After 1950's, the rapid expansion of Istanbul has created tremendous demand for new public facilities as well as the need for evaluation of existing facilities. Although the service areas of hospital is a very important information in order to use efficently scarce resources, there are very few studies on this subject in devoloping countries. This study investigates the spatial behavior of in patients in relation to three different types of hospitals ( teaching, general public and private) in order to provide background for the efficient planning of health facilities in Istanbul. According to the results, all three types of hospitals receive patients from different parts of the city as well as throughout the country. The service areas of these hospitals are investigated also according to their location within the different zones of the city. As the speciality of the hospitals increases, the density of the patients becomes more widely distributed than the local hospitals. According to the results, the areas which are not served by any hospital are determined. Further, research is suggested on more detailed analysis of spatial behavior of patients with respect to patients' characteristics.

M. Aykut Sadi

Vedia Dokmeci

English

Research Papers in Economics

ANALYSIS OF HOSPITAL SERVICE AREAS IN ISTANBUL
Istanbul Technical University
Department of Urban and Regional Planning
Taksim / Istanbul / TURKIYE
 V. DOKMECI
Istanbul Technical University
Department of Urban and Regional Planning
Taksim / Istanbul / TURKIYE
M. $\NXW6$'ø
1. Introduction
Hospitals are costly institutions to establish and maintain, and health care is a costly item
for most families in developing countries. It is to the advantage of all concerned, therefore, that
investments in health care be made wisely and that hospitals be located so as to assure a viable
operation while meeting the needs of the patient population (Morrill and Earickson (1969)).
Medical care researchers have long been concerned with the affect of distance on the frequency
with which services are used. Early work demonstrated empirical relationships between medical
care utilization and distance, while later writing applied these findings to service area. Delineation
(Bosanag, Parkinson and Hall(1976)).
The identification of the service area of existing health facilities is an important step in the
evaluation of a health care facility system. Variations in the use of health services by the population
of a geographic area have long been a concern of health planners and geographers. Service area
studies can be used as a base to determine the needed capacity and characteristics of a hospital. The
population within the area can be monitored as to demographic characteristics, incidence ofdiseases, and hospital utilization. Hospitals would be to expand or contract certain services on the
basis of population changes and could, on the basis of the accurate information provided by
patients, coordinate activities with one another so that duplication of services and physical facilities
would be avoided (Studnicki (1973)). Thus, there is potential for efficient organization of
geographic markets for hospital care.
The service area concept is based on the assumption that people tend to use the nearest
facility if there is no differences among the quality of services they provide. The behavioral
assumption, which underlies this expectation, is that human beings tend to minimize the effort
required to interact with the people and places around them. Consequently, numerous planning
projects have been concerned with dividing a region into “study districts”, “areas of major
influence”, “catchment areas”, or “service areas”. These geographical subdivisions are constructed
on the often-unstated assumption that each hospital provides services to the residents of its service
area, and that the residents of the service area obtain their hospital services at that hospital.
Unfortunately, these service area delineation’s are not consistent with the actual floes of patients to
hospitals, specially in metropolitan areas. There are overlaps among the service areas of the
hospitals (Studnicki (1973)).
In metropolitan areas, the large number of alternative hospitals, the relatively small
distances between choices, and the large numbers of patients serviced confuse the affect of physical
accessibility on the distribution of patients to hospitals. However, a few studies have attempted to
analyze metropolitan geographical areas relating to the hospital-patient spatial relationship. These
studies of patient origin have all demonstrated that hospital “trade areas” or “catchment areas” may
be identified by collective patient travel patterns while the methods and techniques used in arriving
at and analyzing these service areas differ widely, they all report one common conclusion. That is,
while the physical relationship between a hospital and a patient's residence is undoubtedly an
influence on the distribution of patients to hospitals metropolitan patients are not distributed in a
way that minimize aggregate distance traveled or travel time occurred. Spatial research in a number
of American metropolitan areas illustrated this trend, such as Drosnoss, Read and Lubin(1965) in
California, Cherniak and Schneider (1967) in Cincinnati, Davise (1968) and Morrill and Earickson
(1968) in Chicago. All of these studies identified “boundary jumping” behavior by 30 to 70 percent
of the inpatient population studied. McGuirle and Porell (1984) give a comprehensive discussion of
the role of travel costs in the use of health services.Moreover, another complexity in the distribution of patients to hospitals in metropolitan
areas is the heterogeneity of the interacting elements. Both hospitals and patients differ so much
that it is extremely difficult to speak in absolute terms about the spatial behavior bringing them
together. In fact, there has been some research aimed et establishing the characteristics of patients
and hospital destinations that make them more or less attractive to one another (McLaughlin
(1988); Wennberg and Gittelson (1973); Knickman and Foltz (1984)),
Therefore, it seems that metropolitan area present a special challenge in seeking to explain
the spatial behavior of patients with respect to the distribution of hospitals. In addition, in
developing countries the varying concepts of geographic space which are employed in health care
policy have been comparatively under-researched in medical geography and health care policy
studies have been neglected. If the service areas are very large, people and the communities to
which they feel they belong find themselves out of reach, and their needs become obscured. The
managers of the service can become remote and less sensitive to the particular needs of the
different communities, The needs of the communities and the networks operating within them
become equally obscured when nursing services are organized solely around general practices and
the populations they serve. Therefore, the present study attempts to investigate the spatial behavior
of in-patients with respect to throe different types of hospitals in Istanbul in order to provido
background for hospital service area studies.
The organization of the paper is as follows. The distribution of beds and the characteristics
of seven types of hospitals in Istanbul are described in section two. Section three analyzes the
relationship between distance and frequency to seven types of hospitals. The final section is
devoted to a conclusion and suggestion for further research.
2. The distribution of beds and characteristics of three hospitals in
Istanbul
A majority of health care in Turkey is a public service and Istanbul has the largest
concentration of health facilities. In 1996 there were 138 hospitals in Istanbul with a total of 30,975
beds. While the average number of beds per 10,000 is 37.8 in Istanbul, it drops to 20.2 for the
country as a whole. Patients are free to decide to which hospital they want to go. At the public
hospitals patients pay a modest fee where services are free for the poor patients.Apart from the overwhelming center-periphery disparity, there are also gross disparities
among the different districts of Istanbul; some of the old districts have a disproportionately high
concentrating of health care facilities (Dokmeci, Dagoglu, Tantolac (1994)). This phenomenon is
observed in other developing countries, as well (Akin, Griffin, Guilkey and Popkin (1984)), The
district of Fatih -one of the oldest district- contains two university medical centers and has the
highest number of beds per 10,000 (5,898). Other districts with relatively high numbers of beds
include Beyoglu (815 beds), Uskudar (2083 beds), Kadikoy (2428 beds) and Sisli (2834 beds).
Neighborhoods in the older, more centrally located parts of the city have relatively easy access to
hospitals. The peripheral districts with a shortage of beds are Kartal (1106 beds) and Eyup (293
beds). In some new peripheral districts there are no hospitals at all, As a result, patients from the
districts without hospitals tend to over-crowd the university medical enters, resulting in insufficient
use of the health facility system and increased traffic congestion at the city center. In order to solve
these problems, a redistribution of hospital beds with respect to the population is needed throughout
Istanbul (Dokmeci, Dagoglu and Tanyolac (1994)). For this purpose, it is necessary to under- stand
the spatial behavior of patients toward different types of hospitals.
In this study, the spatial behavior of patients is analyzed with respect to seven different
types of hospitals in Istanbul
(1) University hospitals,
(2) General public hospitals,
(3) Local public hospitals,
(4) General private hospitals,
(5) Local private hospitals;
(6) Specialized hospitals,
(7) Workers hospitals.
Capa University Hospital is investigated as a case study for university hospitals. This
hospital is located in the historical core of the city. It has 1567 beds (1996), Since it is a teaching
hospitals it has a large influence area: throughout the country: 16% of its patients come from other
cities. Its large number of patients, staff and personnel exacerbate traffic congestion at the core of
the city.Haydarpasa hospital is taken as an example for the general public hospitals. It is located on
the Anatolian side of the city and it attracts the Anatolian patients, which come to Istanbul to seek
hospital care. It has 685 beds.
Two local public hospitals are taken into consideration: One of them is Bakirkoy Hospital,
which serve a peripheral district with 1,300,000 people. The other one is Beykoz hospital, which
serve a peripheral district with a population of 160,000 people, Bakirkoy public hospital has 164
beds which is far below the needs of the district. As a result, the number of private hospitals is
rapidly increasing, Beykoz Hospital has 109 beds and together with other hospitals, it provides
sufficient beds for this small district.
American and German Hospitals are taken as example for the general private hospitals.
These hospitals provide top level of care with a very wide variety of specialties. American hospital
has 126 beds and German Hospital has 189 beds. German hospital is located in the old CBD and
the American hospital is located in the new CBD with wealthy community.
Eight local private hospitals are taken into consideration for the different districts of
Istanbul, which are located in the first ring and the periphery. The number of beds changes from 30
to 70 which make difficult to run efficient hospitals, Kosuyolu Cardiovascular Disease hospital is
investigated as a case study for specialized care hospitals. It is located in the Anatolian side of the
city and it serves mostly poor and middle class patients. It has186 beds. It has a very high
occupancy rate because of rapid increase in the number of cardiovascular disease patients in
Istanbul and at the country level.
SSK Kartal, SSK Goztepe, SSK Pasabahce and SSK 8amatya are investigated as case
studies for the workers hospitals, These hospitals serve health care only to patients which have
workers insurance, So, they serve the areas where the workers are concentrated. SSK Kartal and
SSK Pasabahce are located in the periphery of the city and the others are located in the first ring.
SSK Kartal has 468, SSK Goztepe 1035, SSK Pasabahce 325 and SSK Samatya 804 beds,
characteristics.
Thus, the characteristics of these hospitals illustrate that (except the small ones), they are
able to attract patients not only from Istanbul but also from other cities irrespective of their private,
public status and different bed prices, because of their high specialty care, which is lacking in manyAnatolian cities. The effect of distance on the utilization of these different types of hospitals in
Istanbul is explained in the next section.
3. Analysis of Spatial Behavior of Patients with respects to
different types of Hospitals in Istanbul.
Patient origin data is used in this study to investigate the spatial behavior of patient’s with
respect to different types of hospitals.
With respect to Capa University Hospital, there is no relationships between the distance to
hospital and frequency (R
2= 0.02). Since this hospital provides a wide variety of hospital care at
lower cost as a public hospital, it attracts patients from all over the city. Therefore, it has a large
service area.
With respect to Haydarpasa General Public Hospital, the relationships between the distance
to hospital and frequency is low, R
2= 0,26 but it is higher than the University Hospital, So,
University Hospital has wider impact spatially than the general public hospital because of the
quality of care and variety of specialties.
The effect of distance on the frequency to local public hospitals is higher such as R
2= 0,41
for Bakirkoy State Hospital and R
2= 0,42 for Beykoz State Hospital. So, a small public hospital
with fewer specialties than general hospitals serve as locally as it is expected.
With respect to general private hospitals, the effect of distance on the use of American and
German Hospitals are investigated. For both of them, distance effect is very low and R
2= 0.07 for
German Hospital and R
2= 0,13 for the American Hospital. Since these hospitals provide top level
of care with high price, for the upper class of people distance does not have any effect of the
frequency to these hospitals. The effect of distance on the use of local private hospitals is R
2= 0,44.
So, distance effect for these hospitals is more important than the general hospitals since their Capa
patient’s city and potential can only attract patients from their vicinity.
As an example for the specialty hospitals, Kosuyolu Cardiovascular Hospital is
investigated. The impact of distance on the use of this hospital is low as the university hospitals
R
2= 0.15 since it attracts patients from all over the city due to the spacial care characteristics, which
are offered.With respect to workers hospitals if the hospital is near a large industrial area, R
2=0.82 the
effect of distance is high as in SSK Pasabahce. If the hospital serve all over the city’s patients
which are worker, the distance effect is lower R
2=0.22 as in SSK Samatya or SSK Goztepe
R
2=0.32, or SSK Training and Research R
2=0.23.
Beside distance, there are other factors, which effect the use of hospitals, The high socio-
economic level of the people living in the surrounding the hospital is another factor which effects
their choice of hospital. The distribution of patients between the European and Asian side of the
city is another factor which effect the use of hospitals.
4. CONCLUSION
This study investigates the utilization patterns of different types of hospitals in Istanbul,
Investigation of the urban-space utilization pattern of social facilities can provide meaningful
background of the morphology of the urban areas. The distribution of present facilities both
medical and those associated with other activities provides important features of the urban
development environment of today.
So population to be served result from many diverse influences of which simple physical
accessibility is but a single one, Substantial travel may only reflect access to high technology or
unique services, which are common for teaching hospitals. Patients referred from peripheral
districts because they require the most sophisticated consultancy and therapeutic facilities of the
teaching hospital. Projections if future demand for individual hospital facilities would do well to
recognize the multiple causation of that demand. Distance complemented by socio-demographic
data, identify and describe populations having differential geographic access to health resources.
Such data can be of considerable utility to health planners, both in determining existing needs and
assessing the impact of planning activities,REFERENCES:
(1) Akin, J.S., C.C. Griffin, D.K.Guilkey and B.M, Popkin (1984) “The Demand
For Primary Health Services In The Third World”, Totowa, N.J.: Littlefield, Adams &
Co.,
(2) Bosanac, E,M., R.C. Parkinson and D.S. Hall (1976) “Geographic Access To
Hospital Care: a 30-Minute Travel time standard”, Medical Care, 14, 7, 616-624.
(3) Cherniak, N, D, and J.B. Schneider (1967) “A New Approach To The
Delineation Of Hospital Service Areas”, Regional Science Research Institute Discussion
Paper Series, No.16, pp, 7-8
(4) DeVise, P,(1988) “Methods And Concepts Of An Interdisciplinary Regional
Hospital Study,” Health Service Research, 3,166-173,
(5) Dokmeci, V.,T. Dagoglu and N, Tanyolac (1994) “Istanbul Health System
for Year 2000”, Hospital Management International, 98-101,
(6) Dokmeci, V, and L, Berkoz (1994) “Transformation of Istanbul from a
monocentric to a polycentric city,'·European Planning Studies, 2, 2, 193-205,
(7) Drosness, D,L. and J. W. Lubin (1966) “Planning can be based on patient
travel,” Modern Hospital, 106, 92,
(8) Knickman,J,R, and A, Foltz(1984) “Regional Differences in Hospitalization:
How much can be traced to population differences? Medical Care, 23,11, 971-986,
(9) McGuirle and Porell (1984) “Spatial patterns of hospital utilization: The
impact of distance and time,” Inquiry 21, 84-85, 93-94.
(10)  McLaughlin, C,G, (1988) “Measuring small area variation in hospital
use: site-of-care versus patient origin data” Socio-economic Planning Sciences, 22, 4,
177·184;(11)  Morillo. R, and R, Earickson (1968) “Hospital variation and patient
travel distances, Inquiry 5,4, 26-34,
(12)  Morrill,R, and R, Earickson(1969) “Locational efficiency of Chicago
hospitals: An experimental model,” Health Service Research, Summer, 128,
(13)  Studnicki, J. (1975) “The Minimization Of Travel Effort As A Delineating Influence
For Urban Hospital Service Areas,” International J. of Health Services, 6, 4, 679-693.

A New Approach To The Delineation Of Hospital Service Areas”,

Earickson(1969) “Locational efficiency of Chicago hospitals: An experimental model,”

Foltz(1984) “Regional Differences in Hospitalization: How much can be traced to population differences?

Geographic Access To Hospital Care: a 30-Minute Travel time standard”,

Measuring small area variation in hospital use: site-of-care versus patient origin data” Socio-economic Planning Sciences,

Methods And Concepts Of An Interdisciplinary Regional Hospital

Planning can be based on patient travel,”

Spatial patterns of hospital utilization: The impact of distance and time,”

The Demand For Primary Health Services In The Third World”,

The Minimization Of Travel Effort As A Delineating Influence For Urban Hospital Service Areas,”

Transformation of Istanbul from a monocentric to a polycentric city,'·European Planning Studies,

Analysis of hospital service areas in Istanbul

http://www-sre.wu-wien.ac.at/ersa/ersaconfs/ersa98/papers/114.pdf

Analysis of hospital service areas in Istanbul

Abstract

Similar works

Full text

Available Versions

Research Papers in Economics