Physician maldistribution persisted despite health system capacity expansion in Türkiye, 2002-23.

BACKGROUND

Equitable access is a core dimension of healthcare quality. Türkiye expanded health system financing, workforce, and infrastructure after the early 2000s, but whether national capacity growth was accompanied by more equitable subnational resource distribution remains unclear. This study examined national trends in health system capacity and financing between 2002 and 2023 and compared provincial resource distribution by Human Development Index group.

METHODS

We conducted a retrospective observational health services study using aggregated national and provincial indicators from Türkiye. National indicators included physicians, nurses, hospital beds, persons per provider, total and per-capita health expenditure, health expenditure as a percentage of gross domestic product, and the public share of total health expenditure. Descriptive trends and ordinary least-squares models were used to summarize temporal co-variation between nominal health expenditure and capacity indicators; no inflation-adjusted or causal effect was estimated. For the subnational analysis, the province with the highest and lowest Human Development Index value within each of Türkiye's seven geographic regions was selected, yielding 14 provinces. Provincial physician, nurse, and hospital bed densities were compared between high- and low-Human Development Index provinces using the exact two-sided Mann-Whitney test. Interprovincial inequality was assessed using the coefficient of variation and Gini index.

RESULTS

Between 2002 and 2023, the number of physicians increased from 91 949 to 204 223, nurses from 72 393 to 248 287, and hospital beds from 164 471 to 266 594. Persons per physician declined from 722 to 418, and persons per nurse declined from 917 to 344. Total nominal health expenditure increased from 18.774 billion Turkish Lira to 1244.24 billion Turkish Lira, while the public share of total health expenditure increased from 70.7% to 77.5%. Over time, higher nominal per-capita expenditure coincided with a larger physician workforce and fewer persons per physician. In the subnational analysis, physician density was higher in high-Human Development Index provinces than in low-Human Development Index provinces (2.86 versus 1.91 per 1000 population; P = .0262), whereas nurse and hospital bed densities did not differ significantly. Physician density showed greater interprovincial inequality than nurse or hospital bed density.

CONCLUSION

Türkiye achieved substantial national expansion in health system capacity and public financing, but physician distribution remained unequal across provinces. Physician maldistribution should be monitored as an equity-sensitive indicator of health system quality and performance.