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 According to the new law, the General Health Insurance Scheme is no longer applicable for international protection applicants one year after their registration, apart from those with special needs or ones approved by the Directorate General.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. In addition, the person should be diagnosed in Türkiye, otherwise they are not provided with health services according to the law.[3]
In addition, international protection status holders often do not know that vulnerable groups are exempted from the one-year limitation. Exceptions are not largely enforced. There is also an appointment problem for all citizens in Türkiye, that includes foreign citizens. [4]
The December 2019 amendment to the LFIP terminated health insurance for international protection applicants with special needs after one year, despite the law stating access should continue. HIV+ patients face high costs without insurance, and Central Anatolia residents often do not disclose their status on their initial applications. In Konya, a HIV+ applicant have been denied health insurance, and a deportation order led to the deactivation of insurance. The Kayseri administrative court ruled that the insurance should be reinstated, and PDMM reactivated it after a long period of resistance in 2022.[5] In Istanbul, access to health care is a continuous problem for individuals with special needs, and their health insurance is de-activated after only one year unless an NGO or bar association is involved.[6]
Access to health services for non-Syrians remained problematic in 2022. It was 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. Nevertheless, once the case is rejected, the health service is terminated, and people are victimized by this application. Therefore, these people access health services in the private sector.[7] In Izmir, when a person applies for international protection, they are expected to prove that they have a medical need in order to benefit from health services. In Istanbul, after one year, international protection holders receive health care under the guise of “health tourism” and pay twice as much as Turkish beneficiaries.[8]
Lack of uniform application among PDMMs continued to cause problems in various areas. For instance, 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.[9]
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 in 2022 in 32 provinces with 190 migrant health centers to increase access to health services.[10]
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 might 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 might 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. In the frame of the SIHHAT project, 10 Community Mental Health Centers operated in 31 provinces in 2022.[13]
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 Centres provides mental health support in 17 cities with its 18 centers (Bursa, Adiyaman, Zonguldak, Malatya, İzmir, Adana, Ankara, Kayseri, Konya, Kocaeli, Kilis, Gaziantep, Kahramanmaraş, Mersin, Mardin, Şanlıurfa and two in İstanbul). The teams consist of psychiatrists, clinical psychologists, child development specialists, psychiatric nurses and translators and reached out to 685,973 people in total.[14] In different locations, the IOM Psychosocial Mobile Teams (PMTs) delivered mental health and psychosocial support services to 571 people from migrant, refugee, and host groups as of September 2022.[15]
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.
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 one of the main problems encountered by asylum seekers in need of access to health care services.[16] Hospitals in Türkiye give appointments to patients over the phone. 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. According to stakeholders, almost all hospitals had interpreters as a result of the EU-funded SIHHAT project, including interpreters for Syrian beneficiaries of temporary protection (see Temporary Protection: Health Care), but there was a shortage of interpreters for uncommon languages.[17] NGOs in some locations also offer limited services to accompany particularly vulnerable asylum seekers to hospitals.
Where an international protection applicant has a medical issue, for which no treatment is available in their 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 PMM 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.
In 2022, unregistered refugees in Van were unable to get health care. They could only be treated if they presented themselves to health care services in an emergency or necessary circumstance. However, if they apply to a public institution, including a hospital, that public institution is required to notify the appropriate law enforcement authorities. As a result, despite the fact that the majority of refugees have health problems, they avoid going to hospitals owing to fears of deportation, and their ability to receive healthcare services, which is a basic human right, is violated.[19]
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. 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.[20]
The visa-free 90-day period and resident permit status did not cover medical expenses. Ukrainians requiring medical appointments had to apply for international protection; otherwise, they had to pay independently for such consultations. In Ankara, primary medical requirements and medications were covered by a private polyclinic contracted by the UNHCR. After initial examinations, Ukrainians with international protection status were referred to the state hospital. It is essential to note that among the new arrivals, there were Ukrainians with chronic or diseases that require long-term and periodic treatment (such as cancer and asthma). There were women who were pregnant or breastfeeding, so prenatal and postnatal care were essential. ASAM provided regular psychosocial support to individuals in need in Izmir and Ankara. In addition to the psychosocial support provided by the ASAM, a UNHCR-contracted polyclinic offered psychiatrist consultations.[21]
[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, June 2023.
[4] Information provided by a stakeholder, April 2022.
[5] Information provided by a stakeholder, June 2023.
[6] Information provided by a stakeholder, April 2023.
[7] Information provided by a stakeholder, April 2022 and May 2023.
[8] Information provided by a stakeholder, April 2023.
[9] Information provided by a stakeholder, May 2023.
[10] Sihhatproject, Instagram, available at: https://bit.ly/3JX78Ka.
[11] Directive No 28597, 24 March 2013.
[12] Article 113(1) RFIP.
[13] sihhatproject, Instagram, available at: https://bit.ly/3JX78Ka.
[14] Toplum Merkesi, ‘Toplum Merkezine Hoşgeldiniz’, last accessed 13 July 2023, available in Turkish at: https://bit.ly/43nB0qi.
[15] IOM, ‘Human Interest Story: Education For A Better Tomorrow’, 2022, available at: https://bit.ly/3OcPuoo.
[16] Information provided by stakeholders, May-June 2023.
[17] Information provided by astakeholder, May 2023.
[18] Information provided by a stakeholder, May 2023.
[19] Information provided by a stakeholder, May 2023.
[20] Information provided by a stakeholder, May 2022.
[21] ASAM report on Ukrainians.