The establishment of the health disaster coordination center (SAKOM) in Turkey and the management of disaster and mass casualty incidents: an official document analysis study

1. Introduction

Disasters arise from a complex interplay of factors, including natural phenomena, human actions, technological failures, and the inherent vulnerabilities within communities [1]. A review of the literature reveals a bifurcation of disasters into natural and man-made categories, with a number of entities such as the American Red Cross adopting broader terminology such as emergencies and natural disasters [2]. Despite the existence of various classifications, a universally accepted definition of disaster remains elusive. The criteria for defining disasters span the nature of the disaster (whether natural or man-made), its duration, the extent of its impact on individuals and communities, its potential for occurrence, and the scale of response it necessitates [3]. An event’s classification as a disaster requires a nuanced evaluation of these five interconnected and subjective factors. This complexity has led to the adoption of the term mass casualty incidents (MCIs) for situations that exceed the coping capacities of local governance and healthcare systems [4]. However, even within the realm of MCIs, definitions vary, with the World Health Organization (WHO) characterizing them as incidents that generate more casualties than can be managed with local resources under standard procedures [5]. The determination of an event as an MCI or disaster is influenced by several factors: the number of affected individuals; the geographical scope; the availability of local and national resources; the impact on societal norms; the event’s onset; recovery duration; severity; and the efficacy of the response efforts. Nonetheless, the subjective nature of these criteria presents challenges in measurement, detection and the establishment of a universally applicable definition, perpetuating confusion and debate over the appropriate classification of such events [5, 6]. Accurate identification and categorization are critical for guiding the scope and strategy of the emergency response. The absence of any objective criteria for defining MCIs continues to fuel ambiguity and discussions in the field.

MCIs require various systems within the healthcare system to operate at levels far beyond their normal capacity, from the site of the incident to the prehospital phase, emergency services, and hospital processes. The coordination and management of these processes are of great importance. Therefore, to manage and coordinate MCIs, many countries around the world have established organizations and systems responsible for regional, national and international coordination. Examples of such organizations and systems include the National Incident Management System (NIMS) created by the Federal Emergency Management Agency (FEMA) in the United States and the Incident Command System jointly developed by the Japan Self-Defense Forces, the National Police Agency, and the National Fire Agency in Japan [7, 8]. In Türkiye, the most authoritative institution for disaster management on a national scale is the Republic of Türkiye Ministry of Interior Disaster and Emergency Management Authority (AFAD) [9]. Other institutions and organizations also have disaster management units at both ministerial and local levels within their respective areas of responsibility.

The Health Disaster Coordination Center (SAKOM) was established by the Republic of Türkiye Ministry of Health in 2009 for health management during disasters. Between 2009 and 2023, the SAKOM operated in collaboration and coordination with the Provincial Health Command and Control Centers. Since January 2023, it was decided to establish the Provincial SAKOM organizations in all eighty-one provinces of Türkiye under the oversight of the SAKOM.

The other significance of this date is that just one month after the decision, on 06 February 2023, two earthquakes occurred in the province of Kahramanmaraş, Türkiye, just nine hours apart. These catastrophic earthquakes affected eleven provinces and resulted in the deaths of 53,000 people [10, 11, 12]. According to the Emergency Events Database (EM-DAT) from 2009 to 2024, Türkiye experienced 104 MCIs, including the February Kahramanmaraş earthquakes, which alone resulted in the deaths of 53,000 people. The SAKOM has played a role in managing these MCIs, and the establishment of the Provincial SAKOM structures has been accelerated to strengthen the disaster management organizations at the provincial level [13].

The SAKOMs play a crucial role in the national disaster response and are central to disaster medical management. They effectively manage and monitor the entire process from the point of the MCI, through the pre-hospital phase, emergency services, mortality, hospital intensive care and inpatient admissions. This comprehensive management positions the SAKOM as a pivotal example of the medical management approach to disasters in Türkiye. However, these changes and developments in the SAKOM structures have mostly been documented through official documents, and there is a lack of both national and international research on the topic in the literature. However, the success of nationally established organizations and systems depends on the sharing of resources and experiences, coordinated disaster preparedness, disaster management during disasters and information communication through common, interoperable approaches. Therefore, national disaster management systems in numerous countries are still in the process of development and discussion. However, because these systems are primarily established, developed and monitored through official communications, research on them is extremely limited.

The aim of this research is to examine the establishment process of the SAKOM, an organization developed for the management of disasters and MCIs in Türkiye, and to explore its evolution through experience gained from various disasters, its current hierarchy, and the systems it uses for disaster management.

2. Methods

2.4 The data analysis

The twelve selected key documents were analyzed using the READ method, which involves the following: reading the material to understand the content and context; examining the documents to identify key themes and patterns; analyzing the data to determine the implications for health policy and disaster management; and developing a comprehensive understanding of the organizational structure and operational strategies of the SAKOM.

The two researchers reached a consensus on three main themes appropriate for the study’s objectives and identified a total of six sub-themes based on the content of the data. The analysis focused on identifying and selecting expressions and information within the documents that aligned with the study’s objectives. These expressions were carefully extracted and used to support the identified themes and sub-themes. The alignment of these subthemes was also monitored by both researchers. Table 2 provides the main themes and subthemes along with their respective content. During this process, the definitions, duties, and responsibilities outlined in the documents were carefully analyzed and referenced against the established criteria, using the twelve key documents.

Table 2.The themes formed by the classification of the data in the research.

Theme	Subtheme	Functions of the Theme
Establishment
	Establishment and Development Process of SAKOM	Focuses on the purpose of SAKOM establishment, its historical development, guidelines, and the establishment, structure, and operation of provincial SAKOMs.
Organization
	Notification Criteria and Activation of SAKOM	Details of the identification of incidents requiring notification to SAKOM, assessment of these incidents, and the activation processes of SAKOM.
	112 Emergency Call Centers	Examines the structure, operation, and features of the system consolidating various emergency call numbers in Türkiye, and its organization and activities at the provincial level.
	Duties and Responsibilities of the Health Command and Control Center	Addresses the role of Health Command and Control Centers in SAKOM activation, changes in duties, incident monitoring, and coordination responsibilities.
Systems Used
	Incident Management System	Analyzes the operation, use of the Incident Management System, data flow between SAKOM and hospitals, and coordination role.
	Incident Management in Emergency Health Automation System (ASOS)	This section examines incident management the Emergency Health Automation System, data entries, integration with SAKOM, and processes for filling out and updating incident notification forms.
SAKOM: The Ministry of Health’s Health Disaster Coordination Center.

The documents were numbered in numerical order based on their publication dates. In the Results section, when information is derived from these documents, the corresponding document number is provided in square brackets at the end of the sentence.

The Results section was structured chronologically, focusing on the establishment of SAKOM as the primary reference point. Consequently, documents related to structures subsequently integrated into the SAKOM framework appear earlier in the Results section despite having later publication dates.

As a result, the document numbering in the Results section is not strictly numerical, as it follows the chronological development of SAKOM rather than the document publication dates.

The research findings and organizational hierarchy will be supported with visual materials. The SAKOM Data Distribution Diagram and processes related to the Incident Management System will be explained using graphs. These visuals have ensured that the research findings are more understandable and accessible (Fig. 1). Using this method, a comprehensive and systematic compilation of the SAKOM’s establishment process, organization and the systems it utilizes is presented. The official documents and regulations used in this study detail the structure and duties of the SAKOM and provide significant insight into disaster and emergency management in Türkiye. This approach has helped us understand how the SAKOM and its related units operate effectively and how these processes are coordinated.

Fig. 1.The SAKOM ’s information sources, management hierarchy and Electronic System Management.

The documents used in this research are official letters, circulars, and declarations published by the Republic of Türkiye Ministry of Health (TCSB). These documents provide accurate and reliable information in regard to the establishment and functioning of the SAKOM. Through content analysis, the documents were carefully examined, and the definitions, duties, and responsibilities were coded according to a predetermined criterion.

The READ method, a well-accepted and reliable approach in health policy research, was employed in this study. An independent qualitative research expert voluntarily reviewed the research to enhance its accuracy and the reliability of the data. The expert had no conflict of interest, financial or otherwise, related to this study. This review was conducted independently and without influence from the study’s findings or conclusions.

3. Results

4. Discussion

The SAKOM is a Disaster-Health organization created by the structure of the Ministry of Health in Türkiye, where information sources consisting of central and peripheral components for medical management of disasters are identified. Events are differentiated as incident/MCI based on certain criteria, a systematic information flow chart, and dynamic information flow from the periphery to the center.

Incidents requiring emergency intervention, such as MCIs, encompass elements of preparedness, mobilization, operation and resilience. The broad scope of responsibilities and the dynamic tasks that emerge complicate emergency response efforts. Managing this complexity necessitates rapid and effective intervention both during and after any MCI [18]. Therefore, to address this complexity dynamically, systems that respond to disasters are managed with a specific hierarchy, starting from regional levels and extending to national and international responsibility pyramids. This hierarchical approach aims to ensure a structured and efficient response to emergencies. Community-based and state-supported disaster organizations are in place to facilitate these interventions. In Türkiye, an example of an official organization for disaster management is AFAD, while the SAKOM is responsible for managing the health aspects of MCIs.

The AFAD’s mission is to conduct the necessary work for the effective management of disaster and emergency processes, ensure coordination among relevant institutions and organizations, and develop policies in this field. In contrast, the SAKOM’s role is to continuously monitor and manage crises related to human health in Türkiye and worldwide during disasters and extraordinary situations that disrupt or halt normal life and activities, requiring emergency intervention. The SAKOM collects and uses information for managing these processes, sharing real-time updates with relevant authorities and institutions when national or international coordination is necessary [19, 20]. When examining the organization and hierarchy of the SAKOMs, it becomes evident that they possess a robust infrastructure for incident identification, communication coordination, and the dynamic tracking and management of MCIs.

The classification of an incident as an MCI fundamentally depends on the adequacy of the response that can be provided [21]. However, determining the adequacy of the response in the MCIs involves considering multiple parameters, including the source of the incident, the number of affected individuals, the social and economic impact on the community, the societal segments affected by the incident, and the location where the incident occurred [22, 23]. Since 1988, the Emergency Events Database (EM-DAT), maintained by the Center for Research on the Epidemiology of Disasters (CRED), has used the following three quantitative inclusion criteria: at least ten deaths (including missing persons); at least one hundred people affected (injured, displaced or otherwise impacted); and a declaration of a state of emergency or an international call for assistance. For historical events where quantitative data may not be available, secondary criteria are employed, such as “the worst disaster in a country’s or region’s history” or “an event resulting in significant damage” [24]. The SAKOM criteria, similar to the EM-DAT inclusion criteria, are based on both quantitative and qualitative data. On a global scale, there are guidelines that define MCIs solely using qualitative data. For instance, the Pan American Health Organization (PAHO) defines an MCI as a single event that negatively impacts a community and results in a number of fatalities that exceed the community’s normal response capacity [25]. The WHO defines MCIs as disasters and major events characterized by the number, severity, and variety of patients that can rapidly overwhelm the ability of local medical resources to provide comprehensive and definitive medical care [26]. Perhaps the most limited aspect of the MCI management guidelines published by both the PAHO and the WHO is the incident identification process. These definitions are often left to subjective decision-making mechanisms. While these definitions are extremely inclusive, defining the incident with more quantitative criteria at the onset can sometimes expedite the identification and activation process. Quantitative data for incidents requiring a SAKOM notification primarily pertain to traffic accidents (with at least five fatalities or ten or more people affected) and situations such as CO poisoning, fires, civil conflicts or armed attacks, where the number of affected individuals is five or more. When examining the Eastern Pennsylvania Emergency Medical Services (PA EMS) Council Disaster Operating Guidelines (DOG) Field Guide, two notable aspects emerge; the definition of MCIs based on the number of casualties, and the categorization of MCIs according to the number of casualties [27]. When examining the SAKOM criteria from this perspective, it is evident that there is no categorization or scaling of an incident or its magnitude. A number of organizations categorize incidents based on the number of patients, while the FEMA has recently published the Incident Complexity Guide as part of the National Incident Management System. This guide categorizes MCIs into five classes based on specific criteria [8]. Considering these global examples, it is necessary to establish criteria for the response-based categorization of MCIs based on regional conditions rather than global standards. Such criteria would facilitate both the pre-planning and post-incident coordination of responses to MCIs.

When examining the SAKOM organization and the hierarchy of systems it uses, it is evident that the SAKOM, through its coordination with the Provincial SAKOMs, aims to encompass both the strong centralized management approach of the NIMS in the United States and the more robust local disaster systems of Japan’s Incident Command System (ICS) [7]. The SAKOM’s ability to transfer information about the injured and affected individuals from the incident site into an electronic system and track it through centralized systems can greatly facilitate both the management and coordination of a disaster. Consequently, the activation of the Incident Management System following an incident that meets the criteria is one of the system’s focal points. This system aims to provide an initial database to identify vulnerable groups, assets, and areas where resources and efforts need to be directed. In MCIs with a certain regional impact, these data can be documented electronically. However, in catastrophic MCIs, such as earthquakes, the potential for these systems to be damaged due to infrastructure issues (for example, power outages, Internet disruptions) should be considered. Additionally, the risk of these systems being targeted by cyberattacks is another important factor to keep in mind. Following the devastating earthquakes in Kahramanmaraş, Türkiye, on 06 February 2023, coordination became a frequently debated topic [11, 28]. During the disaster, the SAKOMs developed and implemented new medical strategies to address the challenges presented by the emergency [12]. As can be seen in the example of the SAKOM, the initial establishment of the SAKOM, followed by the need for the Provincial SAKOMs, and ultimately the necessity for the SAKOM structures in all provinces, reflects the lessons learned from the disasters Türkiye has experienced since 2009. This organizational cycle demonstrates that while strong national-scale organizations are essential, regional disaster organizations also have a significant impact on resilience during disasters.

The establishment and development process of the SAKOM, based on the literature and the examination of other national disaster management systems, can be summarized into four key recommendations. First, there is the management of complexity: incidents requiring emergency intervention, such as MCIs, involve elements of preparedness, mobilization, operation and resilience. To manage this complexity, the SAKOM must have a robust communication and coordination infrastructure. Second is the quantitative and qualitative criteria: both quantitative and qualitative criteria should be considered when defining MCIs. The criteria established by the SAKOM provide sufficient information to accurately classify the scale and impact of an incident. However, developing more detailed and comprehensive criteria at both global and regional levels can facilitate a more effective and rapid response to MCIs. Third is the strengthening of technological infrastructure: enhancing technological infrastructure, such as the Incident Management System, and ensuring systems are continuously updated is crucial for the dynamic tracking and management of incidents. Integration with the Hospital Information Management System and maintaining a seamless data flow can significantly aid coordination during a disaster. Fourth is training and awareness: for the SAKOM to operate effectively, particularly the personnel working in the Health Command and Control Center, regular training and awareness in disaster management are essential. Additionally, educating the public on how to act during emergencies can reduce panic and chaos during incidents.

5. The limitations of the study

One of the primary limitations of this study is the absence of interviews with individuals involved in disaster management, such as policymakers, emergency responders and administrators. This study is based on the analysis of twenty-two official documents, which results in a relatively small sample size. Incorporating their perspectives could have enriched the findings by providing insight into operational challenges and potential system improvements. Additionally, the study relied solely on document analysis, which may have limited the depth of the understanding of the practical implementation of disaster management strategies.

6. Conclusions

In Türkiye, the current structure, development process and systems of the SAKOM, developed over fifteen years through the experience of managing disasters and MCIs, highlight a robust management hierarchy. This research can guide and provide material for many countries working on disaster and MCI management systems. The SAKOM organization, with its strong centralized and local management approach, is the result of a long process and experience, particularly in the aftermath of recent catastrophic disasters.

Availability of data and materials

This study is based on the analysis of publicly available official documents, which did not require special research permission. There are no conflicts of interest. The entire de-identified dataset, data dictionary and analytic code for this investigation are available upon request, from the date of article publication by contacting Sarper YILMAZ, Assoc. Prof., at sarperyilmaz08@gmail.com.

Author contributions

GAU—designed the trial. SY—supervised the conduct of the trial and data collection. GAU and SY—conceived the study; undertook recruitment of the participating centers and patients and managed the data, including quality control; provided statistical advice on study design and analyzed the data; chaired the data oversight committee; drafted the manuscript, and both authors contributed substantially to its revision; assume responsibility for the paper as a whole.

Ethics approval and consent to participate

Although this study is based on the analysis of publicly available official documents and does not involve human participants, ethical approval was obtained from the İzmir Provincial Directorate of Health Tepecik Training and Research Hospital Non-Interventional Clinical Research Ethics Committee (Approval number 2024/06-07, dated 02 July 2024) in accordance with institutional requirements. Since this study was based on the analysis of publicly available official documents and did not involve human participants, the Izmir Provincial Health Directorate Tepecik Training and Research Hospital (Izmir/Turkey) Non-Interventional Clinical Research Ethics Committee approved the exemption from informed consent.

Acknowledgment

We would like to extend our gratitude to the individuals and institutions who contributed to this research. We are particularly grateful to Figen Ünal Çolak for her role as an independent qualitative observer, who meticulously reviewed our data.

Funding

This research received no external funding.

Conflict of interest

We confirm that research permission was obtained for this study. Additionally, the authors declare that there is no conflict of interest related to this research.