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rate ratios and population-attributable risks to understand how this reduction in infant mortality was shown in regions during the same period (1993–2008).2 We note that, in 1993, for every 1·41 infant deaths in the eastern region, there was one death in the western region. This diff erence reached 2·7 in 2008, suggesting that inequalities between regions have been increasing.

Preventable infant mortality for every 100 infants increased from 18·8% in 1993 to 44·7% in 2008 (table). There were 1 286 796 livebirths in 2008, and infant mortality was 21 876: 9 779 of these deaths were preventable. The maximum increase in rate ratio and population-attributable risk occured between 2003 and 2008 (table).

Clearly, inequalities between regions have increased in terms of health services use and other population health indicators. To discuss the success of the Health Transformation Program without considering these issues would mean overlooking the facts.I declare that I have no confl icts of interest.

Onur Hamzaoglu ohamzaoglu@kocaeli.edu.tr

Department of Public Health, Kocaeli University Medical Faculty, 41380 Kocaeli, Turkey

1 Atun R, Aydın S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet 2013; 382: 65–99.

2 Kunst AE, Mackenbach JP. Measuring socioeconomic inequalities in health. Copenhagen: WHO, 1994: 47–55.

announced by the Ministry of Health are based on unrealistic outstanding data.2,3

Turkey used to have a remarkable social health system that covered the entire population and gave all people access to health care at no cost. The recording system was almost perfect, from follow-up of 15–49-year-old females for detection of pregnancy to mortality data. With the erosion of the social health system, the present situation is in turmoil: only treatment with payment is available, while preventive and rehabilitative medicine are not provided.

The Ministry of Health’s data are not reliable in view of its previous misleading presentations;2 data are engineered to make the health situation look better than it really is. I declare that I have no confl icts of interest.

Gazanfer Aksakoglugazanfer.aksakoglu@deu.edu.tr

Dokuz Eylul University, Izmir, Turkey

1 Atun R, Aydın S, Chakraborty S et al. Universal health coverage in Turkey: enhancement of equity. Lancet 2013; 382: 65–99.

2 Baris E, Mollahaliloglu S, Aydin S. Healthcare in Turkey: from laggard to leader. BMJ 2011; 342: c7456.

3 Aksakoglu G. Can you beat that? BMJ 2011; published online May 4. http://www.bmj.com/content/342/bmj.c7456?tab=responses (accessed Dec 10, 2013).

Substantial im prove ments have occured in health services and population health in Turkey (see tables 5 and 6 in Rifat Atun and colleagues’ report).1 However, in-equalities between locations (urban vs rural) and regions have increased over the years. Despite the promising trend recorded in the infant mortality rate, I would like to draw attention to the increased amount of inequality between regions.

We analysed data from the Turkish Demographic and Health Survey 1993, 1998, 2003, and 2008, and found different results (table). The infant mortality rate in Turkey fell between 1993 and 2008 (from 52·6 to 17 per 1000 livebirths; table). We estimated

1993 1998 2003 2008

Total 52·6 42·7 29 17

Region

West 42·7 32·8 22 9·4

South 55·4 32·7 29 21·8

Central 57·9 41·3 21 18·5

North 44·2 42 34 11·4

East 60 61·5 41 25.3

Rate ratio (east/west) 1·41 1·88 1·86 2·69

Population-attributable risk (%) 18·8% 23·2% 27·6% 44·7%

Data are author’s analysis of data from Turkish demographic and health surveys 1993, 1998, 2003, and 2008.

Table: Infant mortality rates in Turkey

For WHO CISID see http://data.euro.who.int/cisid/

Rifat Atun and colleagues1 emphasise that immunisation coverage against major communicable diseases (diphtheria, pertussis, tetanus, polio, and measles) increased from about 85% in 2000 to reach 97% in 2010. Despite this high coverage, Turkey reported a measles outbreak with 80 cases in January, 2011, and according to the UN there have been 3000–4000 reported measles cases in Turkey since 2012, including 300 in Syrian refugees.2,3 Additionally, even though reported coverage is 96–98%, WHO reduced the grade of confi dence in data in 2011.4

According to WHO’s centralised information system for infectious diseases (CISID) data, there have been 6078 cases of measles in Turkey in 2013. However, the Ministry of Health rejected the terms outbreak and epidemic, and used controlled increase when referring to the 1005 measles cases in Turkey between January, 2012, and February, 2013.5 Importantly, 26% of these cases were children aged 1–4 years, which suggests insuffi cient immunisation coverage or cold chain management problems, or both.5 Individuals who are not registered to the family medicine system, who are unvaccinated, who face access diffi culties to primary health care and fi nancial barriers could also explain the increase in measles cases.

We are concerned about the negative effects of the health-care

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28 www.thelancet.com Vol 383 January 4, 2014

I read Rifat Atun and colleagues’1 report—Universal health coverage in Turkey: enhancement of equity—and I was astonished by the number of errors, distortions, and omissions.

Surprisingly, the infant mortality rate of 7·7 per 1000 from the Ministry of Health for 2011 is considered by Atun and colleagues as broadly

similar to 12·0 given by UNICEF. One should be lacking any epidemiological background to fi nd these two fi gures broadly similar! Moreover, the report1 does not discuss the recorded infant mortality rate (11·7 for 2011) provided by the Turkish Statistics Institute (TÜİK).2

Although Atun and colleagues1

stress that the poor, notably, are covered by the insurance scheme with the Health Transformation Program (HTP), this is far from representing the real situation. According to the Social Security Institution, in 2011, more than 10 million people in Turkey were not covered by any insurance scheme—14% of the population.3 Additionally, an estimated 6 million individuals do not have access to health services.4

Atun and colleagues overlooked some important issues arising with the HTP, such as the increase in admissions to emergency services, with more than 90 million admissions in 2011.5 With HTP, Turkey is now the only country where the number of emergency admissions exceeds the total population.I declare that I have no confl icts of interest.

Kayihan Pala kpala@uludag.edu.tr

Department of Public Health, Uludag University School of Medicine, 16059 Gorukle, Bursa, Turkey

1 Atun R, Aydın S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet 2013; 382: 65–99.

2 Turkish Statistics Institute. Mortality statistics 2011 (in Turkish). http://www.tuik.gov.tr/PreHaberBultenleri.do?id=13440 (accessed July 7, 2013).

3 Social Security Institution. Statistical Yearbooks, 2011 yearbook. http://www.sgk.gov.tr/wps/portal/en/english/statistics_new/statistical_yearbook/ (accessed July 7, 2013).

4 Turkish Tradesmen and Craftsmen Confederation. Report (in Turkish). http://www.tesk.org.tr/tr/yayin/esnafraporu.pdf (accessed July 7, 2013).

5 Cander B. Emergency services burden and critical patients, 2012 (in Turkish). http://www.atuder.org.tr/OnlineNewspaper.aspx?content=90 (accessed July 7, 2013).

in the past decade. 92% of physicians describe the managerial structure of their workplaces as a stress factor.4

Most physicians are working very long hours: family doctors declared that they work on average 59 hours per week, specialists 68 hours per week, and residents 85 hours per week.4 The quality of the doctor–patient relationship has worsened: 66% of physicians have been exposed to some sort of violence from their patients.4 Suicide among physicians is also an issue that cannot be ignored.

Physicians’ dedication and future expectations have decreased. Most physicians do not want to be a part of commercialised health care. Physicians need secure work and futures. As Otmar Kloiber noted, ”When physicians are forced to follow third party orders, the interests of the patients will always come last.”5

I declare that I have no confl icts of interest

Feride Aksu Tanikferideaksu59@gmail.com

Public Health, Ankara University, 06590 Ankara, Turkey

1 Atun R, Aydın S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet 2013; 382: 65–99.

2 Turkish Medical Association. Physicians’ evaluations about working conditions and the law of full time working, 2009 (in Turkish). http://www.ttb.org.tr/c_rapor/2008-2010/ 2008-2010.pdf (accessed July 3, 2013).

3 Turkish Medical Association Ethics Committee. Physicians’ evaluations about Pay for Performance, 2009 (in Turkish). http://www.ttb.org.tr/kutuphane/performansaday aliodeme.pdf (accessed July 3, 2013).

4 Turkish Medical Association. Consensus on the working conditions, workload and labor force of physicians. 2010 (in Turkish). http://www.ttb.org.tr/kutuphane/OG2010.pdf (accessed July 3, 2013).

5 Kloiber O. A diffi cult start into the year. World Medical Journal 2012; 58: 1.

With the introduction of the Health Transformation Program (HTP) in Turkey,1 working conditions for doctors have worsened. Although HTP was supposed to promote better salaries, this is absolutely not the case.

According to the Turkish Medical Association in 2011, basic monthly salaries for physicians in the public sector were €803 for specialists, €643 for general practioners, and €779 for retired physicians. Pay For Performance (PFP), which was included in the HTP, is not an incentive, but rather the main salary for doctors in Turkey. During illness, pregnancy, and holiday leave PFP is not paid, and PFP is not included in retirement plans.

Most physicians are not happy with the PFP: 90·1% fi nd PFP insuffi cient.2 Time allocated for training and continuous medical education decreased, after the implementation of PFP.3 Prerequisites of professional development have been neglected.

Moreover, job security, crucial for professional autonomy, has eroded

Rifat Atun and colleagues1 present the improvements in universal health coverage and equity in health made

reform on the primary health-care system in Turkey.We declare that we have no confl icts of interest.

*Cavit Yavuz, Muzaff er Eskiocakcavityavuz@gmail.com

Department of Public Health, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey (CY); and Department of Public Health, Trakya University Faculty of Medicine, Edirne, Turkey (ME)

1 Atun R, Aydın S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet 2013; 382: 65–99.

2 WHO. Global Alert and Response: Measles outbreaks in Europe. http://www.who.int/csr/don/2011_04_21/en/ (accessed June 3, 2013).

3 UN News Centre. UN steps up vaccination campaigns amid measles outbreaks among uprooted Syrians, 30 April 2013. http://www.un.org/apps/news/story.asp?NewsID=44792#.UdPV7klrMUA (accessed June 3, 2013).

4 WHO. Turkey: WHO and UNICEF estimates of immunization coverage: 2012 revision. http://www.who.int/immunization/monitoring_surveillance/data/tur.pdf (accessed Dec 13, 2013).

5 Turkish Society of Public Health Specialists. Measles in Turkey: MoH information note (in Turkish). http://hasuder.org.tr/anasayfa/jupgrade/index.php/guncel/48-guncel/620-kizamik (accessed June 3, 2013).