Should health services be centralized and free in pandemics? The case of Turkey as an example

The scientific board published the prevention and treatment guidelines for COVID-19 in January before the emergence of COVID-19 cases in Turkey. The constantly updated guidelines address all disease stages from the first diagnosis to the intensive care processes in detail. Furthermore, a list of reference hospitals across the country is provided in the guideline. In February, MoH stopped flights to China firstly. Then, MoH banned outbound flights to countries that reporting COVID-19 cases . The Minister of Education announced that schools were closed. It was announced on March 9th, 2020 that the first patient was diagnosed with COVID-19 in Turkey . At the beginning of May, the president announced that controlled social life would begin and that closed facilities and stopped activities would be allowed to start again in a controlled manner. The Turkish government took the necessary precautions early and swiftly. The main payer health care expenditures in Turkey is the social security institution (SSI), and also the SSI belongs to the state. The Turkish health system has already been ready for extraordinary health conditions such as this pandemic.

Abbreviations

COVID-19: Corona Virus Disease-19; MoH: Ministry of Health; OECD: Organisation for Economic Co-operation and Development; USA: United States of America; SSI: Social Security Instution.

Per the COVID-19 (Corona Virus Disease-19) pandemic with a potentially fatal disease course, the Turkish Ministry of Health (MoH) established a scientific health committee on 10 January to take necessary precautions. The scientific committee started as MoH’s advisory board [1], acting as a legally binding organ for all bodies of the government. The scientific board then published the prevention and treatment guidelines for COVID-19 in January before the emergence of cases in Turkey. The constantly updated guidelines address all disease stages from the first diagnosis to the intensive care processes in detail. Furthermore, a list of reference hospitals across the country is provided in the guideline [2].

The MoH announced that passengers from China would be quarantined. In February, MoH stopped flights to China firstly. Then, MoH banned outbound flights to countries that reported COVID-19 cases [3]. In March; disinfection activities started in some public areas, squares, and in public transport settings. A presidential announcement stipulated that matches would be played without spectators all over the country [4]. The Minister of Education announced that schools were closed [5]. It was announced on March 9th, 2020 that the first patient was diagnosed with COVID-19 in Turkey. On March 17th, the first death from COVID-19 in Turkey was reported [5]. The MoH launched a cluster working group with 44,053 primary care physicians [6]. The health minister announced that 277 people died, and 15,679 cases were diagnosed with COVID-19 at the beginning of April. In April, the minister noted that the increase rate of newly diagnosed cases started to decelerate and that 82% of cases were over 60 years of age. In April, curfew was declared on weekends and public holidays. On May 5, the minister reported that the total number of tests performed reached a figure of 1,265,119 and that 133.21 cases were diagnosed with COVID-19. The total number of deaths due to COVID-19 has been declared as 3,520.

At the beginning of May, the president announced that controlled social life would begin and that closed facilities and stopped activities would be allowed to start again in a controlled manner. The education minister announced that the schools would be open in June. Turkey has taken early actions as a developing country, consequently achieving low figures of new cases and mortality.

The World Health Organization stated that different health systems in countries are affected by the basic norms and values that prevail in the societies of the countries. France applies the Bismark model and Spain applies the Beveridge model. USA (mixed method) and Turkey (General Health Insurance) is implementing its own models. Although health expenditures differ in OECD countries with different health systems (Table 1), it has been found that these different expenditures are not directly related to health indicators and the success and efficiency of health systems [7] . The Covid 19 pandemic also confirms this (Table 2).

According to the Constitution of the Republic of Turkey, health care is a public property, it is one of the state’s duty and the MoH is responsible for health services. Health services are provided by public, semi-public, private and non-profit foundation organizations Health services are financed by taxes, social security premiums, private insurance premiums and out-of-pocket payments [8]. With the accelerated reforms in the last 20 years and the “Health Transformation” program that started in 2003, the Turkish health system was reorganized, and the General Health Insurance system was put into effect with the Social Security Reform. As a result of these changes, citizens’ access to health services has been facilitated and financial protection has been improved for the low-income segment against high health expenditures [9,10]. As of 2012, it was imposed that all citizens should be included in the General Health Insurance system.

According to the OECD (Organisation for Economic Co-operation and Development) 2011 data of the Turkish health system; the number of hospital beds in Turkey is 2.8 per 1000 people, which is the same figure as the one in the USA (United States of America). While many countries have decreased the number of beds in intensive care units since the 2000s, Japan and Turkey increased the number of beds in those units [7]. The state is in a dominant position in the Turkish health sector. The number of intensive care beds in Turkey is 46 per 100 thousand people; which is more than the figure in the United States and Germany [6]. The Turkish government has increased health investments since 2002.

When the pearls of the success of the Turkish health system are listed, it is apparent that the leading one is the dominant position of the state institutions in the healthcare sector. This situation facilitated to manage the condition in a centralized manner. The main payer health care expenditures in Turkey is the Social Security Institution (SSI), and also the SSI belongs to the state. Emergency health services and intensive care services are provided free of charge. Furthermore, the state covered the COVID-19 expenses of private health institutions; which have a small share in the healthcare sector. The Turkish health system has already been ready for extraordinary health conditions such as this pandemic. Turkey has increased the number of hospital beds in the country at a steady pace since the 2000s. The scientific board was established early and the guidelines were published readily. Outbound and inbound international travel activities were halted early in the process. The number of primary care physicians is adequate in Turkey and the cluster working group has started its actions early.

In extraordinary health conditions such as a pandemic, it may be relevant for all countries in the world that health care services should be centralized and be free of charge. Failure in the management of the pandemic in some countries may result from their highly different approaches to this issue. Compared to most of the countries; especially, developed countries took different actions, ending in a more fatal disease course for COVID-19.

Pandemic reminded Avicenna’s recommendations again from history.

“Clean with vinegar. Always wash your hands, dishes and clothes with vinegar.

Do not wander together. Do not create crowds by gathering five to ten people.

Leave the markets.

Drop the coins.

Do not worship collectively

Do not be afraid of the epidemic, avoid the disease, do not leave your patients.

Sit at your home and be happy. The disease escapes from joy”

Avicenna, The Canon of Medicine.

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