From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Turkey’s response to the coronavirus pandemic – the August update (2020)

Zeynep Güldem Ökem, PhD
TOBB University of Economics and Technology, Department of International Entrepreneurship, Ankara, Turkey

zgokem@etu.edu.tr, guldemokem@gmail.com 

Encouraged by the plateau reached in the rate of increase in confirmed cases around mid-May, the Turkish government announced a “gradual normalization process”. By June, however, what was meant to be a gradual transition to a “new normal” has proved to be rather an abrupt return to business as usual. In the absence of thorough testing, the confirmed cases will probably keep on riding on the plateau, while actual situation will continue to be debated.

 Along with normalisation the government decided to continue measures to support employment and business by adding crafted monetary and fiscal tools. With scarce reserves, expansionary policies should be expected to take their toll on price stability, the value of the currency and on household income.

An elusive “new normal”

Following the Eid holidays in late May, almost all restrictions in economic and social life were removed, except for masks and social distancing which were hardly enforced. Hospitals returned to their routine operations. Private hospitals were taken out of the pandemic response system, as reimbursement for COVID-19 cases was terminated by the Social Security Institution (the sole payer). Turkey’s health system remains effective at and capable of responding current levels of confirmed cases. The number of cases, however, could well be on the rise due to unrestricted and casual mobility.

The tourist season has been the primary motive, yet Turkey remains excluded by the EU from the “safe list” of countries for travel, despite having been more resilient than most of the EU countries. The lifting of the travel ban and the Eid holidays have propelled domestic tourism, which constitutes a major cause of concern along with overcrowded urban public transport.

By 8 August the number of cases has peaked back at 1,172, compared to 961 on 21 May when the normalisation was announced. As of 8 August, the total number of cases reached 239,622, which ranks Turkey 18th worldwide.

Economic woes

When the outbreak hit, Turkey had already been in a process of recovery from the economic downturn due to a sharp devaluation of Turkish lira in 2018. The pandemic saw a net foreign currency outflow, a loss of export and tourism revenues, and depreciated Central Bank reserves. These factors were compounded by additional monetary and fiscal relief measures. The interest rates were further reduced by the Central Bank, with softened credits handed out by public banks, and VAT rates have been slashed to stimulate earnings in critical service sectors. Meanwhile, a ban on termination of employment contracts and government support for salaries continued during the “normalisation process”.

While everybody agrees upon the need for continued expansionary policies, as in many other countries that are coping with the burden of the pandemic, there are now substantive concerns as to the growing fragility of the Turkish economy. Analysts particularly highlight serious risks on price  stability, fuelled mostly by continued devaluation (20% since January 2020), an increased public and private debt burden due to a vastly increased budget deficit (twice of what was foreseen for the current year), and reduced private business activity. The short-term foreign debt stock to be paid within one year as of April 2020 was 164.5 billion dollars.

Public health: a need for new strategy

The “normalisation process” is mainly composed of lifting restrictions. There is a need for a new strategy in defending the public against the pandemic. It should involve more testing and more contact tracing, to target the super spreaders more than the diagnosed COVID-19 patients. With approximately 60K tests per million population Turkey ranks far behind others with similar resources and population (i.e. Germany 105K, UK 266K, Italy 119K), despite a rapid increase in its testing and tracing capacity initially. Treatment dimension is no less critical. The Ministry of Health recently changed their advice on COVID-19 patients with milder symptoms – to stay at home instead of in hospitals. This attracted criticism from experts who argued that the new method will increase infections among other family members.

Strategy should also devise necessary tools to ensure social distancing in public transport and other gatherings. In a recent move, the Ministry of Interior has imposed stringent measures, yet a more comprehensive approach  nationwide is needed.

Quo Vadis?

The Ministry of Education announced the date for schools to open: 31 August. However, there is a need to consider risks awaiting society with respect to the looming flu season, particularly if schools are open. Finally and more importantly, Turkey needs an adequate number of doses of any possible COVID-19 vaccine in the period that lies ahead.

Turkey’s response to the coronavirus pandemic – Update (May 2020)

 Zeynep Güldem Ökem

TOBB University of Economics and Technology, Department of International Entrepreneurship, Ankara, Turkey

zgokem@etu.edu.tr, guldemokem@gmail.com 

The number of confirmed cases in Turkey increased rapidly within a month since the first case was detected on 11 March. The trend of outbreak spiked twice, on 11 and 20 April, and reached a peak on 24 April. Since then a decreasing trend in cofirmed cases has been observed and seemed to have reached a plateau in the first week of May.

As of 7 May, Turkey ranks as the eighth highest per absolute number of cases worldwide with 131,744 confirmed cases, with a relatively low mortality per absolute number of detected cases (2.7%).

The Health Minister Dr. Fahrettin Koca underlined the strategy as “prevention, detection and treatment, tracing”. Rapid expansion in testing capacity and deployment of “filiation teams” have been effective in detecting cases and tracing their contacts. The number of laboratories providing confirmation tests for COVID-19 rose from 73 to 114 and on average 34,390 tests per day were performed during the past 30 days. The filiation teams, composed of two-three health personnel, identify cases and contacts of COVID-19; it ensures that those whose test positive are treated and suspected cases are quarantened in their homes and monitored for 14 days. In general, GPs are in charge of daily monitoring for the health of contacted cases and their compliance with home-quarantine by phone.

The Science Board announced that the treatment protocols have been updated to involve rather “aggressive” methods activated at an early stage of the disease, as compared to the practices adopted in other countries. By end of April, the bed occupancy ratio fell from 60% to 30%.

In addition to a partial lockdown for citizens who are at risk (elderly and those having chronic diseases) and those under the age of 20, weekend curfews have been imposed in 31 cities starting from 10 April. However, age groups outside those brackets continue to work.

On 4 May, President Erdogan announced “the first phase of combatting COVID-19 has ended and normalization processes will be implemented gradually”; 7 out of 31 metropolitan cities will now be exempted from the weekend curfews, and malls and shops will be opened incrementally from 11 of May.

A hard choice: health risks or economic livelihood

In our previous posting dated 9 April, we highlighted that Turkey was not immune to the universal dilemma in the fight against COVID-19, whereby the measures required to protect public health are bound by its economic resilience. As such, the recent decision to lift lockdown measures are not only due to the initial success in diagnosis and treatment, but also, like in many other countries, to a sharp economic downturn. In Turkey’s case however, the economy was also already hit by compelling circumstances when the pandemic phased in around mid-March; i.e. an entrenched current account deficit accompanied by a devaluing Turkish lira (nearly 20% since January), rising unemployment (from 13.8% in January to an estimated 27.7% as of April) and inflation (12.37% in February), and a deterioration in public finances with diminishing Central Bank reserves (by 18% from January to May).

As COVID-19 pushes the world towards an unprecedented global financial crisis, Turkey on its part needs to find ways to refinance its public and private sector debt, as well as to stabilise its macroeconomic indicators, while effectively increasing transfers to households. Some commentators argue that the required financing must come from a fresh arrangement with the IMF, which the government adamantly objects to on political grounds. Some others pointed at cooperation possibilities (i.e. debt postponement or a global COVID-19 fund) among the G20 countries, which yielded no significant outcome following the “virtual summit” of G20 leaders on 26 March. Analysts, however, converge on the need to reverse the negative trend in foreign investments and to stop rapid dollarization by readjusting the currently negative interest rates.

In his meeting with international investors on 6 May, Minister of Finance and the Treasury Berat Albayrak stressed that the public sector debt that needs to be serviced stands at only USD 4.5 billion, whereas the Central Bank keeps no target for reserves and export revenue loss will be offset by diminished import expenditures mainly due to the recent fall in oil prices (recent figures for April only partly construe this statement as the export revenues fell by 41.4%, whereas import expenditures by only 28.1%).

Turkey’s  response to the coronavirus pandemic – Original post (April 2020)

Zeynep Güldem Ökem, PhD
TOBB University of Economics and Technology, Department of International Entrepreneurship, Ankara, Turkey

Murat Anil Mercan, PhD
Gebze Technical University, Department of Economics, Kocaeli, Turkey

Turkey started some precautionary measures since the beginning of January 2020 in response to the emergence of the COVID-19 pandemic. On 10 January the Ministry of Health set up the Coronavirus Scientific Board that is composed of 31 experts and chaired by the Health Minister. The Board continuously assesses worldwide developments, and proposes warnings and public health measures in the fight against the virus; the executive departments of government, led by the President, decide interventions.

Several travel restrictions were imposed initially. Flights from China were stopped on 1 February. Due to a sharp increase of COVID-19 cases in Iran and Italy, flights with Italy, South Korea and Iraq were stopped, the borders with Iran and Iraq were closed at the end of February and Istanbul-Sofia train services were suspended afterwards.

The first COVID-19 case was officially confirmed on 11 March 2020. The person contacted the virus while travelling to Europe. The early cases who were tested positive were mainly from Europe, US and pilgrims who recently returned from Umrah-Saudi Arabia.

The public health measures have been put in place gradually in accordance with advice from the Scientific Board. Citizens were urged not to travel abroad and to administer self-quarantine for 14 days after returning from abroad. All schools were closed for two weeks as of  March 16^th, and then the distance/online education programmes have been started. Except supermarkets, pharmacies and restaurants those providing home delivery, all public gathering places, shopping centres, small businesses (shops, barbers, restaurants, cafes) were temporarily closed. Several circulars aiming to impose the social and physical distancing were released – e.g. buses within/between cities are allowed to operate at half capacity, mass gathering in mosques and at parks were banned. The government is calling for a “voluntary quarantine” for everyone. Two weeks quarantine requirement has been put in place for citizens who returned from Umrah-Saudi Arabia and Europe in state dormitories in specific cities. On March 21^st the curfew for people aged 65 and older and with chronic diseases was imposed. The partial curfew has been extended to include citizens under 20 years of-age as of 4^th April.

The government announced further travel restrictions – e.g. the northern borders were closed, all overseas flights were banned, a travel permit to inter-city travels on 28 March, and 31 provinces are put under quarantine and domestic flights were halted as of 4^th April. Wearing face masks and the three-steps rule for social distancing became mandatory.

Health System capacity and the management of COVID-19
All public hospitals that have two or more related specialities (e.g.  infections, internal medicine, clinical microbiology, etc.) have been specified as referral hospitals for corona cases. Private hospitals have also been included as pandemic hospitals and are required to provide tests and treatment free-of charge. As for capacity enhancing measures and controlling health services demand, the Ministry of Health circulated a decree to all hospitals, which included the intensive care units to be prepared appropriate for the treatment process and unloaded to the extent possible by transferring existing ICU  patients to other units, postponing elective surgeries and new admissions except for emergency cases. New admissions would be referred to GPs. Access to essential drugs for chronic patients was facilitated through extending the validity of previous prescriptions. The government will make additional payment to health personnel for three months.

The Ministry of Health published and regularly updates screening and triage protocols for COVID-19 and homecare for patients. The Ministry has also approved 73 laboratories that can provide confirmatory testing for COVID-19 throughout the country.

Since the first publicly available statistics on March 27th the test performance has been considerably improved and 20,063 tests were done on 5^th April. Between 11-31 March 13,531 people tested positive, and an additional 10,403 cases were added from 1^st to 4^th April.

On 3 March the statistics concerning the cases detected across provinces were made public. Turkey’s three most populated cities, Istanbul, Izmir and Ankara, have the highest risk. 56.51% of cases were registered in Istanbul (with more than 15.5 million inhabitants) and the number of newly infected people from a single case is 16, which is much higher than the current estimates of the world average of R0 of roughly 2.0-2.5. It was also reported that 601 health personnel had tested positive and 1 had died. At the time of writing (April 4^th), 501 people have died – i.e. the death rate per 100,000 is calculated at about 0.6.

Reflection on Covid-19 response in Turkey
While the universal health coverage and well-equipped health infrastructure has been an advantage, the number of doctors and nurses per 1,000 (1.9 and 2.8 respectively) is relatively low.

The detected COVID-19 cases across regions were not made public initially to avoid people’s movement from these cities and the outbreak spreading to other regions. However, the outbreak has spread all over the country within two weeks after the detection of the first case. The partial curfew and self-isolation have been inadequately followed by the population. Circulation initially surged following the closure of schools (people flocked to coasts, students returned to their hometowns) and almost half of returning Umrah pilgrims from abroad avoided quarantine, which were among the main reasons for the spread of disease to the whole country.

The strategy of self-quarantine by all as proposed by the Ministry of Health has been criticised by the Turkish Medical Association who proposed a nationwide curfew except for those who provide essential services. This strategy was recently reinforced by severe restrictions by the government. The government announced a ₺100 billion (about €13.9 billion) economic package, including ₺2 billion transfer to families in need. The critics of the package argued that the financial support is insufficient and not easily available for the poor, including in particular the unemployed, informal workers and those laid off due to the pandemic.

The Ministry of Health is generally successful in fighting the pandemic. But the government seems to be caught in a universal dilemma as it tries to restrict social interaction, while attempting to preserve economic livelihood. In that strain the critics argue that targeted economic support should accompany the public health measures. Hence, in the absence of readily available public funds to deal with the pandemic, the government announced a donation campaign by the general public. As more funds are made available stricter measures could be expected including a general curfew.

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