What America's Broken After-Hours Pharmacy Access Could Learn from Istanbul's Rotating Duty System
What America's Broken After-Hours Pharmacy Access Could Learn from Istanbul's Rotating Duty System
On any given Tuesday night in Istanbul, a parent whose child develops a sudden fever at midnight has a clear, reliable path to medication: find the nearest nöbetçi eczane — the legally designated duty pharmacy for their district — and walk in. The lights are on. A licensed pharmacist is present. The medication is available at a government-regulated price. The entire interaction may take fifteen minutes.
On that same Tuesday night in Columbus, Ohio, or Memphis, Tennessee, or Fresno, California, that same parent faces a meaningfully different set of options. If they live within driving distance of a 24-hour Walgreens or CVS, they are fortunate. If they do not — and tens of millions of Americans do not — the realistic alternatives narrow to an urgent care clinic (if one happens to be open) or an emergency room visit that will generate a bill their insurance may only partially cover weeks later.
This disparity is not incidental. It reflects a fundamental difference in how two societies have chosen to conceptualize pharmaceutical access: as a market service, or as a public health infrastructure.
Understanding the Nöbetçi System in Structural Terms
Turkey's nöbetçi eczane model — the framework that İstanbul Nöbetçi Eczane is built around — operates on a principle of distributed, mandatory obligation. The Istanbul Chamber of Pharmacists coordinates a rotating schedule in which every licensed pharmacy in each district takes its turn serving as the 24-hour duty location. The rotation is typically weekly. The schedule is publicly posted, digitally accessible, and legally enforced.
Critically, this is not a system that relies on economies of scale or corporate willingness to absorb overnight operating costs. A small, independently owned pharmacy on a residential street in Kadıköy carries the same duty obligation as a larger establishment in a commercial corridor. The burden — and the honor — is shared equally across the profession.
The Turkish government also maintains price controls on medications dispensed through this system, which means that a patient arriving at a nöbetçi eczane at 3 AM will pay the same regulated price they would during daytime hours. There is no surge pricing, no premium for inconvenience, no financial penalty for having a health need outside of business hours.
The American Landscape: Access by Accident, Not Design
By contrast, after-hours pharmaceutical access in the United States is largely the product of corporate real estate strategy rather than public health planning. The 24-hour pharmacy model pioneered by chains like Walgreens and CVS was never designed as a universal public service — it was designed to capture market share in high-density, high-traffic locations where overnight operations could be justified financially.
The result is a geography of access that mirrors broader patterns of economic inequality. Wealthier urban and suburban areas with dense retail corridors are reasonably well-served by 24-hour chain locations. Rural communities, lower-income urban neighborhoods, and mid-sized cities without dominant retail pharmacy presence are significantly underserved. According to research published by the National Association of Chain Drug Stores and subsequently analyzed by health equity scholars, roughly one in five Americans lives more than a mile from any pharmacy — and that figure worsens dramatically after 10 PM when the majority of independent and smaller chain pharmacies close.
The consequences of this access gap are not abstract. Patients who cannot obtain medications after hours frequently delay treatment, skip doses, or — most expensively for the healthcare system as a whole — present to emergency departments for conditions that a pharmacist could have addressed at a fraction of the cost. A 2022 analysis in the American Journal of Managed Care estimated that between 10 and 15 percent of non-emergency ER visits involved pharmaceutical access issues that could have been resolved at a pharmacy if one had been available.
The Cost Argument: Why the ER Is an Absurd Alternative
The financial case for a duty pharmacy system in the United States is, frankly, overwhelming once you examine the numbers.
The average cost of an emergency room visit in the United States — even for a relatively minor, non-critical complaint — ranges from $1,500 to $3,000 before insurance adjustments. A visit to a 24-hour pharmacy for the same presenting concern (fever management, a respiratory inhaler, a UTI antibiotic) might cost $20 to $80 out of pocket. The difference is not marginal; it is an order of magnitude.
Insurers, hospital systems, and public health economists have long recognized this dynamic, and yet the structural incentives in American healthcare have historically failed to redirect patients toward lower-cost access points when those access points simply do not exist. You cannot choose a pharmacy over an ER if no pharmacy is open.
A rotating duty pharmacy mandate — even one applied only to major metropolitan areas initially — would create a reliable, low-cost alternative that could meaningfully reduce unnecessary emergency department utilization. The savings would accrue not only to individual patients but to Medicaid and Medicare systems, employer-sponsored insurance pools, and hospital operating budgets strained by non-emergency ER traffic.
What Implementation Could Look Like in an American Context
Adapting the nöbetçi model to the United States would require acknowledging several structural differences. American pharmacy ownership is far more concentrated in corporate chains than in Turkey, where independent pharmacies remain the dominant model. A mandate applied uniformly to all licensed pharmacies would face significant legal and lobbying resistance from large retail corporations.
However, a more targeted policy approach is entirely feasible. State pharmacy boards — which already hold substantial regulatory authority over licensing and operating standards — could implement district-based duty rotation requirements as a condition of licensure in metropolitan areas. Pharmacies serving a designated duty shift could receive modest government reimbursements to offset overnight staffing costs, funded through existing public health budgets or redirected from emergency department cost-reduction programs.
Some cities have already experimented with adjacent concepts. Several municipal health departments have piloted after-hours medication access through mobile pharmacy units or extended-hours community health centers. These programs demonstrate both the demand for the service and the feasibility of the model — but they remain isolated experiments rather than systemic infrastructure.
The Equity Dimension That Cannot Be Ignored
Perhaps the most compelling argument for adopting a duty pharmacy framework in the United States is not financial but moral. Pharmaceutical access after hours is not a luxury concern — it is a matter of health equity with documented racial and socioeconomic dimensions.
Studies consistently demonstrate that pharmacy deserts are disproportionately concentrated in Black and Latino neighborhoods, in low-income rural counties, and in communities that have experienced retail disinvestment over recent decades. The populations least likely to have a 24-hour pharmacy nearby are, by a significant margin, also the populations least able to absorb an emergency room bill or the health consequences of delayed medication access.
Turkey's nöbetçi system is not perfect, and it operates within a healthcare context that differs from the American one in important ways. But its core principle — that pharmaceutical access is a neighborhood-level public obligation, not merely a market outcome — is a principle the United States has yet to seriously adopt. Given the costs, the inequities, and the entirely solvable nature of the problem, the question worth asking is not whether America could implement something like Istanbul's duty pharmacy model. It is why, in 2025, it still has not.
