A Market Research Of Obesity And Bariatric Surgery In Turkey And Tunisia

. This article aims to discuss four topics according to the recent scientific data a) to overview the frequency of obese and overweight individuals among Tunisia and Turkey populations; b) to examine health technology assessment of bariatric surgery (BS) report (HTA) in Tunisia and Turkey; c) to evaluate the cost and cost reimbursements by social health systems for bariatric surgery in Turkey and Tunisia; d) to examine the total number of bariatric surgical procedures and their costs in state and private health organizations in Tunisia and Turkey. The OECD (2011-2017) Turkey report was included for the data for the frequency of obese these investigations demonstrated a general situation in bariatric surgery. This study aims to examine the findings of obese population in the field of bariatric surgery in Tunisia and Turkey, the reimbursement status of bariatric surgery, the status of bariatric surgery costs in Tunisia and Turkey, HTA Reports, Health Economics analysis such as bariatric surgery cost, cost-effectiveness, and the number of bariatric surgery surgeries in comparison. In Tunisia and Turkey, the post-operative recovery and complications of the patients who had sleeve gastrectomy in bariatric surgery in the diseases caused by obesity were analyzed comparatively.

Health Economics and Management Review, 2020, Issue 1 39 http://armgpublishing.sumdu.edu.ua/journals/hem Organization's (WHO) Research «Diabetes Prevalence and risk factors related to Diabetes» published in 2016(Diabetes, 2016. 62.8% of Tunisia's population is overweight and 27.1% is obese, according to research results published by the WHO; c) data on reimbursement status of bariatric surgery in Turkey were obtained from SUT (SUT, 2020). The operational cost of gastric tube surgery in Turkey was taken from the Turkish Public Hospitals Association (TKHK, 2020). 5.814 Turkish lira for a hospital according to the price tariffs of the Union of public hospitals. The operational cost of sleeve gastrectomy in Turkey (2020) was found to be 20,000 according to the information obtained by the healthworker of a private hospital; d) data on the reimbursement status of bariatric surgery in Tunisia was obtained by contacting an officer in the Ministry of social affairs in Tunisia and found to be 1310 TND. The operational cost of Sleeve gastrectomy from the website docteur-adala.com, it was found as € 3950 (Gastric sleeve, 2020). The euro exchange rate was converted to Tunisian Dinar and the operational cost was calculated as 12.679.50 TND; e) in the study, data on the patient profile and the reason for the application of bariatric surgery in Turkey were obtained from the following sources: − the cost-effectiveness and economic value of Bariatric Surgery in Turkey (Kockaya, 2016); − the HTA report on Obesity Surgery in Turkey (2014) prepared by the Turkish Center for Strategic Research Development and integration (SAGEM); f) data on the number of bariatric surgery surgeries in Turkey, Health Management Center (Health Technologies, 2019). According to the findings from this site, the number of surgeries performed in Turkey in 2018 was 15,800 and the number of surgeries performed in the last 4 years was 44,453.
Methodology and research methods. This research was carried out by field research/document review method. Document review is a method of research that is used in the collection and systematic review of official or private records and provides a detailed analysis (Ekiz, 2009).
The data collected were analyzed by content analysis method. Content analysis of the coding of the data collected for the research proceeds in the form of classification-identification and identificationclassification (Glesne, 2012). The necessary process of content analysis is to bring together similar data within the framework of specific concepts and themes and to organize and interpret them in a way that the reader can understand (Yıldırım, 2008). The data obtained as a result of the articles, reports and researches were compared in Tunisia and Turkey. Expert opinion has been taken from private hospitals for the cost of gastric sleeve.
Total bariatric surgery costs in Tunisia and Turkey PPP value were compared. GDP Per Capita (PPP), (The World Bank, 2020) was compared to GDP per capita (The World Bank, 2020) and the PPP values of the countries were found. PPP costs were calculated by proportion to the obtained PPP values to the total costs. In Turkey, bariatric surgeries are defined as special operations. Additional fees for exceptional health services can be up to three times as high. For this reason, the amount paid by the SGK was multiplied by three. The figure obtained was collected with the amount paid by SGK and the ceiling price was calculated.
Results. Research findings from the WHO published in 2016, «Diabetes Prevalence and Risk Factors Related to diabetes» were examined. As a result of the study, the findings of the obese population in Tunisia are shown in Table 1.
The «overweight» population accounts for the majority of the total population in Tunisia, at a rate of 62.8%. «Obesity» is followed by the «Overweight» population with a rate of 27.1 % ¹⁰. The percentage of female population in all proportions is further (WHO, 2020). The OECD (2011-2017) Turkey report was examined in order to reach the findings of obese population in Turkey (OECD, 2019). The results obtained are shown in Table 2.

40
Health Economics and Management Review, 2020, Issue 1 http://armgpublishing.sumdu.edu.ua/journals/hem  According to the findings in Table 2  When the percentage of the overweight and obese population of Turkey 2017 and Tunisia 2016 was calculated, it was found that 52,229,618 of the population of Turkey and 5,081,124 of the population of Tunisia were overweight and obese.
To reach the findings regarding the reimbursement status of bariatric surgery in Tunisia, an official working at the Ministry of social affairs in Tunisia was contacted and the data obtained are given in Table  4 (TKHK, 2020).
The Tunisian National Security Fund: CNAM (Caisse Nationale d'assurance Maladie) for bariatric surgery in Tunisia offers a refund of 1310 Tunisian dinars (TND) for patients with morbid obesity status who are only covered by public health insurance. Each patient is reimbursed on a patient-by-patient basis according to the private insurance contract and the state of their operations in the private sector. To ensure that bariatric surgery is reimbursed in the private sector, an agreement must be made with the Department of Social Affairs and the Department of Health. Only Gastric Sleeve is practiced in the public sector in Tunisia. It costs 3950 €, including hospitalization (Gastric Sleeve, 2020).
Health Economics and Management Review, 2020, Issue 1 41 http://armgpublishing.sumdu.edu.ua/journals/hem The study examined the SUT published by the Social Security Institution to reach the findings regarding the reimbursement status of bariatric surgery in Turkey (SUT, 2020). Operational costs of bariatric surgery in Turkey are taken from the Health Services Price List. The results of the examination are given in Table 5 and Table 6. Sources: developed by the authors on the basis of (SUT, 2020). .00 ₺ Sources: developed by the authors on the basis of (TKHK, 2020).
The Social Security Institution in Turkey has determined the fixed prices of bariatric surgery as follows: a) For By-pass, 6750TL; b) For Sleeve Gastrectomy, 4650 TL; c) For Gastric Banding, 2700 TL; d) For Duodenal Switch Biliopancreatic Diversion, 1281 TL (SUT, 2020). Fixed price; includes pre-surgery (15 days), surgery, and post-surgery (45 days). The fixed price has been shown to be lower than the actual cost of bariatric surgery. The highest reimbursement and actual cost have been reported for by-pass gastrectomy. However, the significant difference was calculated for gastric tube surgery by 117%. In other words, if a hospital administration permits tube stomach surgery, the hospital budget suffers more losses than the amount of reimbursement. Less loss can be achieved with the banding process.
The operational cost of the gastric sleeve was 5,813 Turkish lira for a hospital from the Turkish Public Hospital Union Hospitals (TKHK, 2020). The operational cost of sleeve gastrectomy in Turkey (2020) was found to be 20,000 ₺ according to the information obtained by the health worker of a private hospital.
In Turkey, bariatric surgeries are defined as special operations by SGK. Hospitals can charge additional fees for exceptional health services up to three times as high to patients. For this reason, the amount paid by the SGK was multiplied by three for retrieving the total amount. The figure obtained was collected with the amount paid by SGK and the exceptional health services price. The data is shown in 42 Health Economics and Management Review, 2020, Issue 1 http://armgpublishing.sumdu.edu.ua/journals/hem  Total bariatric surgery costs in Tunisia and Turkey PPP value were compared. GDP Per Capita (PPP), (The World Bank, 2020) was compared to GDP per capita (The World Bank, 2020) and the PPP values of the countries were found. PPP costs were calculated by proportion to the obtained PPP values to the total costs. The data is shown in Table 8. Sources: developed by the authors on the basis of (SUT, 2020).
In order to reach HTA reports and cost-effectiveness analysis in the field of Bariatric Surgery in Turkey, «Cost effectiveness and economic value of obesity surgery for Turkey (CEVOS-T)» and «The Role Of Obesity Surgery In Obesity Treatment In Turkey» named HTA reports were examined. HTA report and cost-effectiveness analysis for Tunisia could not be reached. Because no CE was ever made in Tunisia for Bariatric Surgery 43 http://armgpublishing.sumdu.edu.ua/journals/hem Turkey BMI>40 and all individuals who try to lose weight and are not successful or who take it after losing weight and relapse again The increase in obese population in Turkey and the inability to treat with diet Tunisia There is no general rule for the patient profile that can be applied to bariatric surgery. Evaluation is performed on a patient basis. In Turkey, all individuals whose body mass index is above 40 and who try to lose weight by various methods (diet, exercise, behavior therapy, medication, etc.) and fail to succeed or who relapsed after losing weight are defined as candidates for laparoscopic bariatric surgery under Social Security. Individuals with BMI over 35kg/m2 and metabolic or systemic complications, and those whose waist circumference is above the figures recommended in the NHMRC guidelines are not under reimbursement of SGK. In Tunisia, there is no general rule for the patient profile that can be a candidate for bariatric surgery. Evaluation of reimbursement decision is performed on a patient basis. It could be said that lack of awareness, cultural reasons, and budget limits of the Tunisian government may lead not to improve the infrastructure for bariatric surgery in Tunisia when compared to Turkey.
The results of the TURDEP I and II study in Turkey show that obesity and accompanying diseases are reaching frightening levels in our country. The second phase of the first study, conducted between 1997-98, was carried out in 2010 and the frequency of Type2 diabetes increased by 90% over the intervening time, increasing from 7.7% to 13.7%, while obesity rates increased from 32.9% to 44.2% in women and from 13.2% to 27.3% in men. In the same process, women's body weight increased by an average of 6 kg, and men's body weight increased by 8 kg. The waist circumference of the women was 6 cm, the hips were 7 cm, the men's waist circumference was 7 cm, and the hips were 2 cm thickened. Even a 10% reduction in body weight results in a very significant reduction in the risk factors associated with obesity. However, according to statistical data, more than 95% of people who have been treated for obesity who have lost weight are gaining weight again. For this reason, trying to treat morbidly obese patients with lifestyle changes is suggestive in terms of both the solution of the patient's health problems and the cost. For this reason, bariatric surgery can provide much more effective results for this group of patients. No such data could be reached for Tunisia.
The number of bariatric surgery surgeries in Turkey has been examined, and the Health Management Center (Health Technologies, 2019). The number of bariatric surgery surgeries in Tunisia has been sought but the data could not be reached. The number of surgeries in Turkey were used for estimating the number of surgeries in Tunisia depending on the obese population number as 1537. The results are given in Table 10.
Examination of post-operative recovery and complications of patients with Sleeve Gastrectomy in Bariatric Surgery in diseases caused by obesity in Tunisia, no data could be reached for Turkey. In the study, bariatric surgery in Tunisia was screened for the post-operative recovery of patients who had sleeve gastrectomy in diseases caused by obesity. For Turkey, these findings have not been reached. The results are given in Table 11. after one year Sources: developed by the authors on the basis of (Gastric sleeve, 2020).
The study was conducted in bariatric surgery in Tunisia, screening for possible post-operative G., Kockaya , E. B., Karahan, S., Oztopcu, G., Oguzhan, A. M At the row of staples is another possible complication that may, in some cases, require a transfusion, or even reintervention, if it persists, to evacuate clots.

Stenosis
Narrowing or stenosis on a segment of the gastric tube (0.6% of patients), which may require endoscopic procedures, or even a reintervention.

Phlebitis and Pulmonary Embolism
Blood clots are a concern for any surgery.

Digestion problems
About 1 in 5 patients had gastroesophageal reflux in the first 12 months. This rate decreases to 3% after two years. Skin sagging For most obese patients Weight regain after a gastric sleeve It is caused by an inappropriate lifestyle.
Return of type 2 diabetes Remission goes from 56% to 20% of patients in year 1 and 5 respectively Sources: developed by the authors on the basis of (Gastric sleeve, 2020).
Conclusions. The fact that 64.4% of Turkey's population and 62.8% of Tunisia's population are obese and overweight individuals suggests that most of the population in both countries is at risk of obesity. Patients who are covered by reimbursement in Tunisia and Turkey are only morbidly obese patients. For both countries, the scope of reimbursement status of bariatric surgery can be extended for patients with BMI below 40 but with chronic illnesses. The cost of reimbursement in bariatric surgery in Tunisia has been set at 1,310 Tunisian dinars. As a result of the ceiling price calculated with the amount paid by SGK in Turkey, Gastric Sleeve was obtained as 18,600, GastricBy-pass 27000. The fact that Gastric sleeve refund is 4650 and Gastric by-pass refund is 6750 indicates that SGK refund is lower than the actual cost.
Turkey has demonstrated its interest in bariatric surgery through the HTA report and studies on this subject, such as «cost effectiveness and economic value of Bariatric Surgery (2016)» and «operational cost of Bariatric Surgery in Turkey (2014)». The number of bariatric surgery surgeries in Turkey has reached 15,800 for the year 2018 and 44,453 in the last four years until 2018. As a result of this data, it is clear that the demand and need for bariatric surgery in Turkey are increasing steadily. In the study, the recovery and complication rates of diseases caused by obesity in Tunisia due to sleeve gastrectomy were examined with percentile rates.
In Tunisia, HTA report and cost-effectiveness studies in bariatric surgery and the number of surgeries were not reached. In Turkey, data on the recovery and complication rates of diseases caused by obesity as a result of sleeve gastrectomy have not been reached. The reach status of data is given in Table 13. According to the researches made in Table 13, the findings that can be reached in bariatric surgery in Turkey and Tunisia are shown with «✓» and the findings that cannot be reached are shown with «X».