Turkey is not alone in facing the iron triangle of access, quality and cost in an environment of unlimited demand and limited resources. According to 2013 data, among all Organisation for Economic Cooperation and Development (OECD) countries, Turkey has the lowest total health expenditures as a percent of gross domestic product (GDP) at 5.1 percent (the OECD average was 8.9 percent). The total expenditures on health per capita (PPP) were US$ 941 compared with the OECD average of US$ 3,453 and it is noteworthy that 78 percent of Turkish healthcare expenditures were public. Despite having limited resources, the number of physician consultations per capita was 8.2 compared with the OECD average of 7.1.
Another reason for increasing demand has been increased access. One of the most significant areas of reform included an overhaul of the universal health insurance system. The Social Security Institution (SSI), the national universal health insurance scheme, merged several public social security schemes into one general health insurance program. SSI was also successful in practically eliminating the informal sector. In 2003, only 68 percent were covered under the national health insurance scheme, but as of 2015, the SSI covered 65 million or 85 percent of Turkey's citizens and legal residents. While the decade of radical health system reform that began in 2001 has led to improved access and quality of care, national healthcare expenditures in Turkey have increased 10-fold with an unsustainable average growth of 7.7 percent per year (1;2). The current strategic plans of the Ministry of Health (3), the Turkish Public Hospital Institution (4), and the Turkish Public Health Institution (5) include goals related to scientific and systematic policy making.
Health technology assessment (HTA) offers health policy decision makers a methodology to conduct holistic assessments of rapidly developing health technologies, but the use of HTA in Turkey is still relatively new. This study attempts to understand the perceptions of stakeholders regarding the current status of health technology assessment and document their recommendations and strategies for promoting systematic use of health technology assessment in Turkey.
BACKGROUND
Turkey began exploring HTA at a national level in 2012 with a cooperative initiative between the Ministry of Health and England's NICE. The co-operation focused on developing evidence-informed guidance for elective c-section deliveries, building HTA capacity within the Ministry, and evaluating the family physician scheme within the context of universal health care. In 2013, the Ministry of Health (MoH) and the Social Security Institute (SSI) established three separate HTA departments. The two offices of the MoH were placed within the Health Research General Directorate (SAGEM) and the Turkish Medicines and Medical Devices Agency (TITCK). To date, these offices have published eight HTA reports on their Web sites.
The SSI office was established under the General Health Insurance General Directorate, which manages the nation's universal health insurance scheme covering 98 percent of the Turkish population (6). It has not produced any HTA reports to date, but successfully completed two initiatives related to HTA use in approving drugs for licensing and reimbursement decisions. The completed projects involved revising the process for drug applications and review to include HTA principles as well as capacity building training for the staff of decision-making bodies within the MoH, the SSI, the Treasury Department, the Turkish Pharmaceutical and Medical Devices Commission, the Ministry of Economics, and the Ministry of Development.
In 2009, the MoH received US$75 million for a Health System Strengthening and Support Project, which included plans for four HTA studies (currently at the Expression of Interest stage), a workshop to form a national institution for HTA (held July 14–15, 2016), a second national HTA conference (held November 16–18, 2016), membership fees for international HTA organizations (including EUnetHTA, HTAi, INAHTA, and ISPOR), subscriptions to databases (including EMBASE, SCOPUS, and the Cochrane Library), and workshops to strengthen university cooperation for HTA work and prepare national HTA guidelines in 2017 (7). The second phase of the Health System Strengthening and Support Project recently funded by the World Bank for US$134 million includes plans for at least twelve HTAs on prioritized topics to be completed and published by the year 2020 (8).
METHODS
The authors designed the methodology to best use the opportunity to reach 250 individuals invited by the Ministry of Health to attend the First Annual Health Technology Assessment Meeting as existing or potential stakeholders in the Turkish health system. The invitation list was prepared by the HTA department within the MoH Health Research General Directorate by first preparing a list of academic organizations actively working in HTA related areas, organizations that are involved in national level health policy and service delivery, MoH hospitals in each of the seven regions of Turkey, public organizations working with the Economic Coordination Council, SSI, and private and nongovernmental organizations in the Turkish health system. The maximum number of attendees was determined by the event's budget and the capacity of the facility. The slots were distributed among the selected organizations by the MoH. Each organization was then asked to submit a list of “academics/managers/employees or individuals actively working in the field of HTA, particularly health economics, finance or health policy.” The individuals listed were then sent personalized invitations to the event.
Of those invited, 216 (86 percent) individuals signed the distributed attendance sheet. We developed two approaches to reach our research objectives: a quantitative survey and a qualitative research method developed by the Turkish National Science & Technology Research Council's Managament Sciences Institute (TÜBİTAK TÜSSİDE) referred to as the Collective Intelligence Platform (OAP®). A total of 178 attendees (83 percent) completed the survey and 183 attendees (85 percent) participated in the Platform. There were thirty-four invited individuals who declined to attend the meeting and thirty-three attendees who declined to participate in the survey or the OAP.
Quantitative Methodology
The written survey contained nineteen questions and was divided into two sections. Section I was a self-assessment of respondents’ awareness of HTA, how HTA is related to their work, as well as their familiarity with Turkish HTA publications, Turkish and/or international HTA Web sites and organizations. Section II asked participants to rate on a scale of 1–4 how well they thought each of the fifteen principles presented by Drummond et al. were achieved in HTA projects in Turkey. The survey was distributed to all attendees of the First Annual Health Technology Assessment Meeting in a large hotel conference room in Antalya during the welcoming statements of the meeting and collected before the first presentation. Results were transcribed by the main researchers and analyzed using SPSS® 17.0.
Qualitative Methodology
The Collective Intelligence Platform® was conducted over two sessions on the first day of the meeting. The Platform methodology is a patented and reproducible qualitative research tool developed at TÜBİTAK TÜSSİDE. Participants were assigned evenly among eighteen roundtables by the research team to ensure a mixed representation of stakeholders at each table. Distribution was designed to prevent dominance or supression among group members. Each group contained 10–11 members representing physicians, pharmacists, delegates from the private sector, researchers and academics, public officials, engineers, and economists.
Participants were given placemats printed with terms and definitions, a basic description of the HTA process, a list of stakeholders, and a Turkish translation of the key principles of HTA proposed by Drummond et al. (Reference Drummond, Schwarts and Jonsson9).
In the first session, participants were given a set amount of time to independently write statements assessing the strengths and weaknesses of current HTA processes in Turkey on self adhesive notes (one statement per self adhesive note). Each table was then asked to synthesize their notes by removing duplicates and stick the unique statements on a flipchart stand visible to all group members. Members were then asked to individually select six statements from the board that they believed to be most important and submit their votes to the research team.
Researchers tallied up the votes from each table and presented each group's top six priorities back to them in the second session for respondent validation. Group members were then asked to develop recommendations to improve each of the six priorities using a form to ensure a standard level of detail for each recommendation. All self adhesive notes, flip chart sheets and forms were collected and labeled with group number by the researchers, transcribed, coded, and analyzed using NVivo®10.
RESULTS
Quantitative Results
The largest group of attendees completing the survey represented various directorates within the MoH, including Health Research, Health Services, Health Management, the Public Health Institution, the Turkish Medicines and Medical Devices Agency, and the Minister's office. Major MoH divisions have been separated in the table. Academic representatives were from ten universities and one teaching hospital in Istanbul, Ankara, Izmir, Konya, and Kayseri. All but one of the private sector representatives were from pharmaceutical companies. One representative from a private sector consulting company and one representative from a nonprofit pharmaceutical organization attended. Respondents were asked which if any HTA activities were conducted at their organizations (n = 216). In response, forty-nine respondents said “Coordinating HTA Activities,” forty-three said “Producing HTA,” forty-one said “Developing Clinical Guidelines,” thirty-eight said “Reimbursement Decision Making,” and twenty-eight said “Using HTA reports for decision support.” Fifty-eight respondents said their organization did not conduct any HTA-related activities. Responses by organization are summarized in Table 1.
Table 1. Self-reported HTA Activities by Organization (216 Respondents)
HTA, health technology assessment.
Respondents were asked if they had ever visited any of the eleven HTA related Web sites listed on the survey. A total of 136 respondents (76 percent) reported having visited www.hta.gov.tr, the MoH's HTA Web site and seventy-eight (44 percent) visited the MoH's clinical guideline dissemination Web site. Thirty-three (19 percent) visited the Ankara Teaching and Research Hospital's hospital-based HTA Web site. With regard to international Web sites, seventy-five (42 percent) had visited the National Excellence for Health & Care Excellence (NICE) Web site, sixty-five (37 percent) had visited HTA International (HTAi), fifty (28 percent) had visited EUnetHTA, forty-seven (26 percent) had visited the International Society of Pharmacoeconomics and Outcomes Research (ISPOR), forty (22 percent) had visited Germany's Institute for Quality and Efficiency in Health Care (IQWIG), twenty-four (10 percent) had visited the Canadian Agency for Drugs & Technology (CADTH), eighteen (10 percent) had visited the Swedish Council on HTA (SBU), and fifteen (8 percent) had visited the Danish Health & Medicines Authority Web sites.
When asked about HTA projects done in Turkey, 103 (58 percent) of respondents said they had no knowledge of any HTA projects. Of the seventy-five (42 percent) respondents that said they did have knowledge of HTA projects done in Turkey, of those, forty-eight (64 percent) were able to name specific HTA projects.
With regard to respondents’ self assessment of their knowledge and awareness regarding HTA, thirty-three (19 percent) described themselves as advanced, sixty-eight (38 percent) intermediate, and fifty-one (29 percent) low. Twenty-six (15 percent) said they had no prior knowledge or awareness of HTA. These twenty-six respondents were asked to end the survey at this point. The others were asked to continue to the final section of the survey regarding the fifteen principles of HTA proposed by Drummond et al. (9). Respondents were asked to rate Turkish HTA activities on their compliance with each of the principles on a scale of 1–4 (disagree to agree). The results can be seen in Table 2. The lowest score was given to the first principle (A clear system for setting priorities for HTA exists), while the highest score was given to the 11th principle (HTAs consider a wide range of evidence and outcomes). The overall average score for all fifteen principles was 3.04.
Table 2. Assessment of Turkish HTA System According to HTA Principles
HTA, health technology assessment.
Qualitative Results
A total of 183 attendees (82 percent) participated in the Collective Intelligence Platform®. The top six priority statements were prioritized by participants individually and tallied up to identify priorities for the group. Some statements contained more than one theme (for example, the statement “there are not enough public sector positions dedicated to HTA and universities do not offer enough HTA training”). These were split into separate statements during the coding process resulting in more than six priorities for some of the eighteen groups. The prioritized statements about the current Turkish HTA system were coded under eleven reoccurring themes. In descending order of prioritization, participants identified a lack of coordination among institutions, problems in the production of HTA, problems regarding access to data and the ability to transform data into knowledge, problems related with the usage of HTA, a lack of awareness about HTA, inadequate capacity, the need for support from the executive level, a lack of communication among stakeholders, a need for a national HTA strategy, sustainability, insufficiency of methodology, and a need for financial support.
Each group then developed recommendations for each of the priorities they had identified using a standardized form. The most frequently repeated recommendations among the groups centered around developing a national framework to coordinate and conduct HTA work that establishes common definitions, models, data sources, and methodology. Many groups encouraged the establishment of a new independent organization for this purpose. Other areas of focus included the consolidation, standardization and sharing of data needed for HTA projects and the development of a local quality-adjusted life-years (QALYs) value set. Some groups suggested that producers of HTA should be certified to ensure standardization and quality. Several recommendations addressed issues of capacity including train-the-trainer, university degree programs, conferences and international collaborations. Finally, the groups offered several suggestions to increase awareness of how HTA can support decision makers at the executive level including lobbying, mandatory usage of HTA, and targeted reporting. The results of this qualitative study have been summarized in Table 3.
Table 3. Current Status Assessment: Prioritized Statements Coded by Themes
HTA, health technology assessment; QALY, quality-adjusted life-year; NGO, nongovernmental organization; ISPOR, International Society for Pharmacoeconomics and Outcomes Research; NICE, National Institute for Health and Clinical Excellence; INAHTA, International Network of Agencies for Health Technology Assessment.
DISCUSSION
In 2008, before any HTA departments had been established in Turkey, Kahveci and Meads (Reference Kahveci and Meads10) analyzed the strengths, weaknesses, opportunities, and threats (SWOT) in the development of HTA in Turkey by interviewing stakeholders in the Turkish healthcare system. The results of that qualitative study are summarized in Table 4.
Table 4. SWOT Analysis for HTA in Turkey (Kahveci)
SWOT, strengths, weaknesses, opportunities, and threats; HTA, health technology assessment.
Since 2008, there has been some improvement in the areas of weakness identified by Kahveci and Meads, specifically around awareness, availability, and quality of data, and interest by universities. In general, participants showed increased acceptance that continuing with the current policy development system will mean a continuing rise in unsustainable healthcare expenditures, but weaknesses around poor multi-disciplinary collaboration, tradional “expert-based” decision making, and a lack of human resources to support HTA continue to be challenges.
A recently implemented national strategy to increase drug and biomedical technology manufacturing in Turkey (11) and the recent approval of legislation in 2014 to establish a national health sciences institute under the MoH (12), are expected to put new pressures on licensing and reimbursement policies. Also, in January of 2015, the Turkish Parliament approved legislation that established a Scientific Advisory Council for the SSI that is charged with providing evidence to support policy development (13). Kahveci et al. recently published a follow-up analysis of Turkey's policy changes in the Turkish health system and developments regarding HTA that concluded by recommending HTA be given a larger role in guiding policy development to optimize investments by promoting evidence-based policy making, developing better collaboration among stakeholders, and increasing awareness of HTA methodology (Reference Kahveci, Koç and EÖ14).
The results of this qualitative study address the same issues identified in WHO resolution WHA7.23 Health Intervention and Technology Assessment in Support of Universal Health Coverage (UHC), which was approved in May of 2014 at the 67th World Health Assembly (15). The resolution urges Member States to consider taking eight steps regarding the use of HTA that include establishing national systems of health intervention and technology assessment, strengthening the link between HTA and regulation and management, developing national guidelines and monitoring systems, collaborating with other Member States to collect and share information and lessons learnt, developing and improving the collection of data to improve assessment capacity, identifying gaps with regard to promoting and implementing evidence-based health policy, and consolidating and promoting HTA within national frameworks like health system research, health professional education, health system strengthening, and UHC. The recommendations of the stakeholders participating in this study matched with all of the WHO resolution steps except for the last step, presumably because it requires a maturity that has not yet been reached in the Turkish HTA environment.
Overall, platform participants described the current HTA environment as disjointed and lacking in resources and support from policy-making leaders. One of the strongest recommended strategies for improving the HTA environment was developing a more transparent, independent, and evidence-based policy decision-making system by coordinating HTA activities under one independent umbrella organization. A first step toward consolidation took place when the SSI dissolved its HTA division in February of 2017 and committed to working with the MoH HTA organization. It is noteworthy that during the study some stakeholders voiced concerns that an HTA agency within the MoH cannot be independent and urged the establishment of an HTA agency outside the jurisdiction of any organizations responsible for policy regarding health technology use. The MoH General Directorate currently responsible for the HTA division is scheduled to close by the end of 2017 and discussions are currently under way regarding how the HTA divison should be restructured.
A second strong recommendation involved aggregating data from different sources. Turkey's centralized healthcare system and universal health insurance scheme with online prescribing and claims processing give the country a significant headstart in terms of quantity, depth, and quality of data. However, providing researchers and policy makers with access to data continues to be a challenge as policy makers struggle to balance the need for access with concerns about privacy and security.
A third focus of recommendations focused on developing human capacity to conduct and use HTA, specifically through part-time, full-time, and online health economics and HTA degree programs in Turkish universities. A successful on-line program was piloted at Hacettepe University which was supported by international instuctors and several other universities have began to offer health economics programs. Finally, there was a general consensus that a national HTA core model and framework with guidelines for terminology, methodology, reporting, use, and monitorization will be important to developing a cohesive and sustainable HTA capacity in Turkey. A workshop to begin developing a national framework is planned for 2017.
It was a strength of this study that representatives of so many stakeholder organizations participated in this study. Although the results revealed consistent frustration regarding the lack of coordination among these stakeholders, a clear commitment to HTA was also expressed as all of the invited organizations sent delegates. It is a weakness of the study that invited organizations did not include many private sector organizations other than pharmaceutical companies. Medical device manufacturers, hospitals, nonprofit organizations representing healthcare professionals, and especially organizations representing patients were not invited to participate, all important stakeholders in the healthcare system. It is likely that the exclusion of these stakeholders made the assessment of the current situation favorably biased as the majority of respondents (52 percent) represented organizations coordinating and producing HTA was high as seen in Table 1.
CONCLUSIONS
Turkey's journey toward using HTA to support policy-making decisions started 3 years ago and while consistent progress toward to the ideals developed by Drummond et al. is being made, it is only the beginning of the journey. Platform participants described the current HTA environment as disjointed and lacking in resources and support from policy-making leaders. The priority recommendations of the participants include developing a more transparent, independent and evidence-based policy decision-making system by coordinating HTA activities under one umbrella agency, aggregating data from different sources, developing capacity through health economics and HTA degrees in Turkish universities, and developing a national HTA core model and framework. Despite the persisting challenges, awareness of the strengths and weaknesses of the current system combined with increasing interaction among Turkish stakeholders and the international HTA community can meaningfully contribute to the continued development and promotion of HTA in Turkey.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
