1. Background
Turkey is hosting the largest number of Syrian refugees. According to an estimated number by United Nations High Commissioner for Refugees (UNHCR), there are more than 2728986 refugees within the country (1). According to the records of UNHCR, other Syrian refugees reside in the following countries with the following percentages: 25% in Lebanon, 12% in Jordan, 5% in Iraq, and 3% in Egypt (2). Refugees were welcomed with open arms and Turkey is doing its best within its power to improve the associated difficulties. Out of the two million, 350000 have been offered homes within 23 camps. The rest have scattered across the country, from Ankara to Istanbul, with many constituting non - camp urban refugees (3). This excessive population of Syrian refugees in temporary protection has brought about serious problems in health, education, security, and other social service systems (4).
One of the most serious problems related to the Syrian refugees in Turkey is that they are not registered. At times, more than 100000 Syrian refugees entered Turkey in one day. Therefore, it was not possible to assess international protection applications individually, and the refugees were included within the scope of temporary protection (5). It was determined that most of the expenses made for the Syrian refugees were covered by the national resources of Turkey. It was reported that the total amount spent for Syrian refugees was 8 billion dollars since 2011 (6).
On the other hand, the amount of monetary aid from external sources was 418 billion dollars (5). Additionally, the refugee influx brought about the need for new legal and administrative regulations. The Department of Immigration was found in order to monitor the advances and develop policies in this regard, and it was organized across the country (7). From the perspective of human rights, refugee health and access to health care are important elements of national health policy. Policies were developed regarding the access of the refugees to health services for meeting their health needs. It is also known that there are social determiners, such as environment, culture, language, homeland, and income, identifying the health needs of the refugees (8), yet the role of access to health services in meeting health needs should be emphasized in this regard (9).
The aim of this study was to reveal the numerical and economic size of the health services provided for Syrian refugees in public hospitals across the country and explain the legal status related to health insurance. In this regard, the health services provided to the refugees are explained primarily and then, the facts related to the health services rendered to the refugees in public hospitals are presented. In the last section, there is a discussion on the results for other countries hosting refugees.
1.1. Access to Health Services for Refugees in Turkey
“Health is a basic human right” and this right was first described in the World Health Organization (WHO) Constitution of 1946 (10). As a member of the WHO, Turkey supports and sustains this right to improve the health of refugees. In this sense, Syrian refugees were taken under “a temporary protection” from the date 04.28.2011 onwards within the scope of “Temporary Protection Regulation”. According to this regulation, “the services provided for temporary protection” are carried out by related ministries and public institutions in coordination with the Prime Ministry, the Presidency of Disaster and Emergency Management (AFAD). The governors are responsible for carrying out the services first hand (11). The health services to be provided to those under temporary protection were arranged with “the Regulation for the Principles Regarding the Health Services to be given to those under Temporary Protection”, which was updated on 11.04.2015 by the MoH and “the Regulation for Carrying out the Services Regarding Foreigners under Temporary Protection” issued by AFAD on 12.18.2014 (12, 13).
According to the legal regulations above, those under temporary protection with an identity card (ID card for refugees) could have free access to emergency health services, primary health services, and hospital services. These people could also have access to health services within the scope of the “insurance package” for general health insurance offered to Turkish citizens. Refugees that are not registered in the Social Security Institution or have not registered yet, and those, who do not have identity cards, could only benefit from free of charge emergency health services and primary health services, likely to cause epidemics in terms of public health, yet not from other health services. Besides, no charge is demanded from health care and medication within the scope of primary and emergency health services. Translation services for communication with the patients must be provided free of charge. When legal regulations are examined closely, it is possible to say the following: The refugees in Turkey have been benefitting from all health services on the same level with those, who have general health insurance when it comes to the fact that adequate number of personnel and technical infrastructure is provided for the Syrian refugees; the health personnel is adequately informed with regards to the legislation; the registration taken under temporary protection is carried on regularly; language problems are solved free of charge by translators; and those under temporary protection could easily have access to all health services. However, there might be some troubles at all stages of the services offered and it is necessary to investigate these problems in every dimension (14, 15).
Moreover, Turkey agreed to work together with international institutions concerning the improvement of health services offered to refugees in Turkey. For instance, a charity organization coming to Turkey within the scope of “the Hope Project” donated free medicine and medical devices for refugees (2). Besides, on 24th of July, 2014, the Ministry of Health (MoH) of Turkey signed a memorandum of understanding with the United Nations Population Fund to coordinate the delivery of essential women’s health services. This will bring the current health status of Syrian women in Turkey to light (16).
2. Methods
One of the aims of this study was to reveal the numerical and economic size of the health services provided for Syrian refugees in public hospitals. The research method of this record - based study was formed by the authors and consisted of the analysis of the Syrian refugees’ utilization of public hospitals between the years 2014 and 2015. Additionally, the data of the Syrian refugees receiving services from public hospitals between 2011 and 2015 were also collected. The study was restricted to patients receiving services from all public hospitals across Turkey. Family physicians, university hospitals, private health institutions, and services provided in camps were excluded from the scope of this study. In this context, the data on utilization of hospitals, numbers of births, deaths, operations, emergency patients, inpatients, outpatients and health spending, were obtained from the MoH, the Institution of Public Hospitals in Turkey. In this study, formal permission was taken from the Institute.
3. Results
In this section, the data on utilization of hospitals, number of births, deaths, operations, emergency patients, inpatients, outpatients, and health spending were presented. The numbers of Syrian refugees receiving services from public hospitals between years 2011 and 2015 are given in Table 1. As seen in Table 1, the number of the patients receiving services increased rapidly and more than 4 million refugees received health services in 2015.
Table 1.Number of Syrian Patients for Years 2011 to 2015a
| 2011 | 2012 | 2013 | 2014 | 2015 | |
|---|---|---|---|---|---|
| Number of patients | 16988 | 301009 | 1606433 | 4735625 | 4113893 |
aSource: Ministry of Health, Institution of Public Hospitals in Turkey, 2016.
The numbers of Syrian refugees receiving outpatient and emergency health services in public hospitals between years 2014 and 2015 are given in Table 2. Besides the health services provided by family doctors and services offered in camps in 2015, almost 2.5 million refugees received outpatient services in hospitals. In the same year, more than 1.5 million refugees utilized emergency services at the emergency departments of hospitals.
Table 2.Number of Outpatient and Emergency Department Visitsa
| Types of Visits | 2014 | 2015 | Total |
|---|---|---|---|
| Outpatient | 3224606 | 2417864 | 5642470 |
| Emergency | 1511019 | 1696029 | 3207048 |
| Total | 4735625 | 4113893 | 8849518 |
aSource: Ministry of Health, Institution of Public Hospitals in Turkey, 2016.
The numbers of in - patients, those taken in for operation and the numbers of births and deaths are given in Table 3. In the last two years, 103347 babies were born and 3460 people died. In these years, 260212 patients had operations and 252470 people had inpatient treatment.
Table 3.Number of In - Patient Department Visitsa
| Types of Visits | 2014 | 2015 | Total |
|---|---|---|---|
| Operations | 123952 | 136260 | 260212 |
| Birth | 45468 | 57879 | 103347 |
| In - patient | 55841 | 196629 | 252470 |
| Death | 668 | 2792 | 3460 |
aSource: Ministry of Health, Institution of Public Hospitals in Turkey, 2016.
The amounts spent for the treatment of Syrian refugees in public hospitals between years 2014 and 2015 are given in Table 4. A total of $ 338392896 was spent for the patients receiving services only at hospitals for the last two years. It should be noted that health spending for utilization of public preventive and primary health services were not included within the scope of this study.
4. Discussion
When the scope of the health services provided to refugees by the countries hosting Syrian refugees except for Turkey was examined, significant differences may be seen. The Lebanon government strives to ensure that both Syrian and Palestinian refugees can access health services easily. The Lebanon government allows Syrian refugees to use public health centers, yet these health centers generally address the poorest segments of the Lebanon population. Higher quality health care services are provided by private health centers. In addition to this, there are obstacles in terms of access of Syrian woman refugees to health services. The fact that the pregnancy rate of Syrian refugees is high increases the health expenses in this field. In this context, maternal and child health, and non - infectious diseases constitute the greatest burden for hospitals. It is suggested that the services provided for pregnant women in Lebanon camps should be made rational (17). On the other hand, in a study conducted in Turkey, the health services provided by local Turkish authorities in refugee camps were found to be adequate and convenient (18).
As the costs of health services in Jordan are gradually increasing, it is not possible to offer free access to health services any longer. While the Syrian refugees registered with UNHCR were able to obtain free medical care from primary, secondary, and tertiary health institutions till November of 2014, Syrian refugees have been paying charges in order to use public health facilities as of this date (19). Syrian refugees living outside camps in Jordan cannot pay for medical examination and cannot have access to health services. It was stated that three out of ten families did not have access to health services they needed in the last six months. For the most part, the reason for this is that the services are too expensive and refugees cannot bear these costs. Half of the pregnant women cannot bear the costs required for prenatal care and the health risks for 60% of new mothers and their babies are increasing as they are unable to get prenatal care (20).
In 2012, the MoH of Egypt published a decree that would provide Syrian refugees with access to health services. Despite the assistance provided for the primary health services by the MoH, the high costs of secondary and tertiary health services required Syrians to spend significant amounts (21). Within this scope, it was stated that the 42.56% of Syrians paid all of their health costs, 41.92% made partial payments for health services, and 15.92% obtained free health services (22).
Twenty - five thousand Syrian refugees to be located in Canada were subjected to health examinations before arrival. In 2016, thousands of Syrian refugees, especially supported by Canadian citizens, gained access to health services with the implementation of the Interim Federal Health Program (23). In Ontario, the place where most Syrian refugees live, a health system is publicly and universally financed by the Ontario Health Insurance Plan. This plan provides guidance in terms of the roles and responsibilities of health service providers regarding refugee health services in general, in order to meet the ongoing needs of the Syrians in Ontario. The ministry continues to work with health system partners in regular business processes in order to meet the health needs of the Syrian refugees (24).
In this study, it was found that all refugees used preventive, primary, and emergency services free of charge and registered refugees also had rights to use public preventive, primary, secondary, and tertiary health institutions free of charge, in accordance with the legal regulations in Turkey. However, it was reported that some refugees avoided registration in order to be able to go to European countries, and therefore, did not benefit from health services, and some did not have relevant information on this subject (25, 26).
The second part of this study presents the size and economic dimensions of health services provided for Syrian refugees in public hospitals. In this regard, it was found that more than 4 million Syrian refugees used public hospitals across the country, frequently, and the number of patients increased over the years. In another study, it was stated that approximately 40% of the total health services in provinces neighboring Syria provided by public hospitals were delivered to Syrian refugees. This brought about the capacity problems in public hospitals and reduced accessibility to hospitals (27). It was argued that doctors provided the services for long hours and were obliged to manage more than one case at a time (8). It was found that 251 Syrian patients applied to Istanbul University Hospital in the first six months of 2014 and approximately 30% of these patients received healthcare from emergency services, 26.29% received pediatrics healthcare, and 10.35% received services from ophthalmology policlinics. It was also found that refugees’ most common diagnoses were diseases of the respiratory system (14.4%); diseases of the eye and adnexa (12.6%), injury, poisoning and certain other consequences of external causes (10.7%) (11). In another study conducted in an emergency service, it was found that most Syrian refugees (70.1%) applied to the emergency service due to gunshot injury (28).
In this study, it was found that approximately 58000 babies were born in 2015. It was emphasized that, especially the prenatal and postnatal care, pregnancy follow - up and maternal health services were necessary as the fertility rate of Syrian women is high (29). In addition to these problems in hospitals, local citizens complained that Syrian refugees are depleting the healthcare resources and they are preventing the Turkish public from using health services when needed (30). In this study, it was determined that a total of $ 217558429 was spent for Syrian patients only in public hospitals. These direct expenses are of vital importance in terms of the economy of Turkey (5).
There are some limitations in this study. The data regarding the refugees’ disease distributions and the periods of hospitalization by province were not included within the scope of this study.
4.1. Conclusions
Results indicated that Turkey provided free utilization of health services and usage of national health resources for Syrian refugees. This was shown by usage data and expenses indicating that there was serious density of patients, especially in public hospitals due to Syrian refugees. It may be suggested that the role and capacity of preventive health services and primary health services provided by family physicians should be increased in order to reduce the work load in public hospitals caused by Syrian patients. There is a need for Turkey to share the data regarding refugees, particularly on regional distribution of epidemics and other diseases. Additionally, it may be suggested that programs should be developed to reduce lingual and cultural differences preventing access of refugees to health services. In the course of scientific considerations (31), it became increasingly clear that the issue of health of refugees is not different to that of natives, as these issues are relevant to human health. In this respect, refugee problems are the problems of all human beings just as are economic problems. Despite the remarkable efforts made in Turkey, it may be stated that international cooperations should be strengthened for improvement of the health status of refugees.
