Conditions for health care
All registered temporary protection beneficiaries, whether residing in the camps or outside the camps, are covered under Türkiye’s General Health Insurance (GSS) scheme and have the right to access health care services provided by public health care service providers.[1] The health care services are no longer free of charge following a legal amendment of 25 December 2019 and they have to pay a contribution fee determined by the Ministry of Interior Affairs to access primary and emergency health care services and medicines.[2] This does not apply to vulnerable groups, however. The practice of contribution fees is different in each province with no uniform application. Reimbursement is not foreseen in the law.
Persons who are eligible for temporary protection but have not yet completed their registration have only access to emergency medical services and health services pertaining to communicable diseases as delivered by primary health care institutions.
Temporary protection beneficiaries are only entitled to access health care services in the province where they are registered. However, where appropriate treatment is not available in the province of registration or where deemed necessary for other medical reasons, the person concerned may be referred to another province.[3]
The “income test” to assess means classifies 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.[4]
During the COVID-19 pandemic refugees and migrants (including undocumented) were given access to COVID-19 treatment and testing, however, a number of barriers to these services remained including other out-of-pocket health care expenditure and the language barrier.[5] Materials have been provided in Arabic to help combat this by UNHCR, ASAM and others. Reports from stakeholders in 2021 included that beneficiaries of international and temporary protection had to pay for vaccines.[6]
Scope of health care coverage
Under the Turkish health system, differentiation is made among 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.
Temporary protection beneficiaries 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.
Temporary protection beneficiaries are also entitled to spontaneously approach public hospitals in their province. Their access to medical attention and treatment in university and research and training hospitals, however, is on the basis of a referral from a state hospital.[7] In some cases, state hospitals may also refer a beneficiary to a private hospital, where appropriate treatment is not available in any of the public healthcare providers in the province. In such a case, the private hospitals are compensated by the GSS scheme and the beneficiary is not charged.
As a rule, referrals to university hospitals and private hospitals are only made for emergency and intensive care services as well as burn injuries and cancer treatment. This is confirmed in practice in Hatay, Adana and Mersin, where temporary protection beneficiaries cannot access the research and training hospitals without a medical doctor referral. Costs are not covered by the State promptly, however.
Temporary protection beneficiaries’ access to secondary and tertiary health care services is conditional upon whether the health issue in question falls within the scope of the Ministry of Health’s Health Implementation Directive (SUT). For treatment for 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 however exceed the maximum financial compensation amounts allowed by the SUT, beneficiaries may be required to make an additional payment. For example, prosthetic surgery was previously not covered by health care services in Adana, thereby posing an important obstacle.[8]
Free health care coverage for registered temporary protection beneficiaries also extends to mental health services provided by public health care institutions. A number of NGOs are also offering a range of psycho-social services in some locations around Türkiye with limited capacity. The need for mental health support is pressing. The University of Marmara highlighted in 2018 that 6 out of 10 Syrian refugee children suffer from mental health conditions such as PTSD and depression.[9]
With ECHO funding until the end of 2019, the “Geçici Koruma Altındaki Suriyelilerin Sağlık Statüsünün ve Türkiye Cumhuriyeti Tarafından Sunulan İlgili Hizmetlerin Geliştirilmesi” (SIHHAT) project has established 187 Migrant Health Centres (Göçmen Sağlığı Merkezi) for Syrian beneficiaries of temporary protection in 28 provinces. Syrians can approach these centres as primary health care institutions. Migrant Health Centres employ 790 mainly Syrian doctors, 790 nurses, 300 support staff, 84 technicians and 960 patient guides.[10] The second phase was announced in December 2020 “Supporting Migrant Health Services in Türkiye (SIHHAT 2)” will focus on increasing the quality of migrant health services and the integration of services and staff to the Turkish Health System. The project aims to increase the number of Migrant Health Centres, the number of healthcare staff with a special focus on Health Literacy, Mental Health and Psychosocial Support, Reproductive Health, Physiotherapy and Rehabilitation with EUR 210 millions of support. [11]
In addition, the “Strengthening Health Care Infrastructure for All (SHIFA)” project aims to construct new migrant health centres and provide medical equipment, maternity, health kits and capacity building with EUR 90 millions of support.[12] A first steering committee meeting was held in October 2021.[13]
Medication costs
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. The same rule also applies to temporary protection beneficiaries, while the rest was previously covered by AFAD.
That said, in terms of access to medication, complications and inconsistent implementation are observed across the country. However, Türkiye has repeatedly claimed that the amount allocated for service expenditure for Syrian refugees is 40 billion Turkish Lira and the major service unit is health care.[14]
Obstacles to access in practice
The language barrier is one of the key problems encountered by temporary protection beneficiaries in seeking to access health care services.[15] The language barrier also hinders access to mental health treatment.[16] Although there are interpreters available in some public health institutions in some provinces in the south of Türkiye, in most health care facilities including Migrant Health Centres no such interpretation services are available.[17] A major practical obstacle for refugees is that hospitals in Türkiye 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.
The Ministry of Health operates a free hotline that provides limited distance interpretation services to temporary protection beneficiaries, doctors and pharmacists. However, the hotline does not provide any general counselling to beneficiaries about the healthcare system or assistance in obtaining appointments at hospitals. The Danish Refugee Council also operates a limited free hotline service providing interpretation services to Syrians in Arabic and Turkish for the purpose of facilitating interactions with health care providers. Türk Kızılay, for its part, provides an interpreter and a social worker under its Child Protection Centre project, who accompany children at hospitals in Ankara where needed. The Numune and Dışkapı State Hospitals in Ankara also have one interpreter each.
Türk Kızılay also runs community centres providing services on health and protection. 16 centres are currently operational. These centres identify the needs of temporary protection beneficiaries e.g. accessing health care, and also offer psycho-social support.[18]
Vulnerable and marginalised groups such as sex workers face more acute challenges to accessing services, including information on sexual health, due to the fact that they do sex work informally, often through intermediaries – who in some cases are perpetrators of discrimination and violence – and under heavy working conditions.[19] A number of Syrian sex workers interviewed in 2017 by Red Umbrella Sexual Health and Human Rights Association were unaware of HIV testing and counselling centres and had limited knowledge of health care facilities they could go to if needed.[20] There is very limited information currently on this vulnerable group.
The new regulation on charging a contribution rate to Syrians refugees will impose a serious barrier to access to health but it may not be applied to vulnerable groups.[27] There was no further information in 2020 as to how this was being applied for different groups.
Seasonal or agricultural workers do not go to secondary and tertiary health centres. There are two reasons for this, the first is the number of people at hospitals and in 2020 there was also the fear of COVID-19 infection. For primary care, they tend to go to family physicians. There is a project run by Doctors of the World who offer health services to seasonal agricultural workers but there is almost no health service for nomadic / semi-nomadic groups who prefer immigrant health centres in Gaziantep when they have the money and when transportation is available.[28]
In September 2021, a new application called ‘emergency travel documents specific to foreigners ’ started to be given to those receiving health treatment in mobile field hospitals in controlled land by the Turkish state in Syria and who have urgent health needs in Türkiye. This document permits them to live and stay in Türkiye to get proper health treatment for a limited period such as three or six months. Once the document has expired, the person has to re-enter Türkiye. The exact number is unknown, but more than 1000 Syrians have this document and live in Türkiye. Generally, their entry is from Hatay, and their first application should be at Hatay State Hospital and then they are referred to another state hospital. Sometimes they are referred to private hospitals, which means that they have to start the process again. Some state hospitals do not recognize this document and do not provide the service. The service is not free of charge, and lawyers have applied for health protection measures before the relevant courts because these people primarily have serious health conditions like cancer. Those affected are issued a code (V-160), and so cannot obtain an ID card. These documents cause many problems- in referral to a university hospital or living in Türkiye for a long time without an ID card. Those affected also cannot access other services, and any person accompanying them has no access to services due to a lack of an ID card. Once these documents expire, and people have to go back to the city of the first entry, often they do not have sufficiently good health to travel from one city to another.[29]
[1] Article 27 TPR.
[2] Article 27(1)b as amended by Regulation no.30989.
[3] Basak Bilecen and Dilara Yurtseven, ‘Temporarily protected Syrians’ access to the healthcare system’ (2018) 15:1 Migration Letters 133, 118.
[4] Türk Kızılay, Syrian beneficiaries of Ankara community centre, September 2018, available at: https://bit.ly/2Yx50zB.
[5] Journal of Migration and Health, COVID-19 barriers and response strategies for refugees and undocumented migrants in Türkiye, Volumes 1–2, 2020, available at: https://bit.ly/2SKkcee.
[6] Information provided by two stakeholders, May 2022.
[7] Ibid.
[8] Information provided by a lawyer of the Adana Bar Association, February 2018.
[9] Diken, ‘Araştırma: Türkiye’deki Suriyeli her 10 çocuktan altısında psikiyatrik hastalık var’, 1 May 2018, available in Turkish at: https://bit.ly/2HF5BJH.
[10] SIHHAT, Proje Faaliyetleri, available in Turkish at: https://bit.ly/2UUEZbi.
[11] Statewatch, ‘Final contracts arranged for €6 billion EU-Türkiye deal’, 22 December 2020, available at: https://bit.ly/3ooLKBF
[12] Statewatch, ‘Final contracts arranged for €6 billion EU-Türkiye deal’, 22 December 2020, available at: https://bit.ly/3ooLKBF
[13] See, Republic of Türkiye, Ministry of Health website, ‘SHIFA Project First Steering Committee Meeting’, 10 November 2021, available at: https://bit.ly/3y8hvEz.
[14] Al-Monitor, ‘Suriyelilere 40 milyar dolar harcandı mı?’, 2 November 2019, available in Turkish at: https://bit.ly/2yd0g9A.
[15] Basak Bilecen and Dilara Yurtseven, ‘Temporarily protected Syrians’ access to the healthcare system’ (2018) 15:1 Migration Letters 133, 118.
[16] Diken, ‘Araştırma: Türkiye’deki Suriyeli her 10 çocuktan altısında psikiyatrik hastalık var’, 1 May 2018, available in Turkish at: https://bit.ly/2HF5BJH.
[17] Information provided by an NGO, February 2019.
[18] For more information, see Türk Kızılay, Syria crisis: Humanitarian relief operation, September 2017, available at: http://bit.ly/2Fsj2YZ.
[19] Red Umbrella Sexual Health and Human Rights Association, Syrians under “temporary protection” in Türkiye and sex work, 2017, available at: available at: http://bit.ly/2nWo6B3, 65-71.
[20] Ibid, 67-68.
[21] Information provided by a stakeholder in Gaziantep in February 2020
[22] Information from a stakeholder in İstanbul, March 2020.
[23] GAR (Association for Migration Research), Barriers to and Facilitators of Migrant Communities’ Access to Health Care in İstanbul, September 2020, available at: https://bit.ly/3wk4nu6.
[24] Association for Solidarity with Syrian Refugees, COVID 19 Pandemisinde Mülteci Kadınların Temel Haklara Erişimine İlişkin Araştırma Raporu, 2020, available in Turkish at: https://bit.ly/3uJnV9T.
[25] Women’s Solidarity Foundation, Gender Based Violence and Discrimination: Syrian Women Living In Ankara, 2020, available at: https://bit.ly/3dPB4r2, 41.
[26] bid., 53.
[27] Information provided by a stakeholder in February 2020.
[28] Information provided by a stakeholder, March 2021.
[29] Information provided by a stakeholder, May 2022.