Türkiye has made significant progress in the field of health care services in the last 20 years under the governments of President Recep Tayyip Erdoğan. The Health Transformation Program, underway since 2003, and the General Health Care Insurance system, which was introduced in 2012, facilitated citizens’ access to health care services significantly, while also completely renewing the health service infrastructure. Within the scope of the transformation, on the one hand, public health institutions were renewed and redeveloped, modern practices such as family medicine and campus hospitals were being introduced into service, and on the other hand, an advanced private sector health care infrastructure was established. As a result, Türkiye has made significant progress in the field of health care outcomes since the 2000s and has turned into a leader from being a laggard.

The direct result of this improvement in health services was the increase in life expectancy at birth. Life expectancy at birth, which was 72.5 for the general population in the year 2002, when the Justice and Development Party (AK Party) came to power, has increased to 77.5 by 2022, showing a consistent increase trend over the years.

Then again, it has been observed that the rate of increase in question has shown a slowing down trend since 2016, there have been visible decreases in satisfaction rates with health care services, and there has been an unexplained increase in crude death rates, similar to the trend seen all over the world after the COVID-19 Pandemic.

Population projections require update

These advancements in health services contributed, on the one hand, to the development of social health and, on the other hand, to the increase in the elderly population and the aging of society. When we look at the population of Türkiye, traces of this situation can be observed. According to data published by the Turkish Statistical Institute (TurkStat), as of the end of the year 2023, the population of Türkiye is 85.4 million. Roughly half a million of this population die each year, while an average of 1 million babies are born, increasing the overall population by almost half a million.

Although the population growth rate is on a downward trend every year as a result of the fertility rate falling to a historic low of 1.51 by 2023, Türkiye's population still continues to increase. To compare, the fertility rate was 2.38 in 2001 and 1.3 million babies were born annually, by 2023 the fertility rate decreased to 1.51 and the number of babies born in a year decreased to 950,000.

TurkStat projections made in 2018 predict that Türkiye's population will exceed the 100 million mark by 2040, peak at 107 million by 2070, and begin to decline after this date. However, considering that these projections do not take into account the rapid decline in the fertility rate since 2018 in the recent years, it seems highly probable that the projections will be revised downward and the population will peak much earlier and with a much lower figure.

Half-a-million die each year

In this context, it seems useful to look at the number of deaths and death-related statistics in order to understand the change in Türkiye's population. According to TurkStat data, the number of deaths in Türkiye was 505,269 in 2022 and increased by 4.1% in 2023, reaching 525,814. In 2023, 53.9% of the dead were men and 46.1% were women. Traces of the global phenomenon of women performing better in terms of longevity can be seen in Türkiye as well.

We see that the crude death rate, which expresses the number of deaths per thousand people, was recorded as 6,200 in 2023, while it was 5,900 in 2022. In other words, while there were 5,900 deaths people in 2022, it increased to 6,200 deaths people in 2023. In fact, it seems that the crude death rate, which peaked in 2021 when the pandemic occurred, has anchored to the figure of 6 since then. For comparison, while 369,000 people died in 2009, it is seen that 525,000 people died in 2023.

The latest data points to a significant increase in the crude death rate, especially since 2019. While this data indicates, on the one hand, an inexplicable increase in deaths after the pandemic, on the other hand, it is seen as the result of a decrease in the quality of health care services, traceable to the decline in satisfaction rates.

Regional differences in crude death rate

It should be noted that the crude death rate is not evenly distributed across Türkiye. In terms of Türkiye's socioeconomic structure, we can see the west-east and Urban-Rural dichotomy in terms of crude death rate data as well. From this perspective, the lowest crude death rates are in the provinces of the eastern and southeastern regions, where the young population is proportionally higher. According to the data, the province with the lowest crude death rate is Şırnak with 2,300, followed by Hakkari with 2,500, and Batman and Van with 3,000, all with a high concentration of Turkish citizens of Kurdish origin.

When we look at the statistical map, we see that the death rates are higher in the western provinces. This is not due to lower socioeconomic development or worse health care services but is associated with the high proportion of elderly people in the population. On the other hand, due to the effects of last year's Great Earthquake, the highest crude death rates are observed in quake-hit regions, as Adıyaman is at the top with 18,000 in 2023, followed by Hatay with 17,100 and Kahramanmaraş with 14,800. The number of Turkish citizens who died in the Kahramanmaraş-centered earthquakes that took place on Feb 6 was 45,784.

It should also be noted that Istanbul, a giant metropolis with a population exceeding 16 million, is below Türkiye's average with a crude death rate of 4.4.

When deaths in Türkiye are examined according to their causes, circulatory system diseases rank first with 33.4% in 2023. This cause of death is followed by benign and malignant tumors with 15%, and respiratory system diseases with 13.2%. When deaths caused by benign and malignant tumors are examined according to the sub-causes of death, 29.2% of the deaths are caused by malignant tumors of the larynx and trachea/bronchus/lung, 7.7% are caused by malignant tumors of the colon and lymphoid and hematopoietic malignant tumors. Stomach and pancreatic tumors also stand out among the causes of death with 7.5% and 6.7%, respectively.

Likewise, when deaths caused by circulatory system diseases in 2023 are examined by sub-causes of death, it is seen that 42.4% of the deaths are due to ischemic heart diseases, 24.1% are due to other heart diseases, and 18.6% are due to cerebrovascular diseases.

Data show that chronic diseases such as cardiovascular diseases and cancer are a serious problem for Turkish society. The high rate of deaths due to health problems such as diabetes and obesity, which are called lifestyle diseases, reveal the need for Türkiye to urgently switch to a preventive and protective health care model and the need to prevent chronic diseases that cause high costs and human loss before they occur.

Infant mortality increasing since pandemic

The development of health care services in Türkiye in the last 20 years has had important consequences, especially in terms of maternal and child health services. Maternal and child health care is one of the areas where the fastest progress is being made. This development, which is also reflected in the United Nations Human Development Indices, shows a historical improvement in the number of women receiving prenatal health services and in live birth and infant mortality statistics.

In this context, when we look at the infant mortality rates per thousand live births, the rate which was 31.5 in 2002, decreased to 6.8 in 2018, is a significant performance. On the other hand, we can determine that the stagnation and partial deterioration experienced since 2019 in terms of infant mortality rates as well. The infant mortality rate, which expresses the number of infant deaths per thousand live births, started to increase after bottoming out in 2020 and rose from 9,200 in 2022 to 10,000 in 2023.

A similar trend is evident in the under-5 mortality rate, which expresses the probability of dying within five years after birth. It is noteworthy that the under-5 mortality rate, which was 17.7 in 2009, started to increase after bottoming out in 2020 and rose from 11, in 2022 to 14,500 in 2023.

When analyzing these data, it is necessary to take into account, both the impact of the burdens created by the pandemic on health care systems and the additional personal health burdens for individuals who were infected by COVID-19, as a phenomenon not yet been fully understood.

In summary, although Türkiye has made significant progress in terms of access to and quality of health care services in the last 20 years, the latest data reveal traces of a serious regression since the 2020 pandemic. It is seen that a quality problem, which is also seen in the decrease in citizen satisfaction rates with health services starting from 2016, has emerged as an area that needs intervention. Likewise, Türkiye's immediate transition from a model that finances disease to a system that finances preventive health services, and taking steps to eliminate chronic diseases, especially those called lifestyle diseases, at their source before they occur and create additional burdens on the health budget, is extremely critical in terms of both the health of citizens and the sustainability of the public health care budget.