United Nations Public Service Awards Case Studies

Turkey is located at the cross-roads between Europe, Asia, and the Middle East. While this geographical location has brought many geo-political strategic advantages to Turkey, it has also placed the country in the middle of various natural and man-made emergencies and disasters.

Throughout history Turkey has faced frequent earthquakes very often and in enormous numbers, most of which measured high on the Richter scale owing to being one of the world’s seismically most active regions. Other natural disasters include floods, severe storms, wild fires, avalanches and landslides. In addition to this list of emergencies/disasters there are also disease outbreaks, traffic accidents, armed conflicts and wars in neighboring countries. For example, in the World Health Organization (WHO) European Region between 1990-2010 the total number of deaths occurred as a result of earthquakes was 22,000, 90% of which were in Turkey.

The main problem emergencies/disasters response was lack of cooperation and coordination within and outside health sector. Most of the deaths and severe injuries occurred as a result of poor management or lack of any management at all. The segmentation of government services and vertical interventions conducted by different key governmental and non-governmental actors further worsened an already bad situation.

Although there were several legislative amendments such as the one in 1988 on the “Emergency Assistance and Planning in Disasters” and the one in 2009 on the “Emergency and Disaster Management Organization and Duties”, the situation in the field seemed to be different from the one on the paper. The latter legislation has foreseen coordination for emergency/disaster preparedness, risk mitigation, response and rehabilitation among all sectors and institutions, how to put them all in practice has remained a challenge.

Prior to the initiative, there was no continuity in emergency/disaster preparedness and response. The health managers and staff who were supposed to be in charge of management and action during any particular emergency/disaster response were assuming their duties only after the onset of the event. There were nobody actively working around the clock and all assignments were done only as and when required. Despite the fact that a “crisis center”, the existence of which was a legal requirement, was supposed to be in charge of responding to emergencies/disasters, it turned out to be that that very center was in fact itself in crisis.

Needless to say the most vulnerable groups such as children, women and the elderly suffered disproportionately from this lack of inter-sectorial cooperation and coordination. Service providers also had many difficulties in fulfilling their duties for the same reason. Hence both service providers and service recipients were dissatisfied with the level and quality of medical rescue, assistance and evacuation during the emergencies/disasters.

Therefore, the Ministry of Health has established a Health Disaster Coordination Center (SAKOM) following a Ministerial Decree in 2009 in order to provide solutions to the aforementioned problems and to improve the quality and quantity of services.

What is the initiative about? (the solution)
SAKOM was established in 1999 within the Ministry of Health as a pilot project. Since then SAKOM has been operational without interruption and has shown tremendous improvement in functions and coverage. SAKOM has direct and continuous communication and interaction with all 81 provinces. It has been interacting with other sectors, some of which are The Prime Ministry/Disaster and Emergency Management Presidency Office (AFAD), Prime Ministry Search and Rescue(SAR) Department, Turkish Red Crescent Society Disaster Management Center, Turkish Military Forces, Civil Aviation Organization, Navy Search and Rescue Center, Meteorological Organization, Ministry of Interior, Ministry of Foreign Affairs, Turkish Coastal Guards Organization and Civil Society Organizations/Non-governmental organizations and with international organizations such as UNOCHA/INSARAG and WHO . SAKOM interacts with all relevant sectors through two ways communication and interacts with all sectors as and when required. SAKOM operates on 24/7 basis through telephones, VOIP telephones, facsimiles, HF/VHF radios, and internet. The Center has the dual function of being a call center and control-command center during emergencies/disasters and extraordinary situations. A back-up system was also put in place to assure continuity in voice and video calls, data transfer and video conferences both at the central and provincial levels just in case a crash happens. A very important feature of SAKOM is the inclusion of Geographic Information System (GIS) which allows the location and monitoring of the event, the movement of personnel, vehicle and equipment through digital maps. The center closely monitors the Turkey Central Earthquake Observatory, audio-visual and print media and internet for a probable emergency/disaster, accident, explosion, fire, poisoning, communicable disease outbreak in order to be alert at the earliest possible time. When something arises that would require the attention and decision making of senior authorities they are informed through SMS/ e-mail/phone/satellite calls. There are certain criteria for informing and alerting the authorities such as: earthquakes that have 4.5 or more with Richter scale domestically and 6.5 off-shore; off-shore tsunamis, floods and volcanic eruptions; traffic accidents resulting in 5 or more deaths and/or 10 or more injuries; domestic fires, avalanches, explosions; acts of terror; mass food, natural gas and carbon monoxide poisoning; communicable diseases; ambulance related news; violence and attempts of violence against health professionals; air/sea vessel accidents; health status of the foreigners who receive health care in Turkey; and lastly the health care of Syrian refugees. SAKOM has increased the efficiency of services in many ways. The time lag between the onset of emergency/disaster and response has significantly decreased. Just to give an example, during the 2011 Eastern Turkey Van earthquake SAKOM received information within seconds and initiated the response within minutes. Thus, all responsible managers and health professionals were up and running in less than an hour. And within hours the medical rescue and assistance were well in place. Standard response time for emergency calls was set at 10 minutes in urban, 30 in rural areas. Thanks to efforts of SAKOM this goal was reached in over 90% of cases.

Who proposed the solution, who implemented it and who were the stakeholders?
SAKOM was initiated by a Project Task Force in the Primary Health Care General Directorate of the Ministry of Health of Turkey. Following the need for an emergency/disaster command and communication center as clearly indicated in the national legislation and lack of capacity in the already existing crisis center, health officials decided to establish a Health Disaster Coordination Center in order to fill in the gap. The Project Task Force was assigned to be in charge of developing the project proposal. As an initial step the Task Force paid observation visits to present crisis centers which were established to respond emergencies/disasters. Among the places visited were the Ministry of Foreign Affairs Crisis Center, The Military Crisis Center etc., some of which were not functioning around the clock and some were mandated only according to specific missions. In 2009 SAKOM started to become functional within the Ministry of Health. Following the establishment of such a center, several assessments were carried out to identify needs and to respond to those needs in a “state of the art” manner. Over time with the establishment of brand new IC technologies SAKOM became a “center of excellence” and was recognized by other relevant sectors. The initial idea of having the center to communicate and coordinate within the health sector has turned into a more inter-sectorial coordination, collaboration and communication center. Currently it is being operated by health staff such as emergency health technicians, nurses, psychologists, laboratory/dental/medical technicians and ICT staff with a direct oversight by senior health professionals and there are also extensions working in the same way and manner at the provincial level. There are intra-sectorial health stakeholders and inter-sectorial stakeholders in the government and non-governmental bodies along with relevant international organizations. Although SAKOM is physically located in and operated by the Emergency Health Care General Directorate, health related stakeholders include other central Ministry of Health departments such as the Public Health Institution, State Hospitals Institution, Border and Costs Health General Directorate, Foreign Relations and EU General Directorate. At the sub-national/provincial levels all the affiliated branches of the central ministry are active contributors as well as beneficiaries of SAKOM. SAKOM has bi- and multi-lateral communication and operation with other key actors in Turkey and abroad, some of which include: The Prime Ministry, Disaster and Emergency Management Presidency Office (AFAD), Prime Ministry Search and Rescue Department, Turkish Red Crescent Society Disaster Management Center, Turkish Military Forces, Civil Aviation Organization, Navy Search and Rescue Center, Meteorological Organization, Earthquake and Seismic Activity Monitoring Center, Ministry of Interior, Turkish Coastal Guards Organization and Civil Society Organizations/Non-governmental organizations as well as with international organizations such as UNOCHA/INSARAG and WHO.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The major objective of SAKOM was to ensure efficient, interactive communication and coordination inside and outside the health sector during the emergencies/disaster and any other extraordinary situations. In order to achieve the major objective, several strategies were identified such as: directly linking policy/decision makers to the field; establishing a system based on order-command principles; maximizing efficient use of time through brand new IT equipment and well trained skillful staff; developing and improving all hazards response abilities; to build the capacity of the Ministry of Health at the national and sub-national levels; to be well prepared to respond to any emergency/disaster; to fully integrate with the other sectors that are active in disaster preparedness and response. The strategies were identified through participatory processes in consultation first within the health sector and afterwards with the involvement of other sectors. Some best practices at national and international arena were also taken into consideration throughout the processes. Observation visits were paid to the other sectors’ crisis centers and internet searches were carried out. It was agreed that the key concept of SAKOM is comprehensiveness of functions. In order to ensure an all-encompassing emergency/disaster management approach several systems were integrated into SAKOM. Those systems included 112 Command-Control and Call Center (record and operation), spare back-up communication center and HF radio coverage, mini command-control center, various audio-visual communication systems, media monitoring and archiving system, digital and video conference systems, air/land ambulances tracking system, and earthquake monitoring. Specifically the integration of HF radio communication has enabled two ways communication and interaction with amateur radio users. A very good example of the utilization of this feature of SAKOM was observed during the 2011 Eastern Turkey Van Province Earthquake. Following the first tremors, some amateur radio loops/calls were received from remote villages providing information and asking for help. As a result of this interactive communication, SAKOM immediately took action and able to reach out to isolated areas with the National Medical Rescue Teams (UMKEs) , which were hard to reach and would have otherwise remained un-served. Another significant achievement of SAKOM as a result of system integration into its functions was SARMaster (search and rescue system). This particular system receives continuous signals form land/air/sea vehicles/carriers/vessels when they face an accident/crash/sink and locates the exact point of the disaster. Accordingly SAKOM mobilizes and directs UMKE Teams for medical rescue and assistance. The SARMaster enabled the SAKOM to locate a helicopter accident in 2011 in Western Turkey Bursa province and SAKOM immediately mobilized National Medical Rescue Teams (UMKEs) to the site of the crash by providing the coordinates. In order to improve response abilities to emergencies SAKOM has started to undertake the coordination of a life-saving issue which is organ transplantation. Following organ donation, SAKOM coordinates, interacts with the responsible bodies and directs the teams in charge of the transfer of organs to the transplantation centers utilizing the most appropriate and fastest means of transportation such as air and land.

b. What were the key development and implementation steps and the chronology? No more than 500 words
A Project Task Force was established in the Ministry of Health in 2009 to develop and implement the project. The Task Force paid visits to other “crisis centers” to observe their functions and look for a model. However none of the visited places seemed to be a model program. Based on lessons learned the Ministry of Health decided to establish a permanent fully functional 24/7 coordination and communication center rather than dealing with crisis as fait accompli. Overtime the functions of SAKOM were expanded to cover more ICT as well as different types of emergencies/disasters. In the event of an emergency/disaster, SAKOM in coordination with the umbrella organization of Prime Ministry Disaster and Emergency Management Presidency Office (AFAD) and other organizations such as Turkish Red Crescent assess the situation and initiate the first response. SAKOM informs the senior health authorities according to a pre-defined hierarchical order and mobilizes the UMKE Teams around the region of the emergency/disaster hit area through the regional coordinator province. The mobilization and composition are done according to the main characteristics of the emergency/disaster such as level, magnitude, coverage and vulnerability. The coordinator province in turn informs and mobilizes the provincial UMKEs within their region. Within hours the UMKEs are in motion. SAKOM also alerts the next in order regions to stand up their response capabilities in case the characteristics of the emergency/disaster worsens and requires extra response assets. Meanwhile SAKOM alerts primary, secondary and tertiary medical facilities to get prepared within the overall pre-designed referral system. Simultaneously, air, land and sea ambulances are also mobilized along with UMKEs to have a whole-of-health approach. This comprehensiveness is achieved as a result of the involvement of all key stake holders, governmental and non-governmental alike, in a pre-planned manner. In 2009 an earthquake hit the East Turkey Van province twice. The health and disaster coordination center, SAKOM, coordinated the medical response. Immediate rescue operations were initiated within minutes of receiving the report of the onset of disaster, and search-and-rescue, medical rescue and first aid teams from 48 other provinces and 39 different institutions were deployed to the earthquake site by air and land corridors . SAKOM also coordinated the mobilization of the Turkish Red Crescent Society, various NGOs and volunteer organizations. Within a few hours after the onset of the disaster 145 land, three helicopter and two airplane ambulances, nine UMKE vehicles along with more than 500 health staff were deployed. SAKOM established a TIR track command and control vehicle in the earthquake province to transfer some of the provincial functions to a mobile facility in order to avoid probable interruptions due to after-shocks. In the aftermath of the earthquake 1700 medical evacuations to neighboring provinces were undertaken as a result of coordinated effort by SAKOM. CEDIM Karlsruhe Center for Disaster Management and Risk Reduction Technology in its report titled “Forensic Earthquake Analysis Group -Turkey (Van) Earthquake - 02.11.2011” stated that “The efficient response of the Turkish government is to be commended in the medical and SAR field”.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
The majority of the obstacles predated the establishment of SAKOM. The preceding crisis center was not functional 24/7, were not well equipped with technical and human resources let alone financial ones, responsibilities and accountabilities were not well defined and assigned. All these pre SAKOM problems made the implementation and transition a bit harder than it should have been. In order to overcome all of these problematic issues “as is” versus “as should be” exercises were undertaken and activities were implemented. SAKOM was established and became fully functional in a short period of time. What was done step-by-step was the inclusion of brand new technologies as appropriate. The lack of a model in Turkey and abroad to some extent was a constraint right at the beginning, well defined tasks helped overcome this particular obstacle as well. One may wish to look at global implementation of such centers and what one would find is the uniqueness of SAKOM. There are only 3 similar examples; one in the United States of America (USA) which only monitors at state levels and the other one in Germany being functional the same way of the USA, and the last one in Japan that monitors the provincial levels. However none of them have a nationwide monitoring as a whole. Hence SAKOM by having a monitoring and management system both at national and sub-national (provincial) levels is a sole example in emergency/disaster management.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
SAKOM employs technical and health professionals to maintain all of the functions without any shortcomings. Health staff includes Emergency Health Technicians, Nurses, Psychologists, Laboratory/Dental/Medical Technicians. Technical staff includes ICT professionals who posses expertise in high-tech standards. There is also ancillary staff to take care of general service related issues. They all work 24/7 in shifts and are all on the payroll of the Ministry of Health. Technical resources include 12 channel TV live system, audio-visual media record and archive system, 24 channel video recording and display system, video teleconference system (VTC), digital conference system, CCTV viewing and recording system, air and land ambulances monitoring system, mini command center fully equipped with HF/VHF/UHF radio systems, fixed/mobile/IP telephones, satellite telephones, facsimile, hospital automation systems, earthquake observatory and monitoring system, Prime Ministry Main Search and Rescue Coordination Center system (SARMASTER). Recently a brand new hardware and software called "Emergency/Disaster Warning, Tracking and Coordination System" was integrated into the existing systems of SAKOM which enables one on one monitoring of each and every teams and persons and vehicles in terms of their location, interventions, motion and any danger they are to face and vice versa. One key benefit of having all resources covered by national budget is that it avoids the problems of turn-over and ensures continuity of services. An important element was the cost-effectiveness of the SAKOM operations. A good example is the conference calls that are organized by SAKOM. Very recently a VTC conference call meeting was organized by SAKOM for the Public Health Institute of the Ministry of Health with 81 Provincial Health Managers on a very important public health issue. There were two managers from each province participating in the conference call, which lasted half a day (four- hours). The cost was estimated to be no more than USD100 for the entire meeting. In the absence of such a facility two managers from 81 provinces would have to travel to Ankara to attend the meeting which would have cost approximately USD50 000, five hundred times more costly than the conference call. The cost comparison reveals the cost-effectiveness of SAKOM organized VTC. In case the other indirect costs that were involved were taken into account such as lost time e.g. two-days travel and one- day stay for a half-day meeting, correspondences in writing (paper and stationery cost) etc. , the overall cost would have been even higher. Another advantage of VTC call which is being utilized via Metro Ethernet Internet is that the participation may go up to 20 persons from each province, thus ensuring high participation from all or a group of provinces when required, a much higher participation rate than would generally. The VTC call feature is being tested at the end of each and every month with all provinces to ensure the functionality and results of such testing are being disseminated widely.

Is the initiative sustainable and transferable?
A good example for the expansion of features and increase in functions of SAKOM was the inclusion of SARMaster (Search and Rescue) System in 2009. This particular system allows the pinpointing of the exact locations of transportation means and persons that are in danger and in need of urgent help within air/land/sea carriers/vehicles/vessels. SARMaster receives aid signals from the sources and the exact location/coordination of accident/disaster is known instantly from the signal. The system also has a feature to remove the falsification and re-confirm the exact location. SAKOM has provided training to international teams and received observation visits from several countries and organizations. These included missions from Syria, Saudi Arabia, Macedonia and World Health Organization (WHO) in 2010, Mauritania, Ukraine, and WHO in 2011, and Japan, Uzbekistan, India and WHO in 2012. Currently SAKOM has become a reliable source of information, communication and technology in emergency/disaster management. It has strategically shifted from being and intra-sectorial to an inter-sectorial center due to availability and reliability of quality services. Financial sustainability depends on the availability of funds especially in the national budget resources. There is an increasing trend in the allocation of funds to the public health sector in Turkey in the recent years. Consolidated public health expenditure increased from 2.8% of GDP in 1999 to 6.4% of GDP in 2007, almost tripled in less than a decade. This was made possible by allocating sufficient resources to the National Budget each and every year. The same trend continues to be the case without any shortcoming, thus ensures the availability of funds to maintain the function of public health services and with SAKOM a top priority. SAKOM is considered sustainable as well as transferable as observed by witnesses and assessors. A good answer to the question of sustainability and transferability comes from the WHO Report in 2011 which titled as Assessment of health systems crisis preparedness; Turkey. The concluding remarks of the assessment read as “Turkey has a high level of political commitment to crisis preparedness and proven capacity to respond to national and international disasters. The emergency response system has a strong legal framework; it is adequately staffed and well equipped. Regulations and detailed instructions at the national and regional levels define the coordination bodies, the designation of authority and the contingency requirements. Dedicated emergency and contingency funds are available at each administrative level. Resources for response and the surge capacity of the health facilities and EMS system are available at all levels (national, provincial and local)”. As regard to the transferability the same WHO report suggests that “ Because of Turkey’s unique position, with its broad experience in disaster situations and its advanced disaster and emergency management system, the country could play a leading role in training and research related to disaster risk reduction at global level”.

What are the impact of your initiative and the lessons learned?
The pressing need for developing and implementing SAKOM was the lack of capacity in the management of emergencies/disasters. Especially the shortcomings/failures during the past emergencies/disasters made it necessary to improve the quality of coordination and communication mechanisms within the Ministry of Health and with other sectors. In addition, there was an increasing pressure from the public to have access to quality services no matter what. Therefore, the Ministry of Health decided to abolish the dysfunctional “crisis center” and replace it with a brand new coordination and communication center moving from crisis reaction phiosophy to a preparedness, response and relief approach. Preparedness at national and sub-national levels was quite important. Simulations/drills raised the level of awareness as well as confidence among all stake holders. SAKOM is coordinating operational emergency/disaster risk reduction and preparedness. The Center is fully equipped with up-to-date means of communication and linked to all 81 provincial centers, including 112 Command-Control-Call Centers. In addition to intra-sectorial coordination, SAKOM coordinates with other governmental disaster management and coordination centers, The Turkish Armed Forces, The Turkish Red Crescent Society, civil aviations and meteorological stations, just a few among a long list of institutions/bodies. Being fully operational 24/7, SAKOM receives statistics on incidents and hospital-bed capacity from all provincial centers, tracks the movement of the Ministry of Health ambulances and air evacuation all over the country. SAKOM provides oversight and guidance to the 81 provincial Emergency/Disaster coordination/crisis centers. SAKOM’s domestic responsibilities include but not limited to around the clock coordination and monitoring of national emergency/disaster management, cooperation with bodies that monitor weather and seismic conditions and activities, SAR, relief aid organizations, organizations that provide early warning systems, auditing the activities pre- and in-hospitals. Besides the coordination of tasks among various actors SAKOM undertakes action for information management, evaluation and dissemination of knowledge. As part of the overall coordination of the Ministry of Health with key partners from public, private and civil society, SAKOM coordinates access to resources in emergencies/disasters from public and private organizations through partnership mechanisms and contractual arrangements. For example ambulances, hospital beds from private, university hospitals, medicines for national and international emergencies/disasters from pharmaceutical companies and provision of food and water from relevant companies are sought to be utilized/obtained during emergencies/disasters as and when required. Stewardship has been of utmost importance to accomplish all the tasks successfully. The governance and leadership in terms of establishing policy frameworks for emergency/disaster management, strengthening/building new partnerships, ensuring the availability and use of resources, financial, technical and human all alike, accountability and provision of incentives and effective oversight were well in place throughout the processes. The World Health Organization (WHO) Regional Director for Europe, Ms. Zsuzsanna Jakab has commented during the assessment of 2011 Eastern Van Province earthquake that “the health response of Turkish authorities, which was mobilized and coordinated by the Ministry of Health, contributed effectively to minimizing acute morbidity and mortality and to preventing further public health consequences”.


Institution Name:		Turkey Ministry of Health, Emergency Health Care General Directorate
Institution Type:		Government Agency
Contact Person:		Ali Coskun
Title:		Director General
Telephone/ Fax:		:+90-312-585 1271/+90-312-432 2672
Institution's / Project's Website:		www.saglik.gov.tr/ASHGM
E-mail:		murat.kaya@saglik.gov.tr
Address:		Acil Saglik Hizmetleri Genel Mudurlugu-Saglik Bakanligi- Sihhiye
Postal Code:		06434
City:		Ankara
State/Province:
Country:		Turkey

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information