Turkey's response to COVID-19 pandemic: strategy and key actions

COVID-19 emerged at the end of 2019 in Wuhan, China, and spread rapidly around the world causing many deaths. Due to the intercontinental escalation in the epidemic, while WHO declared a pandemic on March 11, 2020, our country's first case was diagnosed. Before this, the MoH established the Operations Center against possible risks regarding the Pandemic Influenza Preparedness Plan on January 10, 2020 and formed the Scientific Committee, which has a critical importance in epidemic management. National and Provincial Pandemic Coordination Boards were established within the scope of this plan. Fast, effective and frequently updated decisions were implemented. The epidemic was kept under control by stopping mutual flights to countries with cases, intermittent curfews, transportation restrictions, closure of schools, filiation, social isolation, use of PPE, social media communication, and intensive work of healthcare workers. Softwares were developed for analysis and data reporting, case and contact tracing. Various mobile applications were developed providing a safe social life in social areas and enabling filiation teams to intervene in the necessary areas in the fastest way and to record data instantly in the system. Prior to normalization process, "COVID-19 Epidemic Management and Working Guide" was prepared including epidemic measures for social life, institutions, organizations, and businesses. Variants of concern, recommended by WHO to be monitored, led to an increase in the number of cases around the world. In our country, the number of laboratories and tests were expanded to monitor variant viruses. Vaccination activities continue in line with the National Vaccine Administration Strategy. In the fight against pandemic, it will be possible to maintain and increase our country's acquisitions so far, owing to the strong health infrastructure both in terms of manpower and institutions, free health care, success in the production of PPE and medical devices, and finally, rapid acceleration of the vaccination.

Potential Criteria for Frameworks to Support the Evaluation of Innovative Medicines in Upper Middle-Income Countries-A Systematic Literature Review on Value Frameworks and Multi-Criteria Decision Analyses.

BACKGROUND: Multicriteria Decision Analysis (MCDA), a formal decision support framework, has been growing in popularity recently in the field of health care. MCDA can support pricing and reimbursement decisions on the macro level, which is of great importance especially in countries with more limited resources. OBJECTIVES: The aim of this systematic review was to facilitate the development of future MCDA frameworks, by proposing a set of criteria focusing on the purchasing decisions of single-source innovative pharmaceuticals in upper middle-income countries. METHODS: A systematic literature review was conducted on the decision criteria included in value frameworks (VFs) or MCDA tools. Scopus, Medline, databases of universities, websites of Health Technology Assessment Agencies, and other relevant organizations were included in the search. Double title-abstract screening and double full-text review were conducted, and all extracted data were double-checked. A team of researchers performed the merging and selection process of the extracted criteria. RESULTS: A total of 1,878 articles entered the title and abstract screening. From these, 341 were eligible to the full-text review, and 36 were included in the final data extraction phase. From these articles 394 criteria were extracted in total. After deduplication and clustering, 26 different criteria were identified. After the merging and selection process, a set of 16 general criteria was proposed. CONCLUSION: Based on the results of the systematic literature review, a pool of 16 criteria was selected. This can serve as a starting point for constructing MCDA frameworks in upper middle-income countries after careful adaptation to the local context.

Trends in the incidence rate of genitourinary system cancers in Turkey: 2004-2015.

OBJECTIVE: To analyze age-standardized urological cancer incidence rates in Turkey during the last twelve years based on the available published data (2004-2015). MATERIAL AND METHODS: Cancer data were obtained from the reports of Turkish Directorate of Public Health Cancer Department for 2004-2015. A trend analysis was conducted using the joinpoint regression analysis to observe the change in the trends over time. The average annual percentage of change, annual percent change, and the corresponding 95% confidence interval were calculated. RESULTS: Throughout the observed period, cancer incidence rates in men significantly increased by 3.04%, 4.70%, 4.03%, and 2.97% for all the genital organs, kidney, testis, and prostate, respectively. A significant increase of 3.11% and 1.91% was observed for the urinary system organs and bladder, respectively, of women during the same period. CONCLUSION: The increase in the incidence rate of urinary system cancers was more prominent than that of all cancers types in general. The total incidence rate of urinary system cancers (bladder and kidney) tends to increase more in women than in men. While there was no cancer with decreased incidence during the entire study period, similar decreases in some urogenital cancer types tended to occur during the second trend period.

Rapid changes in the incidence of urinary system cancers in Turkey.

Estimation of national cancer incidence for major cancer sites in Turkey has been carried out by analyzing the data obtained from active cancer registry, and published regularly by Institute of Public Health of Ministry of Health. In the light of these statistics, the incidence of urinary cancers in both sexes and their age related distributions have been discussed, paying special attention to prostate, kidney and bladder cancers. The annual incidence of all cancer cases increased gradually, reaching to 221.5 per 100,000 population in 2009, the latest confirmed figure available at present. Among males the most frequent cancers were those of the lung, prostate and bladder. The incidence rates of urinary cancers among males were 36.1, 21.4 and 6.3 per 100,000 for prostate, bladder and kidney respectively. The reliability of current data concerning the incidence of cancer has been discussed by comparing them with the previously reported national cancer data.

The relationships between metabolic syndrome, erectile dysfunction and lower urinary tract symptoms associated with benign prostatic hyperplasia.

OBJECTIVE: To determine the relationship between erectile dysfunction and metabolic syndrome (MetS) in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). MATERIAL AND METHODS: Seventy-eight patients who were admitted to our outpatient clinic because of BPH-related LUTS over 40 years of age were included in the study. Patients with LUTS and erectile dysfunction (ED) were evaluated by International Prostate Symptom Score (IPSS) and International Index of Erectile Function-5 (IIEF-5) forms. The National Cholesterol Education Program Adult Treatment Panel III criteria was used for the diagnosis of MetS. LUTS were classified as mild, moderate, and severe according to IPSS and ED was classified as mild- moderate, moderate, and severe according to the IIEF-5. For the evaluation of data, descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, and maximum) and also for the comparison of the variables with non-normal distribution in 3 or more than 3 groups Student's t test, Mann-Whitney U, ANOVA, chi-square, Fisher Exact tests, and Pearson correlation analysis were used. P<0.05 was accepted as the level of statistical significance. RESULTS: Mean age of the patients included in the study was 61.83±9.15. In 34.6% of the patients with MetS, 70.5% of the patients with ED and 37.2% of the patients with severe LUTS were determined. There were no significant differences between the mean age of patients with and without metabolic syndrome (p>0.05). There was a positive correlation with age and severity of LUTS but this relationship was not found to be statistically significant (p>0.05). Mean age of the patients with ED was significantly higher than those without (p<0.001). A statistically significant relationship was not observed between the mean IPSS scores and the severity of LUTS with Mets. However, we observed a weakly positive correlation between triglyceride levels and IPSS. Mean IIEF-5 scores of the patients with MetS were significantly lower than those of the patients without MetS. Severity of ED in the patients with MetS was significantly higher than patients without MetS. The percentage of ED in patients with severe LUTS was found to be statistically higher than other patients with mild, and moderate LUTS. In addition, we found a low degree of negative correlation between IPSS and IIEF-5 scores. CONCLUSION: In patients with LUTS as a consequence of BPH, when severity of symptoms increases, frequency of MetS increases proportionally and severe ED is observed much more frequently.

Universal health coverage in Turkey: enhancement of equity.

Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003-13, which coincides with the Health Transformation Program (HTP). The HTP rapidly expanded health insurance coverage and access to health-care services for all citizens, especially the poorest population groups, to achieve universal health coverage. We analyse the contextual drivers that shaped the transformations in the health system, explore the design and implementation of the HTP, identify the factors that enabled its success, and investigate its effects. Our findings suggest that the HTP was instrumental in achieving universal health coverage to enhance equity substantially, and led to quantifiable and beneficial effects on all health system goals, with an improved level and distribution of health, greater fairness in financing with better financial protection, and notably increased user satisfaction. After the HTP, five health insurance schemes were consolidated to create a unified General Health Insurance scheme with harmonised and expanded benefits. Insurance coverage for the poorest population groups in Turkey increased from 2·4 million people in 2003, to 10·2 million in 2011. Health service access increased across the country-in particular, access and use of key maternal and child health services improved to help to greatly reduce the maternal mortality ratio, and under-5, infant, and neonatal mortality, especially in socioeconomically disadvantaged groups. Several factors helped to achieve universal health coverage and improve outcomes. These factors include economic growth, political stability, a comprehensive transformation strategy led by a transformation team, rapid policy translation, flexible implementation with continuous learning, and simultaneous improvements in the health system, on both the demand side (increased health insurance coverage, expanded benefits, and reduced cost-sharing) and the supply side (expansion of infrastructure, health human resources, and health services).

Turkey. Health system review.

Turkey has accomplished remarkable improvements in terms of health status in the last three decades, particularly after the implementation of the Health Transformation Program (HTP (Saglikta Donus, um Programi)). Average life expectancy reached 71.8 for men and 76.8 for women in 2010. The infant mortality rate (IMR) decreased to 10.1 per 1000 live births in 2010, down from 117.5 in 1980. Despite these achievements, there are still discrepancies in terms of infant mortality between rural and urban areas and different parts of the country, although these have been diminishing over the years. The higher infant mortality rates in rural areas can be attributed to low socioeconomic conditions, low female education levels and the prevalence of infectious diseases. The main causes of death are diseases of the circulatory system followed by malignant neoplasms. Turkeys health care system has been undergoing a far-reaching reform process (HTP) since 2003 and radical changes have occurred both in the provision and the financing of health care services. Health services are now financed through a social security scheme covering the majority of the population, the General Health Insurance Scheme (GHIS (Genel Saglik Sigortasi)), and services are provided both by public and private sector facilities. The Social Security Institution (SSI (Sosyal Guvenlik Kurumu)), financed through payments by employers and employees and government contributions in cases of budget deficit, has become a monopsonic (single buyer) power on the purchasing side of health care services. On the provision side, the Ministry of Health (Saglik Bakenligi) is the main actor and provides primary, secondary and tertiary care through its facilities across the country. Universities are also major providers of tertiary care. The private sector has increased its range over recent years, particularly after arrangements paved the way for private sector provision of services to the SSI. The most important reforms since 2003 have been improvements in citizens health status, the introduction of the GHIS, the instigation of a purchaser provider split in the health care system, the introduction of a family practitioner scheme nationwide, the introduction of a performance-based payment system in Ministry of Health hospitals, and transferring the ownership of the majority of public hospitals to the Ministry of Health. Future challenges for the Turkish health care system include, reorganizing and enforcing a referral system from primary to higher levels of care, improving the supply of health care staff, introducing and extending public hospital governance structures that aim to grant autonomous status to public hospitals, and further improving patient rights.

Turkey: health system review

The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of policy initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.

Sperm motility changes after coincubation with various uropathogenic microorganisms: an in vitro experimental study.

OBJECTIVE: We investigated the relationship between semen motility and various uropathogenic microorganisms. MATERIALS AND METHODS: Semen specimens from healthy donors were divided into portions and incubated with uropathogenic microorganisms in concentrations varying from 2 x 10 to 2 x 10(7) microorganisms/ml(-1). Uninfected suspensions of spermatozoa served as controls. In all samples, sperm motility was examined at the second, fourth, and sixth hours after incubation in order to assess motility as a function of time. Enterobacter aerogenes, Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli were used as bacterial agents. Besides these bacterial strains, Candida albicans was also used. RESULTS AND CONCLUSIONS: Observed negative impact on sperm motility was not correlated with microorganism concentration. However, until a certain concentration threshold, this impact was prominent. Regardless of the microorganism, this deleterious effect could not be confirmed in specimens coincubated with lower microorganism concentration. No or poor correlation was found between motility and bacteria concentration except with E. aerogenes at the second hour. The data indicates that sperm function impairment is not related to direct sperm and bacteria interaction. Instead, bacterial concentration enough to change the environment or to consume high energy might result in motility loss.

Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison.

OBJECTIVES: To prospectively compare the outcome of standard and tubeless percutaneous nephrolithotomy (PNL) in a selected group of patients with renal stones. METHODS: Patients with simple, isolated renal pelvis or lower pole caliceal stones and no significant hydronephrosis were randomly enrolled to undergo either standard PNL, in which routine nephrostomy tube was placed at the end of operation, or tubeless PNL. Occurrence of intraoperative complications, total operative time exceeding 2 h, indication for additional access or second-look PNL due to residual stones were exclusion criteria. RESULTS: There were 11 isolated lower pole caliceal stones (mean stone burden: 3.1 cm(2)) and 6 isolated renal pelvis stones (mean stone burden: 2.8 cm(2)) in the tubeless PNL group (n: 17), and 9 isolated lower pole caliceal stones (mean stone burden: 3.4 cm(2)) and 9 isolated renal pelvis stones (mean stone burden: 3.1 cm(2)) in the standard PNL group (n: 18). Mean operation time was 59.6 +/- 9.1 (range: 50-90) min in the tubeless group, and 67.3 +/- 10.1 (range: 60-115) min in the standard PNL group (P > 0.05). Successful stone removal was achieved in all patients, and no significant complication was observed in any case. The mean postoperative analgesic requirement was significantly less in the tubeless group (P < 0.05). Mean hospital stay was 1.6 +/- 0.4 (range: 1-3) days in the tubeless group, and 2.8 +/- 0.9 (range: 2-4) days in the former group (P < 0.05). CONCLUSION: Our results indicate that tubeless PNL is safe in the management of selected patients and that mean analgesic requirement as well as hospitalization time is diminished with this modification.

Multiple primary malignant neoplasms in urologic patients.

METHODS: Second primary cancers constitute approximately 9-10% of malignancies diagnosed in the United States. We aimed to show the risk and incidance of second primary tumor occuring associated to urologic tumors and show the distrubution of tumors in Tracia region. We retrospectively examined the patients' files with the diagnosis of malignant disease between the years 1985-2000. Hazard function analysis was performed to estimate the relative risk of secondary malignancy occuring. Age, sex and tumor number were examined to find out if they affect on mortality rate. RESULTS: A total number of 25 MPMNs were diagnosed. In 52 percent of the cases the second primary neoplasm developed within six months. The relative risk of development of a second neoplasm is found as increasing 1.111 times per month. The incidence of secondary malignancy occuring in the patients with one tumor was found as 6.31%. Age (p < 0.001) and tumor number (p < 0.001) are found as statistically effective predictor on mortality rate where the sex is not. CONCLUSIONS: In the patients with a primary tumor not only the metastasis must be investigated but also second primary tumors should be taken into consideration.

Diagnostic value of cytokeratin-18 as a tumor marker in bladder cancer.

OBJECTIVES: The aim of the study was to compare serum levels of cytokeratin-18 of patients with bladder cancer with those of the healthy controls, and to investigate the relation between cytokeratin level and the tumor stage. DESIGN AND METHODS: Serum cytokeratin-18 levels of 38 patients with bladder cancer and of 25 healthy people were determined. Tumor stage was T(1) in 12 patients, T(2) in 9 patients, T(3) in 10 patients and T(4) in 7 patients. The serum cytokeratin-18 levels in these cases were analyzed with respect to the stage of the tumor. RESULTS: Cytokeratin-18 level in the patient group was found to be significantly higher than that of the control group (p < 0.010) when the groups were totally compared. However, when the levels in patients with different tumor stages were compared with that of the controls, the difference was not significant in patients with stage 1 and 2 tumors (p > 0.05). Regarding the cut off value as 4.0 ng/mL, sensitivity and specificity for serum cytokeratin-18 were found to be 53% and 72% respectively. When sensitivity was calculated with respect to tumor stages, it was 8% for T(1,) 33% for T(2,) 90% for T(3) and 100% for T(4.) On the other hand, considering higher stage (T(3) and T(4)) tumors only, the sensitivity was calculated as 94%, but the sensitivity for lower stage (T(1) and T(2)) tumors was 19%. CONCLUSIONS: It is clear that serum cytokeratin-18 level increases in patients with bladder cancer. However, it can only be useful as a tumor marker in the diagnosis of T(3) and higher staged tumors. This study indicated that cytokeratin-18 does not have any diagnostic value in lower stage bladder cancers.