Salih Mollahaliloglu

Healthcare in Turkey: from laggard to leader

Enis Baris and colleagues observe that a political commitment to universal health coverage together with a significant investment in health has seen Turkey’s health indicators catch up and surpass other middle income countries

Assessment of the Turkish health care system reforms: A stakeholder analysis

BACKGROUND The Turkish health care system has been undergoing a significant transformation with the Health Transformation Program (HTP) since 2003. The HTPs overall objective is to improve governance, efficiency, user and provider satisfaction, and long-term fiscal sustainability of the health care system in Turkey. OBJECTIVES To systematically evaluate the effects of the HTP Phase I reforms on various stakeholders, and to outline strategic options for the implementation of the second phase of health transformation in Turkey. METHODS A total of 47 formal structured stakeholder interviews, representing 29 different institutions, are conducted between December 2008 and January 2009. Five main components of the HTP were examined: strengthening of the Ministry of Health (MoH) capacity for stewardship, universal health insurance, reorganizing health service delivery, human resources development, and national health information system. RESULTS AND CONCLUSIONS There is a general agreement among stakeholders that the progress made thus far is the greatest in the national health information system and the slowest in strengthening the MoH capacity for stewardship. It appears that the HTP has the capacity to deliver cost-effective health care services and the implementation progress, so far, is in congruence with the overall economic development and growth in Turkey.

Health worker densities and immunization coverage in Turkey: a panel data analysis

BackgroundIncreased immunization coverage is an important step towards fulfilling the Millennium Development Goal of reducing childhood mortality. Recent cross-sectional and cross-national research has indicated that physician, nurse and midwife densities may positively influence immunization coverage. However, little is known about relationships between densities of human resources for health (HRH) and vaccination coverage within developing countries and over time. The present study examines HRH densities and coverage of the Expanded Programme on Immunization (EPI) in Turkey during the period 2000 to 2006.MethodsThe study is based on provincial-level data on HRH densities, vaccination coverage and provincial socioeconomic and demographic characteristics published by the Turkish government. Panel data regression methodologies (random and fixed effects models) are used to analyse the data.ResultsThree main findings emerge: (1) combined physician, nurse/midwife and health officer density is significantly associated with vaccination rates – independent of provincial female illiteracy, GDP per capita and land area – although the association was initially positive and turned negative over time; (2) HRH-vaccination rate relationships differ by cadre of health worker, with physician and health officers exhibiting significant relationships that mirror those for aggregate density, while nurse/midwife densities are not consistently significant; (3) HRH densities bear stronger relationships with vaccination coverage among more rural provinces, compared to those with higher population densities.ConclusionWe find evidence of relationships between HRH densities and vaccination rates even at Turkeys relatively elevated levels of each. At the same time, variations in results between different empirical models suggest that this relationship is complex, affected by other factors that occurred during the study period, and warrants further investigation to verify our findings. We hypothesize that the introduction of certain health-sector policies governing terms of HRH employment affected incentives to provide vaccinations and therefore relationships between HRH densities and vaccination rates. National-level changes experienced during the study period – such as a severe financial crisis – may also have affected and/or been associated with the HRH-vaccination rate link. While our findings therefore suggest that the size of a health workforce may be associated with service provision at a relatively elevated level of development, they also indicate that focusing on per capita levels of HRH may be of limited value in understanding performance in service provision. In both Turkey and elsewhere, further investigation is needed to corroborate our results as well as gain deeper understanding into relationships between health worker densities and service provision.

Scientific Evidence for Korean Medicine and Its Integrative Medical Research

The Korean Medicine (KM) incorporates same clinical techniques as East Asian traditional medicine; however it also has typical characteristics such as Sasang typology, Sa-am acupuncture, Chuna therapy, pharmacopuncture, and Korean psychotherapy. Modernized KM currently utilizes cutting-edge techniques of orthodox medicine, though it is rooted on the Donguibogam, one of the best Korean medical classics written in 1610 and enlisted on the Memory of the World by UNESCO in 2009. In 2013, the National Health Insurance of Korea paid about 2 billion dollars for medical services provided by 18,000 KM doctors in 210 KM hospitals and 13,200 KM local clinics. The role of KM in health service is expected to expand since Korea is anticipated to be an aged society in 2018 and hyperaged society in 2028 which means increased chronic disease patients. Thus the evaluation of efficacy and safety of KM and improvement of its clinical skills have been emphasized recently. Our special issue, which had opened for 6 months in the first half of 2015, focused on scientific evidence for KM and its integrative medical research. An article by C. Na et al. described that Jakyak-Gamcho decoction extracted with 70% ethanol exhibits higher amounts of effective index components than that extracted with water; it may be worthwhile to investigate alternative extraction methods in terms of extraction efficiency and in vivo effectiveness for other herbal medicines besides Jakyak-Gamcho decoction. A study by D.-S. Hwang et al. evaluated that Kyung-Ok-Ko significantly protects against heat-induced damage to testicular function in male mice by inhibiting oxidative stress and apoptosis. B. Joh et al. described that Morus alba treatment of infertility, jaundice, cognitive disorder, and hyperpigmentation is found to be effective and diabetes with Morus alba is recognized to have clinical importance. An interesting study by S. J. Lee et al. elucidated the biopsychological mechanism underlying the Sasang typology (a traditional Korean personalized medicine) using Behavioral Inhibition System (BIS)/Behavioral Activation System (BAS) scale. S. J. Lee et al. reported significant differences in BIS and BAS scores between So-Yang and So-Eum Sasang types. K. Lee and B.-J. Lee reported the exact plant origins, efficacies, uses, components, and toxicities of Polygoni Multiflori Radix, Cynanchi Wilfordii Radix, and Cynanchi Auriculati Radix so that they can be correctly understood and used. A study by D. R. Kim et al. reported that Trigonellae semen treatment could enhance sperm function by promoting spermatogenesis and the expression of cation channel of sperm proteins in mouse testes. J.-H. Hwang et al. reported that intratracheal Chung-pae administration effectively decreases the chronic inflammation and pathological changes in a porcine pancreatic elastase- and lipopolysaccharide-induced chronic obstructive pulmonary disease mouse model. An interesting study by H.-G. Kim et al. suggested that one can find the Bonghan systems under the skin as putative acupuncture points by tracing the intraexternal Bonghan systems, from which a new KM will be born. T.-H. Kim et al. suggested a recommendation for reporting cases of acupuncture-related infections. The recommendation includes items on patients condition and adverse events (or complications) in detail, which are necessary to establish the causality between acupuncture and the event as well as to provide information for judging appropriateness of acupuncture practice. A study by M.-H. So and Y.-K. Choi reported that the water extracts of Scutellariae radix and Liriopis Tube significantly suppressed the increased production of nitric oxide, interleukin-6, macrophage inflammatory protein-1α, macrophage inflammatory protein-1s, macrophage inflammatory protein-2, and granulocyte colony-stimulating factor as well as the increase of the intracellular free calcium in mouse macrophages induced by lipopolysaccharide. A research article by J. S. Ha et al. reported that the ethyl acetate fraction from Actinidia arguta containing physiological phenolics might enhance drug-induced amnesia through acetylcholinesterase inhibition and neuroprotection. Another study by W.-M. Jung et al. demonstrated that the indications of each acupoint were primarily associated with the corresponding meridian system, using data mining methods to analyze the characteristics of the indications of each acupoint and to visualize the relationships between the acupoints and disease sites in the classic KM text Chimgoogyeongheombang. A study by J. Y. Park et al. suggested that Artemisia asiatica extract and eupatilin could cure or prevent cisplatin-induced renal toxicity without any adverse effect; Artemisia asiatica extract can be used in combination with cisplatin to prevent nephrotoxicity. An interesting review article by M. Park and S. Kim reported that Sa-am acupuncture, which operates with five shu points as a main aspect of treatment, has the advantage of increasing parasympathetic nerve activity and adjusting the balance of the autonomic nervous system; to maximize this effect, inserting a needle into the skin layer and providing gentle and light stimulation while considering the respiratory phase may be desirable. A research article by K. Kim et al. reported that KM combination therapy may be beneficial for decreasing pain and improving function in lumbar spinal stenosis patients and may produce comparatively few adverse events. Another study by J. W. Suh et al. reported that the Emotional Freedom Technique, a meridian-based psychological therapy that alleviates psychologic and psychosomatic conditions by applying tapping stimulations at certain meridian acupoints, is more effective in improving anger and anxiety in the Hwabyung patients compared to the conventional meditation technique of Progressive Muscle Relaxation. An interesting study by H. G. Kim et al. suggested that those with a Taeumin type (one of four Sasang types) may tolerate psychological or oxidative stress better than those with the other types in accordance with the differences in the serum levels of stress hormones and the oxidative stress markers. In conclusion, we expect that this special issue updates scientific evidences in KM and makes useful progress on KM integrative research.

Assessment Of The Prescriptions Written In Different Provinces Of Turkey In Terms Of Drug Utilization Principles

Objective: To learn how physicians’ prescribing habits contribute to the rational use of medicine (RUM). We investigated the content of prescriptions written out in different provinces. Material and Method: A total of 3201 prescriptions written in Bartin, Bayburt, Cankiri, Denizli, Eskisehir, Gumushane, Karabuk, Kirsehir, Nevsehir and Nigde were collected from pharmacies. Prescriptions were analyzed using some indicators such as average number of medicines per-prescription (NMPP), average cost per-prescription (CPP) etc. Prescriptions indicating anxiety, hypertension, osteoarthritis, acute (A) otitis media, A.sinusitis, A.tonsillopharyngitis, A.cystitis, diabetes mellitus, dyspepsia and A.diarrhea were evaluated by provinces. Results: Except in three provinces, respiratory drugs were the most commonly written agents. NMPP was highest in Denizli (3.21±0.95), lowest in Cankiri (2.65±1.09). CPP was highest in Denizli (133.35±650.92TRL), lowest in Bartin (42.54±49.91TRL). As for gold standard-compatibility, the prescribed medicines in 4/10 indications seemed better in Cankiri and Gumushane. Injections, antibiotics, analgesics and gastroprotectives were most commonly prescribed in Denizli (14.1%), Kirsehir (43.3%), Gumushane (48.1%) and Bayburt (19.8%) respectively. Conclusion: In the provinces, there were substantial differences in the content of prescriptions. Generally, rational drug prescribing performance was found quite low. These findings should be considered in the activities to the extension of RUM. (Marmara Medical Journal 2011;24:162-73)

How firms set prices for medical materials: A multi-country study

OBJECTIVES This study presents a comparison of medical material prices, discusses why differences exist, and examines methods for comparing prices. METHODS Market prices for drug-eluting stents (DES), non-drug-eluting stents (non-DES), and percutaneous transluminal coronary angioplasty (PTCA) catheters were collected from five countries: the United States, Japan, Korea, Turkey, and Thailand. To compare prices, three adjustment methods were used: currency exchange rates, purchasing power parity (PPP), and gross domestic product (GDP) per capita. RESULTS The ratios of medical material prices compared with those in the United States were higher in Japan (from 1.4 for DES to 5.0 for PTCA catheters) and Korea (from 1.2 for DES to 4.0 for PTCA catheters), and lower in Turkey (from 0.8 for non-DES to 1.4 for DES) and Thailand (from 0.5 for non-DES to 1.3 for PTCA catheters). The PPP-adjusted ratios changed slightly for Japan, Korea, and Turkey. When the prices were adjusted by GDP per capita, the ratios were much higher. CONCLUSIONS Comparing prices using currency exchange rates or PPP is applicable only between countries with stable economic relations; adjustment by GDP per capita reflects the actual burden. Further study is needed to fully elucidate the factors influencing the global medical material market.

Acupuncture for Lateral Epicondylitis

Lateral epicondylitis (LE), known as tennis elbow, is one of the most common diseases of elbow (1). Its cardinal symptom is tenderness and pain while using the extensor muscles of wrist repetitively. Men and women seem to be equally predisposed to this disease, and the age of onset is usually between 35 and 55 years (2). The incidence is estimated between 1% and 3% per year in the adult general population. It occurs because of overuse injury. But a sudden extreme effort or activity such as trauma can also cause damage to the epicondylar area (3). The classical description is pain at the lateral aspect of the elbow that often radiates down the forearm. It leads to the failure of common extensor tendon, specifically the extensor carpi radialis brevis portion. The diagnosis of LE includes palpation of the lateral epicondyle, resisted wrist extension, resisted wrist and middle finger extension, and passive wrist flexion (4,5).

Investigation of Physicians’ Perspectives of Drug Promotional Activities

Programlanmis hucre olumu olan apoptoz bircok fizyolojik surecte aktif rol oynamaktadir. Apoptozun, buyume faktorlerinin eksikligi, DNA hasari ve birden fazla faktoru iceren cesitli hucresel stresle aktive olan ‘hucre ici’ ve olum reseptorlerine ligandin baglanmasiyla kaspazlarin aktive oldugu ‘hucre disi’ olmak uzere iki yolagi vardir. Apoptotik hucre sayisi ile organizmanin saglikli olup olmadigi belirlenir. Apoptoz oraninin azalmasi hucre sayisini arttirirken, apoptoz oraninin artmasi hucre sayisini azaltarak dokularda tahribata neden olmaktadir. Apoptotik sinyallemede duzensizlik cesitli hastaliklarda/bozukluklarda primer ya da sekonder rol oynamaktadir. Son yillarda apoptozun norodejeneratif hastaliklarla ilgili calismalari on plana cikmaya baslamistir. Apoptotik sinyal yolaklarinin daha iyi tanimlanmasi, pro- ve anti-apoptotik genlerin belirlenmesiyle, calismalar hiz kazanmistir. Travma Sonrasi Stres Bozuklugu gibi norodejeneratif bozukluklarda beyindeki yapisal ve fonksiyonel degisiklikler mitokondriyal stres ile iliskilidir. Fizyolojik kosullarda hayati oneme sahip olan apoptoz, patolojik kosullarda mekanizmanin tetiklenmesine ve kontrolsuz hucre cogalmasina yol acmaktadir. Hucre olumunu engelleyen terapotik ilaclarin gelistirilmesiyle apoptoz aracili norodejenaratif bozukluklarin tedavisine yeni umutlar olusacaktir.