Spatial Accessibility and Health Utilization: Evidence from Türkiye’s Mega Hospital PPP Program
This study utilizes a difference-in-differences approach on Turkish provincial data to demonstrate that the country's large-scale Public–Private Partnership hospital program significantly increased healthcare utilization, particularly in outpatient services, with the strongest effects observed in regions where populations had greater spatial accessibility to the new facilities.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine the healthcare system as a giant, bustling city. In this city, hospitals are like massive libraries of healing, stocked with doctors, medicines, and beds. But here's the catch: just because a library exists doesn't mean everyone can get inside. If the library is locked behind a mountain, or if the only road to it is a bumpy, hour-long hike, most people will stay home, even if they are sick. This is the problem of "spatial accessibility." It's not just about having enough doctors or beds; it's about how far you have to travel to reach them.
Now, imagine the government decides to build a brand-new, super-modern library in the middle of town. They hope this will make reading easier for everyone. But how do we know if the new library actually helped? Did people start reading more because the building is there? Or did they only read more because the new library was built right next to their houses, making it easy to walk to? This is the big question researchers ask when they study "Public-Private Partnerships" (PPPs). Think of a PPP as a team-up: the government says, "We need a new hospital," and a private company says, "We'll build and run it, and you pay us a fee." It's a massive experiment to see if these new, shiny hospitals actually get people the care they need, and whether where they are built matters more than just that they were built.
The Big Experiment: Turkey's Mega-Hospital Project
In the early 2010s, Turkey decided to play a massive game of "build it and they will come." They launched one of the world's largest construction projects: building 22 "city hospitals" through a Public-Private Partnership (PPP). These weren't just small clinics; they were giant, modern medical campuses designed to replace old, crumbling hospitals and add thousands of new beds. The government hoped these new giants would modernize healthcare and make it easier for millions of people to get sick and get better.
But the researchers, Irem Kizilca and Sarah Xue Dong, wanted to know the real story behind the construction. They didn't just want to count the bricks; they wanted to count the patients. They asked: Did these new hospitals actually make people visit doctors more often? And crucially, did it matter if the hospital was built right next to a neighborhood, or if it was a bit further away?
To find the answer, they acted like detectives with a time machine. They looked at data from all 81 provinces in Turkey from 2012 to 2023. They used a clever method called "Difference-in-Differences," which is like comparing two groups of friends: one group that got a new, super-fast video game console (the provinces with new hospitals) and one group that didn't (the provinces without). By watching how their "game time" (healthcare visits) changed before and after the console arrived, they could figure out if the console actually made them play more. They also used high-tech maps (GIS) to measure exactly how many people lived within a 5-kilometer walk or a 15-minute drive of these new hospitals.
What They Found: The "Walkability" Factor
The results were fascinating and a little surprising. The study suggests that yes, the new hospitals did make people use healthcare more, but mostly in a specific way.
First, the new hospitals were like magnets for outpatient visits. This means people started going to see doctors for check-ups, minor illnesses, and specialist advice much more often. The data shows that after a hospital opened, the number of doctor visits per person went up. Specifically, in the years following the opening, physician visits increased significantly. It's as if the new hospital opened a door that people were eager to walk through.
However, the story was different for inpatient admissions (people staying overnight in the hospital). Even though the new hospitals added a huge number of beds—increasing the total capacity by over 18 percent—the number of people actually staying in the hospital didn't really change much. It's as if the new building had plenty of empty rooms, but people weren't rushing to sleep in them. The study suggests that the new hospitals didn't turn healthy people into overnight patients; instead, they just made it easier for people to get their regular check-ups and treatments without staying overnight.
The Location Matters: Proximity is Power
Here is the most important part of the story: Location, location, location.
The researchers found that the benefits of these new hospitals depended entirely on how close people lived to them. They measured this by looking at the "population coverage"—how many people lived within a 5-kilometer radius or a 15-minute drive.
The study suggests that the closer the hospital was to the people, the more they used it. In provinces where a larger chunk of the population lived close to the new hospital, the increase in doctor visits was much bigger. It's like having a new pizza place: if it's right around the corner, you'll probably order from it every week. If it's a 45-minute drive away, you might only go once a month, even if the pizza is amazing. The data showed that for every 10 percentage points increase in the population living within 5 kilometers of the hospital, doctor visits went up by a measurable amount.
Similarly, the size of the hospital mattered, but only for outpatient care. Adding more beds per person was linked to a modest increase in doctor visits, but again, it didn't seem to change how many people needed to stay overnight.
The Verdict
So, what's the takeaway? The study suggests that Turkey's massive investment in these mega-hospitals did improve healthcare utilization, but primarily by making it easier for people to see doctors for regular care, not by filling up hospital beds. The "magic" of the new hospitals wasn't just in the steel and glass; it was in the geography. The closer the hospital was to the people, the more it was used.
The authors point out that this is a crucial lesson for the future. Building a giant hospital is great, but if it's built in a spot that's hard to reach, it might not help as many people as it could. The success of these projects depends on making sure the "library of healing" is within walking distance or a short drive for the people who need it most. While the new hospitals added a lot of capacity, the real win was in the accessibility, turning a distant dream into a nearby reality for millions of people.
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