The political economy of health reforms and out-of-pocket spending in Türkiye: evidence from household microdata, 2014–2023

Out-of-pocket (OOP) health spending remains a major challenge to financial protection and health equity in many middle-income countries, even in contexts where insurance coverage has expanded. Türkiye represents a salient case, as large-scale health reforms over the past two decades have coincided with persistent OOP burdens and increasing macroeconomic volatility. This study analyzes nationally representative microdata from the Turkish Household Budget Survey covering the period 2014–2023. Log-linear regression models were used to examine the socio-demographic determinants of individual-level out-of-pocket (OOP) health expenditures. To assess equity and financial protection, both the OOP-to-income ratio and a World Health Organization–referenced 10% threshold were employed as descriptive benchmarks, rather than to estimate full population-level catastrophic health expenditure incidence. OOP health expenditures increased over the study period and remained above OECD averages. While higher-income groups incurred greater absolute spending, the relative financial burden was disproportionately concentrated among lower-income households. After 2018, the concentration of high OOP-to-income burdens increased, particularly among disadvantaged groups, suggesting a weakening of financial protection during periods of economic turbulence and structural reform. The findings indicate that health reforms in Türkiye expanded access to services but did not prevent the unequal distribution of financial risk across income groups. From a health equity perspective, modernization strategies that rely on public–private partnerships and digital expansion may unintentionally shift cost pressures onto households. Strengthening financial protection mechanisms and systematically monitoring distributional effects are essential for advancing equity-oriented health reform.