Türkiye’de Sağlık ve Sosyal Hizmet Alt Sektörlerinde Finansal Kırılganlık ve Başarısızlık Riskinin Çoklu Skor Modelleriyle Değerlendirilmesi: 2009–2023 Dönemi Panel Veri Analizi

Öz

Amaç- Bu çalışma, Türkiye’de insan sağlığı ve sosyal hizmet alt sektörlerinde finansal kırılganlık ve başarısızlık riskini 2009–2023 dönemi için incelemeyi amaçlamaktadır. Yöntem- TCMB sektör bilançolarından elde edilen 12 alt sektör ve 15 yıllık dengeli panel veri kullanılmıştır. Zmijewski, uyarlanmış Springate, Grover skorları ve bileşik kırılganlık oranı hesaplanmış; sabit etkili panel modelleri Driscoll-Kraay dirençli standart hatalarla tahmin edilmiştir. Bulgular – Finansal kırılganlık COVID döneminde artmış, pandemi sonrasında azalmıştır. En yüksek risk çocuk gündüz bakım, yaşlı-engelli yatılı bakım ve hemşireli yatılı bakım faaliyetlerinde gözlenmiştir. Sonuç –Borçluluk ve duran varlık yoğunluğu kırılganlığı artırırken; likidite, aktif devir hızı ve satış büyümesi finansal sağlığı desteklemektedir. Finansal riskin azaltılması için borçluluk, likidite ve kapasite kullanımı birlikte yönetilmelidir.

Anahtar Kelimeler

• Finansal kırılganlık; Finansal başarısızlık
• Sağlık sektörü; Panel veri analizi
• Alt sektörler

Evaluation of Financial Fragility and Failure Risk in Health and Social Service Sub-Sectors in Türkiye Using Multiple Score Models: Panel Data Analysis for the 2009–2023 Period

Öz

Purpose –This study aims to examine financial fragility and failure risk in Türkiye’s health and social service sub-sectors for 2009–2023. Methodology – A balanced panel dataset covering 12 four-digit NACE sub-sectors over 15 years was constructed from CBRT sector balance sheets. Zmijewski, adjusted Springate, Grover scores and a composite fragility ratio were calculated; fixed-effects panel models were estimated with Driscoll-Kraay robust standard errors. Findings – Financial fragility increased during the COVID period and declined after the pandemic. The highest risks were observed in child day-care, residential care for older and disabled people, and nursing care activities. Conclusions –Leverage and fixed-asset intensity increase fragility, whereas liquidity, asset turnover and sales growth support financial health. Debt, liquidity and capacity utilization should be jointly managed to reduce financial risk.

Anahtar Kelimeler

• Financial fragility
• Financial failure
• Health sector
• Panel data analysis
• Sub-sectors

Kaynakça

1. Altman, E. I. (1968). Financial ratios, discriminant analysis and the prediction of corporate bankruptcy. The Journal of Finance, 23(4), 589–609. https://doi.org/10.1111/j.1540-6261.1968.tb00843.x
2. Aminian, A., Mousazade, H., & Khoshkho, O. I. (2016). Investigate the ability of bankruptcy prediction models of Altman and Springate and Zmijewski and Grover in Tehran Stock Exchange. Mediterranean Journal of Social Sciences, 7(4 S1), 208–214. https://doi.org/10.5901/mjss.2016.v7n4S1p208
3. Augurzky, B., Engel, D., Schmidt, C. M., & Schwierz, C. (2012). Ownership and financial sustainability of German acute care hospitals. Health Economics, 21(7), 811–824. https://doi.org/10.1002/hec.1750
4. Balakrishnan, K., Li, Z., Hinkle, H. E., Weidenbacher-Hoper, V. L., Reynolds, C., & Keesee, A. O. (2026). Predictors of rural hospital closures in the United States: A systematic review and call for AI-driven early warning systems. BMC Health Services Research, 26(1), Article 86. https://doi.org/10.1186/s12913-025-13847-7
5. Baltagi, B. H. (2021). Econometric analysis of panel data (6th ed.). Springer.
6. Bazzoli, G. J., & Andes, S. (1995). Consequences of hospital financial distress. Hospital & Health Services Administration, 40(4), 472–495.
7. Beauvais, B., Ramamonjiarivelo, Z., Betancourt, J., Cruz, J., & Fulton, L. (2023). The predictive factors of hospital bankruptcy—An exploratory study. Healthcare, 11(2), Article 165. https://doi.org/10.3390/healthcare11020165
8. Beauvais, B., Ramamonjiarivelo, Z., Kruse, C. S., Fulton, L., Shanmugam, R., Sharma, A., & Tomic, A. (2026). The predictive factors of US hospital bankruptcy: A multi-model comparison. Health Care Management Science, 29(1), Article 8. https://doi.org/10.1007/s10729-025-09750-6

9. Breusch, T. S., & Pagan, A. R. (1980). The Lagrange multiplier test and its applications to model specification in econometrics. The Review of Economic Studies, 47(1), 239–253. https://doi.org/10.2307/2297111
10. Carroll, C., Euhus, R., Beaulieu, N., & Chernew, M. E. (2023). Hospital survival in rural markets: Closures, mergers, and profitability. Health Affairs, 42(4), 498–507. https://doi.org/10.1377/hlthaff.2022.01191
11. Cataife, G., & Liu, S. (2025). Medicare Advantage penetration and the financial distress of rural hospitals. Health Economics Review, 15(1), Article 9. https://doi.org/10.1186/s13561-025-00599-7
12. Çavmak, Ş., & Yücedağ Erdinç, N. (2024). Sağlık sektöründe finansal başarısızlık tahmini: Türkiye Cumhuriyet Merkez Bankası sektör bilançoları üzerine bir uygulama. İşletme Akademisi Dergisi, 5(2), 155–170. https://doi.org/10.26677/TR1010.2024.1423
13. Çil Koçyiğit, S., Uysal, B., & Kandil Göker, İ. E. (2024). Türkiye’de insan sağlığı ve sosyal hizmet faaliyetleri sektöründe kârlılığı etkileyen faktörler. Hacettepe Sağlık İdaresi Dergisi, 27(3), 397–410. https://doi.org/10.61859/hacettepesid.1390358
14. Deng, Y. (2025). Spatio-temporal evolution of financial sustainability in Chinese public hospitals: Evidence from provincial panel data (2010–2022). Frontiers in Public Health, 13, Article 1665487. https://doi.org/10.3389/fpubh.2025.1665487
15. Driscoll, J. C., & Kraay, A. C. (1998). Consistent covariance matrix estimation with spatially dependent panel data. The Review of Economics and Statistics, 80(4), 549–560. https://doi.org/10.1162/003465398557825
16. Dubas-Jakóbczyk, K., & Kozieł, A. (2020). Towards financial sustainability of the hospital sector in Poland: A post hoc evaluation of policy approaches. Sustainability, 12(12), Article 4801. https://doi.org/10.3390/SU12124801
17. Enumah, S. J., & Chang, D. C. (2021). Predictors of financial distress among private U.S. hospitals. Journal of Surgical Research, 267, 251–259. https://doi.org/10.1016/j.jss.2021.05.025
18. Gholampoor, H., & Asadi, M. (2024). Risk analysis of bankruptcy in the U.S. healthcare industries based on financial ratios: A machine learning analysis. Journal of Theoretical and Applied Electronic Commerce Research, 19(2), 1303–1320. https://doi.org/10.3390/jtaer19020066
19. Gidwani, R., & Damberg, C. L. (2023). Changes in US hospital financial performance during the COVID-19 public health emergency. JAMA Health Forum, 4(7), Article e231928. https://doi.org/10.1001/jamahealthforum.2023.1928
20. Hausman, J. A. (1978). Specification tests in econometrics. Econometrica, 46(6), 1251–1271. https://doi.org/10.2307/1913827
21. Holmes, G. M., Kaufman, B. G., & Pink, G. H. (2017). Predicting financial distress and closure in rural hospitals. The Journal of Rural Health, 33(3), 239–249. https://doi.org/10.1111/jrh.12187
22. Imansyah, F., Sjaaf, A. C., Nadjib, M., & Hartini, R. (2025). Contribution of national health insurance patient revenue to financial performance of private-profit hospitals from 2017 to 2022. Kesmas: Jurnal Kesehatan Masyarakat Nasional, 20(5), 37–46. https://doi.org/10.7454/kesmas.v20isp1.2078
23. Karaçadır, V. (2025). Borsa İstanbul sağlık sektöründe finansal başarısızlık riski ve piyasa gücünün değerlendirilmesi: Grover G, Zmijewski Z ve Tobin’s Q modelleri üzerinden bir analiz. Üçüncü Sektör Sosyal Ekonomi Dergisi, 60(3), 2336–2353. https://doi.org/10.63556/tisej.2025.1548
24. Karadeniz, E. (2016). Hastane hizmetleri alt sektörünün finansal performansının incelenmesi: Türkiye Cumhuriyet Merkez Bankası sektör bilançolarında bir uygulama. Hacettepe Sağlık İdaresi Dergisi, 19(2), 101–114.
25. Karakolias, S. (2025). Rethinking financial distress in public healthcare: Evidence from Greek hospitals’ governance attributes. Frontiers in Public Health, 13, Article 1690901. https://doi.org/10.3389/fpubh.2025.1690901
26. Karim, S. A., Thompson, K. W., Pink, G. H., & Holmes, G. M. (2026). Fixed-to-total cost ratio is predictive of rural hospital financial distress and closures. The Journal of Rural Health, 42(1), Article e70123. https://doi.org/10.1111/jrh.70123
27. Kruse, F. M., & Jeurissen, P. P. T. (2020). For-profit hospitals out of business? Financial sustainability during the COVID-19 epidemic emergency response. International Journal of Health Policy and Management, 9(10), 423–428. doi:10.34172/ijhpm.2020.67
28. Langabeer, J. R., II, Lalani, K. H., Champagne-Langabeer, T., & Helton, J. R. (2018). Predicting financial distress in acute care hospitals. Hospital Topics, 96(3), 75–79. doi:10.1080/00185868.2018.1451262.
29. Langabeer, J. R., Puroega, F. R., Cohen, A. S., Champagne-Langabeer, T., Yatsco, A. J., & Lalani, K. (2026). Determinants of severe financial distress in U.S. acute care hospitals: A national longitudinal study. Healthcare, 14(3), Article 366. https://doi.org/10.3390/healthcare14030366
30. Liew, K. F., Lam, W. S., & Lam, W. H. (2023). Financial distress analysis of technology companies using Grover model. Computer Sciences & Mathematics Forum, 7(1), 6. https://doi.org/10.3390/IOCMA2023-14405
31. Liu, L. L., Jervis, K. J., Younis, M. Z., & Forgione, D. A. (2011). Hospital financial distress, recovery and closure: Managerial incentives and political costs. Journal of Public Budgeting, Accounting & Financial Management, 23(1), 31–68. https://doi.org/10.1108/JPBAFM-23-01-2011-B002
32. Lord, J., Landry, A., Savage, G. T., & Weech-Maldonado, R. (2020). Predicting nursing home financial distress using the Altman Z-score. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 57, 1–9. doi:10.1177/0046958020934946.
33. Malone, T. L., Pink, G. H., & Holmes, G. M. (2025). An updated model of rural hospital financial distress. The Journal of Rural Health, 41(2), Article e12882. https://doi.org/10.1111/jrh.12882
34. Nurhayati, I., Endri, E., Suharti, T., Sundarta, I., & Rinda, R. T. (2022). The accuracy of financial distress prediction during the COVID-19 pandemic on healthcare sub-sector companies. WSEAS Transactions on Business and Economics, 19, 1463–1475. doi:10.37394/23207.2022.19.132.
35. Oner, N., Zengul, F., & Agirbas, I. (2024). Evaluation of the financial distress of hospitals through machine learning: An application of AI in healthcare industry. Intelligent Systems in Accounting, Finance and Management, 31(4), Article e70000. https://doi.org/10.1002/isaf.70000
36. Orlando, A. W., & Field, R. I. (2021). Measuring the COVID-19 financial threat to hospital markets. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 58, 1–10. https://doi.org/10.1177/00469580211059985
37. Pai, D. R., & Park, S. (2025). Has the Pennsylvania Rural Health Model alleviated the financial vulnerability of rural hospitals? Health Care Management Review, 50(3), 211–220. https://doi.org/10.1097/HMR.0000000000000442
38. Pakdaman, H. (2018). Investigating the ability of Altman and Springate and Zmijewski and Grover bankruptcy prediction models in Tehran Stock Exchange. Revista ESPACIOS, 39(14), 33.
39. Pesaran, M. H. (2015). Testing weak cross-sectional dependence in large panels. Econometric Reviews, 34(6–10), 1089–1117. https://doi.org/10.1080/07474938.2014.956623
40. Planey, A. M., Thomas, S. R., Friedman, H., Hecht, H. K., Kent, E., & Holmes, G. M. (2024). Rural hospital closures: A scoping review of studies published between 1990 and 2020. Journal of Health Care for the Poor and Underserved, 35(2), 439–464. https://doi.org/10.1353/hpu.2024.a928626
41. Puro, N., Borkowski, N., Hearld, L. R., Carroll, N. W., Byrd, J. D., Smith, D. G., & Ghiasi, A. (2019). Financial distress and bankruptcy prediction: A comparison of three financial distress prediction models in acute care hospitals. Journal of Health Care Finance, 46(3), 1–15.
42. Ramamonjiarivelo, Z., Weech-Maldonado, R., Hearld, L., & Pradhan, R. (2014). Public hospitals in peril: Factors associated with financial distress. Journal of Health Care Finance, 40(3), 14–30.
43. Ramamonjiarivelo, Z., Weech-Maldonado, R., Hearld, L., Menachemi, N., Epané, J. P., & O’Connor, S. (2015). Public hospitals in financial distress: Is privatization a strategic choice? Health Care Management Review, 40(4), 337–347. https://doi.org/10.1097/HMR.0000000000000032
44. Rhodes, J. H., Santos, T., & Young, G. (2023). The early impact of the COVID-19 pandemic on hospital finances. Journal of Healthcare Management, 68(1), 38–55. doi:10.1097/JHM-D-22-00037
45. Rhoades, C. A., Whitacre, B. E., & Davis, A. F. (2023). Community sociodemographics and rural hospital survival. The Journal of Rural Health, 39(3), 643–655. https://doi.org/10.1111/jrh.12728
46. Salim, M. N., & Ismudjoko, D. (2021). An analysis of financial distress accuracy models in Indonesia coal mining industry: An Altman, Springate, Zmijewski, Ohlson and Grover approaches. Journal of Economics, Finance and Accounting Studies, 3(2), 1–12. https://doi.org/10.32996/jefas.2021.3.2.1
47. Shanmugam, R., Beauvais, B., Dolezel, D., Pradhan, R., & Ramamonjiarivelo, Z. (2024). The probability of hospital bankruptcy: A stochastic approach. International Journal of Financial Studies, 12(3), Article 85. https://doi.org/10.3390/ijfs12030085
48. Springate, G. L. V. (1978). Predicting the possibility of failure in a Canadian firm: A discriminant analysis [Unpublished master’s thesis]. Simon Fraser University.
49. Szewieczek, A., & Lisicki, B. (2019). Discriminatory models’ adaptation in small and medium sized health care entities. Serbian Journal of Management, 14(2), 389–403. doi:10.5937/sjm14-22902.
50. Tariq, S., Zaffar, M. A., Riaz, Y., & Jalil, M. N. (2025). Revenue composition and financial health of nonprofit humanitarian and emergency health services. Journal of Economic and Administrative Sciences, 41(2), 806–824. https://doi.org/10.1108/JEAS-07-2022-0174
51. Türkiye Cumhuriyet Merkez Bankası. (t.y.). Sektör bilançoları. https://www3.tcmb.gov.tr/sektor/
52. Türkiye İstatistik Kurumu. (2024). Sektör bilançoları, 2024: Metaveri. https://veriportali.tuik.gov.tr/en/press/54080/metadata
53. Upadhye, D., Alzeen, M., Aswani, M., Cendoma, P., & Borkowski, N. (2025). Altman Z-score and its application to Federally Qualified Health Centers. Journal of Hospital Management and Health Policy, 9, Article 14. https://doi.org/10.21037/jhmhp-24-100
54. Verlekar, R. P., & Kamat, M. S. (2019). Recalibration and application of Springate, Zmijewski and Grover bankruptcy models in Indian banking sector. International Journal of Business Analytics and Intelligence, 7, 19–27.
55. Wooldridge, J. M. (2010). Econometric analysis of cross section and panel data (2nd ed.). MIT Press.
56. Zmijewski, M. E. (1984). Methodological issues related to the estimation of financial distress prediction models. Journal of Accounting Research, 22, 59–82. https://doi.org/10.2307/2490859