomic determinants affecting the decision to make out-of-pocket (OOP) health expenditures and the expenditure amount among older adults individuals aged 65 and over in Turkey, utilizing the Turkish Statistical Institute 2023 Household Budget Survey data. Due to the high rate of zero expenditure observations, a two-stage econometric model strategy was adopted, employing Logistic Regression to examine the expenditure decision and Linear Regression to examine the positive expenditure amount. The analysis revealed that core disability statuses (working disability: OR=1,959) and health insurance ownership (OR=2,777) strongly increase the probability of making an expenditure. This is consistent with descriptive findings showing that expenditure tendency increases as income and education levels rise. However, a paradoxical situation was detected: while the probability of making OOP expenditure decreases for lower socioeconomic groups (low-income, low-education), the amount they spend increases once they decide to make an expenditure (low-income: B=0,092; low-education: B=0,042). The largest share of the expenditure burden stems from items where SGK/GSS coverage is insufficient, such as dental care, inpatient treatment, and pharmaceuticals, indicating that financial inequalities structurally shape OOP behavior. Consequently, it is recommended that the scope of SGK/GSS be expanded in high-burden areas and that the costs of preventive services be completely zeroed out to protect lowincome older adults and prevent delayed care.

Anahtar Kelimeler

• Out-of-Pocket Expenditure
• Older Adults
• Social Determinants of Health
• Two-Stage Model
• Turkey

Kaynakça

1. Ali, M. A. (2025). Measuring Socioeconomic Disparities in Out-of-Pocket Healthcare Expenditure: Evidence from Saudi Arabia. Qubahan Academic Journal, 5(3), 368-384.
2. Alrashed, A., & Mohamed, H. R. Patient Out-of-pocket Expenditure in Primary Care Comparing High Income, Middle Income and Low-income Countries. International journal of health sciences, 8(S1), 1365-1388.
3. Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: does it matter?. Journal of health and social behavior, 36(1),1-10.
4. Aregbeshola, B. S., & Khan, S. M. (2024). Determinants of out-of-pocket health expenditure among older adults: Evidence from the Nigeria Living standards Survey 2018–19. Ageing International, 49(2), 450–466.
5. Arun, O. (2013). Ageing in Turkey: The Peter Pan Syndrome? In J. Troisi & H. J. von Kondratowitz (Eds.), Ageing in the Mediterranean (pp. 297-323). London: Policy Press.
6. Azubuike, C. D., & Alawode, O. A. (2024, November). Delayed healthcare due to cost among adults with multimorbidity in the United States. In Healthcare (Vol. 12, No. 22, p. 2271). MDPI.
7. Boz, C., & Ozsarı, S. H. (2020). The causes of aging and relationship between aging and health expenditure: an econometric causality analysis for Turkey. The International journal of health planning and management, 35(1), 162-170.
8. Chowdhury, P., & Goli, S. (2025). Informal employment and high burden of out-of-pocket healthcare payments among older workers: Evidence from the Longitudinal Ageing Study in India. Health Policy and Planning, 40(2), 123–139.

9. Clemente-Marcuello, M., Gutiérrez, M. J., & Orbe, S. (2024). Assessing Economic Barriers to Healthcare Access: A Multidimensional Deprivation Analysis. Available at SSRN 5269599.
10. Du, J., Yang, X., Chen, M., & Wang, Z. (2019). Socioeconomic determinants of out-of-pocket pharmaceutical expenditure among middle-aged and elderly adults based on the China Health and Retirement Longitudinal Survey. BMJ open, 9(7), e024936.
11. Faraji, M., Sharifi, T., Mohammad-Pour, S., Javan-Noughabi, J., Aboutorabi, A., Yousefi, S., & Jakovljevic, M. (2024). Out-of-pocket pharmaceutical expenditure and its determinants among Iranian households with elderly members: A double-hurdle model. Cost Effectiveness and Resource Allocation, 22(1), 15.
12. Fout, J., O'Malley, G., & Dusek, S. (2024). Health care expenses and financial hardship among Medicare beneficiaries with functional disability. JAMA Network Open, 7(6), e2417300.
13. Gheshlaghi, A., Esmayeli, N., Zare, H., & Ahmadi, S. (2024). Out-of-pocket pharmaceutical expenditure and its determinants among Iranian households with elderly members: A double-hurdle model. BMC Public Health.
14. Heider, D., Matschinger, H., Müller, H., Saum, K. U., Quinzler, R., Haefeli, W. E., ... & König, H. H. (2014). Health care costs in the elderly in Germany: an analysis applying Andersen’s behavioral model of health care utilization. BMC health services research, 14(1), 71.
15. Ipek, E. (2019). Determinants of out-of-pocket health expenditures in Turkey: Unconditional quantile regression [in Turkish]. Eskişehir Osmangazi University Journal of Economics and Administrative Sciences, 14(2), 409-420.
16. Kaiser, A. H., Mao, S., Sundewall, J., Ross, M., Koy, S., Vorn, S., ... & Ekman, B. (2025). Assessing the determinants of out-of-pocket health expenditures among Cambodian households in informal employment using survey data. International Journal for Equity in Health, 24(1), 33.
17. Khan, J. J., Sehrin, F., Quayyum, Z., Sarker, A. R., & Rahman, M. S. (2025). Factors affecting out-of-pocket expenditures for chronic and acute illnesses in Bangladesh. PloS one, 20(4), e0320429.
18. Khoshshekan, D., Hafezi, B., & Rajabi, M. (2025). Analyzing the Socioeconomic Factors Influencing Household Expenditures on Medical Equipment and Supplies in Iran. Health Scope, 14(14).
19. Kumar, K., Singh, A., Kumar, S., Ram, F., Singh, A., Ram, U., . . . Kowal, P. R. (2015). Socio-economic differentials in impoverishment effects of out-of-pocket health expenditure in China and India: evidence from WHO SAGE. PloS one, 10(8), Article e0135051. https://doi.org/10.1371/journal.pone.0135051.
20. Meulman, I., Jansen, T., Uiters, E., Cloin, M., Polder, J., & Stadhouders, N. (2025). Decomposing socioeconomic differences in self-rated health and healthcare expenditure by chronic conditions and social determinants. International Journal for Equity in Health, 24(1), 154.
21. Mohsin, K. F., Ahsan, M. N., & Haider, M. Z. (2024). Understanding variation in catastrophic health expenditure from socio-ecological aspect: A systematic review. BMC Public Health, 24(1), 1504. https://doi.org/10.1186/s12889-024-18579-7
22. Muhammad Malik, A., & Azam Syed, S. I. (2012). Socio-economic determinants of household out-of-pocket payments on healthcare in Pakistan. International journal for equity in health, 11(1), 51.
23. Nguyen, T. P., Nguyen, H. T., & Dinh, K. T. (2021). Health service utilization and out-of-pocket expenditure associated with the continuum of disability in Vietnam. International Journal of Environmental Research and Public Health, 18(10), 5129. https://doi.org/10.3390/ijerph18105129
24. Osmani, A. R., & Okunade, A. A. (2021). A Double-Hurdle Model of Healthcare Expenditures across Income Quintiles and Family Size: New insights from a Household Survey. Journal of Risk and Financial Management, 14(6), 246.
25. Ozer, M. (2023). Socioeconomic determinants of out-of-pocket health care expenditures in Türkiye. Fiscaoeconomia, 7(2), 1196-1211. Paul, S., John, D., & Yadav, J. (2025). Catastrophic Health Expenditure Out-of-pocket and Impoverishment Among Persons with Disability in India: Reflection from NSS, 2018. ResearchGate.
26. Pinchoff, J., et al. (2023). Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: Findings from a modeling study. BMC Health Services Research, 23(1), 967.
27. Prada, S. I., & Pizarro, A. B. (2024). Out-of-pocket expenses in older adults with noncommunicable diseases: A scoping review. Journal of Public Health, 1-15
28. Quintal, C. M. M., & Lopes, J. (2021). Catastrophic expenditure on medicines: An analysis based on the Portuguese Household Budget Survey 2015/2016. Journal of EU Research in Business, 2021(Article ID 935298), 1–7. https://doi.org/10.5171/2021.935298
29. Rahman, M. M., Hossain, M. S., Nakamura, R., Alam, M. A., Azmat, S. K., & Sato, M. (2025). Unmet healthcare needs, out-of-pocket payments and catastrophic health expenditures among hypertensive adults in Bangladesh. BMC Health Services Research, 25(1), 1088.
30. Rezaei, S., Karimi, M., Soltani, S., Barfar, E., Gharehghani, M. A. M., Badakhshan, A., . . . Brown, H. (2024). Household financial burden associated with out-of-pocket payments for healthcare in Iran: Insights from a cross-sectional survey. BMC Health Services Research, 24(1), 1062.
31. Sangar, P., et al. (2025). Understanding out-of-pocket expenditure in India: A systematic review. Frontiers in Public Health. Szűcs, P. (2024). Demographic Shifts and Economic Challenges in the European Union: Addressing the Impact of Aging Populations on Social Security, Healthcare and Labour Markets. Európai Tükör, 27(1), 87-106.
32. Srivastava, S., Kumar, M., Mishra, S., Chaurasia, H., & Singh, S. K. (2022). Gender differentials in out of pocket health expenditure among older adults in India: evidence from National Sample Survey 2014 and 2018. Ageing International, 47(4), 779-800.
33. Thomson, S., et al. (2024). Health care affordability for older adults: How the U.S. compares to other countries. The Commonwealth Fund.
34. Xu, K. (2008). Global trends in health expenditure and financial risk protection. (Health Financing Policy Briefs). World Health Organization.
35. Zewotir, T., Ramroop, S., & Palamuleni, M. E. (2014). Determinants of out-of-pocket healthcare expenditure in Ethiopia: A two-part model approach. African Health Sciences, 14(4), 1017–1026.
36. Zhang, M., Zhao, Y., & Zhang, H. (2023). Out-of-pocket health expenditures associated with chronic health conditions and disability in China. International Journal of Environmental Research and Public Health, 20(15), 6465.