The monetary value of human life losses associated with COVID-19 in Turkey

Background: This study aimed to appraise the monetary value of human life losses associated with COVID-19 in Turkey. To our knowledge, it is the first study in Turkey to value human life losses associated with COVID-19. Methods: A human capital approach (HCA) model was applied to estimate the total monetary value of the 4,807 human lives lost in Turkey (TMVHL) from COVID-19 by 15 June 2020. The TMVHL equals the sum of monetary values of human lives lost (MVHL) across nine age groups. The MVHL accruing to each age group is the sum of the product of discount factor, years of life lost, net GDP per capita, and the number of COVID-19 deaths in an age group. The HCA model was re-calculated five times assuming discount rates of 3%, 5%, and 10% with a national life expectancy of 78.45 years; and the world highest life expectancy of 87.1 years and global life expectancy of 72 years with 3% discount rate. Results: The 4807 human life losses from COVID-19 had a TMVHL of Int$1,098,469,122; and a mean of Int$228,514 per human life. Reanalysis with 5% and 10% discount rates, holding national life expectancy constant, reduced the TMVHL by Int$167,248,319 (15.2%) and Int$ 429,887,379 (39%), respectively. Application of the global life expectancy reduced the TMVHL by 36.4%, and use of world highest life expectancy increased TMVHL by 69%. However, the HCA captures only the economic production losses incurred as a result of years of life lost. It ignores non-market contributions to social welfare and the adverse effects of economic activities. Conclusions: Additional investment is needed to bridge the persisting gaps in International Health Regulations capacities, Universal Health Coverage, and safely managed water and sanitation services.


Introduction
Turkey has a population of 84.040 million people; a total gross domestic product (GDP) of International Dollars (Int$) 2,464.61 billion; a GDP per capita of Int$ 29,326.503 in 2020 1 ; a human development index (HDI) of 0.806 in 2018 2 ; an inequality-adjusted HDI of 0.675 in 2018 2 ; and a Gini Coefficient of 41.9 in 2017 2 . National income share held by the poorest 40% is 15.6% compared to 32.1% held by the wealthiest 10% and 23.1% held by the wealthiest 1% in 2017 2 . The real GDP growth is predicted to decline by 5.0% during 2020 due to COVID-19 pandemic 3 .
As of 15 June 2020, Turkey had notified a total of 178,239 coronavirus disease 2019 (COVID- 19) cases, which included 4,807 deaths, 151,417 recoveries, and 22,015 active cases 4 . There were a 2,114 total cases per million population; 57 deaths per million population; and 31,225 COVID-19 tests per million population. The rate of COVID-19 transmission may hinge on the strength of International Health Regulations (IHR) core capacities 5 , the extent of universal health coverage (UHC) 6 , and population coverage of safely managed water and sanitation services.
IHR core capacity refers to the minimum core public health capability to detect, assess, notify and report events, and respond promptly and effectively to public health risks and public health emergencies of international concern 5 . There are 13 IHR core capacities, including national legislation, policy and financing; coordination and national focal point functions; surveillance; response; preparedness; risk communication; human resources; laboratory; points of entry; and the four IHR potential hazards (chemical, zoonotic, food safety, and radionuclear events). Each of the core capacities is assessed on a scale of ranging from 0% (non-existent) to 100% (optimal/ target). The national IHR capacity score is an average of the 13 core capacities 7 .
In 2017, Turkey had an average IHR core capacity score of 77% 8 , implying an overall gap of 23%, i.e. the difference between the optimal (100%) and actual Turkey's capacity of 77%. The IHR capacity components of legislation and financing, points of entry, and zoonotic events and human-animal interface had a score of 100, implying optimal target capacities 9 . The scores for the laboratory was 93; surveillance was 90; health service provision was 87; the chemical events were 80; coordination and national focal point functions was 70; human resources were 60; national health emergency framework was 60; food safety was 60; radiation emergencies were 60 and; risk communication was 40 9 . These scores imply gaps of 7, 10, 13,20,30,40,40,40,40, and 60 in the IHR components of laboratory, surveillance, health service provision, chemical events, coordination and national focal point functions, human resources, national health emergency framework, food safety, radiation emergencies, and risk communication.
The United Nations (UN) Sustainable Development Goal 3.8 is about achieving UHC, including access to high-quality essential healthcare services for all 10 . The WHO and World Bank UHC index, measured on a scale of 0% to 100%, is a measure of average proportion of people in need receiving reproductive, maternal, new-born and child health services; infectious diseases (including COVID-19) prevention and management services; and non-communicable diseases prevention and control services 6 . According to WHO 8 , the UHC index for Turkey is 74%, signifying that 26% of people in need do not receive high quality essential health services. Approximately 2,689,280 (3.2%) of the population has health expenditures that are over 10% of total household income, implying a high risk of impoverishment 8 . The Turkish Government should assure access to COVID-19 prevention, testing, treatment and palliative services, especially for this vulnerable segment of the population.
About 840,400 (1%) of the population use unimproved drinking water sources 11 , and 29,414,000 (35%) of the population have no access to safely managed sanitation services 8 . These people have difficulty practising personal hygiene measures recommended by WHO for the prevention and control of COVID-19 12 .
Monetary valuation of human life is useful in quantifying the size of disease burden in dollar terms 13 , building a justification for intervention programmes and research 13 and advocacy for increased investments 14 to bridge gaps in IHR capacities, UHC, and safely managed water and sanitation services. There is a paucity of literature on the valuation of human life losses associated with COVID-19 [15][16][17] . This study appraised the monetary value of human life losses associated with COVID-19 in Turkey as of 15 June 2020.

Empirical framework for monetary valuation of human life
This study replicates the human capital approach (HCA) methodology proposed by Weisbrod in 1961 18  The monetary value for human life losses accruing to each k th age group (MVHL k=1,.,9 ) is the sum of the product of discount factor, years of life lost, net GDP per capita, and the number of COVID-19 deaths in an age group 15 . Algebraically: Where: is a summation from the 1 st to the n th year of life lost; D 1 is the discount factor (1/(1+r) n ) where r is the discount rate of 3%; D 2 is the mean life expectancy at birth of Turkey; D 3 is the mean age of onset of death in k th age group; D 4 is the GDP per capita for Turkey; D 5 is the current health expenditure per person in Turkey; D 6 is the total number of COVID-19 deaths in Turkey as of 15 June 2020; D 7 is the proportion of COVID-19 deaths borne by k th age group.
The sensitivity analysis According to Thabane et al. 19 , sensitivity analysis is a way of assessing the effect of variations in key assumptions on overall conclusions of the study. In this study, a sensitivity analysis was conducted to answer two questions: Data and data sources Table 1 contains the data and data sources used to estimate the economic model. The model was estimated using Microsoft Excel Software.

Results
Analysis assuming Turkey's mean life expectancy of 78.45 years and a 3% discount rate As depicted in Table 2   The total monetary value of human life losses associated with COVID-19 was equivalent to 0.045% of the total GDP for Turkey. The mean monetary value per human life lost was eight times the size of the GDP per capita for Turkey in 2020. The magnitude of TMVHL will continue growing as the pandemic persists.
The study found that use of higher discount rates produced lower TMVHL, which is consistent with past economic studies [15][16][17]27,28 . Furthermore, the analysis has revealed that TMVHL is quite sensitive to both the sizes of the discount rate used to convert the monetary value of future YLL into their present values; and the magnitude of the life expectancy at birth. The latter determines the number of YLL.
Comparison with similar studies in other countries As alluded earlier, globally, there is a dearth of literature on the valuation of human life losses associated with COVID-19. Second, while GDP per capita is a good indicator of economic activity in a country, it ignores non-market contributions to social welfare; distribution of income and wealth; quality of life (or wellbeing); and adverse effects (including pollution) of the economic production process on the environment 22 .
Fourth, although there is consensus that future monetary values of YLL ought to be adjusted to their present values, there is no consensus in the health economics literature on the discount rate to be used 32,33 . In this study, we chose to use a discount rate of 3% because of extensive use in health-related economic studies [15][16][17]23,24,28 . As mentioned earlier, due to the uncertainty surrounding the choice of a discount rate, a sensitivity analysis was conducted using 5% and 10% discount rates to test the robustness of the TMVHL [15][16][17]28 .

Suggestions for further research
The following three economic studies would be useful to the health development policymakers in Turkey: • Cost of multi-sectoral resources invested in COVID-19 prevention and control measures.
• Estimation of resources needed to bridge the persisting gaps in IHR capacities, UHC, and safely managed water and sanitation services.

Conclusion
The average monetary value per human life loss associated with COVID-19 was eight-fold that of the GDP per capita for Turkey in 2020. Thus, COVID-19 pandemic is imposing a substantive burden on both population health but also the economy of Turkey. There is an urgent need for the country to invest more in health-related sectors to bridge the persisting gaps in IHR core capacities, UHC, and safely managed water and sanitation services to eradicate the ongoing COVID-19 pandemic and mitigate future public health emergencies.

Data availability
Source data The economic model was estimated using data from the following sources: •