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A Resilient Health System in Response to Coronavirus Disease 2019: Experiences of Turkey

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Turkey's response experience thus far with the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic affords the globe and the region a unique opportunity for and distinctive insights into combating this novel virus. The country's pandemic response, having one of the lowest case fatality ratio (2.8%; 52.5 infections/million population), particularly among the elderly (the high-risk group), rising to the occasion to shoulder its long-standing role in global solidarity and humanitarian support by providing personal protective equipment (globally scarce) to many countries in their desperate time of fight against the pandemic while also meeting its own critical domestic needs, stands out. This paper aims to highlight key decisions, actions, and partnerships behind Turkey's successful fight against the SARS-CoV-2 pandemic that have enabled the country to turn the corner, as well as the components of its success story.
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COMMUNITY CASE STUDY
published: 07 January 2021
doi: 10.3389/fpubh.2020.577021
Frontiers in Public Health | www.frontiersin.org 1January 2021 | Volume 8 | Article 577021
Edited by:
Lara Lengel,
Bowling Green State University,
United States
Reviewed by:
Lan Hoang Nguyen,
Hue University, Vietnam
Emel Parlar Dal,
Marmara University, Turkey
*Correspondence:
Emine Alp Mese
emine.alp.mese@gmail.com
Specialty section:
This article was submitted to
Public Health Policy,
a section of the journal
Frontiers in Public Health
Received: 28 June 2020
Accepted: 12 November 2020
Published: 07 January 2021
Citation:
Keskinkiliç B, Shaikh I, Tekin A, Ursu P,
Mardinoglu A and Mese EA (2021) A
Resilient Health System in Response
to Coronavirus Disease 2019:
Experiences of Turkey.
Front. Public Health 8:577021.
doi: 10.3389/fpubh.2020.577021
A Resilient Health System in
Response to Coronavirus Disease
2019: Experiences of Turkey
Bekir Keskinkiliç 1, Irshad Shaikh 2, Ahmet Tekin 1, Pavel Ursu 3, Adil Mardinoglu 1and
Emine Alp Mese 1
*
1Ministry of Health (Turkey), Ankara, Turkey, 2World Health Organization (Turkey), Ankara, Turkey, 3World Health Organization
(Switzerland), Geneva, Switzerland
Turkey’s response experience thus far with the severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2) pandemic affords the globe and the region a unique
opportunity for and distinctive insights into combating this novel virus. The country’s
pandemic response, having one of the lowest case fatality ratio (2.8%; 52.5
infections/million population), particularly among the elderly (the high-risk group), rising
to the occasion to shoulder its long-standing role in global solidarity and humanitarian
support by providing personal protective equipment (globally scarce) to many countries
in their desperate time of fight against the pandemic while also meeting its own
critical domestic needs, stands out. This paper aims to highlight key decisions, actions,
and partnerships behind Turkey’s successful fight against the SARS-CoV-2 pandemic
that have enabled the country to turn the corner, as well as the components of its
success story.
Keywords: SARS-CoV-2, management - healthcare, pandemic (COVID-19), public policies, health system -
organization and administration
INTRODUCTION
Turkey’s response to and experience thus far with the severe acute respiratory syndrome
coronavirus-2 (SARS-CoV-2) pandemic affords the world and the region a unique opportunity for
and distinctive insights into combating this novel virus. On the one hand, Turkey has one of the
lowest case fatality ratios (2.8%; 52.5 infections/million population), particularly among the elderly
aged 65 years and older (the high-risk group). It has also risen to the occasion and shouldered
its role as a long-standing propagator of global solidarity and provider of humanitarian support.
Turkey’s success in scaling up local manufacturing of personal protective equipment (PPE), a
globally scarce commodity, and dispatching supplies on humanitarian grounds to many countries
in their time of desperate need to fight against the pandemic, while still able to meet critical
domestic needs, offers key lessons in manufacturing and adjusting supply chains. This paper aims
to highlight key policies and practices and partnerships behind Turkey’s effective and successful
fight against the SARS-CoV-2 pandemic until the end of May 2020. These have enabled the country
to significantly lower the case load and to expand upon the elements behind this success.
Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
PREVENTION AND PREPAREDNESS
Health Systems Reforms
Turkey, though geographically located between Europe and Asia,
is also a Mediterranean country with Mediterranean heritage and
culture. Close contact and conviviality is part of its long-standing
and rich tradition. Spending time together and congregating
during social events and hugging and cheek-to-cheek contact
are very common greeting gestures in daily life. Such physical
contact-based cultural factors become particularly important
when considering infection prevention and control measures at
the population level for an affliction that is inherently spread by
droplet and close contact.
Turkey has been implementing a health reform initiative
called the Health Transformation Program since 2002 (1). This
program has covered and changed nearly all building blocks of
health systems in Turkey—from governance to health financing
to health service delivery, with heavy investments in health
infrastructure, redefining the roles of all key relevant stakeholders
for the better (2).
Three key macrolevel features of this health system
transformation that have played critical enabling roles during the
pandemic are as follows:
1. Strengthening of primary health care (PHC). With
accessibility and equity as foundational principals, staff
in PHC facilities links peoples and communities through a
network of nearly 8,000 hubs with 25,000 family medicine
units. Each serves, free of charge, a surrounding catchment
unit of 3,000 persons and thus traversing the geographical
and social extent of the country. Every person in this 3,000
catchment population unit thus has an assigned family
physician in charge of their health, facilitated by electronic
health records for each, including street address records of
all. This comprehensive PHC network with improved access
to and an up-to-date health and geographical information on
each person made community outreach and engagement for
the SARS-CoV-2 response efficient, effective, and timely, from
risk communication to testing to contact tracing.
2. Turkey built large “healthy cities” harnessing a public–private
partnerships model that boosted its health infrastructure
manifold, especially intensive care bed capacity (3),1with
some hospitals specifically equipped with negative pressure
rooms—assets and capacities that proved decisive in saving
lives among those severely ill with SARS-CoV-2 without
seriously straining critical care systems and capacities.
3. The population was extensively covered with a reliable
information technology (IT) infrastructure that enabled
and supported critical response elements. These ranged
from timely reporting of surveillance and early warning to
telemedicine for the elderly and those with chronic diseases, as
well as those with mental health problems and home/facility-
bound persons. It also connected those who were “healthy
but worried” with a healthcare provider, precluding crowding
1The number of ICU beds was 2,214 in 2002, 869 of which were in public hospitals.
As of 2019, the total number of total ICU beds in Turkey is 39,279, including 16,887
in public hospitals.
of health facilities and possibly excessive healthcare worker
(HCW) infections.
Before the pandemic, Turkey had one of the most comprehensive
Universal Health Coverage schemes [accessible by 99% of all
inhabitants including over 3.6 million Syrians seeking refuge in
Turkey—Syrians under Temporary Protection (SuTP)] (4).
Strong Culture of Health Emergencies and
Disaster Management
Supported by Health Transformation Program, the country also
has a long-standing strong and resilient health system, tested
and retested by many natural and man-made disasters and
emergencies. A WHO publication of 2011 entitled “Assessment
of Health Systems’ Crisis Preparedness: Turkey” concluded
that “With its broad experience in disaster situations and its
advanced disaster and emergency management system, Turkey
could play a leading role in training and research related to
disaster risk reduction at global level” (5). It is this realization
and appreciation of Turkey’s expertise in health emergencies
and disaster management that has made it appropriate for the
WHO Regional Office for Europe to house its new regional center
of excellence on Preparedness for Humanitarian and Health
Emergencies in Istanbul. This center is part of a system of the
WHO Regional Office for Europe’s outposts (centers) also called
geographically dispersed offices (GDOs)2(6), with each working
on and offering expertise in thematic areas.
Pandemic Influenza Preparedness
Another supporting WHO initiative has been the
implementation of an intersectoral approach-based,
multidimensional process entitled the Pandemic Influenza
Preparedness (PIP) Framework to help Member States prepare
for and to be ready to respond to pandemic influenza.
After the publication of the National Pandemic Influenza
Preparedness Plan with a presidential decree, members were
selected and assigned to the PIP Scientific Consultancy Board
(7). Provincial pandemic plans were prepared by provincial
health directorates and the Ministry of Health (MoH) organized
a workshop for the evaluation of the developed provincial
plans. The MoH also organized training of trainers for
PIP implementation and training of healthcare workers and
the public.
WHO and International Health Regulations
(IHR, 2005)
After restructuring and re-aligning its position on global health
emergencies within the United Nations system, the WHO
established the WHO Health Emergencies Programme (WHE)
in 2016 (8). The IHR (2005) have also defined the core
capacities of a strong health system, built on an all-hazards,
intersectoral coordination approaches, to manage any public
health emergency. Guided by the IHR (2005), the WHE has been
2GDOs are defined as entities that constitute a fully integrated part of the WHO
Regional Office for Europe and its programs but which are physically located
outside Copenhagen.
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
leading and coordinating the coronavirus disease 2019 (COVID-
19) pandemic and has been ready to respond to other public
health emergencies by strengthening preparedness and readiness
capacities at country and subcountry levels.
Progressive Policies and Historical
Measures
Turkey has had a long history of prevention and control
of communicable diseases starting from the early Ottoman
Empire era with its quarantine regulations. Since the early
stages of the foundation of the Republic of Turkey, relevant
public health and public safety laws and regulations have been
consistently updated, improved, and published on public health
and communicable diseases. Because of its historical emphasis
and experience and capacity building of its physicians and other
health workforce, Turkey has been successful in keeping many
global and/or regional outbreaks out of its borders and territories.
Generations of Turkish citizens have also inherited/embraced a
culture of civic responsibility and embracing rules, regulations,
and expert guidance from the State, citizenry attributes that have
only enhanced the efficiency and effectiveness of the prevention
and containment measures instituted against pandemics at
national levels.
The foundation of the current policies of Turkey on
outbreaks and pandemics emanates from the notification system
established in 2004.3This was followed by the creation of the
early warning and response system (EWRS) in 2007 for the
surveillance and control of communicable diseases.4In addition,
pandemic preparedness plans have also been regularly updated
and published.
Turkey’s years’ long and incremental experience with the
prevention of outbreaks accumulated over the years, EWRS
system, and continuous learning with updated pandemic
preparedness plans have helped prevent and control influenza
pandemics and other outbreaks on its territory. Turkey’s past
experiences with swine flu (H1N1), avian influenza (H5N1), and
SARS outbreaks only attest to the effectiveness and efficiency of
Turkey’s policies (9).
Health Security: an Intersectoral,
All-Hazards Approach
In a globally interconnected world coupled by Turkey’s
geopolitical importance in the region, the country has
increasingly recognized the critical need to comply with its
global (IHR, 2005) (10) and regional (EC 1082/2006) obligations
(11), showing how national and global health security are
intertwined and interdependent. For the past 15 years, a
series of projects on strengthening surveillance and control of
communicable diseases, strengthening and expansion of EWRS,
laboratory sector and linking lab surveillance with disease
surveillance, and building field epidemiology training have been
3Communiqué on Notification and Reporting System of Communicable Diseases
(& November 2004). Official Gazette no: 25635 (in Turkish).
4Regulation on Surveillance and Control of Communicable Diseases (30 May
2007). Official Gazette no: 26537. Updated on May 4th 2019. Official Gazette No:
30764 (in Turkish).
implemented in collaboration with the WHO and the European
Union (EU). These projects have cemented and expanded
the health security capacities of Turkey and helped prioritize
health threats including those due to emerging and re-emerging
diseases and refined and improved EWRS. The country has
also updated technical guidelines in alignment with global and
regional standards, and best practices of EU and WHO, on a
regular basis.
Under these projects, coordination mechanisms have been
strengthened for EWRS between the MoH and other line
ministries across relevant sectors, and protocols prepared and
signed to cement this interministerial collaboration between and
across sectors.
Establishment of a national reference laboratory was also a key
component of these projects. Within the scope of the currently
ongoing Health Security Project, 4th in the series, a laboratory
assessment tool was updated, and a capacity assessment study was
completed in 2019 that included on-site evaluations of selected
laboratories to monitor and evaluate the application of national
standards and compliance therewith at the provincial levels. This
strengthened and expanded EWRS and the laboratory sector, but
more importantly, strengthened linkages between the two have
been instrumental in combating this pandemic.
READINESS STEPS OF TURKEY: ONSET
OF THE SARS-COV-2 OUTBREAK IN THE
WORLD
On December 31, 2019, the People’s Republic of China notified
the WHO on atypical pneumonia cases of unknown origin in
Wuhan. The WHO published its first report on the outbreak on
5 January 2020. Following the decisions of its IHR Emergency
Committee, the WHO declared “public health emergency of
international concern” (PHEIC) on 30 January 2020 regarding
the outbreak of novel coronavirus. The disease was later
named as COVID-19 in February. Due to the rapid increase
in the number of cases and affected countries, the WHO
declared COVID-19 outbreak a global pandemic on 11 March
2020 (12).
Activation of EWRS—Emergency
Operations Center
Turkey activated its preparedness/contingency plans and began
its readiness activities soon after the news of the outbreak of this
atypical pneumonia in China. As early as January 6, 2020, the
EWRS Emergency Operations Center (EOC) in Ankara, Turkey,
was activated and situational monitoring of the outbreak from
this novel coronavirus in China started with updates from China
and through WHO resources. Starting from early February,
with cases increasing, this EOC started to work on a 7/24
basis with technical staff manning key/priority technical areas,
namely surveillance, logistics, IHR focal point, and official focal
points of other relevant line ministries and stakeholders. This
operations center continues to remain operational with a similar
configuration as of date.
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
Convening of the Coronavirus Scientific
Advisory Board
On 10 January 2020, just before the announcement of the
first fatality by China, the Ministry of Health convened
the Coronavirus Scientific Advisory Board (CSAB), bringing
together experts from different medical disciplines. CSAB is
composed of 26 members, all senior and high-level specialists
and academicians in various relevant fields, e.g., public health
and epidemiology, pulmonology, infectious diseases, and clinical
microbiology, among others. The CSAB has been a critical
technical support body since then and has guided not only
MoH leadership and staff but also those from other relevant line
ministries and other stakeholders. Though formally convening
twice a week, in practice, board members spent most of
their times at MoH discussing emerging pandemic-related
issues thoroughly in detail and in real time, generating
discussions and garnering consensus on critical and emerging
issues. One of the important and critical outputs especially
at the beginning was the drafting of the National 2019-
nCoV Disease Guidelines that set the stage for prevention,
mitigation, and containment. CSAB meetings were later moved
to a videoconference platform. Realizing the importance of
communication, an online messaging platform was formed to
ensure a constant communication channel. As the needs grew,
additional experts/scientists were added to the board, allowing
additional technical subgroups to work on emerging priority
areas and concerns.
Release of the 2019-nCoV Disease
Guidelines
The first version of the 2019-nCoV Disease Guidelines was
published on the MoH website on 14 January 2020 and served
as a dynamic, living document (13). As new information and
knowledge trickled in, these guidelines were frequently updated
to incorporate new knowledge and emerging evidence. Training
of healthcare workers was continually conducted at the provincial
levels, in line with the national guideline and to ensure the latest
global and regional knowledge trickled down and was shared and
used at the provincial/municipal levels, the first line of contact
between health staff and the community.
Development of PCR Diagnostic Test for
SARS-CoV-2
Laboratory diagnosis with PCR testing was initiated at the
National Microbiology Reference Laboratory; however, it was
a time- and resource-intensive effort initially. In particular,
a research protocol was initiated to develop and produce
a rapid laboratory PCR test kit for domestic use as well
as for export to other countries. With the help of the
WHO country office, the WHO’s Emergency Use Listing
was readily secured for the newly developed test which also
extended to test the necessary quality cover for national
use and for international marketing. At the end of May
2020, there were 115 laboratories strategically spread across
the country capable of performing PCR test for SARS-CoV-
2 infections.
Initial Steps to Prevent Importation of
Disease
Anticipating a high risk of imported cases, temperature screening
with thermal scanners was initiated of passengers arriving on
flights originating from infection-reporting countries from 24
January at all involved airports. No symptomatic passenger was
admitted on Turkish Airlines’ planes at points of departure,
and all passengers were asked to fill a Passenger Contact
Information to ensure efficient and effective contact tracing if any
exposure was later suspected on board. Passengers demonstrating
any symptom of disease were quarantined. These passenger
screenings were later expanded to include all countries that
reported a large number of confirmed cases. Later, all arriving
international passengers were subjected to 14 days quarantine at
designated places.
SARS-CoV-2 Referral Hospitals
A total of 563 hospitals with the necessary infrastructure and
staff were selected to serve as reference hospitals for COVID-
19 cases, and all elective procedures and surgeries were put on
hold indefinitely in these hospitals. Hospital admissions were
minimized and allowed only through a centralized healthcare
appointment system—reachable through a hotline, website, or an
online app.
Travel Restrictions
Turkey canceled all flights from China as early as 3 February,
followed by Iran on 23 February. Turkey also temporarily closed
its border land crossings with Iran for 4 days to mount field
hospitals at eight border land crossings and then reopened land
border crossings with necessary health screenings.
Risk Communication and Infographics
On 29 January, brochures, banners, and posters prepared in
Turkish, English, and Arabic were distributed to inform the
public, highlighting precautions and actions to stop virus
transmission. Starting from February, TV spots and social
media communication campaigns were broadcasted widely on
the media.
Controlled Airlifting of Turkish Citizens
From Abroad
Turkey also evacuated its citizens stranded in disease-prone
areas/countries as international travel shrank. The first flight
brought stranded citizens from Wuhan on 31 January and the
second from Tehran on 23 February. Airlifting continued from
several countries since then, and so far, over 70,000 citizens have
been brought back home from across the globe under controlled
and risk mitigation strategies. All arriving citizens were subjected
to 14 days of quarantine at dedicated locations.
Activation of Provincial Emergency
Operations Centers and Health Protection
Boards
Provincial operation centers are activated and provincial health
protection boards established under the leadership of governors.
They started working to manage the pandemic at the provincial
level to guarantee effective management.
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
Public Engagement and Risk
Communication
Showing leadership from the front, Minister of Health
Fahrettin Koca regularly held press conferences, especially
after scientific board meetings, to inform the public about
the latest developments as related to the management of
the pandemic, emerging knowledge, and best practices. Risk
communication meetings and events (with social distancing
observed) were organized to share information and to get
feedback from all relevant stakeholders and other governmental
ministries and entities.
Strategic Prepositioning of Critical
Personal Protective Equipment and
Therapeutic Agents
In line with recommendations made by the CSAB, the MoH
ensured provision of appropriate and adequate amounts of
therapeutic regimens such as hydroxychloroquine, the antiviral
favipiravir, and other drugs for use in hospitals and PPE for
healthcare workers in healthcare settings. Sufficient stockpiles of
these critical drugs were ensured before the start of the pandemic
in the country.
Overcoming Challenges to Be Ready for
the Pandemic
Turkey experienced some difficulties at the onset of the
pandemic, such as ensuring PPEs for health workers and the
general public, obtaining some more bedside ventilators to be
ready for possible patient influx, preparing the pile of possible
drugs for patients’ treatment, etc. It may also be problematic
to implement some of the CSAB decisions related to other
ministries’ roles and responsibilities.
To cover domestic needs, a transient ban on exporting PPEs
and medical equipment is implemented initially. All industrial
corporations are promoted to change their production lines
to produce medical equipment especially ventilators. Domestic
pharmaceutical companies are supported to produce meds to be
used for the treatment of COVID-19 patients. However, there are
more to be done to face pandemics, which is beyond the Ministry
of Health’s mandate.
With the strong support and commitment by the President, all
line ministries worked in harmony to implement and put CSAB
recommendations into practice. Border and airport controls,
regulations on importing goods from risky areas, quickly
initiating distance learning models for continuing education
online, curfew practices, etc. are put into practice in an
extraordinary manner.
ARRIVAL OF SARS-COV-2 IN TURKEY:
PUBLIC HEALTH MEASURES AND
MULTISECTORAL ACTIVITIES BASED ON
WHOLE-OF-GOVERNMENT APPROACH
The First SARS-CoV-2 Case
Turkey announced the first confirmed case on 11 March,
incidentally the same day that the WHO announced SARS-CoV-
2 outbreak as a pandemic (14). Minister Koca later shared a graph
showing how contact tracing of the first case was performed
(Figure 1).
The day after the first case was reported, President Erdo˘
gan
led a ministerial cabinet meeting to initiate implementation of
the response road map of the Turkish Government.
Mitigation Measures
i Closure of On-Site Instruction in Education Institutions
Across the Country
All primary, middle, and high schools and universities in Turkey
were closed, effective the following Monday (16 March 2020), and
online and TV broadcasting supported education for primary,
middle, and high schools starting after a 1-week period of
midterm break (15).
ii Banning of Mass-Gathering Events
A large number of measures to prevent mass gatherings were
put into practice (16). All sport games; scientific, cultural, or
artistic meetings; conferences; and congresses were postponed
until further notice. Mosques and all places of worship, libraries,
cafes, gyms, movie theaters, etc. were closed. Public banks started
delivering pensions to retirees above the age of 76 years to their
homes to help them stay at home.
iii Restrictive Measures for Public Officials
Public officials over 60 years of age and those suffering from
chronic conditions (presumed to be at high risk of SARS-CoV-
2 based on global evidence) were granted administrative leave
(17,18). Public institutions and organizations were ordered to
allow alternating and flexible working schedules and enforce
remote/tele-working if and where possible.
iv Additional Travel Restrictions
Flight bans were later extended to include most of the
European countries.
v Curfews and Lockdowns
1. Selective Curfew for the Elderly Over 65 Years and
Establishment of “Vefa (Fidelity) Social Support Groups” (18)
Effective from 22 March, a curfew was imposed for those over
65 years of age while their daily needs were met through newly
established special teams called “Vefa (fidelity) social support
groups.” These curfew measures for the elderly seemed to have
played a major role in reducing the incidence of new cases of
SARS-CoV-2 in the elderly (Figure 2).
2. Curfew for Those Under 20 Years
Ten days after imposing the curfew for the elderly over 65 years,
curfew imposition was extended for those under age of 20.
vi Weekend Total Lockdowns
The curfew for the whole population was first imposed on the
weekend of 11 April and continued till June in selected cities. It
was extended to cover public holidays adjoining weekends.
vii In-Country Travel Restrictions
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FIGURE 1 | Contact-tracing scheme of the first case in Turkey. Source: Daily reporting from the Directorate General for Health Information Systems, Ministry of Health,
Turkey (https://covid19.saglik.gov.tr/?_Dil=2).
On 3 April, entrance ban to 30 metropolitan municipalities
and provinces was announced by the President. All these
measures are implemented with a whole-of-government
approach, with active participation and contribution of all
relevant authorities.
viii Economic Relief
An economic relief package of 100 billion TL (roughly 15 billion
dollars) was announced by President Erdo˘
gan on 18 March 2020
to address immediate financial woes of companies and costs in
low-income households (15). With this package, the government
also agreed to postpone tax liabilities, social security premium
payments, and credit debts of employers in sectors worst affected
by the crisis. The government also coordinated cash-raising
campaigns and transferred 11.5 billion TL to families in need (2
billion TL was raised through an aid campaign called “We Are
Enough For Each Other Turkey”), among other measures.
ix Incentives for Healthcare Workers
Special economic incentives for HCWs were provided by the
government. Additional remuneration was granted to HCWs
with a regulation published on 14 March 2020 (19). GSM
operators in the country also provided 15 GB Internet packages
for HCWs free of charge to facilitate continued contact of HCWs
with their patients under isolation/quarantine and contact of
HCWs with their own as well as patients’ families and loved ones.
Similarly, for those HCWs who could not commute or did not
want to go home after their shifts for fear of transmitting the
virus to family members/loved ones, alternate accommodations
were provided free of charge.
x Free Health Coverage for SARS-CoV-2 for All
With a presidential decree published in the Official Gazette on 14
April 2020, all costs related to diagnosis and provision of medical
treatment of persons with SARS-CoV-2 were made free of charge
for all citizens and residents of Turkey (20).
xi Mental and Psychosocial Health
Some professionals working in healthy living centers and in some
hospitals were trained and organized to provide psychosocial and
mental health support to the community by placing such staff in
at least one healthcare facility in each province.
xii Smartphone Apps/IT Usage
A specific software module for COVID-19 was added to the
Public Health Management System software to ease surveillance
of the disease and contact tracing.
A mobile application called Mental Health Support System
was developed by the MoH to provide a direct channel between
mental health professionals and HCWs, to protect the mental
health and support the well-being of HCWs providing health care
under challenging circumstances.
Another mobile application called “Hayat Eve Si˘
gar” (Life Fits
in Home) was also developed by the MoH, to inform, guide, and
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
FIGURE 2 | The incidence of new cases of SARS-CoV-2 in the elderly. Source: Daily reporting from the Directorate General for Health Information Systems, Ministry of
Health, Turkey (https://covid19.saglik.gov.tr/?_Dil=2).
protect the public about areas with high exposure risk and by
alerting them about high-risk behaviors. Residents could obtain a
code through this application if that individual’s travel between
provinces was not restricted (not during the isolation period
or recovery phase). Ten million residents have downloaded
this application.
Special arrangements were also made to reduce the need for
visits to healthcare facilities for purposes other than medical
consultation, to reduce potential exposure risks for visitors as well
as HCWs. Such measures included prescription refills for chronic
diseases directly from pharmacies without a fresh prescription
from a clinician.
xiii Role of Family Physicians
Family physicians have played a critical role in this response.
They shouldered the provision of medical care in hospitals on the
one hand and provided follow-up for vulnerable groups, such as
the elderly, pregnant women and children, and refugees, on the
other hand. They provided daily health checks of such vulnerable
members of the community who were confined/isolated in
their respective homes because of known close contact with
confirmed SARS-CoV-2 patients but were asymptomatic and
thus not hospitalized.
xiv Research and Development
1. Clinical Trials for Vaccine Development
The MoH has organized a committee to synchronize and
coordinate all clinical trials related to SARS-CoV-2. Data from
multicentric scientific trials are intended to be submitted for peer
review and publication in various journals. Multiple institutions
initiated research on vaccine development, therapeutics, and
plasma convalescent therapy.
2. Transfer and Sharing of Global/Regional Knowledge
MoH officials organized several videoconferences with many
countries and with three levels of WHO and other international
organizations to acquire/share/transfer knowledge, emerging
best practices, and experience gained.
PANDEMIC COURSE IN TURKEY AND
CONTAINMENT MEASURES
The Course of the Pandemic in Turkey
Containment measures in Turkey basically comprised four
essential strategies: testing, (contact) tracing, treatment, and
quarantine/isolation. The epidemiological curve of cases with
SARS-CoV-2 reported in Turkey is displayed in Figure 3.
The highest number of daily new cases was reported on
11 April with 5,138 cases, the peak of the pandemic in the
current wave. The peak tapered to a daily new case of less than
a thousand by 20 May 2020 (Figure 3). Another key attribute
responsible for Turkey’s successful course is its strong testing
capacity; Turkey rapidly increased its daily testing capacity up
to 40,000–50,000/day, one of the best in the region, while many
other developed economies continued to face the testing glut.
With its high testing capacity, Turkey was able to test for cases
and rapidly trace and test close contacts early. It was also able
to isolate/quarantine and/or treat cases and thus interrupt the
transmission chains early and effectively, preventing the spread
of the virus to new susceptible individuals (Figure 4).
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
FIGURE 3 | The epidemiological curve of SARS-CoV-2 cases reported in Turkey. Source: Daily reporting from the Directorate General for Health Information Systems,
Ministry of Health, Turkey (https://covid19.saglik.gov.tr/?_Dil=2).
All confirmed cases can access case management and
treatment easily and free of charge. Treatment recommendations
are given in the COVID-19 Guidelines developed by the
CSAB and are updated regularly in line with new evidence
and information.
Testing, Contact Tracing, and Case Finding
Turkey has implemented a comprehensive contact-tracing
strategy. More than 6,000 field teams, composed of three staff
each, were organized all around the country for contact tracing
and epidemiological investigation of cases that had interactions
with confirmed cases. A special software called FITAS (Filiation,
Isolation and Tracing System) has been prepared and used to
monitor all tracking activities and to reach all contacts, family
relatives, colleagues at work, and others. This application is used
also for monitoring individuals isolated at their homes. Family
physicians regularly check their health status and refer them to
hospitals at the earliest stage if any symptom arises. Through
this process, Turkey has been able to reach 99.6% of all contacts,
that is, approximately 792,000 people (more than five persons
per one confirmed case), and each contact was detected within
a timeframe of <32 h (21).
While the testing capacity has averaged on or around
25,000/day or so, the yield rate of positive tests has gradually
lowered from a high of 15% in mid-April to single digits (5–6%)
by mid-May. This sustained lower yield despite the high number
of tests underscores the fact that the country is now ready to
implement cascading, controlled relaxation of lockdowns. Both
the numbers of patients in need of ICU care and those in need to
be intubated have decreased over time (Figure 5).
This could be attributed to the introduction of specific
successful treatment protocols, as recommended by the
CSAB. The Ministry of Health had recommended starting
hydroxychloroquine and/or azithromycin treatment if the
likelihood of pneumonia was high. The large number of
cases with only mild pneumonia in hospital admissions also
lowered the need for intensive care and intubation. The full
efficacy and safety of such treatment regimens still remain to
be ascertained after compilation and analysis of observational
data supplanted with retrospective chart reviews of patients.
Initial therapy regimen with hydroxychloroquine was elaborated
recently by the CSAB, and they advised to give the drug only to
hospitalized patients.
It may also be useful to compile additional evidence to
document the benefits of early treatment with favipiravir.
Additionally, the accumulated clinical evidence on what
is beneficial ranges from high-flow oxygenation, nursing
in the prone position, late intubation, and the use of
immunomodulators (such as anakinra and tocilizumab) and
anticoagulants as supportive therapies for case management,
with improved health outcomes in severe cases. Early diagnosis,
contact tracing, and case management have helped greatly by
lowering new infections, improving prognosis, and reducing the
strain on the healthcare system. The proportion of intubated
patients compared with those in intensive care has remained
stable (50%) over time, also a proxy validation of effective case
management practices (Figure 5).
LEAVING NO ONE BEHIND
Turkey hosts 3.6 million Syrians and additional nearly one and
a half million regular and irregular migrants within its borders.
Only 60,000 Syrians are living in the camps, while the rest
live within host communities scattered across various provinces.
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
FIGURE 4 | Testing capacity, positivity rate, and case numbers per 1,000 population starting from 11 March to 20 May. Source: Daily reporting from the Directorate
General for Health Information Systems, Ministry of Health, Turkey (https://covid19.saglik.gov.tr/?_Dil=2).
Although it would be relatively easier to provide health services
to displaced populations living in camp settings, since >97% of
Syrians in Turkey reside in host communities, Turkey established
a network of migrant health centers for provision of health
services and built these centers especially in provinces heavily
inhabited by Syrians. In 2019, more than 17 million visits were
recorded to these health facilities. Relevant health education
and communication materials, including those for the pandemic,
were developed in Arabic and English to facilitate linguistic
and cultural acceptability by the refugee/migrant community.
These migrant health centers helped to educate and train
populations about the disease and the health protection measures
they should take, and facilitated contact-tracing activities,
especially for migrants. All related diagnostics and treatment
procedures for SARS-CoV-2 during the pandemic are considered
as emergencies, and accordingly, under this emergency approach,
all services related to pandemic prevention and treatment were
provided free of charge for both regular and irregular migrants as
is the case with citizens (4).
Special arrangements were made to protect virus transmission
in prisons and care homes for the elderly. Fixed staff teams,
prescreened and determined to be non-infected, were arranged
to work for longer hours in these facilities. Cases in prisons and
care homes were isolated immediately in hospitals, and contacts
of these cases were also screened and quarantined/isolated as
needed. Meetings, visits, and transfers of prisoners were also
postponed, minimizing exposures.
TURKEY’S CONTRIBUTION TO
INTERNATIONAL SOLIDARITY
As an eminent and dutiful country as part of the international
community, Turkey has been determined to fight an effective
battle against COVID-19 at the national, regional, and global
levels. Turkey’s holistic approach, its deep-rooted state traditions,
strong organizational structure, solidarity between the strong
state and the nation, and effective leadership with political will—
all such elements came to the fore, arming the nation in this fight.
Since the beginning of the outbreak, 136 countries and 8
international organizations have requested to cooperate with
Turkey as part of their COVID-19 response efforts.
These cooperation requests were about:
Sharing scientific and technical knowledge and experiences
Donation of medication, medical supplies, and
medical devices
Provision of sales and export licenses for medication, medical
supplies, and medical devices.
Under the coordination of the Presidency, the Ministry of
Health, Ministry of National Defense, Ministry of Foreign Affairs,
Turkish Red Crescent, Turkish Coordination and Cooperation
Agency (TIKA), and Disaster and Emergency Management
Presidency of Turkey (AFAD), as well as many professional
organizations, civil society organizations, and international
foundations and associations, took part in these aid efforts.
Frontiers in Public Health | www.frontiersin.org 9January 2021 | Volume 8 | Article 577021
Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
FIGURE 5 | The number of patients in intensive care and those who were intubated. Source: Daily reporting from the Directorate General for Health Information
Systems, Ministry of Health, Turkey (https://covid19.saglik.gov.tr/?_Dil=2).
Turkey has supported more than 80 countries with personal
protective equipment, diagnostic kits, medical devices, and
medication and issued exceptional export licenses for 65 different
countries and international organizations allowing the export of
medication, personal protective equipment, and medical devices
from Turkey to these end-beneficiaries.
In terms of scientific and technical knowledge and exchange
of experiences, the Minister of Health, Dr. Fahrettin Koca, has
conducted bilateral meetings with the Director-General of WHO,
Regional Director of WHO European Region, and the ministers
of health of the USA, Azerbaijan, the UK, Spain, Bulgaria, Libya,
Pakistan, Romania, Tunisia, Kazakhstan, Russia, and Iran, as well
as multilateral meetings at the Turkic Council. In addition, the
CSAB members have taken part in meetings with the scientific
committees of other countries.
Turkey has also tried to fulfill requests for personal protective
equipment and ventilators from outside as much as possible
while taking into consideration priority domestic needs. Turkey
has continued to support cross-border healthcare services at the
border with northern Syria during this period.
For Turkey, global cooperation and solidarity are part
and parcel of COVID-19 response efforts. Accordingly, Dr.
Fahrettin Koca’s recommendations on the establishment of a
“Supply Chain Group,” “Health Scientific Board,” and “Health
Business Forum” were unanimously accepted by Member
States of the Turkic Council, again setting an example among
international platforms.
The words of Mevlana Celaleddin-i Rumi (famous Anatolian
mystic philosopher), displayed on the boxes of supplies sent to
other countries, constitute the essence of Turkey’s efforts:
”There is hope after despair and many suns after darkness.”
Through the act of global solidarity exhibited in COVID-19
response efforts, Turkey has once again demonstrated that it
may not be the wealthiest, but it is one of the most generous
of countries.
TOWARD THE NEW NORMAL;
CONTROLLED SOCIAL LIFE
President Erdo˘
gan announced a road map for normalization
on 3 May. It is called “a new normal,” meaning some public
health measures will be implemented permanently even after
all facilities reopened. The CSAB provides advice on this
normalization plan and prepares guidelines for various sectors.
A research study is planned to determine the immunity level of
the community at the provincial level; 150,000 samples will be
collected for testing during that study.
Turkey’s normalization is a dynamic process. Depending
on up-to-date developments, some measures may be loosened
earlier or later. The future of normalization will be decided not
only by the impact of measures but also by public behavior.
Therefore, public engagement plays a vital role. That is why
the public is informed on a daily basis and communities are
engaged efficiently throughout the process with a whole-of-
society approach.
As also echoed by the WHO, countries need to ensure that
they have capacities in place to detect and manage any upsurge in
the number of cases once the transition period to a new normal
is initiated. Despite low levels of intensive care and hospital
bed occupancy ratios, construction of some additional pandemic
hospitals and development of health system capacity is ongoing
in Turkey.
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
CONCLUSIONS
Turkey has successfully turned the corner in the current wave
of the pandemic and stands among the countries with lower
mortality rates generally but remarkably low mortality rates in
the elderly. A multitude of factors seem to have worked in tandem
and may hold the answers to these results:
1. Political commitment and leadership, multisectorial
engagement, and whole-of-government approaches are all
pillars of any public health struggle, as emphasized by the
WHO and demonstrated by Turkey’s experience.
2. The proportion of elderly (>65 years) in the overall
population of Turkey is smaller as compared with countries
with higher deaths rates (e.g., 6.5% as compared with >14%
in Italy). Specific preventive and testing measures were
instituted early to protect the elderly and prevent the spread
of infection.
3. Early imposition of selective curfew for the elderly and
people with chronic conditions protected them from being
exposed to the circulating virus.
4. Turkey was an avid observer and a quick learner to
adopt selective containment and mitigation measures closely
observing the experiences of other countries and applying
these nationally. Turkey adapted its national guidelines
several times according to the latest knowledge and best
practices—Think globally and apply locally.
5. Turkish SARS-CoV-2 guidelines were prepared with
clear evidence-based recommendations, providing
standardized therapeutic algorithms to all stakeholders
around the country.
6. Strategic stockpiles, local production, and prepositioning
allowed Turkey to avoid any critical shortages of personal
protective equipment, drugs, and medical equipment.
7. Pre-pandemic high ICU bed/population ratios allowed the
dilution of the strain on critical care systems even at the peak
of the pandemic, and the highest occupancy for ICU beds did
not exceed 60%.
8. Turkey has been active and flexible to extend the use of
all possible treatment options to clinicians, ranging from
antivirals to even some of the regimens from traditional
Chinese medicine, and updated its guidelines according to
clinical experiences.
9. Hydroxychloroquine is given to all positive and suspected
cases as soon as diagnosis of SARS-CoV-2 is made. Early
medication particularly with antivirals and high-flow oxygen
seems to play some protective role, precluding the need for
use of mechanical ventilators in the ICU.
10. Late intubation and prone position seem to have contributed
to improved health outcomes in patients in the ICU.
Turkey is not among the richest of the countries. In fact, Turkey
is the 17th country by virtue of population size and the 19th
largest economy. Its gross domestic product (GDP)/capita scale
[as measured by the purchasing power parity (PPP)] is around
75th in the world. The total expenditure on health is not more
than 5% of GDP and that means a little more than $1,000
is spent on health per capita (on a PPP scale). Despite this,
Turkey has been the most generous country as measured by its
GDP. Turkey continued to support global solidarity and unity
by sending lifesaving personal protective equipment and other
supplies to countries in need without creating any shortages of
these much-needed products at home.
Turkey’s experience with its therapeutic algorithms, political
and policy decisions, and public health measures have kept
mortality rates from COVID-19 low particularly among the
elderly. With technical backstopping from the WHO and other
stakeholders, Turkey offers lessons and best practices that could
be useful in contributing to the global health arsenal against
the pandemic.
THE WAY FORWARD
With all critical indicators of the severity of the pandemic
tapering consistently and continually for over 4 weeks, since mid-
April, Turkey is preparing for a measured exit into a socially
controlled life starting from June 2020. Nonetheless, it will be
extremely critical for communities to ensure compliance with
social distancing, personal hygiene, and personal responsibilities
to keep the infection rates low and the spread of the disease in
check to ensure that there is no second peak in the initial wave
that the country has successfully tamed. A critical marker is the
looming autumn (fall) season, which is the flu season. Social
distancing and personal hygiene coupled with compliance with
flu vaccination are the interventions that can see Turkey safely
through the fall.
Turkey will also continue to work with the WHO to ensure the
containment, mitigation, and therapeutic and case management
measures that have worked to its unique advantage in turning
the corner, and best practices are shared and applied in a timely
manner for the ultimate benefit of humanity (22).
DATA AVAILABILITY STATEMENT
The data analyzed in this study is subject to the following
licenses/restrictions: Datasets belong to Ministry of Health.
Requests to access these datasets should be directed to
Emine Alp Mese, eminealpmese@gmail.com.
AUTHOR CONTRIBUTIONS
BK wrote the manuscript. IS, AT, PU, AM, and EM read and
edited the manuscript. All authors contributed to the article and
approved the submitted version.
ACKNOWLEDGMENTS
A similar version of this manuscript by the same authors has
been published at the WHO: https://apps.who.int/iris/bitstream/
handle/10665/335803/WHO-EURO-2020-1168- 40914-55408-
eng.pdf (authors: BK, IS, AT, PU, and EM).
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Keskinkiliç et al. Turkey’s Response to SARS-CoV-2 Pandemics
REFERENCES
1. Turkey Health System Performance Assessment 2011. Copenhagen: WHO
Regional Office for Europe (2012). Available online at: https://www.euro.who.
int/en/countries/turkey/publications/turkey-health- system-performance-
assessment-2011 (accessed September 26, 2020).
2. OECD Reviews of Health Care Quality: Turkey 2014 – raising standards.
France: Organization for Economic Co-operation and Development (2014).
Available online at: https://www.oecd.org/publications/oecd-reviews-
of-health- care-quality-turkey- 2013-9789264202054-en.htm (accessed
September 26, 2020).
3. Health Statistics Yearbook 2018. Republic of Turkey: Ministry of Health
(2019). Available online at: https://www.saglik.gov.tr/TR,62400/saglik-
istatistikleri-yilligi-2018-yayinlanmistir.html (accessed September 26,
2020).
4. Temporary Protection Law (22 October 2014). Official Gazette No:
29153. Available online at: https://www.resmigazete.gov.tr/eskiler/2014/
10/20141022-15.htm (accessed September 26, 2020).
5. Assessment of Health Systems Crisis Preparedness – Turkey, 2010. Copenhagen:
WHO Regional Office for Europe (2011). Available online at: https://www.
euro.who.int/en/countries/turkey/publications/assessment-of-health-
systems-crisis- preparedness-turkey (accessed September 26, 2020).
6. EUR/RC54/9. Strategy of the WHO Regional Office for Europe with regard to
geographically dispersed offices. In: Fifty-fourth sessions of the WHO Regional
Committee for Europe; Copenhagen, 6–9 September 2004. Copenhagen:
WHO Regional Office for Europe (2004). Available online at: https://www.
euro.who.int/__data/assets/pdf_file/0005/88205/RC54_edoc09.pdf (accessed
September 26, 2020).
7. Presidential Decree on National Pandemic Influenza Preparedness
Plan (13 April 2019). Official Gazette No: 30744. Available online
at: https://www.resmigazete.gov.tr/fihrist?tarih=2019-04- 13 (accessed
September 26, 2020).
8. Resolution A69/30. Reform of WHO’s work in health emergency
management: WHO Health Emergencies Programme. In: Sixty-ninth World
Health Assembly. Geneva: WHO (2016). Available online at: https://apps.
who.int/gb/ebwha/pdf_files/WHA69/A69_30- en.pdf (accessed September 30,
2020).
9. Making Preparation Count: Lessons From the Avian Influenza Outbreak in
Turkey. Copenhagen: WHO Regional Office for Europe (2006). Available
online at: https://www.euro.who.int/en/publications/abstracts/making-
preparation-count- lessons-from- the- avian-influenza- outbreak-in-turkey
(accessed September 26, 2020).
10. Strengthening Health Security by Implementing the International Health
Regulations (2005), 2nd ed. Geneva: WHO (2018). Available online at: https://
www.who.int/ihr/publications/9789241596664/en/ (accessed September 26,
2020).
11. Regulation (EC) No. 1082/2006 of the European Parliament and of the Council
of 5 July 2006 on a European Grouping of Territorial Cooperation (EGTC).
Legislation.gov.uk. Available online at: https://www.legislation.gov.uk/eur/
2006/1082/contents (accessed September 26, 2020).
12. Report of the Regional Director: the work of WHO/Europe in 2019–2020.
Copenhagen: WHO (2020). Available online at: https://www.euro.who.
int/en/about-us/governance/regional- committee-for- europe/70th-session/
multimedia/report-of- the-regional-director-the-work- of-whoeurope-in-
20192020 (accessed September 26, 2020).
13. COVID-19 Guides. Republic of Turkey Ministry of Health: General
Directorate of Public Health.Available online at: https://hsgm.saglik.
gov.tr/en/covid-19- i-ngilizce- dokumanlar/rehberler.html (accessed
June 27, 2020).
14. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-
19 – 11 March 2020. World Health Organization. Available online at: https://
www.who.int/dg/speeches/detail/who-director-general-s- opening- remarks-
at-the-media-briefing-on-covid-19-11-march-2020 (accessed September 26,
2020).
15. Remarks by President Recep Tayyip Erdogan in Address to the Nation Following
the Meeting on Coordination of Fight Against Coronavirus. (2020). Available
online at: Available online at: https://www.tccb.gov.tr/konusmalar/353/
118038/koronavirusle-mucadele-esgudum-toplantisi- sonrasi-yaptiklari-
konusma (accessed September 26, 2020).
16. An additional circular on coronavirus measures sent to 81 provincial
governorships. 16 March 2020. Ministry of Interior. Available
online at: https://www.icisleri.gov.tr/81-il- valiligine-koronavirus-
tedbirleri-konulu- ek-genelge- gonderildi (accessed September
26, 2020).
17. Presidential Decree on Additional Measures Against Coronavirus for Public
Officials (22 March 2020). Official Gazette No: 31076. Available online at:
https://www.mevzuat.gov.tr/MevzuatMetin/CumhurbaskanligiGenelgeleri/
20200322-4.pdf (accessed September 26, 2020).
18. Presidential Circular with E.12362 Reference Number on Administrative Leave
of Public Servants. (2020). Available online at: https://iidb.adalet.gov.tr/
Home/SayfaDetay/cumhurbaskanliginin-kamu- kurum-ve-kuruluslarinda-
calisanlara-yonelik- idari-izin-konulu- duyurusu18032020022519 (accessed
September 26, 2020).
19. Regulation on Additional Remuneration for Healthcare Workers
Serving at Healthcare Facilities of the Ministry of Health. 4 March
2020. Official Gazette No: 31058. Available online at: https://www.
resmigazete.gov.tr/eskiler/2020/03/20200304-4.htm (accessed September
26, 2020).
20. Presidential Decree Addition to the Presidential Decree of 13 April 2020
No: 2399. (2020). Available online at: https://www.resmigazete.gov.tr/eskiler/
2020/04/20200414-16.pdf (accessed September 26, 2020).
21. COVID-19 Information Page. Republic of Turkey Ministry. Available
online at: https://covid19bilgi.saglik.gov.tr/tr/ (accessed September
26, 2020).
22. Turkey’s Response to Covid-19: First Impressions. Ankara: WHO Regional
Office for Europe (2020). Available online at: https://apps.who.int/iris/
bitstream/handle/10665/335803/WHO-EURO- 2020-1168-40914- 55408-
eng.pdf (accessed November 5, 2020).
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2021 Keskinkiliç, Shaikh, Tekin, Ursu, Mardinoglu and Mese. This is an
open-access article distributed under the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
Frontiers in Public Health | www.frontiersin.org 12 January 2021 | Volume 8 | Article 577021
... The five countries had developed different health systems and health insurance schemes before COVID-19, and Turkey has been implementing health reform initiatives since 2003 [18]. This programme improved governance, health financing, and health service delivery significantly, with heavy investment in health infrastructure [19]. The General Health Insurance Scheme (GHIS), funded by a tax surcharge on employers [20], covers 99% of all inhabitants, including over 3.6 million Syrian refugees. ...
... The General Health Insurance Scheme (GHIS), funded by a tax surcharge on employers [20], covers 99% of all inhabitants, including over 3.6 million Syrian refugees. Health services are provided both by public and private sector facilities [19]. The GHIS ensures free treatment for various conditions, such as emergency care, occupational illness, childbirth, and infectious diseases [21]. ...
... Turkey established an emergency operations centre immediately after the confirmation of COVID-19 in China and coordinated response activities through a Whole-of-Government approach. Turkey also established a scientific advisory board in the early stages [19,31]. The Ukrainian government set up the Health Emergency Operation Committee in the MoH on 24 January and an inter-sectoral working group on 25 April 2020. ...
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Background The COVID-19 pandemic had a colossal impact on human society globally. There were similarities and differences in the public health and social measures taken by countries, and comparative analysis facilitates cross-country learning of contextual practices and sharing lessons to mitigate the COVID-19 pandemic impact. Our aim is to conduct a situational analysis of the public health and social measures to mitigate the health and economic impact of the COVID-19 pandemic in Turkey, Egypt, Ukraine, Kazakhstan, and Poland during 2020–2021. Methods We conducted a situational analysis of the COVID-19 pandemic response in Turkey, Egypt, Ukraine, Kazakhstan, and Poland from the perspectives of the health system and health finance, national coordination, surveillance, testing capacity, health infrastructure, healthcare workforce, medical supply, physical distancing and non-pharmaceutical interventions, health communication, impact on non-COVID-19 health services, impact on the economy, education, gender and civil liberties, and COVID-19 vaccination. Results Since the onset of the COVID-19 pandemic, Turkey, Egypt, Ukraine, Kazakhstan, and Poland have expanded COVID-19 testing and treatment capacity over time. However, they faced a shortage of healthcare workforce and medical supplies. They took population-based quarantine measures rather than individual-based isolation measures, which significantly burdened their economies and disrupted education. The unemployment rate increased, and economic growth stagnated. Economic stimulus policy was accompanied by high inflation. Despite the effort to sustain essential health services, healthcare access declined. Schools were closed for 5–11 months. Gender inequality was aggravated in Turkey and Ukraine, and an issue was raised for balancing public health measures and civil liberties in Egypt and Poland. Digital technologies played an important role in maintaining routine healthcare, education, and public health communication. Conclusions The COVID-19 pandemic has exposed weaknesses in healthcare systems in the emerging economies of Turkey, Egypt, Ukraine, Kazakhstan, and Poland, and highlighted the intricate link between health and economy. Individual-level testing, isolation, and contact tracing are effective public health interventions in mitigating the health and economic impact of the COVID-19 pandemic in comparison to population-level measures of lockdowns. Smart investments in public health, including digital health and linking health security with sustainable development, are key for economic gain, social stability, and more equitable and sustainable development.
... 18 This programme improved governance, health nancing, and health service delivery signi cantly, with heavy investment in health infrastructure. 19 Health services are now nanced through the General Health Insurance Scheme (GHIS), funded by a tax surcharge on employers, currently at 5%. 20 The GHIS covers 99% of all inhabitants, including over 3.6 million Syrian refugees. Health services are provided both by public and private sector facilities. ...
... Health services are provided both by public and private sector facilities. 19 The GHIS ensures free treatment for various conditions, such as emergency care, occupational illness, childbirth, and infectious diseases. 21 Their health system transformation enabled the outbreak response to be effective and timely with relatively limited strain on the existing health system and capacity. ...
... Turkey also established a scienti c advisory board in the early stages. 19,31 The Ukrainian government set up the Health Emergency Operation Committee in the MoH on 24 January and an inter-sectoral working group on 25 April 2020. Kazakhstan created an interdepartmental commission under the government to coordinate activities to prevent the spread of COVID-19 with all related ministries on 27 January 2020. ...
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Background The COVID-19 pandemic had enormous impacts on human society. There were similarities and differences in the public health and social measures taken by countries, and comparative analysis facilitates cross-country learning of contextual practices and sharing lessons to mitigate the COVID-19 pandemic impact. We aim to conduct a situational analysis of the public health and social measures to mitigate the health and economic impact of the COVID-19 pandemic in Turkey, Egypt, Ukraine, Kazakhstan, and Poland during 2020-2021. Methods We conducted a situational analysis of the COVID-19 pandemic response in Turkey, Egypt, Ukraine, Kazakhstan, and Poland from the perspectives of the health system and health finance, national coordination, surveillance, testing capacity, health infrastructure, healthcare workforce, medical supply, physical distancing and non-pharmaceutical interventions, health communication, impact on non-COVID-19 health services, impact on the economy, education, gender and civil liberties, and COVID-19 vaccination. Results Since the onset of the COVID-19 pandemic, Turkey, Egypt, Ukraine, Kazakhstan, and Poland have expanded COVID-19 testing and treatment capacity over time. However, they faced a shortage of healthcare workforce and medical supplies. They took population-based quarantine measures rather than individual-based isolation measures, which significantly burdened their economies and disrupted education. The unemployment rate increased, and economic growth stagnated. Economic stimulus policy was accompanied by high inflation. Despite the effort to sustain essential health services, healthcare access declined. Schools were closed for 5-11 months. Gender inequality was aggravated in Turkey and Ukraine, and an issue was raised for balancing public health measures and civil liberties in Egypt and Poland. Digital technologies played an important role in maintaining routine healthcare, education, and public health communication. Conclusions The COVID-19 pandemic has exposed weaknesses in healthcare systems in emerging countries of Turkey, Egypt, Ukraine, Kazakhstan, and Poland, and highlighted the intricate link between health and economy. Individual-level testing, isolation, and contact tracing are effective public health interventions in mitigating the health and economic impact of the COVID-19 pandemic in comparison to population-level measures of lockdowns. Investment in health, including digital health and communication, is essential to minimize the impact of the pandemic and for more equitable and sustainable development beyond the pandemic.
... Since then, the demand for health care services has progressively increased while the number of cases has grown 5 , similar to the situation in other countries. At the initial phase of the outbreak, the Ministry of Health of Turkey defined a pandemic referral hospital as a hospital with a tertiary intensive care unit and employing specialists with at least any two specialties of internal medicine, infectious diseases, and chest medicine 4,6 . Thus, being among the essential members of the health care services during the outbreak in Turkey meant HCWs practicing chest medicine have faced occupational risks and contracted COVID-19 since the early days of the pandemic. ...
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Article
Objective: This study aimed to evaluate the data of Turkish health care workers practicing chest medicine on their coronavirus disease 2019 (COVID-19) status and related parameters. Methods: This descriptive study included online survey data that the Turkish Thoracic Society conducted with its members in two phases starting in June and December 2020. The 33-item survey included demographic data, smoking status, the presence of any chronic diseases, occupation, working status, and non-work-related and work-related COVID-19 exposure characteristics. Results: Of 742 responses, 299 (40.3%) reported that they had contracted COVID-19. The second survey detected a higher frequency of health care workers who had contracted COVID-19 (12.1% versus 57.4%, p<0.001) than the first survey. The analysis of the association between study parameters and COVID-19 in health care workers using logistic regression revealed statistical significance with working at the onset of the outbreak (OR 3.76, 95%CI 1.09-12.98, p=0.036), not working at the time of survey (OR 5.69, 95%CI 3.35-9.67, p<0.001), COVID-19 history in colleagues (OR 2.27, 95%CI 1.51-3.41, p<0.001), any non-work-related COVID-19 exposure (OR 4.72, 95%CI 2.74-8.14, p<0.001), COVID-19 exposure at home (OR 6.52, 95%CI 3.52-12.08, p<0.001), and COVID-19 history in family members (OR 8.16, 95%CI 5.52-12.08, p<0.001) after adjusting for age and sex. The study also observed an inverse relationship between the use of aprons and goggles and COVID-19 in health care workers. Conclusion: Occupational and nonoccupational characteristics are related to COVID-19 in health care workers practicing chest medicine. Therefore, active surveillance to detect health care workers contracting COVID-19 and to document and control occupational and nonoccupational risks should be provided.
... Relevant public health laws and regulations have been published on public health and communicable diseases since the beginning of the foundation of Republic of Turkey. As the latest recent development in the notification system of infectious diseases, an early warning and response system was established in 2007 in Turkey for the surveillance of communicable diseases [8]. Various electronic registry applications have been used for contact screening in Turkey such as "Laboratory Information Management System", "Public Health Management System", "Contact Tracing and Isolation Tracking System", and the "Family Medicine Information System" [10]. ...
Article
Non-pharmaceutical interventions (NPIs) are actions apart from getting vaccinated and medications, in order to promote deceleration of the spread of illness among people and communities during pandemic. In this article, we aim to examine NPIs applied in Turkey and worldwide due to the COVID-19 pandemic. Some of the NPIs such as isolation, quarantine, and contact tracing were maintained with updates of the Ministry of Health guidelines in Turkey. Some NPIs including travel and partial or full curfew mobilization restrictions were set in accordance with the various periods by the number of cases. Periods of restrictions at autumn 2021 to summer 2022 are national partial curfews, national extended curfews, local decision-making phase, revised local decision-making phase, partial lockdown, full lockdown and gradual normalization. Mitigation and suppression have been implemented in Turkey with restrictions of varying severity throughout the course of the epidemic. It is seen that the restrictions implemented in Turkey contributed to the flattening of the epidemic curve. Even some countries mainly applied the suppression method, and others applied the mitigation method, in general it is seen that similar methods were applied with different weights. Examples of different countries demonstrated that NPIs are effective for flattening epidemic curve. NPI have been the main instrument for a year and a half from the beginning of the epidemic to mid-2021 in Turkey as well as worldwide.
... Preparation of useful brochures to guide all in reducing their psychological problems. 9. Contact tracing and directing people who got in contact with COVID patients to refer to health centers for checkup before hospitalization was also a substantial practice. ...
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Preprint
Background: COVID-19, a rapidly spreading virus, has severely challenged all countries worldwide with no certain prevention and treatment so far. Various clinical and public health interventions have been in action since its first report in December 2019. Sharing the lessons learnt and strengths and weaknesses might cast some light on the future similar crisis management. Methods: This was a qualitative exploratory research including 22 semi-structured, face-to-face, virtual interviews with key informants and decision makers in the management of current epidemic. Data was analyzed using thematic analysis. Results: The lessons learnt from and the weaknesses and challenges of COVID crisis management were categorized under the main areas of management and planning, workforce and education and research, decision making and communication. Conclusions: The current unprecedented crisis has affected various aspects of human life. Policy makers and managers, especially in health care, worldwide are struggling to abate the consequences of this nasty virus, though facing tough challenges. Here some hands-on and real-time experiences from the fight of a developing and highly affected country against this virus is provided which might be of a high value. Whatever approach adopted, it is key to be multifaceted and support all rightly mentioned aspects of health as physical, mental and social.
Turkey Health System Performance Assessment
Turkey Health System Performance Assessment 2011. Copenhagen: WHO Regional Office for Europe (2012). Available online at: https://www.euro.who. int/en/countries/turkey/publications/turkey-health-system-performanceassessment-2011 (accessed September 26, 2020).
Republic of Turkey: Ministry of Health
Health Statistics Yearbook 2018. Republic of Turkey: Ministry of Health (2019). Available online at: https://www.saglik.gov.tr/TR,62400/saglikistatistikleri-yilligi-2018-yayinlanmistir.html (accessed September 26, 2020).
Copenhagen: WHO Regional Office for
Assessment of Health Systems Crisis Preparedness -Turkey, 2010. Copenhagen: WHO Regional Office for Europe (2011). Available online at: https://www. euro.who.int/en/countries/turkey/publications/assessment-of-healthsystems-crisis-preparedness-turkey (accessed September 26, 2020).
Strategy of the WHO Regional Office for Europe with regard to geographically dispersed offices. In: Fifty-fourth sessions of the WHO Regional Committee for Europe; Copenhagen
EUR/RC54/9. Strategy of the WHO Regional Office for Europe with regard to geographically dispersed offices. In: Fifty-fourth sessions of the WHO Regional Committee for Europe; Copenhagen, 6-9 September 2004. Copenhagen: WHO Regional Office for Europe (2004). Available online at: https://www. euro.who.int/__data/assets/pdf_file/0005/88205/RC54_edoc09.pdf (accessed September 26, 2020).
Reform of WHO's work in health emergency management: WHO Health Emergencies Programme
Resolution A69/30. Reform of WHO's work in health emergency management: WHO Health Emergencies Programme. In: Sixty-ninth World Health Assembly. Geneva: WHO (2016). Available online at: https://apps. who.int/gb/ebwha/pdf_files/WHA69/A69_30-en.pdf (accessed September 30, 2020).
Making Preparation Count: Lessons From the Avian Influenza Outbreak in Turkey. Copenhagen: WHO Regional Office for
Making Preparation Count: Lessons From the Avian Influenza Outbreak in Turkey. Copenhagen: WHO Regional Office for Europe (2006). Available online at: https://www.euro.who.int/en/publications/abstracts/makingpreparation-count-lessons-from-the-avian-influenza-outbreak-in-turkey (accessed September 26, 2020).
Strengthening Health Security by Implementing the International Health Regulations
Strengthening Health Security by Implementing the International Health Regulations (2005), 2nd ed. Geneva: WHO (2018). Available online at: https:// www.who.int/ihr/publications/9789241596664/en/ (accessed September 26, 2020).