Health care

Türkiye

Country Report: Health care Last updated: 17/08/22

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Independent

Türkiye’s General Health Insurance (Genel Sağlık Sigortası, GSS) scheme makes it compulsory for all residents of Türkiye 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 PMM. The law also states that where PMM 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 PMM 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 Türkiye’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 PMM.

Article 89(3) LFIP designates that PMM shall make the premium payments on behalf of international protection applicants and status holders. Previously the Ministry of Family 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 According to the new law, the General Health Insurance Scheme is no longer applicable for international protection applicants one year after their registration, apart from those with special needs or ones approved by the Directorate General.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 PMM 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 addition, international protection status holders often do not know that vulnerable groups are exempted from the one-year limitation. Exceptions are not enforced to a large extent. There is also an appointment problem for all citizens in Türkiye, that includes foreign citizens. [4]

In 2020 some applicants with special needs had difficulties accessing healthcare. After the LFIP amendment in December 2019, an applicant for international protection with special needs had her health insurance terminated after one year even though the law states that people with special needs should continue to have access. For patients who were HIV-positive or with chronic illnesses it was necessary to submit a medical certificate to prove a specific disease, but it is very expensive to get them without health insurance. Documents can sometimes be provided with the financial support of NGOs.[5] In Van there was no free access to medical care except in emergency cases during COVID-19 in 2020.[6] In Central Anatolia people did not disclose their HIV+ status during the initial application for health insurance because if they do their applications for health insurance are not accepted. However, if they report their HIV status after being registered, their insurance will be activated. There are different practices in different cities against LGBTI people but in Kayseri, for instance, all LGBTI people received a rejection for their application for health insurance so far. There was a HIV-positive applicant in Konya who received a deportation decision and whose health insurance was not activated by PDMM. His lawyer challenged the deactivation decision of the health insurance. The administrative court in Kayseri ruled that the deactivation was unlawful and that the insurance should be re-activated. However, the PDMM did not activate the insurance. Sex workers do not inform PDMM about their vulnerabilities and needs because PDMMs often try to deport them.[7]

In İstanbul in 2021, the right to health of non-Syrians is often only accessible in emergencies. Usually, the patient and those who need treatment in the family of the person with international protection status have an identity card during the court application process. But, once the case gets rejected, the health service is terminated, and people get victimized by this application. So, these people access health services in the private sector.[8]

When a person applies for international protection in İzmir, they are expected to prove that they have a medical need in order to benefit from health services. While the pandemic continued, health insurance was necessary even just to be vaccinated. It should automatically get activated according to regulations, but it does not. In addition, if the person gets a diagnosis before coming to Türkiye, they are not provided with health services according to the law. This is a nationwide practice. After one year, international protection applicants cannot benefit from health services. This caused the disruption of hormone therapy for trans people. They fear their third-country placements will be revoked if they win their cases in Türkiye. The exception for vulnerable groups applies to some pregnant women. There was a child patient with spinal muscular atrophy (SMA). After a long debate in Türkiye it was decided social security should cover this medicine but in this case it was not covered.[9]

In Central Anatolia, in 2021, the one-year requirement for access to health services has also negatively affected foreign citizens. There is no uniform application among PDMMs. Some require a disability report proving that the applicant has 50% disability to consider them as vulnerable whilst others require 40% or 60%. Some PDMMs accept disability reports, others do not. Counselees cannot access health services if their international protection case is rejected. In this case, foreign citizens are recommended to open a new administrative lawsuit against PMM. There are two positive decisions from Kayseri administrative court ruling that the applicant’s insurance should be reactivated until the legal process ends (for about six months). In another decision, the judge accepted the interim judgment and cancelled the administrative application, but in these two cases, the applicants had severe health conditions (like cancer). Another problem is the insurance debts of foreign citizens with grave health conditions who cannot access health services due to high debts.[10]

 

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).[11]

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 and a small additional cost depending on the number of items.

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 PMM authorities may cooperate with relevant public institutions, international organisations and NGOs for this purpose.[12] 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 psychosocial services in different locations around Türkiye although capacity is limited. SGDD-ASAM, IKGV, Support to Life and Türk Kızılay are some of the NGOs providing psychosocial support in different cities across Türkiye. Türk Kızılay Community Centre in Şanlıurfa collaborates with UNICEF, PMM and the Ministry of Health on empowering the mental health of refugees. Mental health centres will be established in Şanlıurfa and Ankara (pilot cities) then extended to 18 cities.[13] As of April 2021 there were twelve community centers in Bursa, İzmir, Adana, Ankara, Kayseri, Konya, Gaziantep, Kahramanmaraş, Mersin, Şanlıurfa and two in İstanbul. The teams consist of psychiatrists, clinical psychologists, child development specialists, psychiatric nurses and translators.[14]

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 in hospitals where high concentration of migrants.

Many initiatives were suspended in 2020 due to the COVID-19 pandemic however, information materials were provided in different languages on the pandemic and different measures for individuals to take. As discussed previously, social cohesion activities were not openly promoted during 2021, perhaps due to sensitivities about the economy.

 

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.[15] 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. There is no nationwide system for the provision of interpretation assistance to international protection applicants and beneficiaries, although the EU-funded SIHHAT project includes 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.[16]

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.[17]

In addition, in provinces such as Afyon and Kırıkkale, 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.[18]

After legal amendments, the health insurance of Afghans was deactivated immediately in Adıyaman and Gaziantep. In Van the health insurance of both Iranians and Afghans was deactivated right after the law entered into force.[19]

Obstacles in accessing healthcare continued in 2020 during the COVID-19 pandemic, although Presidential Decision number 2399 from 13 April 2020 guaranteed that everyone, regardless of whether they have social security or insurance, could access personal protective materials, diagnostic tests and medicine free of charge. There have been some problems due to the lack of a written regulation about how to register unregistered/undocumented immigrants who do not benefit from general health insurance in the system and it is unclear at time of writing if hospitalization is covered. [20]

In 2021 refugees in Van who were not registered could not use the health services. They can only receive treatment when they apply to health care units in an emergency or mandatory situation. However, when they apply to any public institution including hospitals, that public institution is obliged to report it to the relevant law enforcement authorities. For this reason, although most of the refugees have health problems, they do not go to hospitals due to deportation concerns, and their right to access healthcare services, which is a basic human right, is violated.[23]Another option for unregistered refugees is to pay for treatment in private hospitals. Private hospitals are also required to report unregistered migrants to law enforcement. However, since it is a paid service, it is known that this obligation is sometimes ignored.[24] Refugees who have applied for asylum and whose application is in the evaluation process are legally entitled to free access to medical services for one year, but the RSD procedure may take years. In this way, health care is no longer a right, but is converted into a “service” that is provided for a fee.[25]

People without identity cards struggled to access COVID-19 health services and could not be vaccinated. Even where an appointment was made by a lawyer for one individual, they did not attend due to fears of deportation.[26] Access to vaccines was not free of charge for migrants who paid 400 TL in some cases (there was no application fee for Turkish citizens).[27]

A system of verification of addresses has been ongoing in the southeastern region since the end of 2021, first for temporary protection holders, then international protection holders. Administrative fines are being issued. In general, the PDMM notifies those who are not living in their declared addresses that first their GSS will be deactivated then their ID will be cancelled. This was the case in Isparta, and there are no online appointments to reactivate the IDs. Individuals have been told that all appointments were taken for 2022 meaning that they would have to live undocumented. It is estimated that in İzmir at least one quarter of all migrants’ IDs will be deactivated if they do not return to their cities of registration. In Afyon, the PDMM said that they would not accept any disability report to reactivate the GSS of international protection holders except for those who are pregnant because there had been an increase in counterfeited health reports. After the COVID-19 lockdowns, refugees have tended not to go to PDMMs for the duty to sign, especially Somalians which has led to a reported increase in cases of ID deactivation. In the Aegean region, it is impossible to hand a written petition to PDMM which makes it difficult for lawyers to open administrative lawsuits in relation to access to health. There is also a problem with health insurance debts. In Denizli, international protection holders go to emergency services and get the service but then the PDMM imposes a fee on their name. As the fees often cannot be paid by international protection holders this creates a huge debt in time.[28]

 

 

 

[1] Law No 5510 on Social Security and General Health Insurance lays down the scope and modalities of Türkiye’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, April 2022.

[5] Information provided by a stakeholder, March 2021.

[6] Information provided by a stakeholder, March 2021.

[7] Information provided by a stakeholder, March 2021.

[8] Information provided by a stakeholder, April 2022.

[9] Information provided by a stakeholder, April 2022.

[10] Information provided by a stakeholder, May 2022.

[11] Directive No 28597, 24 March 2013.

[12] Article 113(1) RFIP.

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

[14] Daily Sabah, ‘Joint Turkish, German project to help traumatized Syrians’, 16 March 2021, available at: https://bit.ly/3bidd2w.

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

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

[17] Information provided by stakeholders, February 2019.

[18]  Ibid.

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

[20] Public Health Professionals Association, Pandemi Sürecinde Göçmenler ve Mültecilerle İlgili Durum, 15 April 2020, available in Turkish at: https://bit.ly/34MbXjI.

[21] ASAM/COVID-19 Salgınının Türkiye’deki Mülteciler Üzerindeki Etkilerinin Sektörel Analizi, Sectoral Analysis of The Impacts of COVID-19 on Refugees In Türkiye, 2020, available at: https://bit.ly/3scBehq, 18.

[22] Information provided by a stakeholder, March 2021.

[23] Kosar, M. A., Refugees Human Rights Violations in Van. Association of Equity Studies (ECD), September 2021, page 27, available at: https://bit.ly/3PpFLc3.

[24] Ibid, page 28.

[25] Ibid, page 28.

[26] Information provided by a stakeholder, May 2022.

[27] Information provided by a stakeholder, May 2022.

[28] Information provided by a stakeholder, May 2022.

Table of contents

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