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]
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.[5] 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 various cities 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.[6]
97 million medical services, more over 3 million inpatient treatments, and 2,6 million procedures were delivered to Syrian beneficiaries in primary, secondary, and tertiary public health institutions up until March 2022. In addition, 754,000 Syrian babies were born in these public health institutions.[7]
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 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 however exceed the maximum financial compensation amounts allowed by the SUT, beneficiaries may be required to make an additional payment.
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. Turk Kizilay provided health support including mental health support to 685,973 people as of May 2023.
With EU funding, from 2019 to 2022 in the frame of the “Geçici Koruma Altındaki Suriyelilerin Sağlık Statüsünün ve Türkiye Cumhuriyeti Tarafından Sunulan İlgili Hizmetlerin Geliştirilmesi” (SIHHAT-1) and (SIHHAT-2) projects, 185 Migrant Health Centres (Göçmen Sağlığı Merkezi) were established for Syrian beneficiaries of temporary protection in 29 provinces. Syrians can approach these centres as primary health care institutions. Migrant Health Centres employ 4,000 staff including 787 Syrian doctors, 1149 nurses, 34 dentists.[8] In 2022, the project’s scope has been expanded to include vulnerable populations, such as seasonal migrant workers, and mobile health services. In addition, doctors with origins in Yemen and Palestine have been recruited for the project.[9]
In addition, the “Strengthening Health Care Infrastructure for All (SHIFA)” project aims to construct migrant health centres and provide medical equipment, maternity, health kits and capacity building with EUR 90 millions of support.[10] The second steering committee meeting was held in July 2022.[11]
In addition, NGOs have operated projects aimed at enhancing vulnerable groups’ access to health care. With the aid of ECHO and in collaboration with Relife International, MUDEM opened a community centre in Izmir to assist vulnerable groups.[12]
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.
Obstacles to access in practice
The fact that Turkish hospitals schedule patients over the phone presents a significant practical barrier for refugees. Foreign nationals require the assistance of a Turkish speaker at the appointment stage, as hospital appointment call centres do not serve prospective patients in any language other than Turkish[14][15].
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 Numune and Dışkapı State Hospitals in Ankara also have one interpreter each.
Türk Kızılay also runs community centres providing services on health and protection. As of May 2023, 18 centres are currently operational. These centres identify the needs of temporary protection beneficiaries e.g. accessing health care, and offer psycho-social support.[16] These centers has reached a total of 1,999,278 people.[17]
Vulnerable and marginalised groups, such as sex workers, face greater obstacles to accessing services, such as information on sexual health, due to the fact that they perform sex work informally, frequently through intermediaries – who, in some instances, are perpetrators of discrimination and violence – and under harsh working conditions. Since 2018, UNFPA has provided multiple services to the ‘key refugee population,’ including sex workers, LGBITQ+, and persons living with HIV, through its implementing partners, Poozitif Yasam and Kirmizi Semsiye Cinsel Saglik ve Insan Haklari Associations, in five cities.[18]
The regulation on charging a contribution rate to Syrians refugees imposes a serious barrier to access to health but it is rarely applied to vulnerable groups.[20]
In Adana, Syrians with the code G-43 were denied access to healthcare unless they filed a lawsuit against the PMM.[21]
[1] Article 27 TPR.
[2] Article 27(1)b as amended by Regulation no.30989.
[4] isvesosyalguvenlik, ‘Gelir Testinde G0 – G1 – G2 – G3 Ne Demek ?’, 2018, available at: https://bit.ly/3XSORnq.
[5] Selin Siviş, ‘Who is (un)deserving? Differential healthcare access and the interplay between social and symbolic boundary-drawing towards Syrian refugees in Turkey’, 2021, available at: https://bit.ly/3XSORnq.
[6] Information provided by a stakeholder, May 2023.
[7] Ministry of Health, ‘Avrupa Bölgesi Göç ve Sağlık Yüksek Düzeyli Toplantısı İstanbul’da Gerçekleştirildi’, March 2022, available in Turkish at: https://bit.ly/3PPNnYY.
[8] AA, ‘Bakan Koca: Ayrım yapmaksızın göçmenlerin sağlık ihtiyacına ilişkin ortak bir yol izlemek hepimizin asli görevi’, 17 March 2023, available in Turkish at: https://bit.ly/3JWGwJt.
[9] Delegation Of The European Union To Türkiye, ‘Homepage’, last accessed 13 July 2023, available at: https://bit.ly/3Oatg6z.
[10] Statewatch, ‘Final contracts arranged for €6 billion EU-Türkiye deal’, 22 December 2020, available at: https://bit.ly/3ooLKBF
[11] Ministry of Health, ‘2nd Steering Committee Meeting of SHIFA Project’, 13 July 2022, available at: https://bit.ly/3rkeIrU.
[12] Mudem, ‘Özelleştirilmiş Sağlık Hizmetlerine Erişim ve Hizmetlerin Devrinin Desteklenmesi Projesi’, 2022, available in Turkish at: https://bit.ly/3XNAHDZ.
[13] Information provided by a stakeholder, May 2023.
[14] Information provided by a stakeholder, May 2023.
[15] Cagla Aydin, ‘Boğaziçi Üniversitesi Sosyal Politikalar Forumu Üyesi Nihal Kayalı: “Türkiye’nin Suriyeli mülteciler için sağlık çalışmaları övgüye değer ama problemler de var”’, 2022, available in Turkish at: https://bit.ly/3PXyBQ4.
[16] For more information, see Türk Kızılay, Syria crisis: Humanitarian relief operation, September 2017, available at: http://bit.ly/2Fsj2YZ.
[17] Toplum Merkesi, ‘Toplum Merkezine Hoşgeldiniz’, last accessed 13 July 2023, available in Turkish at: https://bit.ly/43nB0qi.
[18] Information provided by a stakeholder, June 2023.
[19] Information provided by a stakeholder, May 2023.
[20] Information provided by a stakeholder, May 2023.
[21] Information provided by a stakeholder, June 2023.