Around The World in HTAs: Türkiye – The bumpy road toward transformation

The health system in Türkiye

Over the last two decades, Türkiye (yes, this is the correct spelling!) has significantly improved population health outcomes. For instance, the overall life expectancy reached 79 years in 2022 (it was 70 years in 2003), and the country achieved almost-universal health coverage through a universal health insurance scheme, covering 99% of the population (up from 72% in 2003) (UN 2023, OECD 2023). However, the country continues to face issues related to health system resources, geographic disparities, and emerging public health threats. Türkiye experiences a significant shortage of health workers, especially nurses and doctors. The uneven distribution of specialists exacerbates regional disparities in access to healthcare.

The Turkish health system is highly consolidated under the Ministry of Health (MoH), which implements policies set by the President (Polin et al. 2022). The service provision is dominated by state-funded institutions, with the MoH overseeing most of the healthcare in the country. A family care model has been implemented but there is no mandatory referral scheme to move from primary to other levels of care. This puts a strain on the efficiency and quality of specialist services.

The country spends 4.7% of its GDP on healthcare, lower than the EU average (10.9%), while public spending accounts for 78% of total health expenditure (WHO 2020). The Social Security Institution (SSI) decides which services to be reimbursed under the universal health insurance scheme through the Health Implementation Guide.

The HTA agency of Türkiye’s MoH was established in 2012 and was later re-named as Research Development and Health Technology Assessment Department (HTAD). Additionally, the Turkish Medicines and Medical Devices Agency (TMMDA) and the HTA department within SSI are the other entities with the capability to produce national HTAs.

A roadmap for new technologies

In principle, a marketing authorisation obtained from the TMMDA is a prerequisite for entry into the Turkish market. The SSI decides which health interventions will be reimbursed to whom, for how much, and under what conditions. While fulfilling this function, the SSI has established the Healthcare Services Pricing Commission (HSPC) which includes delegates of various Ministries. Each innovative technology related to medicines is evaluated by one of the HSPC sub-commissions (either the Drug Reimbursement Commission, or the Alternative Reimbursement Commission).

Considering that the entire pharmaceutical reimbursement system is based on mandatory discounts, the Alternative Reimbursement Scheme (ARS) has been implemented since 2016, which has changed the face of the system by allowing the use of innovative reimbursement models. These models are mostly decided following negotiations on drug price, number of patients or total budget impact. ARS has helped to mitigate problems associated with financial pressure on the pharmaceutical budget and provided a good return to the pharmaceutical industry and the SSI so far.

Another way to access the market is the Named Patient Program (NPP), which was formulated as an exceptional way of reaching the market. Accordingly, medicines that the TMMDA has yet to authorise or that cannot be obtained domestically, even if authorised, are imported from abroad for individual use. The SSI manages this process based on the permission given by the TMMDA on an individual basis. The introduction of new technologies has become more frequent in recent years and, as a consequence, they may enter the market through the NPP. ARS conditions may also apply to imported medicines for individual use.

Current challenges for HTA in Türkiye

Lack of transparency is perhaps the most significant challenge for HTA in Türkiye. In particular, there is little opportunity for public scrutiny in the absence of a clear and transparent process (Ozturk et al. 2017). Even though there is a number of bodies conducting HTA, only the MoH publishes national HTA reports. In addition, the topic selection processes for those HTAs have not been made publicly available despite the Ministry’s Directive mandates.

There is no legal requirement for the SSI to conduct HTAs before making reimbursement decisions. Thus, there is little incentive for allocating resources to HTA activities, which hinders the comprehensive evaluation of health technologies, restricting the scope and depth of assessments. On top of that, the fragmented structure of HTA bodies and lack of coordination between HTA authorities is a barrier to the efficient use of limited capacity.

Türkiye does not have standardised methodologies and clear guidelines for conducting HTA, which leads to discrepancies in assessment processes and outcomes, affecting the consistency and comparability of results (Avşar and Yıldırım 2023). Recently, the CHEERs reporting guidelines for economic evaluation studies were adapted to Turkish, which might be helpful for the economic evaluation component of HTAs.

Next steps for HTA in Türkiye

According to Castro et al.’s (2020) HTA framework, Türkiye is at the policy formulation stage, with sporadic HTA activities taking place in different organisations. HTA in Türkiye has been waiting for the legal regulations and formalisation of HTA for over a decade.

The Smart Life and Health Products and Technologies Roadmap (you can access here), published by the Ministry of Industry and Technology, proposes the establishment of a politically independent national HTA institution between 2022 and 2025. This institution would provide objective scientific advice, like NICE in the UK. This is promising but political will is required to determine the role of HTA in reimbursement decisions.

After the establishment of an independent HTA body, an important step is to create national HTA guidelines to produce consistent and useful HTA evidence that can inform policy. Related to this, some experts believe the country should adopt a cost-effectiveness threshold (Atikeler 2023) – but further discussions and empirical research about the potential implications of setting a threshold are needed.

In terms of expertise in HTA methodologies, the country has an emerging capacity in health economics; however, training and development programs for HTA professionals are essential to improve the quality and reliability of assessments (Gheorge et al. 2020). Collaboration with established HTA agencies, such as NICE, could be beneficial.

With the promise of national guidelines, consideration of cost-effectiveness thresholds, and ongoing capacity-building efforts, Türkiye is poised for a transformative leap. The convergence of political commitment, national guidelines, stakeholder engagement, and enhanced public awareness holds the key to unlocking a future where evidence-based decision-making becomes the cornerstone of healthcare resource allocation.