Health care

Turkey

Country Report: Health care Last updated: 30/11/20

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Independent

Turkey’s General Health Insurance (Genel Sağlık Sigortası, GSS) scheme makes it compulsory for all residents of Turkey to have some form of medical insurance coverage, whether public or private. For persons whose income earnings are below a certain threshold and are therefore unable to make premium payments to cover their own medical insurance, the scheme extends free of charge health care coverage.[1]

A means assessment for the purpose of health care coverage decisions on applicants is foreseen in the law (see Criteria and Restrictions to Access Reception Conditions) and is carried out by DGMM. The law also states that where DGMM at a later stage identifies that an applicant is partially or fully able to pay their own health insurance premiums, he or she may be asked to pay back in part of in full the premium amount paid for by DGMM to the general health insurance scheme.

Article 89(3) LFIP provides that “international protection applicants and status holders who are not covered by any medical insurance scheme and do not have the financial means to afford medical services” shall be considered to be covered under Turkey’s GSS scheme and as such have the right to access free of charge health care services provided by public health care service providers. For such persons, the health insurance premium payments shall be paid by DGMM.

Article 89(3) LFIP designates that DGMM shall make the premium payments on behalf of international protection applicants and status holders. Previously the Ministry of Family, Labour and Social Services made the payments in the framework of an arrangement between the two agencies. The assessment of means took the form of an “income test” which classified the beneficiary according to the level of income. Persons in the “G0” class have health care premiums covered entirely, while individuals in categories “G1”, “G2” and “G3” proportionally cover some of their health care costs.[2] However, the assessment criteria changed in 2019 after changes to the LFIP. According to the new law, the General Health Insurance Scheme is no longer applicable for international protection applicants one year after their registration, apart from those with special needs or ones approved by the Directorate General.

Assessment criteria are, therefore, no longer applied to non-Syrians apart from vulnerable groups. For vulnerable cases the DGMM requires evidence such as health and medical reports issued by state hospitals showing the vulnerable person’s health condition. These medical reports are difficult to obtain for those who do not have health care coverage.[3]

In 2019 some PDMMs did not activate the health insurance of some international protection applicants who were eligible to renew their IDs for another year. There were at least 100 cases from diverse central Anatolian cities. On the other hand, Karabuk PDMM activated health insurance in conformity with an internal document sent by DGMM for those whose international protection application was rejected but who had appealed the decision. [4]

 

Scope of health care coverage

 

Under the Turkish health system, differentiation is made between primary, secondary and tertiary public health care institutions:

  • Health stations, health centres, maternal and infant care and family planning centres and tuberculosis dispensaries that exist in each district in each province are classified as primary healthcare institutions;
  • State hospitals are classified as secondary health care institutions;
  • Research and training hospitals and university hospitals are classified as tertiary health care institutions.

Persons covered under the GSS scheme are entitled to spontaneously access initial diagnosis, treatment and rehabilitation services at primary health care institutions. These providers also undertake screening and immunisation for communicable diseases, specialised services for infants, children and teenagers as well as maternal and reproductive health services. The EU-funded SIHHAT project supported and developed primary health care services between 2016 and 2019 in 28 provinces with a dense Syrian population to increase access to health services.

GSS beneficiaries are also entitled to spontaneously approach public hospitals and research and training hospitals in their province. Their access to medical attention and treatment in university hospitals, however, is on the basis of a referral from a state hospital. In some cases, state hospitals may also refer a beneficiary to a private hospital, where the appropriate treatment is not available in any of the public health care providers in the province. In such a case, the private hospital is compensated by the GSS and the beneficiary is not charged.

In principle, referrals to university hospitals and private hospitals are only made for emergency and intensive care services as well as burn injuries and cancer treatment.  That said, in situations of medical emergency, persons concerned may also spontaneously approach university hospitals and private hospitals without a referral.

GSS beneficiaries’ access to secondary and tertiary healthcare services is conditional upon whether the health issue in question falls within the scope of the 2013 Health Implementation Directive (Sağlık Uygulama Tebliği, SUT).[5]

For treatment of health issues which do not fall within the scope of the SUT or for treatment expenses related to health issues covered by the SUT which exceed the maximum financial compensation amounts allowed by the SUT, beneficiaries may be required to make an additional payment.

According to SUT, persons covered by the general health insurance scheme are expected to contribute 20% of the total amount of the prescribed medication costs. In addition, beneficiaries are expected to pay 3 TL per medication item up to three items, and 1 TL for each item in more than three items were prescribed.

If persons have a chronic disease such as diabetes, hypertension, or asthma that requires taking medicine regularly, in this case, they can approach a state hospital and ask them to issue a medication report. By submitting the medication report to the pharmacy, they can be exempted from the contribution fee.

People can also approach public health centres (toplum sağlığı merkezi) in their satellite city to benefit from primary health services free of charge.

According to Article 67(2) LFIP, applicants who are identified as “victims of torture, rape and other forms of psychological, physical or sexual violence” shall be provided appropriate treatment with a view to supporting them to heal after past experiences.  However, as to the actual implementation of this commitment, guidance merely mentions that DGMM authorities may cooperate with relevant public institutions, international organisations and NGOs for this purpose.[6] That said, the free health care coverage of international protection applicants would also extend to any mental health treatment needs of applicants arising from past acts of persecution. In any case, free health care coverage under the general health insurance scheme also extends to mental health services provided by public health care institutions. Provincial Directorates of Family and Social Policies also offer psychological assistance, although interpreters are not available in all of them.

A number of NGOs also offer a range of psycho-social services in different locations around Turkey although capacity is limited. SGDD-ASAM, IKGV, Support to Life and Türk Kızılay are some of the NGOs providing psycho-social support in different cities across Turkey. Türk Kızılay Community Centre in Urfa has a new project in collaboration with UNICEF, DGMM and the Ministry of Health on empowering the mental health of refugees. Two new mental health centres will be established in Urfa and Ankara (pilot cities) then extended to 18 cities.[7]

According to the Cohesion Strategy and National Action Plan (2018-2023) the following were priorities for improvements in the area of health:

  • Health assessments for immigrants upon arrival
  • Vaccinations
  • Access to primary care
  • Increasing capacity for access to secondary and tertiary care
  • Coordination
  • Sensitizing health sector staff to needs of immigrants

The Action Plan includes:

  • Ensuring better coordination of services;
  • Health assessments upon arrival and vaccination programmes;
  • Migrant health centres where there are high concentrations of people with temporary protection;
  • Development of health services in return centres;
  • Mobile health services for disadvantaged groups such as the elderly and disabled as well as for agricultural workers;
  • Access to reproductive health;
  • Migrant health centres able to provide oral/dental health services;
  • Increasing access to community health centres;
  • Central health appointment system in other languages than Turkish;
  • Information tools in different languages;
  • Bilingual patient orientation staff eg in hospitals where high concentration of migrants.

 

Practical constraints on access to health care

 

To benefit from GSS, applicants must already be registered with the PDMM and issued an International Protection Applicant Identification Card, which also lists the YKN assigned by the General Directorate of Population Affairs to each applicant. This YKN designation is a prerequisite for hospitals and other medical service providers to be able to intake and process an asylum seeker. The current obstacles to Registration thus have repercussions on asylum seekers’ access to health care.

The language barrier remains the predominant problem encountered by asylum seekers in seeking to access to health care services.[8] Hospitals in Turkey give appointments to patients over the telephone. Since hospital appointment call centres do not serve prospective patients in any language other than Turkish, foreign nationals need the assistance of a Turkish speaker already at appointment stage. There is no nationwide system for the provision of interpretation assistance to international protection applicants and beneficiaries, although the EU-funded SIHHAT project 2016 and 2019 included interpreters for Syrian temporary protection beneficiaries (see Temporary Protection: Health Care). NGOs in some locations also offer limited services to accompany particularly vulnerable asylum seekers to hospitals. In some provinces such as Hatay, doctors only accept interpreters under oath, while in others like Ankara hospitals have their own interpreters.[9]

Where an international protection applicant has a medical issue, for which no treatment is available in his or her assigned province of residence, he or she may request to be assigned to another province to be able to undergo treatment (see Freedom of Movement). Article 110(5) RFIP allows applicants to request to be assigned to another province for health reasons.

Article 90(2) LFIP states that for applicants who fail to comply with the obligations listed in Article 90(1) or about whom a negative status decision was issued, the DGMM may proceed to a Reduction of rights and benefits, with the exception of education rights for minors and basic health care. In practice, however, PDMM have proceeded with the de-activation of the GSS for persons whose application for international protection is considered withdrawn (“cancelled”) due to non-compliance with the obligation to stay in the assigned “satellite city” or rejected, even without the decision having become final. Lawyers have challenged these cases but unsuccessfully so far.[10]

In addition, in provinces such as Afyon and Kırikkale, where individuals are able to re-activate their GSS, they cannot benefit from health care before paying outstanding premium debts for the period during which their GSS was de-activated.[11]

After the recent legal amendments, the health insurance of Afghans was deactivated immediately in Adiyaman and Antep. In Van the health insurance of both Iranians and Afghans was deactivated right after the law entered into force.[12]

 


[1] Law No 5510 on Social Security and General Health Insurance lays down the scope and modalities of Turkey’s general health insurance scheme.

[2] Türk Kızılay, Syrian beneficiaries of Ankara community centre, September 2018, available at: https://bit.ly/2Yx50zB.

[3]Information provided by a stakeholder, March 2020.

[4]Information provided by a stakeholder, February 2020.

[5]Directive No 28597, 24 March 2013.

[6]Article 113(1) RFIP.

[7]Information provided by Türk Kızılay Community Centre Urfa, February 2020.

[8]Information provided by Bosphorus Migration Studies, January 2019.

[9]Information provided by Bosphorus Migration Studies, January 2019.

[10] Information provided by stakeholders, February 2019.

[11]Ibid.

[12]Information provided by a lawyer from the Van Bar Association, March 2020.

 

Table of contents

  • Statistics
  • Overview of the legal framework
  • Overview of main changes since the previous report update
  • Introduction to the asylum context in Turkey
  • Asylum Procedure
  • Reception Conditions
  • Detention of Asylum Seekers
  • Content of International Protection
  • Temporary Protection Regime
  • Content of Temporary Protection