Sağlık hizmetlerine erişim ve hastane yer seçimi:  
İstanbul örneği
Access to healthcare and hospital location: The case of Istanbul
Yazar: MUHAMMED ZİYA PAKÖZ
Danışman: YRD. DOÇ. DR. MEHMET ALİ YÜZER
İstanbul Teknik Üniversitesi / Fen Bilimleri Enstitüsü / Şehir ve Bölge Planlama Ana Bilim Dalı
Derece: Doktora, 2014
Konu: Şehircilik ve Bölge Planlama = Urban and Regional Planning
Dizin: Bölgesel planlama = Regional planning ; Cazibe modelleri = Gravity models ; Erişim = Access ; Sağlık tesisleri = Health facilities ; Tesis yer seçimi = Site selection

Özet:
Bu tez çalışması, İstanbul'da sağlık arzı ile sağlık talebi arasındaki ilişkinin (sağlık hizmetlerine erişimin) ortaya konulması, mekânsal erişilebilirliğin ölçülmesi ve hastane yer seçimi için önerileri içermektedir. 
Bireylerin, firmaların ve kamu kuruluşlarının yer seçimi kararları, kent formunun biçimlenmesinde önemli yönlendiriciler arasındadır. Özel sektörün yer seçimi kararı, kârını maksimize etmeye yönelik iken, kamuya ait tesislerin yer seçiminde,  toplumsal faydanın maksimize edilmesi hedeflenmektedir. Diğer taraftan bütçe kısıtı ve kaynak israfından kaçınma gerekliliği,  kamuya ait tesislerin mekânsal dağılımının nasıl olacağı ve 'eşitlik/etkinlik' dengesinin nasıl sağlanacağı sorusunu sürekli gündemde tutmaktadır. Bununla birlikte yer seçimi davranışlarında sadece ekonomik kaygılar değil diğer birçok sosyal, mekânsal, kültürel faktör de etkili olmaktadır.
Yer seçimi teorilerinin özünde,  mesafe arttıkça insan etkileşimlerinin azaldığı kabulü yer almaktadır. Sağlık hizmetleri de mekân/zaman bağımlı hizmetler olduğu için, sağlık tesislerinin sağlık arzı ve talebi arasındaki mesafeyi optimize edecek şekilde yer seçimi önem kazanmaktadır. Buna ilaveten, yer seçimi yapılırken hastaların ihtiyaç ve tercihleri de gözetilmelidir.
Türkiye'de ve İstanbul'da sağlık tesislerinin yer seçimini yönlendirmek için yönetim mekânizmasının bazı düzenleyici tedbirleri söz konusu olsa da, özel girişimler veya kar amacı gütmeyen kuruluşlara (vakıf, dernek, STK) ait sağlık tesislerinin sayıca artışı, yer seçiminde eşitlik ve herkes için erişilebilirlik anlayışını zayıflatmakta ve neticede mekânsal dağılım, gittikçe daha dengesiz bir yapı arz etmektedir. Yaşam kalitesi yüksek mekân organizasyonunda, sağlık tesislerinin hem toplumun tüm bireylerinin kolay erişimini mümkün kılacak, hem de en verimli işleyişi temin edecek şekilde yer seçmesini sağlamak önemlidir.
Tez çalışmasının amacı, İstanbul'da sağlık arzı ile talebi arasındaki ilişkinin hastanelere erişim ve mekânsal erişilebilirlik üzerinden irdelenmesi, hastanelerin ilçe bazında optimum mekânsal dağılımının ve yer seçiminin sayısal tekniklerle modellenmesidir. Bu kapsamda öncelikle İstanbul'daki yataklı sağlık tesislerinin mevcut mekânsal dağılımı araştırılmış, mekânsal erişilebilirlik değerleri ortaya konulmuş, nüfusun gelecekteki dağılımı da dikkate alınarak, yeni yapılacak tesisler için mekânsal dağılım ve yer seçimi önerileri geliştirilmiştir.

Tez çalışmasında, öncelikle yer seçimi kuramı ve yer seçimi faktörleri detaylı olarak incelenmiş, sağlık hizmetlerine erişim ve sağlık hizmetleri yer seçimi farklı boyutlarıyla açıklanmıştır. Sağlık hizmetlerine mekânsal erişilebilirliği ölçmek için yapılan çalışmalar ve bunlar içerisinde gravite modelleri ayrıca ele alınmıştır. Daha sonra, Türkiye'de sağlık hizmetlerinin sunumuyla ilgili yasal / yönetsel çerçeve ile sağlık politikaları özetlenmiş, ülke genelinde sağlık hizmetlerinin dağılımı ve bu dağılım içerisinde İstanbul'un yeri değerlendirilmiştir. İstanbul'da sağlık arzının (yataklı hastaneler) ve sağlık talebinin (nüfus) dağılımı, özellikleri ve birbirleriyle ilişkisi, istatistiki veriler üzerinden sorgulanmıştır. Ayrıca, İstanbul'daki her ilçenin erişilebilirlik değerleri (ilçelerin birbirine olan seyahat mesafesi) hesaplanmıştır. Devamında, İstanbul'da sağlık hizmetlerine erişimin boyutlarını, talep ve arz noktasının özellikleri ile hastane tercihi ve hastaneden yararlanma ilişkisini inceleyen ve tez kapsamında gerçekleştirilen alan araştırmasının sonuçları paylaşılmıştır. Bu çerçevede, mesafenin etkisi özellikle irdelenmiştir. 
Tezin model kısmında, anket sonuçlarından elde edilen mesafe eşik değerleri ve hastane tercih oranları mesafe sürtünme katsayısının hesaplanmasında, ilçeler arası seyahat mesafesi matrisinden elde edilen erişilebilirlik değerleri ise kümelenme analizinde kullanılmıştır. Sonraki aşamada, gravite temelli bir model geliştirilerek, her ilçenin hastane türüne (kamu, özel) ve işlevine (yerel, bölgesel) göre yeterlilik oranları ve mekânsal erişilebilirlik değerleri ölçülmüştür. Daha sonra, yine anket sonuçlarından ve istatistiki verilerden elde edilen katsayılarla, yaş, cinsiyet ve gelire göre oluşan hastane talebi hesaplanmış, bu talebin Huff modeliyle ilçelere dağıtımı yapılmış, bu dağıtım sonucunda her ilçenin ihtiyaç duyduğu hastane yatağı sayısı ve hastane türü belirlenmiştir. Son olarak, yine hastane talebi ve mesafe sürtünme katsayısı kullanılarak, Ağırlıklı Uzaklıklar Toplamı Yöntemiyle bölgesel hastaneler için yer seçimi yapılmıştır.

Abstract:
This dissertation reveals the relation between healthcare supply and demand in Istanbul (access to healthcare), measures spatial accessibility to healthcare services and puts forth proposals on the location of healthcare facilities. 
Location decisions, which may be made by individuals, companies and public institutions, play an essential role in how the urban form is shaped. While the location decisions made by the private sector prioritize profit maximization, the maximization of social benefit is aimed when selecting the locations of public facilities. On the other hand, due to the constraints on budget and the necessity to avoid the waste of resources, the spatial distribution of public facilities and how 'equity/efficiency' will be achieved remain on the agenda. 
The behavioral evolution of location decision-making and the diversification of the factors which influence the location decisions should be tackled in parallel to the transformation of settlements. Globalization and technological advances are the dynamics behind this transformation. In recent years, location processes are influenced by not only economic concerns but also social, spatial and cultural factors. The role and importance of planning during this process still constitute a primary topic of debate.
'Health geography' is among the major areas on which the location theory is focused. Access to healthcare services and achieving a healthy environment are still current topics and keep on drawing further attention. The location theory is based on the understanding that increased distance leads to decreased human interaction. As healthcare services are space/time dependent, it becomes more important that healthcare facilities are located in order to optimize the distance between healthcare demand and supply. In addition, it is necessary to consider the needs and preferences of the patients.
Although administrative bodies take regulatory precautions in order to steer the facility location decisions for healthcare services in Turkey and Istanbul, increased number of healthcare facilities owned by private entities and non-profit organizations (such as foundations, associations, NGOs) impair accessibility, and consequently, the spatial distribution presents an increasingly uneven structure. In spatial orders which achieve a higher quality of life, it is important to locate healthcare facilities so that they are easily accessible by all segments of society while they also function efficiently.
The purpose of this dissertation is to address the relation between the supply of and demand for healthcare in Istanbul with a particular focus on the access and spatial accessibility to hospitals, and to develop a model for the optimum spatial distribution and accessibility of healthcare facilities. Within this scope, first the existing spatial distribution of the hospitals in Istanbul was researched, spatial accessibility values were identified, and location suggestions for new facilities were proposed by considering the future distribution, needs and preferences of the population.
To obtain healthy results, certain limitations were observed in the dissertation. First of all, instead of the entire health system, the research only addresses healthcare services. Second, it only focuses on hospitals instead of all of the healthcare facilities in Istanbul. Finally, the evaluations and proposals expressed in the research were developed on a district basis. 
After the introductory chapter, the second chapter of this dissertation addresses the location theory, and explains the content, interest areas, historical course of the theory and location factors. In addition, the spatial characteristics and location patterns of public services are evaluated based on the notions of 'equality/efficiency' and 'accessibility/agglomeration'. The changes in the approach to urban space, facility location factors and the nature of public services, and how the relation between location and planning is formed are other issues which are addressed in this chapter.
In the third chapter, access to healthcare services and location of healthcare services are evaluated theoretically. For this purpose, health system and healthcare services system, their purposes and components are defined, and the spatial and non-spatial dimensions of access to healthcare services are identified. In this chapter, studies which were carried out for measuring spatial accessibility to healthcare services and out of these studies the gravity model are addressed, and the role and contribution of distance to healthcare services with regard to spatial accessibility to healthcare services are explained in detail. 
In the fourth chapter, legal/administrative framework and health policies in Turkey are briefly explained, and the distribution of healthcare services and Istanbul's position within this distribution are evaluated. The characteristics of and the relation between the distribution of healthcare supply (hospitals) and demand for healthcare services (population) in Istanbul were examined by using statistical data. Also, the accessibility rates (travel distance between districts) were calculated for each of the districts in Istanbul. 
The relation between healthcare supply and demand in Istanbul was presented in two steps. In the first step, the distribution of hospitals, the number of doctors and patients in Istanbul were presented per districts by using secondary data. Secondary data include the statistics of the Turkish Statistical Institute (TÜİK) and data obtained from Istanbul Local Health Authority. The demographic structure in Istanbul is explained by using TÜİK statistics and household surveys, which were conducted for the purposes of the Transportation Master Plan of Istanbul (İUAP) prepared by the Transportation Department of the Greater Municipality of Istanbul. These data were then statistically analyzed and compared. Travel distances between the districts were calculated by using Google Maps service; the accessibility data was accepted as the shortest overland distance (in km) between the centers (i.e. the district governor's office) of two districts. 
Statistical data reveals that healthcare services in Istanbul are accumulated in districts which have higher accessibility and/or higher income. Such a distribution causes certain areas in the city to be deprived of using the healthcare services supplied. The deprivation is more significant in areas which developed recently.
The fifth chapter provides the results of the field survey which investigated the dimensions of access to healthcare and which was conducted for the purposes of this dissertation. First of all, the construct of the survey, the scope of the survey form and the sampling method are explained. Afterwards, the data collected by the field survey, which was conducted with 756 households, are statistically analyzed, and the need for hospitals and hospital preferences in Istanbul per the characteristics of the demand and supply are evaluated in light of these primary data. The coefficients and ratios obtained by the results of the field survey provided input into the modeling phase of the research. The analysis in this chapter, which examines the relation between healthcare services supply and demand in Istanbul, were conducted by using various statistical methods such as Pearson Correlation Coefficient, One-way Analysis of Variance, Hierarchical Cluster Analysis, Two-step Cluster Analysis, Jenks Natural Breaks Classification Method and by using SPSS and ArcGIS software.
The results of the field survey, which was conducted with the participation of 2509 individuals in 756 households, indicate that the need for hospitals, preferences for and usage rate of hospitals are influenced by the characteristics of the demand and supply.
Preferences for hospitals (public or private), the rate of having a private health insurance, the medium of transport to the hospital, and the need for hospitals change in relation to socio-economic characteristics (i.e. level of income and educational attainment level) of the demand/population. Upper and upper-middle income groups are similar to each other in terms of their hospital preferences; and lower and lower-middle income groups are akin to each other in terms of their need for hospitals. The demographic structure of the population (age and sex) is also influential on the need for and the usage rate of hospitals. The rate of chronic diseases and the usage rate of hospitals are higher among the elders in comparison to younger individuals, and among women in comparison to men. 
The characteristics of supply are influential on hospital preferences. The proximity of hospitals to the patient's place of residence, and pricing are the major factors which are taken into account by patients. However, when the pricing factor is neglected, the preference rate for public hospitals is higher than that for private hospitals. 
The acceptable/the realized travel distances to hospitals, and the rate of travel time/distance made out of the district of residence change in relation to the level of services offered by the hospital (regional/local) and the type of the hospital with respect to ownership status (public/private). Regional hospitals in comparison to local hospitals, and private hospitals in comparison to public hospitals demonstrate higher flexibility of demand, and consequently, longer travel times. The availability and diversity of healthcare supply, the geographic location of the districts, and their proximity to other districts are other factors that determine the rate of travels made within the district/travels bound to other districts. In addition, the results of the field survey reveal that the Bosporus is a significant threshold with regard to hospital preferences.
In the sixth chapter, travel thresholds and the rate of hospital preferences were used to calculate the distance friction coefficient, and the accessibility data was used to conduct the cluster analysis. The next phase involves the quantification of availability rates and spatial accessibility values in each district per the type of hospital (public/private) and the level of services offered by the hospital (regional/local) by using a model based on gravitation.
Distance thresholds, which change in relation to hospital types, define the supply and demand service areas of each district. Accordingly, the catchment areas of regional hospitals cover a higher number of districts in comparison to that of local hospitals. The change in the distance threshold values and the number of patients also influence the distance friction coefficient. The distance friction coefficient calculated for regional hospitals is lower than that calculated for local hospitals. 
The availability rates for each district were calculated by the comparison made between the hospital beds capacity and the number of patients in each district and the corresponding values in the city. It is not realistic to expect that each district would only serve its inhabitants. Therefore, the spatial accessibility rates of local and regional hospitals, which is calculated by considering each district's service area, becomes critical. , The importance of a planning approach, which takes into account the relation between the demand within each district and other districts, is apparent in hospital location.
As an alternative to the method, which involved the determination of distance thresholds and catchment areas, cluster analysis was conducted to identify the catchment areas by considering geographical location and proximity, regardless of distance thresholds. Consequently, 6 clusters on the European side and 4 clusters on the Asian side with a population between 1,000,000 and 2,000,000 were determined. 
In the seventh chapter, data and coefficients, which were provided by using the results of the survey and statistical data, were utilized to calculate the demand for hospitals per age, sex and level of income, and the number of beds and types of hospitals needed in each district were outlined. Finally, facility location decisions were made by using the Total Weighted Distance Method and the hospital demand and distance friction coefficient. 
Demand for hospitals is closely related to the socio-demographic and socio-economic characteristics of the population. While demographic characteristics (such as age and sex) determine demand for hospitals, socio-economic characteristics (such as level of income) provide clues on how hospital preferences are shaped. Therefore, demand for hospitals, which was calculated based on age and sex, was used to determine the number of hospital beds in each district per the local demand for hospital; and demand for hospital, which was calculated by considering level of income, was used to identify the rate of public/private hospitals.
Demand for hospitals generated in each district tends to benefit from the hospitals that are located within the boundaries of the district and in neighboring districts which are located within its service area. So, the demand generated in each district was distributed to the districts which are within its catchment area by using the Huff model. Thus, the number of local hospitals projected for the next 10 years was identified. Similarly, the number of local hospitals and the ratio between public and private hospitals in each district were determined by distributing the demand based on level of income to the districts by using Huff model.
Location decisions for regional hospitals were individually conducted for each of the clusters formed in the previous chapters. By using the Total Weighted Distance method, the district where hospital demand and total travel distance are minimized, were identified as the most appropriate district for a regional hospital. Also, the same method was utilized for the determination of the district where a regional hospital should be located in the case that only one regional hospital would be built in both the European and Asian sides.
This dissertation and the model it offers, which address both the demand-side and supply-side barriers in access to healthcare and evaluate the changes in hospital preferences based on the type and nature of supply and urban form, prove to be a significant contribution to the available literature. They are also a model which considers the change in healthcare services and aims to manage this change, and consequently, offer a facilitating tool that can be used by decision-makers and executors in health policy and planning.