Domestic production import dependence and next generation therapies Behlül Ünver | President, World Health Tourism Platform When a patient leaves the consulting room, much of their treatment often continues at home rather than in hospital. A tablet that regulates blood pressure, insulin that controls diabetes, an antibiotic prescribed for an infection, a biological product used in cancer treatment, or medication taken for years for a chronic condition... Medicines carry much of the health system's less visible workload. This is why discussing medicines solely in terms of prices, exchange rates or the number of packs is inadequate. Medicines are simultaneously a matter of public health, industrial policy, scientific research, security of supply and public expenditure. The central question for Türkiye is not simply how many packs it manufactures, but how far it can develop the active ingredients, manufacturing know-how and intellectual property behind them. A large market whose figures need careful interpretation According to the Preliminary Pharmaceutical Sector Inquiry Report published in 2026, the sales value of Türkiye's pharmaceutical market reached TRY 479 billion in 2025. Of this, TRY 417 billion was generated through pharmacies and TRY 61 billion through hospitals. In other words, approximately 87% of market value comes from the pharmacy channel. This percentage does not directly represent the number of outpatients, but it clearly illustrates the central role medicines play in treatment beyond hospital walls. The same report ranked Türkiye 19th worldwide in 2024, with a pharmaceutical market worth USD 11.5 billion. Market size matters, but in an economy with high inflation, growth expressed in lira cannot be treated as a sufficient measure of success. What matters is whether patients receive the medicines they need on time, whether public resources are used appropriately, and how much technology the country develops through this market. What manufacturing medicines in Türkiye actually tells us In 2025, 89.98% of the medicines sold, measured by packs, were manufactured in Türkiye. Finished products manufactured in Türkiye accounted for 59.59% of sales value, while imported finished products accounted for 40.41%. These figures demonstrate the strength of Türkiye's pharmaceutical manufacturing infrastructure. However, percentages describing the place of manufacture do not establish that a product's active ingredient or molecule is domestically developed or produced. We must distinguish at least four separate levels: a medicine whose finished product is manufactured in Türkiye; one whose active ingredient is produced in Türkiye; one whose molecule is developed in Türkiye; and one whose patent and manufacturing know-how belong to Türkiye. Current publicly available statistics mainly describe the first level. Equally clear, comprehensive data are not available on active ingredient origin, the number of domestically developed molecules, intellectual property ownership or the value added retained in Türkiye. Sales value does not identify a domestically developed molecule We mislead ourselves if we measure domestic capability solely by a factory's address or a product's sales value. Sales value is affected by pricing, exchange rates, patent protection, reimbursement coverage and therapeutic area, among many other factors. High revenue does not necessarily mean substantial domestic technology, just as low revenue does not imply low scientific value. Genuine domestic capability extends across the value chain, from a research idea and molecule discovery to active ingredient production, clinical research, regulatory submissions, commercial manufacturing and exports. Dependence on imported active ingredients and critical inputs varies by product group and production stage. The problem is the absence of a transparent dataset covering the sector as a whole. Where is each medicine's active ingredient produced? Who owns the molecule's patent? How many suppliers provide a critical input? For which products does the public sector depend on a single country, and how much sales revenue remains in Türkiye? Pharmaceutical policy should rest on an inventory that answers these questions and is updated by product and stage of the value chain. Such an inventory is essential for health security as well as economic planning. During a pandemic, war, trade restriction or logistics crisis, having a factory capable of making the finished product is not enough. If the active ingredient or a critical auxiliary material does not arrive, the production line cannot operate. The world is moving beyond tablets towards cell and gene therapies The global pharmaceutical industry no longer grows solely through conventional chemical molecules. Biological and biosimilar medicines, mRNA technologies, targeted therapies, personalised medicine, gene therapies, somatic cell therapies and tissue-engineered products are changing healthcare. The European Medicines Agency places gene, cell and tissue-engineering-based advanced therapies within a distinct regulatory category. Biotechnology medicines are also becoming more significant in Türkiye. According to the Türkiye Biopharmaceutical Platform, these products reached TRY 60.9 billion in 2024, representing 18.8% of the total market. Nevertheless, the scope of domestic biosimilar production remains limited. If we do not want to remain merely an importing market for next generation treatments, we must build laboratories, clinical research capabilities, bioreactor capacity, data infrastructure and a skilled workforce now. The journey from a drug candidate to an approved medicine can take an average of 10 to 15 years. Approximately USD 201.3 billion was spent on pharmaceutical R&D worldwide in 2025. The estimate for Türkiye in the same report is around USD 540 million. Although calculation methods may differ between sources, the difference in scale is clear: Türkiye needs an ecosystem that can finance sustained research, as well as manufacturing facilities. New treatments also influence health tourism A new molecule, an original formulation or a particular treatment protocol is more than a scientific publication or an industrial product; it can also affect international demand for a country's healthcare services. Patients, particularly those with diseases such as cancer where time and treatment options are critical, may travel abroad to access treatments that are not authorised, reimbursed or provided in their own country, or are available only at selected centres. The European Union's guidance on planned cross-border care explicitly recognises that patients may seek treatment in another country because an intervention is unavailable at home or waiting times are long. Competition in health tourism therefore involves more than hospital buildings, attractive prices and physician promotion. Targeted cancer medicines, immunotherapies, cellular therapies, radiopharmaceuticals, personalised treatment approaches, clinical trials and molecular tumour boards can directly influence a patient's choice of country. Generating scientific evidence for a molecule, formulation or treatment approach developed in Türkiye, securing intellectual property and the relevant regulatory approvals, and providing it in qualified centres can benefit patients while supporting high-value health tourism. However, turning a patient's hope into a commercial promise poses a serious risk, particularly in oncology. Experimental interventions must be clearly distinguished from authorised treatments. The evidence, eligible patient groups, alternatives, costs, potential adverse effects and follow-up arrangements should be explained in the patient's own language. Success in health tourism should be measured by the ability to translate scientific innovation into safe, ethical and traceable care, not simply by announcing a new treatment. Universities must contribute to development rather than observe it We cannot leave drug development solely to pharmaceutical companies' investment decisions. Companies are indispensable for manufacturing, scaling and market access, but commercial expectations alone should not determine which molecules and critical therapeutic areas the country prioritises. The public sector, universities, clinicians, pharmacists, engineers and industry should establish a shared research agenda. Faculties of pharmacy should be central to this structure. Medicinal chemistry can contribute to molecular design; pharmaceutical technology to formulation and manufacturing methods; pharmacognosy to the scientific assessment of plant-derived resources; pharmacology and toxicology to safety studies; and clinical pharmacy to appropriate use, drug interactions and the monitoring of treatment outcomes. This expertise should produce patents, regulatory dossiers, pilot manufacturing, clinical research and public policy, as well as publications. Instead of each university attempting to build expensive infrastructure independently, shared research centres and pilot facilities compliant with good manufacturing practice could be established. Academic promotion criteria should recognise developed molecules, patents, licences, clinical protocols, technology transfer and public health problems addressed, alongside publication counts. University-industry collaboration should extend beyond providing laboratory services to companies. Research initiated to address public priorities should define data rights, intellectual property, pricing and access conditions from the outset. It must be clear how a publicly funded product will benefit society. Pharmaceutical policy is also outpatient care policy Much chronic disease care in Türkiye is delivered on an outpatient basis. Medicines sustain treatment for hypertension, diabetes, asthma, heart disease and many mental health conditions. Access to the right medicine is therefore more than a pharmaceutical or industrial policy issue; it is an element of healthcare that directly affects hospital admissions, emergency department visits, lost working time and quality of life. Medicine shortages interrupt treatment, while inappropriate or unnecessary use harms both patients and budgets. These are distinct problems. Making essential medicines harder to obtain in the name of savings is not rational use. Rational use means patients receive medicines appropriate to their clinical needs, at the right dose, for the right duration and at the most appropriate attainable cost. Unnecessary medicine use is not solely a patient choice The World Health Organization has long emphasised that more than half of medicines worldwide are prescribed, dispensed or sold inappropriately, and that approximately half of patients do not take them correctly. Major problems include polypharmacy, antibiotic use for non-bacterial illnesses, prescribing that departs from clinical guidelines, use of prescription medicines without medical supervision and non-adherence to treatment. In Türkiye, the solution requires more than calls for greater public awareness. Physicians need an up-to-date medication list for each patient. Digital systems should flag duplicate prescriptions containing the same active ingredient, older patients should undergo regular medication reviews, and pharmacist counselling should become part of treatment. Diagnosis-based feedback on antibiotic prescribing, hospital antimicrobial stewardship programmes and comparative reports showing physicians their prescribing patterns should be implemented. We should measure more than the number of packs consumed. Treatment adherence, preventable drug interactions, unnecessary antibiotic use, duplicate prescriptions, treatment interruptions and medicine-related hospital visits should also be monitored. Data should support feedback that improves clinical quality, rather than serve as an instrument of punishment. Products marketed as medicines without being medicines Any discussion of the pharmaceutical market must also consider food supplements, vitamin and mineral products, herbal mixtures and similar products sold online. It would be wrong to treat them all alike. Supportive products may have a role in correcting a deficiency identified by a physician or in other appropriate circumstances. However, blurring the distinction between a supplement and an authorised medicine is a serious health concern for consumers. Food supplements are not medicines. Under the applicable regulations, their labelling, presentation and advertising cannot claim to prevent, treat or cure disease. Nevertheless, social media posts, personal testimonials, promotional imagery suggesting medical endorsement and the assumption that natural means harmless can position some products as though they were medicines. The risks extend beyond unnecessary spending. They may include uncertain composition, incorrect dosing, interactions with medicines, liver or kidney damage, delays in receiving effective treatment and unsupervised use, particularly by people with chronic conditions. The word natural is not a safety certificate, and approval does not mean that therapeutic efficacy has been demonstrated to the standard required for medicines. The solution is a single verification system that clearly distinguishes authorised medicines, traditional herbal medicinal products, food supplements and cosmetics. A QR code on the product should reveal the type of authorisation or approval, manufacturer, permitted claims and warnings. Health claims in digital advertising should be monitored regularly, sales platforms should take responsibility, suspected adverse effects should be reportable, and pharmacists' advisory role should be strengthened. What Türkiye should do to develop domestic medicines First, we should redefine domestic capability. A product packaged in Türkiye should not be placed in the same category as one whose active ingredient, technology and intellectual property have been developed domestically. Incentives should measure the stages at which domestic value is added. Second, we should identify critical products instead of trying to localise every medicine simultaneously. Priorities should include active ingredients dependent on a single supplier, essential medicines, products needed during epidemics and biological treatments with a substantial budget impact. Third, public procurement and reimbursement policies should consider security of supply, domestic R&D, technology transfer and export capacity, rather than the lowest price alone. Protection should not be indefinite or unconditional; it should be assessed against manufacturing, quality, investment and export targets. Fourth, universities, and particularly faculties of pharmacy, should be core participants in pharmaceutical policy. Shared research centres, pilot manufacturing infrastructure, efficient contracting and ethics review processes should be established so that academic knowledge can move from molecular research into clinical practice. Collaboration with companies is necessary, but research agendas must not be confined to their commercial priorities. Fifth, pricing should become more predictable. Sustainable manufacturing matters as much as medicine affordability. A pricing system disconnected from raw material, energy, labour and technology costs can lead to product withdrawals, supply shortages and postponed investment. Sixth, active ingredient and biotechnology manufacturing need long-term financing. Developing molecules requires patience over a decade. Incentives should be sustained and tied to milestones rather than annual budget cycles. Unsuccessful research must also be recognised as part of scientific learning. Finally, rational medicine use should not be positioned against domestic production policy. Türkiye grows stronger by developing appropriate medicines and delivering them to the right patients, not by consuming more unnecessary medicines. Domestic industry's objective should be better health outcomes and greater value added, rather than more packs sold. The issue goes beyond the number of packs we manufacture Türkiye is not starting from scratch in pharmaceutical manufacturing. It has strong facilities, a skilled workforce, a large market, universities and substantial production experience. It now needs to deepen this capacity through molecule development, active ingredients, biotechnology, clinical research and exports. We should therefore monitor the scientific knowledge generated and the value added retained in Türkiye, rather than sales figures alone. Pharmaceutical independence does not mean manufacturing every product domestically; that is neither realistic nor necessary. It means understanding the risks we face when a critical treatment is needed, managing alternative sources of supply, and possessing the scientific and industrial capabilities to develop strategic products. A country's pharmaceutical strength is measured not by the number of packs on its shelves, but by its ability to research the molecules it needs, manufacture them safely and deliver them to patients without interruption. Drog in Turkey Key indicators Indicator Latest value Türkiye pharmaceutical market sales value TRY 479 billion 2025 Pharmacy channel share of market value Approximately 87% 2025 Pack share of finished products manufactured in Türkiye 89.98% 2025 Value share of finished products manufactured in Türkiye 59.59% 2025 Biotechnology medicine share of the Türkiye market 18.8% 2024 Global pharmaceutical R&D expenditure USD 201.3 billion 2025 Sector-wide share by active ingredient origin No comprehensive public data Market share of original molecules developed in Türkiye No comprehensive public data Principal sources Turkish Competition Authority Preliminary Pharmaceutical Sector Inquiry Report 2026 World Health Organization Promoting Rational Use of Medicines European Medicines Agency Advanced Therapy Medicinal Products Türkiye Biopharmaceutical Platform Pharmaceutical Market Ministry of Agriculture and Forestry Food Supplement Approval Procedures Implementation Guidelines European Union Your Europe Guidance on Planned Medical Treatment Abroad

Managing care, education, research, referral pathways, and financial sustainability within a single system It would be incomplete to define university hospitals merely as hospitals with high bed capacity or advanced technology. These institutions simultaneously treat patients, train physicians and other health professionals, provide specialist education, produce scientific research, develop new diagnostic and treatment methods, and often serve as referral centers for the most complex cases that the broader health system cannot resolve. For this reason, the management challenge of a university hospital is broader than the operational challenge of a conventional hospital. The OECD’s 2026 study on tertiary care describes this structure in tertiary institutions integrated with academic functions as a “triple mission”: health care, medical education, and research. The OECD also emphasizes that tertiary services do not fit easily into standard payment mechanisms because they are multidisciplinary, resource-intensive, and exposed to rapid technological change [1]. This observation is one of the clearest explanations for why university hospitals need a distinct governance and financing architecture. Managing a university hospital means managing not only a hospital, but also the present health system, its human capital, and its future scientific capacity at the same time. Why is the patient profile of a university hospital different? One of the core functions of tertiary and academic centers is to manage patients who require advanced expertise, advanced technology, and multidisciplinary decision-making. The OECD notes that tertiary care particularly includes complex and severe health problems, organ transplantation, neurosurgery, cardiac surgery, advanced cancer treatments, rare diseases, intensive care, and advanced diagnostic methods [1]. The Alliance of Academic Health Centers International (AAHCI) likewise defines academic health centers as institutions specializing in the most complex and difficult diagnoses and treatments while also educating future generations of health professionals [3]. For this reason, the patient population referred to university hospitals may naturally include a higher proportion of advanced-stage, rare, multimorbid, treatment-resistant, or previously treated cases. It would not be correct to generalize that “every patient is severe”; however, the nature of being a referral center increases case complexity and resource utilization. Even two patients with the same diagnostic label may consume very different levels of resources. This leads to an important management principle: not every high cost represents inefficiency. Sometimes high cost is the price of treating the most difficult patient in the health system with the most advanced technology and highest level of expertise. Therefore, evaluating a university hospital only by revenue per patient, length of stay, or departmental profitability can be misleading. Without a referral chain, the mission of the university hospital is eroded For university hospitals to fulfill their core functions, the different levels of the health system need a functioning referral and back-referral mechanism. The World Health Organization positions primary care as people’s first point of contact with the health system and considers referral to secondary or tertiary institutions when needed to be part of primary care’s coordination role [2]. The OECD similarly emphasizes that access to tertiary care in many systems occurs through referral by general practitioners or secondary-care providers [1]. Primary care should resolve preventive services, early diagnosis, a substantial share of chronic disease management, and basic treatments as close as possible to where people live. Secondary care should undertake standard specialty services, common surgical procedures, and a substantial share of general hospital care. The core capacity of university hospitals should then be reserved for cases that cannot be resolved at these two levels and require advanced expertise and multidisciplinary management. An uncontrolled flow of routine and low-complexity patients into university hospitals does more than create crowding. It can reduce the time faculty members can devote to complex cases, push research into the background, consume advanced technology capacity on routine services, lengthen waiting times, and make access more difficult for true referral patients. In addition, if the financing system turns routine cases into easier revenue-generating service lines, the institution may gradually become dependent on low-complexity patient volume in order to finance its academic mission. The OECD’s example from Slovenia highlights exactly this type of incentive risk: when institutional add-on payments to tertiary institutions do not sufficiently distinguish routine elective procedures from genuinely high-complexity cases, cross-subsidization may emerge between profitable routine services and advanced specialty services [1]. This example shows that the referral chain is not merely a bureaucratic gatekeeping mechanism, but also a system tool that protects appropriate resource allocation and the academic mission. The stronger primary and secondary care become, the more university hospitals can focus on their true mission. A university hospital is not merely an institution that applies existing treatments What distinguishes an academic hospital is that it does not stop at applying the treatments already known today. It is expected to investigate new therapies, conduct clinical research, evaluate new medicines and devices, establish referral structures for rare diseases, develop personalized medicine and genomics applications, and bring artificial intelligence and biotechnology into clinical practice. The OECD particularly emphasizes the central role of university hospitals in clinical research, translational research, and the development of new treatments [1]. The economic logic of these activities differs from routine health care. Research outcomes do not always emerge in the short term; some projects take years, some generate scientific knowledge without becoming a commercial product, while others pave the way for a new treatment only after hundreds of attempts. For this reason, evaluating the research budget only by asking “how much revenue did it generate this year?” weakens the scientific mission. Charité – Universitätsmedizin Berlin in Germany is a strong example of this scale. According to Charité’s 2025 figures, the institution operated across four campuses with approximately 100 departments and institutes, 3,293 beds, 25,256 employees, and 5,882 researchers and physicians, while educating 10,199 students. In the same year, it secured approximately EUR 292.5 million in third-party research funding [7]. A structure of this scale is no longer simply a “hospital”; it is an academic health system in which clinical care, education, research, and innovation are managed within one ecosystem. Financial risk: Three different missions cannot be sustained by a single revenue stream One of the most critical structural problems of university hospitals is the mismatch between service revenues and the costs of the academic mission. Complex patients may require more specialists, more consultations, longer hospital stays, more expensive medicines and devices, and more advanced laboratory and imaging services. At the same time, the same institution must finance student and resident education, scientific research, laboratory infrastructure, data management, ethics committee processes, clinical research organization, and research personnel. AAMC studies on “funds flow” in academic health systems describe a similar problem: who generates clinical revenue, how much of it should be transferred to education and research, and how resources should be distributed across different missions are among the fundamental management challenges of academic health systems. Narrowing clinical margins and rising education and research costs make it even more critical to align financial flows with institutional strategy [8]. There are two extreme risks. The first is forcing a university hospital to maximize profit according to the logic of a conventional commercial enterprise. This may create pressure to avoid high-cost, low-return complex cases, education, and research. The second is to push financial discipline completely into the background in the name of the academic mission. An institution that continuously loses money, cannot service its debt, cannot renew its equipment, and cannot develop its staff cannot sustain its scientific mission either. Therefore, the correct objective is not “maximum profit” but financially sustainable value creation. A university hospital should be capable of generating a positive operating result; however, the purpose of the resulting surplus should not be distribution to shareholders, but reinvestment in service quality, human resources, research, education, and technology. This is a more appropriate framework for the institutional sustainability of an academic health system. Around the world, the cost of the academic mission is recognized through separate funding International examples show that the burden of education and research is not left entirely within ordinary service tariffs. According to the OECD’s 2026 study, France supports education, research, referral, and innovation missions through a separate financing mechanism known as MERRI. In 2023, MERRI funding reached EUR 5.91 billion, equivalent to approximately 5.8% of the total hospital budget. Of this amount, EUR 1.53 billion was allocated to education [1]. In Austria, the additional costs generated by university hospitals’ education and research missions are covered through a separate clinical additional-cost mechanism known as “Klinischer Mehraufwand - KMA.” For example, in addition to the global hospital budget for AKH Vienna, KMA components cover investment, cash, and clinical physician personnel costs [1]. These models do not need to be copied directly by other countries; what matters is the underlying principle: making the burden of education and research visible and financing it separately. This approach also creates financial transparency. When the cost of service delivery, education, and research are blended together, the institution cannot see which mission consumes which resources. Under such a structure, genuine efficiency analysis is also impossible. “Mission-based cost accounting” should therefore be one of the core management tools for university hospitals. The solution: Multi-source and mission-based financing Linking all university hospital financing to patient-care revenue creates a conflict between the institution’s academic responsibilities and its financial incentives. A healthier structure should bring together service revenues, publicly defined education support, research funds, national and international project grants, clinical trials, university-industry partnerships, technology transfer and intellectual-property income, and donations and philanthropy within the same ecosystem. Research and project-development capacity in particular should be professionalized. It is not enough for a university hospital simply to employ scientists who conduct research; it also needs a professional research and innovation office that develops projects, monitors national and international funding opportunities, prepares budgets, builds partnerships, and manages contracts and intellectual-property processes. The institution should move from being a structure that “waits for resources” to an organization that designs projects with measurable impact and secures funding for them. Donations and philanthropy are not a way to close deficits; they are partnerships in mission One of the important characteristics of strong academic health systems is the voluntary-support relationship they establish with society. Philanthropic individuals, alumni, foundations, and companies can support concrete goals such as research centers, scholarship programs, new treatment projects, child health, cancer care, rare diseases, simulation centers, or researcher-development programs. Mayo Clinic explicitly states that philanthropy supports clinical care, pioneering research, and the education of future health leaders [10]. In Singapore, NUHS manages donations through a separate registered charity, the NUHS Fund, with governance and internal-control mechanisms to support research, education, and patient programs [6]. These two examples point to an important principle: philanthropy is not a method for covering an unplanned budget deficit; it is a vehicle for voluntary partnership in a clearly defined health and scientific mission. University hospitals should therefore build a professional “development/fundraising” capability. Resource requests should not be abstract. Instead of saying “our hospital needs money,” institutions should prepare projects with clearly defined objectives, budgets, timelines, patient and societal impact, success indicators, and sustainability models. Examples include a genomic diagnostic program for rare diseases, an advanced stroke center, a childhood cancer research fund, an AI-assisted early-diagnosis platform, or a simulation center for health professionals. These are fundable structures with both scientific and social value. The correct sequence: Develop the project - define its impact - fund it - measure it - transparently communicate the results to society and supporters. Value-based management: Measuring success beyond profitability Financial discipline is indispensable in a university hospital; however, turnover or operating profit alone cannot be the measure of success. Michael Porter’s value framework in health care defines value by evaluating the health outcomes achieved for patients together with the resources used to produce those outcomes [11]. In a university hospital, this framework needs to be expanded even further. The value of an academic health center should be assessed by considering together its clinical outcomes, patient safety, health gains achieved in complex cases, the specialists and health professionals it trains, scientific publications and research outputs, clinical trials, new treatments and technologies produced, contribution to society, access, and financial sustainability. Removing education and research from the performance dashboard and measuring only service revenue distances the university hospital from its own mission. What should a distinct management model mean? Proposing a distinct management model for a university hospital should not mean exempting it from financial or operational discipline. On the contrary, a more complex mission requires more professional and transparent management. The authorities and responsibilities of the rectorate, medical faculty/dean’s office, hospital administration, chief medical office, department chairs, and research structures should be clearly defined. Academic freedom should be preserved while patient safety, quality, budget, human resources, and operational standards are managed within institutional discipline. Johns Hopkins Medicine states that since 1997 it has brought together the leadership of the medical school and the health system within an integrated governance framework, enabling the missions of patient care, research, and education to be managed together [4]. The National University Health System (NUHS) in Singapore explicitly defines itself as an integrated academic health system based on the triple mission of care, education, and research, while also operating as a regional health system through hospitals, specialty centers, polyclinics, and community providers [5]. This structure is a strong example of how the referral chain and the academic center can be managed not as disconnected entities but as different levels within the same system. What model could be proposed for Türkiye? For Türkiye, the need is to reassess university hospitals from an “academic health system” perspective rather than forcing them into a single conventional hospital performance model. Each institution will differ in scale, ownership structure, and regional role, but the core architecture can be shared. First, the referral chain should be strengthened; a substantial share of routine and standard cases should be resolved in primary and secondary care, while preserving the university hospital’s capacity to receive complex and referral cases. Electronic referral, back-referral, teleconsultation, shared clinical protocols, and regional service networks can support this structure. The patient should not be someone who is “turned away,” but someone who is directed to the right level of care. Second, financing should make four separate missions visible: clinical care, education, research, and referral/advanced-technology capacity. While payment models sensitive to case complexity are developed, the additional costs of education and research should be supported through separate budget lines. Cross-subsidization within the institution should be as transparent as possible; it should be measurable which service line produces what and which academic mission it finances. Third, professional management capacity in university hospitals should be strengthened. Academic leadership and healthcare management are not alternatives to one another. A strong model requires joint leadership by academics and professional managers who understand academic culture, can interpret the clinical system, and are competent in finance, human resources, quality, technology, research management, and operations. Fourth, separate professional structures should be established for research, project development, clinical trials, technology transfer, international funding, and philanthropy. A university hospital’s ability to diversify its resources should depend on institutional systems, not personal relationships. Donations and voluntary support should also be directed to defined projects through ethical, transparent, and traceable governance. Finally, the performance system should be redefined. Bed occupancy, outpatient volume, number of operations, and revenue are important indicators, but they are not sufficient on their own. Outcomes in complex patients, mortality and complications, patient safety, resident and student education quality, research funding, number of clinical trials, scientific output, technology transfer, access for referral cases, patient experience, and societal impact should be monitored on the same management dashboard. Conclusion: The true balance sheet of the university hospital University hospitals may be among the most expensive institutions in a health system, but when properly managed they can also be among the institutions that generate the greatest strategic value. These organizations do more than treat today’s patient. They train tomorrow’s physicians and specialists, investigate new treatments, offer hope to the most difficult patients, contribute to the development of health technology, and expand the country’s scientific capacity. For this reason, the financial sustainability of a university hospital and its academic mission should not be seen as opposing objectives. When an effective referral chain, mission-based financing, professional governance, research funding, project-development capacity, transparent philanthropy, and a value-based performance system come together, these two objectives can reinforce each other. The success of a university hospital should not be measured by how many patients it sees, but by how much advanced value it creates for patients who truly need it, how many qualified professionals it trains, and how much it contributes to the treatments of the future. The true balance sheet of a university hospital is not merely its year-end financial result; it is the lives it saves, the people it trains, the science it produces, and the value it leaves to the health system of the future. Behlül Ünver President, World Health Tourism Platform References 1. Lorenzoni, L. (2026). Best practice in the regulation and financing of tertiary care based on case studies from five OECD Countries: Lessons for Slovenia. OECD Health Working Papers, No. 191. https://doi.org/10.1787/8e7ae7ab-en 2. World Health Organization. (2022). Primary health care - Questions and answers. https://www.who.int/news-room/questions-and-answers/item/primary-health-care 3. Association of American Medical Colleges (AAMC). Alliance of Academic Health Centers International (AAHCI). Academic health centers and systems. https://www.aamc.org/career-development/affinity-groups/alliance-academic-health-centers-and-aahci 4. Johns Hopkins Medicine. Leadership - integrated governance of Johns Hopkins Medicine. https://www.hopkinsmedicine.org/about/leadership 5. National University Health System (NUHS), Singapore. Who We Are - Academic Health System and Regional Health System. https://www.nuhs.edu.sg/about-nuhs 6. National University Health System (NUHS), Singapore. About NUHS Fund. https://www.nuhs.edu.sg/giving/about-nuhs-fund 7. Charité - Universitätsmedizin Berlin. Facts & Figures 2025. https://www.charite.de/en/charite/about_us/facts_figures/ 8. Association of American Medical Colleges (AAMC). (2018). Funds flow: What you need to know. https://www.aamc.org/news/funds-flow-what-you-need-know 9. Association of American Medical Colleges (AAMC). Patient Care Data Snapshots - teaching hospitals, complex care and hospital financing. https://www.aamc.org/data-reports/teaching-hospitals/report/aamc-patient-care-data-snapshots 10. Mayo Clinic. Philanthropy at Mayo Clinic / Giving to Mayo Clinic. https://www.mayoclinic.org/giving-to-mayo-clinic 11. Porter, M. E. (2010). What Is Value in Health Care? New England Journal of Medicine, 363, 2477-2481. https://doi.org/10.1056/NEJMp1011024 University Hospitals

From patient mobility to the export of health system and management capacity The global health sector has entered a new era shaped simultaneously by demographic change, financial pressure, shortages in the health workforce, digitalization, artificial intelligence, patient safety, and rising service expectations. In this environment, the success of health systems depends not only on clinical capacity, but also on how effectively resources, people, technology, and processes are managed. The economic scale of this transformation is striking. According to the World Health Organization (WHO), global health expenditure rose from USD 4.5 trillion in 2000 to USD 9.8 trillion in 2022, reaching 9.9% of global GDP [1]. OECD data for 2025 show that hospitals occupy a central position within this economic structure. On average, hospital activities account for 39% of total health expenditure across OECD countries, while in Türkiye the share is 50% or more [2]. This scale reminds us of an important reality: hospital management is not an ordinary administrative function; it is a strategic field of expertise in which human resources, finance, technology, clinical risk, and public responsibility must be managed at the same time. Türkiye has also built substantial capacity in health tourism. According to USHAŞ statistics based on TÜİK data, the number of international visitors coming to Türkiye for health services increased from approximately 757,000 in 2019, with health tourism revenues of USD 1.46 billion, to 1,398,580 visitors and USD 3.022 billion in revenue in 2025 [3]. This achievement is valuable; however, the value Türkiye can offer internationally in health goes beyond serving foreign patients within its borders. The new strategic objective should be to preserve the model that brings patients to Türkiye while also building a structure that carries Türkiye’s healthcare knowledge, hospital operations experience, workforce-development capacity, technology, and management model to the world. This approach can be defined as “healthcare management export.” The global challenge is not only a shortage of hospitals Across many regions of the world, billions of dollars are being invested in healthcare. New hospitals and health campuses are being built, advanced medical devices are being purchased, and digital infrastructure is being expanded. Yet the health sector has its own distinctive reality: constructing a hospital building and establishing a functioning hospital system are not the same thing. The physical completion of a health facility does not mean that it is ready to deliver effective, high-quality, and sustainable care. Decisions about which clinical services to prioritize, physician and nurse staffing plans, bed utilization, operating-room capacity, intensive care organization, emergency flow, integration of laboratory and imaging services, management of medicines and supplies, patient admission and discharge processes, quality indicators, revenue-cost systems, and the governance model all need to be designed together. Millions of dollars can be spent on medical equipment; however, without the right clinical capacity, appropriate patient volume, and a trained workforce, such investments become inefficient. Hundreds of beds can be built; yet without well-designed patient flow and clinical organization, bed numbers alone do not create value. For that reason, in healthcare investments, OPEX, the clinical operating model, and the management system must stand at the center of feasibility analysis, alongside CAPEX. Why healthcare management is a distinct field of expertise What distinguishes the health sector from many other sectors is that managerial decisions usually have multiple consequences at once. A staffing decision is not merely a human-resources issue; it can also affect patient safety and continuity of care. A procurement decision is not only about cost; it can influence clinical quality and treatment capacity. Inefficiency in operating-room utilization does not simply generate revenue loss; it may also delay a patient’s access to treatment. Poor inventory management may create financial strain, while simultaneously causing life-saving medicines or materials to be unavailable when needed. For this reason, the equation facing healthcare managers is multidimensional: patient safety, clinical quality, workforce capability, financial sustainability, efficiency, ethics, regulation, technology, and patient experience. Successful healthcare management does not mean maximizing one of these at the expense of the others; it means balancing all of them around a common institutional purpose. Professional healthcare managers are not easy to develop When health systems are discussed, physicians, nurses, technology, and physical infrastructure are usually at the forefront. Yet one of the critical human resources that holds the entire system together is the professional healthcare manager. Being appointed to a management role is not the same as being a professional healthcare manager. Education is an important foundation, but a diploma alone is not enough. In its full sense, healthcare management develops through the gradual combination of academic knowledge, field experience, institutional memory, understanding of clinical processes, financial literacy, people management, crisis experience, regulatory knowledge, technology, and leadership capability. A hospital is not an organization that can be understood solely through theory. It is difficult to grasp this profession in its entirety without seeing how an emergency department functions at night, experiencing how delays in the operating room affect the whole institution, understanding what happens when no ICU bed is available, managing the clinical and financial impact of equipment failure, balancing the different expectations of physicians, nurses, technicians, and administrative staff, and taking responsibility during crises. International professional frameworks also emphasize the wide competency range required in healthcare management. The International Hospital Federation’s 2023 Leadership Model, developed with input from 45 experts across 30 countries, does not reduce hospital leadership to a single managerial skill; rather, it places future readiness, people and culture management, systems thinking, and institutional resilience at the center [4]. Similarly, the American College of Healthcare Executives (ACHE) identifies communication, relationship management, leadership, professionalism, business skills, and knowledge of the healthcare environment as core competency domains [5]. The responsibility carried by a healthcare manager is different from that of many other managers Poor management in a factory may result in production losses. Poor management in a commercial enterprise may produce financial losses. A wrong managerial decision in a healthcare institution, however, can affect not only finances and operations, but also human health and human life. WHO patient-safety data underline the magnitude of this responsibility. According to WHO, approximately one in ten patients receiving health services is harmed in some way, and more than half of this harm is considered preventable. Unsafe care is associated with more than 3 million deaths each year [6]. These outcomes cannot be explained by physicians’ or nurses’ practices alone. Patient safety is also the result of correct staffing, medication management, infection control, quality systems, information technologies, communication, organizational culture, and managerial leadership. A systematic review examining the role of hospital managers in quality and patient safety showed that the active involvement of management in strategy, quality culture, the use of performance data, and participation in quality processes is highly relevant to clinical performance [7]. The manager’s desk therefore holds more than a budget; it also holds human life. This awareness is the core ethical responsibility of professional healthcare management. A hospital is a team game Another issue that deserves special emphasis in healthcare management is teamwork. No hospital can be managed through the success of a single individual. The best hospitals do not succeed because of strong stars alone, but because of strong systems and teams that can work together effectively. Consider a patient’s journey through a healthcare institution. The patient first meets the registration officer. A nurse performs the initial assessment. A physician conducts the examination. Then laboratory services, radiology, anesthesia, the operating room, intensive care, pharmacy, blood bank, infection control, biomedical services, technical services, information systems, and many other units may become involved. In the background, procurement, finance, human resources, quality, patient services, and administration continue to work. In most cases, the patient receives the combined output of dozens of professionals. For that reason, the quality of healthcare is not simply the sum of individual performances; it is determined by how harmoniously teams work with one another. One of the most important responsibilities of a professional healthcare manager is to make this team function well. However, it is not enough for the manager merely to “manage the team.” The manager must also be able to act as part of the team. A healthcare manager must be able to listen to physicians, understand the realities of nurses on the ground, take the finance team’s sustainability concerns seriously, grasp the constraints of technical teams, recognize patient expectations, and understand the needs of academic structures. The manager must make decisions when necessary, listen when necessary, delegate authority when necessary, and assume responsibility when necessary. A good healthcare manager is not someone who stands above the team, but someone who enables the team to work properly. Recent systematic evidence on leadership likewise indicates that leadership style is associated with teamwork, communication, organizational learning, and a culture of patient safety [8]. The world is already doing this Healthcare management export is not a theoretical idea. Leading health institutions around the world have long been transferring their clinical expertise, operating models, educational know-how, and corporate governance experience across borders. An important example is Cleveland Clinic Abu Dhabi. The institution is based on the partnership established in 2006 between Mubadala and Cleveland Clinic in the United States, with the aim of adapting Cleveland Clinic’s patient-centered clinical model and institutional approach within the local health system of Abu Dhabi [9]. What matters here is not copying an American hospital exactly into another geography; it is the adaptation of knowledge, organizational culture, the clinical model, and the management system to local needs. Another strong example is Johns Hopkins Aramco Healthcare (JHAH). Johns Hopkins Medicine International states that this collaboration integrates Johns Hopkins’ clinical and management expertise with Saudi Aramco’s health system capacity in order to improve care quality, patient safety, education, and institutional performance [10]. More broadly, Johns Hopkins Medicine International reports more than 25 years of work in hospital planning, clinical program development, operations management, human resources, quality, accreditation, information technologies, and education across different countries [11]. In other words, the world no longer sees health export merely as “bring the patient and treat them.” It increasingly operates through the logic of “take the knowledge, build the system, train the people, and establish long-term partnerships.”Türkiye should translate the areas in which it is strong into the same strategic model. Türkiye’s invisible capital: healthcare management experience Over the last 20–25 years, Türkiye has gone through an intense transformation in health. Public hospitals were restructured. Private hospital groups expanded. University hospitals continued to provide advanced care. Large-scale city hospitals entered service. Health informatics became more widespread. Health tourism developed. Significant know-how accumulated in specialized clinical services. In all these processes, Türkiye did not merely construct buildings or purchase equipment. It also trained a considerable number of healthcare managers, physician executives, nurse managers, quality professionals, biomedical specialists, health-finance professionals, health informatics experts, and hospital operators. One of Türkiye’s real export potentials lies in this institutional memory and operational know-how. The need in another country is not always a new building. Sometimes it is the effective operation of an existing hospital, the reorganization of operating rooms, the training of human resources, the establishment of revenue-cost systems, the development of a quality and patient-safety culture, or the restructuring of a university hospital’s education, research, and service functions. These are precisely the fields in which Türkiye can export solutions. The health workforce crisis creates a new field of cooperation WHO notes that the global health workforce exceeds 70 million people, yet a shortage of around 11 million health workers is still projected by 2030, especially in low- and lower-middle-income countries [12]. This reality opens another strategic field: the export of workforce-development capacity. Türkiye’s aim should not be to deepen workforce shortages in other countries by attracting away scarce qualified professionals. A more sustainable model is to strengthen local capacity through in-country education, joint specialty programs, nursing-development programs, manager-training tracks, simulation centers, distance education, tele-consultation, and joint clinical programs. In this sense, healthcare management export is also a form of capacity-building partnership. University hospitals should stand at the center of the model University hospitals hold a special place in this strategy because they simultaneously treat patients, train physicians, educate specialists, develop nurses and other health professionals, conduct research, implement new treatment methods, and shape the future workforce of the health system. Contributing to the development of a strong university hospital in another country does not only improve that hospital’s current performance. It also influences the health capacity of that country over the next 20 or 30 years. Türkiye has a major opportunity to develop joint clinical programs, education models, specialty partnerships, research collaborations, telemedicine activities, management-development programs, and shared centers of excellence with universities in Turkic republics, Central Asia, the Balkans, Africa, and the Middle East. No new model can be built without digital health and artificial intelligence Healthcare management export should not be understood only as sending people or producing consulting reports. The modern health system has to be digital. Electronic health records, hospital information systems, clinical decision-support tools, patient portals, telehealth, data analytics, performance dashboards, artificial intelligence applications, and the digital patient journey are now core elements of contemporary hospital infrastructure. For that reason, Türkiye’s healthcare operations experience must be integrated with its health-technology capacity within the same export model. The professional healthcare manager must also be able to transform technology from something merely purchased into a management instrument that improves clinical quality, efficiency, and the quality of decision-making. Hospital management that is not data-driven will become increasingly difficult to sustain in the future. From health tourism to healthcare ecosystem export In 2025, Türkiye reached approximately USD 3.022 billion in health tourism revenue [3]. The next step is to turn this economic value into a broader ecosystem. Imagine a hospital model supported by Türkiye in another country: management and clinical processes receive knowledge and consulting from Türkiye; physicians participate in joint education programs; the institution uses Turkish health technologies; medical-device and pharmaceutical companies enter the ecosystem; complex cases are referred or co-managed with reference centers in Türkiye when needed; and joint research and telemedicine services are conducted. In such a model, we are no longer selling only a single health service; we are creating a sustainable healthcare ecosystem and a long-term institutional relationship. This is exactly where the economic multiplier emerges. One of the most durable models of health diplomacy Health is different from other economic sectors. Selling a product to another country establishes a commercial relationship; contributing to the development of that country’s health system creates a long-term relationship of trust that directly touches human life. Jointly trained physicians, educated nurses, established intensive care units, developed cancer centers, or strengthened university hospitals can elevate bilateral relations far beyond economic agreements. For this reason, healthcare management export is not only an economic activity; it is also an instrument of health diplomacy. In countries where Türkiye has strong historical, cultural, and geographical ties, this model holds particularly high potential. Yet its foundation must not be dominance; it must be joint capacity building. Türkiye should go not to replace another country’s system, but to help that country manage its own health system more strongly and sustainably. An integrated model for Türkiye To realize this potential, Türkiye needs an integrated strategy rather than fragmented initiatives. Public institutions, universities, private hospital groups, professional healthcare managers, the pharmaceutical and medical-device industries, health technology companies, financial institutions, investors, and health tourism actors should be able to align within a common framework. For example, a 500- or 1,000-bed university hospital project in another country should not be seen merely as “hospital management consulting.” The same project is also an education project, a technology project, a pharmaceutical project, a medical-device project, a research project, a health tourism project, a workforce-development project, and an investment project. If the right model is established, a single hospital can become a long-term health corridor between Türkiye and the partner country. We should measure success with new indicators Türkiye naturally measures its health-tourism success through patient numbers and revenue. These indicators should remain, but additional indicators should also be developed to measure the new strategy: In how many countries is a Turkish healthcare management model being applied? In how many foreign hospitals are Turkish healthcare managers taking operational or advisory roles? In how many countries do Turkish universities have clinical education partnerships? How many foreign health workers are we training? In how many countries are Turkish health technologies being used? How much do these projects contribute to Turkish pharmaceutical and medical-device exports? How many joint centers of excellence have we created? In how many countries have we contributed to the development of sustainable local health capacity? One more indicator must be added: How many professional healthcare managers capable of working internationally are we developing? Because, in the end, the core capital of healthcare management export is still people. Not buildings, but systems; not position, but leadership capacity Technology will become more important in healthcare. Artificial intelligence will be used more widely. New hospitals and new devices will continue to emerge. Yet technology will not eliminate the need to manage health systems. On the contrary, as systems become more complex, the importance of professional management will increase. The healthcare manager of the future will understand the clinical system, manage finance, use technology, interpret data, develop the workforce, protect patient safety, manage crises, and build strategy. All of this will be achieved not alone, but as part of a strong team. Because healthcare management is not a position; it is a responsibility. If thousands of people enter a hospital every day, if hundreds or thousands of health professionals are working there, if large financial resources and advanced technologies are being managed, and if human life stands at the end of every decision, then the management of that organization cannot be left to chance. One of the important assets Türkiye has built over the years is this experience. Now is the time to systematize that experience, develop professional healthcare managers, and turn it into a model that can be carried to the world. Patients should continue to come to Türkiye. At the same time, Türkiye’s healthcare knowledge, technologies, universities, and professional healthcare managers should also reach the world. Türkiye should be positioned not only as a country that treats patients, but as a global actor capable of building health systems, training people, producing technology, and exporting healthcare management. One of Türkiye’s next major areas of transformation in health will be the shift from health tourism to healthcare ecosystem export. At the center of this transformation will be well-trained professional healthcare managers who can assume responsibility, build teams, and at the same time know how to be team players. Behlül Ünver President, World Health Tourism Platform References 1. World Health Organization. (2024). Global spending on health: Emerging from the pandemic. https://www.who.int/publications/i/item/9789240104495 2. OECD. (2025). Health at a Glance 2025 - Health expenditure by provider. https://www.oecd.org/en/publications/health-at-a-glance-2025_8f9e3f98-en/full-report/health-expenditure-by-provider_e3cf1a7d.html 3. USHAŞ. Health Tourism Data (TÜİK-based 2019-2026 series). https://www.ushas.gov.tr/saglik-turizmi-verileri/ 4. International Hospital Federation. (2023). IHF Leadership Model 2023. https://ihf-fih.org/what-we-do/ihf-leadership-model/ 5. American College of Healthcare Executives. Healthcare Leadership Competencies. https://www.ache.org/about-ache/resources-and-links/healthcare-leadership-competencies 6. World Health Organization. (2023). Patient safety - Fact sheet. https://www.who.int/news-room/fact-sheets/detail/patient-safety 7. Parand, A., Dopson, S., Renz, A., & Vincent, C. (2014). The role of hospital managers in quality and patient safety: a systematic review. BMJ Open, 4(9), e005055. https://pubmed.ncbi.nlm.nih.gov/25192876/ 8. Althobaiti, F. M. (2026). The effects of leadership on patient safety culture in health care: a systematic review. BMC Nursing, 25, 125. https://pubmed.ncbi.nlm.nih.gov/41507881/ 9. Cleveland Clinic Abu Dhabi. Who We Are / About Our Partners. https://www.clevelandclinicabudhabi.ae/en/about-us/who-we-are 10. Johns Hopkins Medicine International. Johns Hopkins Aramco Healthcare. https://www.hopkinsmedicine.org/international/health-care-consulting/emea/johns-hopkins-aramco-healthcare 11. Johns Hopkins Medicine International. Global Collaborative Health Care Consulting / Hospital Design and Development Support. https://www.hopkinsmedicine.org/international/health-care-consulting/ 12. World Health Organization. Health workforce / Health workforce education and training. https://www.who.int/health-topics/health-workforce

Can Türkiye transform wellness services from a hotel amenity into a scientific, measurable and holistic health offering? Behlül ÜnverPresident, World Health Tourism Platform When health tourism is mentioned, surgeries, advanced treatments, dental care, aesthetic procedures and hospitals are usually the first things that come to mind. SPA and wellness, meanwhile, are still often regarded as little more than massage, personal care, relaxation and leisure services offered within hotels. Yet the world’s understanding of health is changing. People no longer want to seek care only after they become ill. They want to live healthier lives, reduce stress, improve sleep quality, eat well and preserve their physical and mental capacity. This shift is moving wellness beyond its role as a complementary tourism service and turning it into an important part of the new health economy. According to the Global Wellness Institute, the global wellness economy reached USD 6.8 trillion in 2024. Türkiye ranked 16th worldwide with a wellness economy valued at USD 73 billion. However, an important distinction must be made: high wellness spending in a country does not necessarily mean that it is a strong global brand in wellness tourism. This is where Türkiye’s real question begins: Can we transform our potential into a trusted, sustainable and internationally preferred wellness tourism offering? Wellness Is More Than Feeling Good It is no longer sufficient to define wellness solely through massage, skincare, saunas and relaxation. The new generation of wellness takes a combined approach to sleep health, healthy nutrition, physical activity, mental well-being, stress management, contact with nature and personal lifestyle habits. The objective should not be to provide a few hours of relaxation, but to help guests establish a healthier routine they can carry into their daily lives. The World Health Organization identifies physical inactivity as a major risk factor for cardiovascular disease, diabetes and certain types of cancer. The fact that approximately one-third of adults worldwide do not meet recommended physical activity levels also helps explain the growing demand for preventive health and lifestyle programmes. The wellness centres of the future should therefore be designed not merely as service facilities, but as places that help people develop healthier living habits. From Hotel Amenity to Holistic Programme Türkiye has many high-quality hotels, SPA centres, thermal facilities and healthcare institutions. Yet most of these structures operate independently of one another. A hotel provides accommodation and SPA services. A healthcare institution offers medical tests and physician support. A nutrition specialist prepares a personalised plan. A fitness centre designs a physical activity programme. Yet systems that integrate all of a guest’s needs into a single journey are still not widespread enough. An international wellness programme could instead be structured around the following journey: A person’s expectations and lifestyle habits can be assessed before travel begins. After arrival, basic health assessments can be conducted within the scope of healthcare professionals’ authority and responsibility. Nutrition, movement, sleep, mental well-being, SPA services and nature-based activities can then be integrated into a personalised programme. Once the guest returns home, continuity can be supported through digital follow-up and advisory services. Such a model could move Türkiye beyond being seen simply as a country people visit to relax and position it as a country chosen to learn how to live more healthily. Wellness Should Not Be Overmedicalised, but It Must Not Abandon Science There is an important balance to maintain. It would be wrong to present every wellness service as medical treatment. Subjecting a healthy person’s needs for rest, movement, nutrition and mental well-being to unnecessary tests or exaggerated health claims can create serious ethical and trust-related problems. Yet it is equally wrong to leave wellness entirely to unscientific, unregulated practices with uncertain outcomes. It must be clearly defined which services should be delivered by healthcare professionals and which should be provided by tourism or wellness specialists. The safety of the methods used, the competence of service providers and the quality standards of facilities should be monitored. Guests should not be given unrealistic promises, and the boundary between wellness and medical treatment must be protected. Trust in Türkiye’s wellness tourism will be determined by this transparency and ethical approach before it is determined by impressive facilities. Türkiye Has a Powerful Story to Tell Türkiye is one of the few countries capable of bringing together, within a single geography, opportunities that many other countries possess only separately. Coastal tourism, forests, highlands, walking routes, thermal resources, the traditional Turkish bath culture, healthy cuisine, strong accommodation infrastructure and advanced healthcare services are all major advantages. When Istanbul’s international connectivity is considered alongside the diverse lifestyles of the Aegean, Mediterranean, Cappadocia, Black Sea and Anatolian regions, Türkiye has the potential to become a multi-destination wellness hub. But possessing these resources alone is not enough. A country becomes a brand by defining its assets, setting standards and presenting them to the world as clear and comprehensible offerings. Türkiye’s regions should not be positioned through identical SPA centres, but through wellness programmes shaped by their own natural and cultural characteristics. The Aegean can focus on healthy nutrition, movement and coastal living; the Black Sea on nature, breathing and mental renewal; Cappadocia on silence and inner balance; thermal regions on safe programmes that support rehabilitation; and Istanbul on short urban programmes for stress, sleep and renewal. Wellness tourism could thus move beyond a service offered only in certain cities and during the summer, becoming a year-round model that generates value across Türkiye’s regions. Success Should Not Be Measured by Room Count If success in wellness tourism is measured only by visitor numbers, length of stay or facility occupancy, the picture will remain incomplete. The real value is what the guest gains from the programme. Has sleep quality improved? Has physical activity increased? Has the guest developed healthier eating habits? Can stress be managed more effectively? Can the programme be sustained after returning home? Would the guest return to Türkiye or recommend the experience to others? Facilities capable of measuring the answers to these questions will move beyond selling services and become trusted wellness brands. Measurability does not mean turning wellness services into medical treatment. On the contrary, it makes the purpose, boundaries and value of the programme more transparent for the guest. Competition Should Be Based on Value, Not Price It would be a strategic mistake for Türkiye to compete in wellness tourism solely on affordability. A price advantage can be lost easily. Another country may offer a cheaper package, open a new facility or spend more on promotion. Lasting competitiveness, however, is built through trusted services, qualified people, personalised programmes, strong experiences and relationships that continue after the journey. Türkiye should make effective use of the space between hotels and hospitals. This field should not be left entirely to tourism or solely to healthcare institutions. Hotels, healthcare providers, universities, nutrition specialists, physiotherapists, psychologists, fitness professionals, technology companies and travel agencies need to operate within a shared model. In international promotion, clearly defined programmes addressing specific needs should take precedence over the image of a country that offers everything to everyone. What Kind of Wellness Model Will Türkiye Build? Türkiye has two possible paths ahead. The first is to keep SPA and wellness limited to a few services added to hotel packages. This approach may generate short-term revenue, but it will not differentiate Türkiye in global wellness competition. The second is to bring our natural resources, healthcare infrastructure, accommodation capacity, gastronomy and human capital together under a shared strategy. In this model, guests are offered not merely accommodation or personal care, but a safe, personalised and sustainable journey towards well-being. Türkiye does not need simply to open more SPA facilities; it needs to develop a wellness model of its own. The wellness tourism of the future will not sell people a few days of relaxation. It will offer them a journey through which they can reassess their bodies, minds and lifestyle habits. If Türkiye reads this transformation correctly, it can become not only a country people visit for medical treatment, but a global destination they choose to learn how to live more healthily.

Can Türkiye build a system that not only treats international patients, but also manages their recovery journey after they return home? Behlül ÜnverPresident, World Health Tourism Platform Healthcare institutions devote considerable effort, time and resources to reaching new patients in the health tourism sector. They conduct international promotional campaigns, allocate digital advertising budgets, establish call centres, recruit multilingual staff, enter into agreements with agencies and build patient referral networks in different countries. The purpose of all these efforts is to earn the trust of a new patient and encourage that person to choose Türkiye for healthcare. But once a patient has made an important decision, travelled to our country, trusted our institution and completed treatment, how does our relationship continue? Does the healthcare provider’s responsibility end when the patient is discharged and returns home? Or is that precisely when the real relationship of trust begins? This is one of the issues in health tourism that has not received enough attention: Post-treatment care and follow-up—in other words, aftercare. Do not forget existing patients while seeking new ones One of a healthcare institution’s most valuable patients is someone who has already chosen it. That person does not know the country, the institution, the physician and the quality of service merely through advertising; they have personally experienced the entire journey. They know how they were welcomed at the airport, how they communicated with their physician, what the hospital service was like, how discharge was managed and how they were treated after returning home. Even so, many institutions invest far less effort in maintaining relationships with existing patients than they do in acquiring new ones. Treatment is completed, the patient returns home and communication gradually declines. Sometimes the patient is contacted when a follow-up appointment is due; sometimes, because no problem is assumed to have occurred, the relationship ends altogether. Yet the end of treatment does not mean that all the patient’s questions have ended. It still matters whether medicines are being used correctly, how wound care is progressing, where follow-up tests will be performed, how nutrition and activity should be managed, which symptoms require medical attention and whom to contact if a complication occurs. When patients are left alone with these questions in their own country, the positive experience they had in Türkiye can gradually give way to uncertainty. Discharge is not the end of the healthcare journey The post-treatment period is not only about patient satisfaction. It is also directly related to patient safety. According to patient-safety evidence from the U.S. Agency for Healthcare Research and Quality (AHRQ), approximately 20% of patients discharged from hospital may experience an adverse event within the first three weeks. Around three-quarters of these events are considered preventable or capable of being mitigated. These figures do not measure medical tourists directly, but they demonstrate how sensitive the post-discharge period is for every patient. For medical travellers, the process can be even more complex. The patient is not simply returning home from hospital; they are returning to another country, another healthcare system and, in many cases, a location from which the treating physician is not physically easy to reach. In a study conducted by the U.S. Centers for Disease Control and Prevention (CDC) with 11 states and territories, 93,492 people were assessed and 517 were found to have travelled abroad for medical care during the previous year. Of those who received care abroad, 5% reported a complication; 67% of those who experienced a complication sought healthcare again after returning home. This finding points to an important reality: A medical traveller’s treatment does not end at the border; only the location where care is delivered changes. Aftercare is more than a phone call Aftercare should not be reduced to a phone call a few days after discharge asking, “How are you?” That call matters, but it is not enough on its own. AHRQ recommends that the clinical team contact patients two or three days after discharge. During this conversation, the patient’s condition, medications, follow-up appointments, services needed at home and what to do if a problem arises are reviewed together. In health tourism, this model needs to be more comprehensive. Before discharge, the patient should receive a care plan in their own language, with medicines and follow-up dates clearly stated. All necessary medical documents should be provided, and a responsible contact person should be identified for the period after the patient returns home. The follow-up process should not be limited to the first few days. Depending on the procedure, a personalised follow-up schedule can cover 48 hours, one week, one month, three months, six months and one year. Tests sent by the patient can be reviewed by the treating physician; online consultations can be arranged when necessary; and information can be shared with the patient’s doctor at home. A strong aftercare model does not wait for the patient to encounter a problem. It reaches the patient before a problem develops. We should not remind patients of ourselves only when selling a service Communication with the patient after treatment is not limited to clinical necessity. At appropriate intervals, a healthcare institution should remind the patient that it remains present, ask about their health and make them feel supported when needed. This does not mean sending constant advertising or steering the patient towards another procedure. The right kind of communication means offering health guidance, reminding the patient of follow-up dates, conveying a short message from the physician, asking about recovery and keeping accessible channels open whenever help is needed. A patient who feels valued not only at the point of payment but also after treatment forms a stronger bond with the institution. This bond affects both repeat choice and recommendations to others. In a systematic review examining the relationship between patient experience and organisational outcomes, 564 full-text publications were assessed and 40 studies that met the research criteria were included in the analysis. One of the strongest findings was that a positive patient experience is associated with both returning to the same institution and recommending it to others. Communication with physicians and nurses, access to services, respect and a sense of trust were particularly influential in repeat choice and recommendation behaviour. In health tourism, a patient’s recommendation can be more powerful than most advertisements. Healthcare decisions are not made through price comparisons alone. People attach great importance to the experience of someone who has already made the same journey—especially what happened after treatment. Trust in an institution becomes much stronger when a patient can say: “They contacted me after I returned home. My physician reviewed my results. I could reach them whenever I had a question. I never felt alone.” This is one of the most credible forms of institutional promotion. Not satisfaction, but relationship management Institutions generally measure patient satisfaction through surveys conducted at discharge. Yet the patient’s real experience often emerges after discharge. Were they able to obtain their medicines? Did they understand the follow-up plan? Could the physician in their own country access sufficient information about the procedure performed in Türkiye? Could the patient reach the right person when a problem occurred? Did the institution contact the patient again? Until these questions are measured, the patient experience cannot be considered complete. The performance indicators used by health tourism organisations should include more than the number of incoming patients, treatment revenue and conversion rates. They should also measure participation in follow-up programmes, completion rates for follow-up consultations, response time to complications, repeat-choice rates and the number of new patients arriving through patient referrals. This approach moves the patient beyond a one-off procedure and places them within a lifelong relationship of trust. Can continuity be built without digital infrastructure? Managing the post-treatment journey of thousands of international patients solely through phone calls, messaging applications and individual staff follow-up is not sustainable. A secure digital record is needed to bring together the medical traveller’s treatment history, procedures, medicines, follow-up dates and recovery progress. This system should be more than an archive. It should remind the patient of follow-up dates, provide necessary documents, facilitate online consultations and, with consent, enable secure information exchange with healthcare professionals in the patient’s home country. Artificial-intelligence-supported systems can monitor symptoms reported by patients, flag risks to the clinical team and prioritise patients who need follow-up. However, clinical decisions and responsibility must remain with healthcare professionals. Technology should be used not to replace human relationships, but to ensure that no patient is forgotten. Where does each party’s responsibility begin? One of the most important challenges in aftercare is unclear responsibility. Who will follow the patient—the physician, the hospital, the international patient unit, the agency or a healthcare provider in the patient’s home country? This question must be answered before treatment begins. When the discharge plan is prepared, the person responsible for follow-up should be identified, communication channels should be defined and a roadmap for potential complications should be established. The roles of the hospital, physician, agency and healthcare professionals in the patient’s home country must be clear. Agencies can support patient communication and coordination, but they cannot perform clinical assessment. Digital platforms can facilitate the process, but they cannot replace the physician. Hospitals, meanwhile, should not assume that their responsibility ends when the patient is handed over entirely to another institution after treatment. Aftercare requires a multi-stakeholder system with clearly defined responsibilities. A new quality standard for Türkiye Türkiye should standardise not only pre-treatment promotion and the care delivered in the country, but also the period after an international patient returns home. For international patients, Türkiye could establish multilingual discharge documents, personalised follow-up schedules, assigned case managers, secure digital health records, online follow-up systems, complication-management protocols and models of cooperation with healthcare professionals in patients’ home countries. Such a system would give Türkiye a significant advantage not only in clinical quality, but also in international trust and brand value. The future of health tourism competition will not be determined solely by which country attracts the patient. What will matter is who follows the patient more safely, who remains present after treatment and who can manage the healthcare journey without interruption. Institutions can continue to spend substantial budgets on finding new patients. But if they forget the patients who have already chosen them, they may be dismantling their strongest networks of trust and referral with their own hands. In health tourism, true quality is measured not on the day a patient leaves the hospital, but by whether that patient still feels safe after returning home. The strongest healthcare institutions of the future will be those that not only deliver successful treatment, but also leave their patients with this assurance after treatment: “We have not forgotten you. We will remain with you for as long as your recovery journey continues.”

In 2025, Türkiye provided healthcare services to approximately 1.4 million international patients and generated more than USD 3 billion in health tourism revenue. These figures demonstrate the country’s capacity and global appeal in health tourism. Yet behind every number is a person arriving from another country, speaking a different language, and carrying distinct expectations and healthcare needs. An international patient’s journey often begins with an online search. Social media, a call centre, a health tourism facilitator, a hospital coordinator, an interpreter, a physician, a transfer company, a hotel, the finance unit and the post-treatment follow-up team then enter the process. Many institutions and individuals are involved. Yet one fundamental question often remains unanswered: Who manages the patient’s entire journey from beginning to end? Everyone may be performing their own task. The health tourism facilitator finds the patient, the transfer company collects them from the airport, the hospital completes the registration, the physician provides the treatment and the hotel arranges the accommodation. Yet when these services are not connected, they do not create a successful healthcare journey from the patient’s perspective. To the patient, they are not separate services. There is one journey, one experience and one relationship of trust. How many people must a patient tell the same story to? During the first conversation, the international patient explains their condition and expectations to the health tourism facilitator. They may then have to repeat the same information to the call-centre agent, hospital coordinator, interpreter, nurse and physician. Medical reports are sent through a messaging application. Passport details remain in an email. The treatment quotation is communicated through another channel. Flight and hotel information is followed by different people, while the physician’s assessment sits in the hospital’s own system. When the patient arrives in Türkiye, they may discover that the programme has changed, that the hospital team does not have the same information as the person they first contacted, or that the proposed service differs from the treatment that will actually be provided. Even when the clinical care is successful, such inconsistencies damage trust in the institution. The problem is not usually a lack of effort or competence among employees. It is the fragmentation of information and responsibility across people and institutions. In healthcare, the most vulnerable moments are not confined to operations or medical procedures. The periods in which a patient moves from one professional to another, from one institution to another, or from hospital to home also carry significant risks. The World Health Organization describes transitions of care as a set of actions designed to ensure the coordination and continuity of healthcare. In health tourism, these transitions are even more complex because the patient changes not only institutions, but also country, language, health system, regulatory environment, culture and means of communication. Health tourism is not a sales process Many organisations operating in health tourism still manage the patient journey as though it were a sales funnel. An advertisement is placed, a prospective patient is found, the enquiry is sent to a call centre, a quotation is provided and the process is considered complete once payment is received. Healthcare, however, is not an ordinary product. The patient is not simply purchasing a procedure; they are entrusting an institution with their health, their body and, in some cases, their life. Success in health tourism therefore cannot be measured merely by bringing a patient to Türkiye or collecting payment. The patient must be properly informed, matched with the right healthcare provider and physician, have their medical file assessed in full, travel under a safe plan, receive coordinated treatment and remain under appropriate follow-up after returning home. Acquiring the patient is only the beginning of the journey. Value is created by managing the entire process safely and without interruption. The greatest risks lie in the gaps between services Many elements of a health tourism journey may be delivered successfully. The flight lands on time. The transfer vehicle is waiting at the airport. The hotel booking is confirmed. The hospital is modern, the physician experienced and the operation successful. The overall patient experience can still end badly because many failures in health tourism arise not within individual services, but at the points where one service hands over to another. Medical reports may not reach the physician in time; an assessment may be made from photographs alone; the scope of the quotation may be unclear; current medications may not be recorded; the interpreter may lack clinical terminology; or the discharge plan may not be shared with the transfer team. If a patient does not know whom to call when a complication occurs, if the hospital and facilitator are waiting for information from each other, or if clinical questions are being answered by non-clinical personnel, there is a serious accountability gap at the centre of the system. Preventing these gaps is itself a core dimension of quality in health tourism. The facilitator matters, but it is not the clinical authority Health tourism facilitators are important stakeholders in the ecosystem. They play an essential role in reaching patients, establishing initial contact, identifying an appropriate healthcare provider and organising accommodation, transport, transfers, interpreting and travel. Their role, however, must not be confused with the responsibilities of the healthcare provider and the physician. A facilitator can organise the patient’s healthcare journey, but cannot diagnose, decide on treatment or perform a clinical risk assessment. A price quotation and a medical treatment plan must not be treated as interchangeable. The proposal presented to the patient should be based on an assessment by an authorised physician, and the scope, alternatives, possible risks and post-treatment requirements should be explained clearly. Equally, a hospital should not hand the entire organisation over to the facilitator and assume that its relationship with the patient is limited to the period of treatment. The facilitator should be accountable for organisation, the healthcare provider for the service system and the physician for clinical decisions. Above them, however, there must be a shared journey-management structure that connects the whole process. The ‘designated officer’ in the regulation is an important starting point The Regulation on International Health Tourism and Tourist Health, published on 26 April 2025, introduced important provisions in this area. It requires healthcare providers to establish an international health tourism unit responsible for coordinating admission, registration, diagnosis, treatment, billing, discharge, interpreting and relations with health tourism facilitators. It also requires a staff member from this unit to be designated for each international patient and recorded on the HealthTürkiye Portal. Facilitators must also maintain an infrastructure capable of responding to calls in at least two foreign languages on a 24/7 basis. These are valuable steps towards ownership of the patient journey. Yet appointing a designated officer is not enough. If that person cannot access the physician’s assessment, the current treatment plan, payment information, transfer programme and follow-up schedule, they may remain little more than a telephone coordinator. A genuine journey manager must be able to access information, communicate with decision-makers, escalate problems to the relevant units and follow the case through to resolution. The patient needs more than a named contact; they need a system with clearly defined authority and accountability. One point of contact, one file and one current source of information Having one accessible contact person gives an international patient confidence. The system, however, must not depend on one individual. The patient’s entire process should not disappear when that person is on leave, changes role or leaves the organisation. The journey therefore needs to be managed through an institutional digital infrastructure. Identity and contact details, medical history, current medicines, test results, physician assessments, treatment plans, quotations, consent documents, travel and accommodation information, appointment dates and post-treatment follow-up records should be held in a secure file accessible to authorised users. The patient then no longer has to repeat the same story at every stage. The physician sees the latest clinical information, the coordinator the current schedule, the finance unit the approved quotation, and the transfer team only the logistical information required for its task. Not everyone sees the same information, but everyone sees the accurate and current information they need. European Union rules on cross-border healthcare also recognise patients’ ability to access their medical records remotely, or at least to receive a copy, as an important right. They further provide for patients who receive treatment across a border to have access to necessary medical follow-up in their home country. This approach shows that health data is not simply an archive confined to the hospital; it is a fundamental part of continuity of care. Responsibilities must be clearly defined No single institution can perform every task in health tourism. A strong system requires multiple stakeholders to work together, but collaboration must not mean blurred accountability. The facilitator should manage patient communication and organisation. The healthcare provider should ensure clinical safety and institutional coordination. The physician should make diagnostic, treatment and follow-up decisions. The interpreter should communicate accurately without offering clinical opinions. Transfer and accommodation providers should meet the quality standards relevant to their services. The digital platform should move data securely, prevent unauthorised access and record the actions taken. The scope of cooperation with healthcare professionals in the patient’s home country should also be agreed in advance. Every stakeholder should understand their role, yet no one should be able to leave the patient outside the system by saying, ‘This is not my responsibility.’ At each stage, it should be clear who is responsible, who approves, who supports and who must be informed. A predefined escalation and response plan is particularly important for medical emergencies, changes to the treatment plan, additional costs, delayed flights and suspected complications. Success cannot be measured by patient numbers alone Health tourism organisations usually measure performance through patient volumes, treatment revenue, conversion rates and market share by country. These indicators matter, but they do not explain the quality of the journey. Organisations should also measure how quickly the first enquiry is answered, how many hours or days pass before a physician reviews the medical file, whether the delivered procedure differs from the approved proposal and how many different people the patient must contact. Waiting times, missing-document rates, transfer failures, complaint-resolution times, the time taken to deliver medical records, attendance at follow-up consultations and response speed when complications arise should also be tracked. It is not enough to ask about satisfaction only on the day of discharge. Organisations that can identify where trust was lost and where information was interrupted can improve their services in a lasting way. We cannot manage a journey that we do not measure. Türkiye can establish an ‘international patient journey standard’ Türkiye has strong hospitals, experienced physicians, advanced technology, extensive transport links and a substantial hospitality infrastructure. The next step is to bring these strengths together within a shared patient-journey model. A digital journey record can begin before treatment and continue through the post-treatment period for every international patient. Within this model, the patient can reach verified healthcare providers and physicians, have medical information assessed securely, receive a transparent description of the service, be assigned a responsible journey manager and follow appointments, payments, transfers, treatment and follow-up in their own language. Hospitals, physicians, facilitators and other service providers can work on the same infrastructure within their respective permissions. Artificial intelligence can help detect missing documents, support multilingual communication, issue appointment reminders, identify delays and route high-risk reports to the clinical team. Clinical decisions and responsibility for patient safety, however, must remain with healthcare professionals. What is needed is not another piece of software, but shared operating rules, defined responsibilities, secure data exchange, measurable service times and an institutional management model that takes responsibility for the patient’s entire journey. The issue before Türkiye is not simply to reach more international patients. It is to determine clearly who manages the entire process from the patient’s first enquiry until their return home. Every patient should have an authorised contact, a current file shared across institutions, clearly defined responsibilities and a response plan that works when a problem arises. Without these elements, many separate services may be delivered, but they do not form a coherent healthcare journey. International patients should not have to understand an organisation chart. For them, the system exists only if they can reach the right person when they need help. If, at any point in the journey, a patient has to ask, ‘Who should I call now?’, that journey is not yet being managed.