The Syrian Refugee Crisis and its Effect on Public Services in Turkey

Impact of Syrian Refugee Crisis on Access to Health Services

by Irfan Kaygısız /photos: Erhan Arık and Vedat Arık

for Public Services International (PSI)*

Introduction

The violent intervention of Syrian security forces against the anti-government protests which had started in the city of Deraa on 15 March 2011 led to clashes which rapidly engulfed the whole country. As a result, some Syrian citizens started to enter Turkey. From that date on this movement of population has continued and is still continuing.

In Syria tens of thousands have lost their lives been wounded, while millions of others have been forced to abandon their homes. This is one of the biggest mass migrations in recent history. As a result, we are faced with a humanitarian problem of world proportions.

The continuing conflict in Syria has left tens of thousands dead and injured, and obliged millions to abandon their homes. We are face to face with the largest migration of recent times, and thus a humanitarian problem on the world scale.

The United Nations High Commissioner for Refugees has stated,

“This is the largest group of refugees, created by a single crisis, in a generation. This population needs the support of the world community, but is living in very difficult conditions and being steadily impoverished.”

The implications for Turkey are very serious.

The “guest” status given to Syrian refugees in Turkey ensures that they have difficult living conditions. Their legal status does not provide them with the possibility of a secure life. This situation also creates the need for them to seek a future in another country. As the effort to reach other countries increase, we hear more news of deaths of refugees with every passing day. The numbers of women and children dying in small boats and inflatables are substantial.

The increasing numbers of Syrian refugees, along with failure to create lasting solutions have brought about an increase in discrimination and racism leading to restrictions on freedoms, equality and human rights. In several cities there have been racist attacks resulting in deaths. The refugees face low wages, insecure and unhealthy working conditions and along with these problems face difficulties in access to public services.

For this research, which aimed to discover the working and living conditions of Syrian refugees, their level of access to public services, problems they encountered in accessing public services and the effects of this wave of migration on public service workers, fieldwork was done in the provinces of İzmir and Hatay during the summer of 2014. Semi structured questions were used to pursue the investigation and attempt to determine the situation.

DATA FOR THE SITUATION IN TURKEY AND THE WORLD

Image Courtesy of Mercy Corps

According to data from the UN High Commission for Refugees, the number of refugees who have fled Syria to neighbouring countries exceeds 4 million. This number is expected to rise to 4.27 million by the end of 2015.

The pre-war population of Syria was 22 million, and, according to UNHCR data, over and above the 4 million who have migrated outside Syria, a further 7.6 million Syrians have been displaced within Syria, mostly living in difficult conditions and in places to which access is difficult.

Amnesty International reports that 95% of the more than 4 million refugees are now living in 5 countries — Turkey, Lebanon, Jordan, Iraq and Egypt. According to Amnesty International:

Lebanon is hosting 1.2 million Syrian refugees. This represents one person in five of the population.
Jordan is hosting 650,000 Syrian refugees. This constitutes 10% of the population.
• With 1.9 million refugees Turkey has more Syrian refugees than any other country.
Iraq, which has suffered the internal displacement of 3 million people in the last 18 months, also has 249,463 Syrian refugees.
Egypt has 132,375 Syrian refugees.

Turkey has now become the country in the world accommodating the most refugees, with 45% of all the Syrian refugees in the region accommodated in Turkey.

António Guterres, UN High Commissioner for Refugees, has said the Syrian crisis, “has become the biggest humanitarian emergency of our era, yet the world is failing to meet the needs of refugees and the countries hosting them.” Before the civil war began, the population of Syria was around 23 million.

According to the United Nations, the number of registered refugees is 1.14 million in Lebanon, 815,000 in Turkey, and 608,000 in Jordan. There are 215,000 Syrians in Iraq, and many have fled to other countries. According to the UN report, the total number of refugees in other countries has risen by 1 million compared with the previous year.

The first contingent of Syrian refugees entered Turkey on 29 April 2011. According to data from the Directorate of the Migration Authority, on 13 November 2015, the number of registered Syrian refugees in Turkey was 2,226,117. 260,913 of these are accommodated in 25 temporary refugee camps in 10 cities. A further 1,965,204 have been dispersed throughout Turkey. These are only the registered refugees. Together with unregistered refugees, the total number is believed to be around 2.5 million.

In Turkey approximately 12% of Syrians are living in the 25 refugee camps in 10 cities. The remaining 88% are distributed throughout Turkey. In 10 cities the number of refugees is equal to the number of indigenous residents. There are some cities where the refugee population now constitutes a majority. The largest numbers of Syrians are found in Istanbul, Gaziantep, Sanlıurfa and Hatay.

The president of the Prime Ministerial administration for Disasters and Emergencies, stated in October 2014, “The total number of Syrians in Turkey is at this moment is 1.6 million”.

UN Under-Secretary-General for Humanitarian Affairs and Emergency Relief, Valerie Amos, in the statement she made in the town of Suruc in the Turkish province of Sanlıurfa on 18 October 2014, said that the crisis had particularly affected Turkey, Iraq, Lebanon and Jordan, continuing,

“We know that 900,000 people are registered as refugees in Turkey as a result of this 4 year conflict. However, we can see that the real figure is over 1.6 million.”

During the period in which this report was being prepared, a second and significant wave of refugees took place. As a result of the attack on Kobanê on 19 September 2014 by the forces of the Islamic State, around 190,000 refugees were forced to seek sanctuary in Turkey.

Syrian refugees’ access to health services

The overwhelming majority of the refugees do not speak Turkish, and know neither how they will solve their problems, nor to which institutions they should apply. Even those who do speak Turkish are reluctant to use these mechanisms for various reasons. Along with the effect of other factors, this means that the refugees have great difficulty in obtaining benefit accessing basic public services.

The major common problems faced by the refugees are housing, security, health, food and education and result from social exclusion.

One of the most important needs of the Syrian refugees is for health services. However, while there have been some improvements in access to health services since 2011, unfortunately, problems continue to exist.

Legal Status

The legal status of the Syrian refugees has important consequences for their access to public services, and in particular health services.

The right to access to the highest level of health services is guaranteed by numerous international agreements.

The social rights of refugees and migrants are laid down by the Law on Social Insurance and General Health Insurance, number 5510. However, because the regulations applied in Turkey do not conform with international agreements, refugees and migrants are only allowed access to health services by paying monthly premiums.

Turkey is not a country that accepts refugees. Turkey has signed the 1951 Geneva Convention and Protocol Relating to the Status of Refugees. However, because Turkey accepted the agreement with a “geographical restriction”, persons arriving from outside Europe are not recognised as refugees.

Access to services such as health, education and accommodation by a person whose status is one of temporary protection is governed by directive. The “Temporary Protection Directive” of 22 October 2014 lays down the health services that are to be provided:

“No financial contribution will be required for the provision of basic and urgent health services and the associated medicines and treatment”.

The directive clearly states that the costs of health care will be met by AFAD (Disasters and Emergency Administration), while the duty for provision of translators and the necessary personnel and service capacity in the hospitals is given to the Ministry of Health.

In the directive issued by the Council of Ministers, in contradiction to the provisions of the relevant law, there are no provisions specifying rights and freedoms of persons with temporary protection status. According to the directive, for those who benefit from temporary protection status, “health, education, access to the labour market, social assistance and social services along with translation and similar services may be provided”. What are specified as rights and freedoms in the law are restricted in the directive to a statement about areas of service.

The statuses of refugee, conditional refugee and asylum seeker are individual. Temporary protection, on the other hand, is given to large groups and is not individual. The greatest disadvantage of temporary protection status is its very temporariness. A decision of the Council of Ministers can remove this status and require those holding it to return to their countries. When, and under which conditions, this will occur is entirely down to the initiative of the Council of Ministers.

People coming from outside Europe are merely given the right of “temporary sanctuary”. The Syrians who have been arriving in Turkey since April 2011 were initially given the status, unrecognized by international law, of “guest”. The decree of April 2012 accepted them as being under “temporary protection”.

Despite fulfilling all the conditions met by those who can gain refugee status, in Turkey, people who come from outside Europe do not have the right to apply for refugee status. These people only have the right to temporary residence in Turkey until they are located to another country by the UNHCR. This temporary protection has now become a virtually permanent status.

Among the 148 states that have signed the Universal Declaration of Human Rights, only Congo, Madagascar, Monaco and Turkey have placed a geographical restriction on the right to asylum, a restriction which puts a severe limit on the exercise of that right.

Providing people who have been forced to abandon their countries with a secure environment is a precondition for humanitarian assistance. Alongside this it is necessary to guarantee refugees their basic rights and freedoms. However, the existing legal framework in Turkey leaves Syrian refugees without proper legal protection and pushes them into the status of “guests”. To provide these people not only with the necessary legal status, but also the means to carry on their lives required by that status is also important for ensuring the maintenance of social peace and overall legal order of the country that they live in.

Legally classifying refugees, not as people with rights and freedoms, but as guests, opens the door to forgetting the conditions from which they are suffering, their treatment as “unwanted guests” and increasing hostility toward refugees. This situation increases the gulf between foreigners and citizens. At the same time it damages the principle of equal treatment before the law.

An approach which ignores the principle of equality and is not based upon rights and freedoms is a threat to the whole of society, not only to refugees.

Even though they still harbour hopes of returning to their own countries, if the fundamental needs, such as education, employment and health of these people who are now becoming a part of the population are not being met then as time goes on, even greater problems will be created.

The legal situation regarding the utilisation of health services

It has become clear, both from our own field work and from the researches of others, that asylum seekers, in particular those living outside the camps, encounter a series of problems when trying to access public services. While the source of some of these problems is in the workings of the providing institutions, some problems also result from the way in which these Syrians have arrived in the country, their unregistered status and their lack of knowledge of their rights.

On 18 January 2013, the Prime Ministerial Disasters and Emergency Administration (AFAD) sent a directive, entitled “Health services for Syrian guests” to 10 provincial governors. According to the provisions of this directive, the treatment and medical equipment costs of registered Syrian refugees in these provinces would be billed to the relevant Provincial governorate according the “Medical Practice Order” and patients would be referred for treatment to other places in the usual way.

Image courtesy of resettlement.be

According to the directive, to benefit from health services, refugees who are staying outside the camps need to apply to a health centre or hospital in one of the ten cities where camps accommodating Syrian refugees are located. These ten cities are Adana, Adıyaman, Gaziantep, Hatay, Kahramanmaraş, Kilis, Malatya, Mardin, Osmaniye and Şanlıurfa.

According to the directive, the costs of protective or basic health care would be met by AFAD. If Syrian migrants were not yet registered with AFAD, they could still apply to hospitals in these ten cities, where officials appointed to these hospitals would carry out a pre-registration so that treatment could be given.

An additional directive issued by AFAD on 9 September 2013 gave orders for the provision of health services in all of Turkey’s 81 provinces to people of Syrian origin. It was foreseen that registration would be carried out in health centres by officials of the Foreigners Bureau for Security Directorate. This directive broadened the scope of the previous directive on health care.

According to the directive issued by AFAD, once people arriving from Syria had been registered and issued with temporary identity papers, they would be able to benefit from publicly provided health services. Migrants from Syria would not be required to make any financial contribution for these services. Syrians would have the same access to emergency health treatment as all citizens of the Turkish Republic.

In Turkey as a whole, the problem of financing pharmaceutical supply is solved in two different ways. In provinces where refugees are concentrated, such as Urfa, Adana, Osmaniye and Antep protocols have been signed between AFAD and the Chamber of Pharmacists. In these provinces AFAD pays 80% of the bill for medicines. On the other hand, in some provinces, including the provinces of Istanbul, Kocaeli, Adiyaman and Bursa, in accordance with the AFAD directive, the provincial governor’s office writes an official request to the chamber of pharmacists for the supply of medicines. In provinces where both practices are applied, medicines are provided to refugees from any pharmacy and the cost is invoiced to AFAD, in accordance with SUT (Health Practices Directive). Registration is a condition for AFAD to pay for medicines. The medicines of unregistered Syrian refugees are not paid for.

Because there is no centrally signed protocol between the Turkey Chamber of Pharmacists and AFAD, there are differences between provinces in the payments for medicines. For example, in İzmir, medicines are still being charged for. In order for medicines to be free of charge to all refugees, there needs to be a protocol between AFAD and the Turkey Chamber of Pharmacists.

Access to health service by refugees living in camps

As of September 2015 260,913 Syrians are living in 25 camps in 10 provinces, some in tents, and some in containers. Because of their “temporary protection” status, those living in the camps have the right not to be deported. Alongside this, it is possible for them to obtain their basic needs. The most important of these are accommodation, food and water, health services, education and some other social services.

Residents in the camps are able to obtain health services. There is at least one doctor and one nurse in each camp. Patients who cannot be treated on the spot are transferred by ambulance to a hospital as out patients. Translators are available to enable refugees to communicate their health problems to health workers, to ensure communication with health workers and solve the language problem. Medicines are provided free of charge.

Those living in the other camps do not have a serious problem in accessing health services. This was confirmed to us directly in interviews with residents of the camps in Hatay.

Consequently, it is possible for all Syrian refugees living in the camps to access free medical treatment.

According to official reports, there have so far been 6,051 births in the camps, and 1.5 million polyclinic appointments.

Access to health care for those outside the camps

In the interviews we have conducted, all migrants have given various reasons for not wanting to live in the camps. Among these reasons are the conditions in the camps, lack of security, ethnic and religious reasons and the need to find work. While the residents of the camps are almost all Sunni Muslims, those not in the camps are mostly Alevis and Kurds. Those who remain outside the camps say they do not feel safe there, and for this reason do not want to stay there.

With effect from November 2015, 1,965,000 of the 2,226,117 Syrians are living outside the camps in 81 provinces. So approximately 88% of Syrians are outside the camps.

Only 12% of Syrians have effective access to health services.

Problems experienced in health services provision

Language problem

As in all other matters, not knowing the language is a serious obstacle to access to public services. Migrants not knowing the Turkish language combined with lack of multi-lingual service provision in public institutions create serious problems in access to public services in general and health services in particular

Our investigation has shown that serious problems are being experienced, from registration, to communication with the doctor, in the carrying out of tests and the provision of information about the taking of medicines.

The language problem is one of the biggest problems for the health sector. The migrants’ inadequate knowledge of Turkish and the lack of Arabic and Kurdish speaking personnel are making access to health services difficult. In Hatay, one of the provinces where many Syrians are found, translators have been appointed in the hospitals. On the other hand, we found that there are no translators in İzmir.

Sometimes help from Arabic or Kurdish speaking neighbours is used to solve the language problem, sometimes hospital personnel are able to help. Lack of language skills creates a number of problems. This situation leads to confidential information being shared with third parties and a consequent loss of personal privacy.

Muhammed Salih Ali, president of the Syrian Refugees Solidarity Association notes the problems with access to health services as follows:

“To obtain health services, a ‘temporary residence permit’ is required. Some hospitals refuse to diagnose patients who lack this document. Because medicines are charged for, those who cannot afford them are unable to obtain them, especially those patients with chronic illnesses.”
“Patients do not know the language. There are no translators in the hospitals. Recently a Syrian was unable to explain his problem to the doctor. Because the patient could not explain the doctor was becoming irritable. Then the patient rang me and asked me to explain his problem to the doctor on the telephone. I spoke to the doctor, but the doctor refused to accept translation over the phone.”
“Because Syrians do not have Turkish Republic citizenship numbers they cannot use the online appointment system.”
“The decree allowing us to benefit from health services has only been issued recently. I took a child to the doctor for vaccination. I explained to the doctor that the decree had been issued and that vaccinations were free of charge. The doctor said that he was unaware of the decree; I told him that I had a copy with me and could show it to him. He replied that he would not accept the decree from my hands, and he needed to consult AFAD and he did not perform the vaccination.”

In interviews that we conducted, both with Syrians and with doctors and other health personnel, all stated that “language is a major problem on its own”. A doctor who is also and academic in İzmir said that he had heard of people acting as paid interlocutors.

One member of the SES health workers union reported a similar situation:

“The same person brings in different patients on different days and describes each of them as “my neighbour”.

In interviews with 32 families in İzmir, 4 families stated that they had not visited a hospital, 28 families reported that the respondents themselves, or their mother, father, child or spouse had visited the doctor because of illness. Of these 28 families, 10 said that they had not faced language problems during their diagnosis, 11 families did not make a clear statement, or did not wish to make a statement. 7 families stated that they had been badly treated by the doctor.

A refugee interviewed in Izmir:

“Our family is 10 people. We have been in Turkey for a year. I have a daughter who is three years old and a second will be born in 3 months time. In Syria I was shot in the foot. The bullets are still in my foot. The doctors made us come and go a lot trying to get an operation. They keep telling me to go away today and come back tomorrow. I went to the doctor with my neighbour’s daughter in order to overcome the language problem. I was so fed up that I tore up and threw away all the documents I had accumulated. What I expect from the state is to operate on me.”

Many migrants state that because of the language problem they are unable to describe their health problems adequately, and, as a result, have problems with their treatment. Some respondents also said that doctors had said they “would not treat those who did not know the language”.

In the interviews conducted in Hatay, the health services problem did not feature as prominently as in the interviews in Izmir. Refugees in Hatay stated that they did not have a language problem when using health services. This was mainly because translators had been appointed to the hospitals, and also, in any event, many local people and also many health workers speak Arabic.

This was confirmed by Ibrahim Sayman, ex branch president of the Hatay branch of the SES Health Workers Union.

“We are not experiencing a language problem in Hatay. Most of the local population know Arabic. It is always possible to find an Arabic speaker at the hospital. At the Antioch State Hospital, there is a sign in Arabic right by the entrance for a special division to the Accident and Emergency department.”

Problems encountered by health staff as a result of language difficulties

Umit Dogan, Izmir branch secretary of the SES health workers’ union, who works in Izmir Konak Dental Hospital, mentions language difficulties as the most important problem faced by Syrians. When Syrian come to the hospital, they call one of the workers for a subcontractor at the hospital who in practice functions as an Arabic speaking staff member.

A member of SES working at the Tepecik Emergency Childrens’ hospital touched on the importance of the language problem and reported, “There is a phone line at the Health Ministry, and sometimes we get support from that phone line.” and added,

“The problems start at registration, the staff say ‘another Syrian arrived’, registration takes a long time because of communication difficulties, attempts are made to get translation support from other patients.”

A SES member working in the Izmir Behçet Uz Hospital:

“When an official translator doesn’t come, registration takes a long time. One child was going to have a heart operation and the family’s permission was required, this was obtained late because of translation difficulties, and because continuous communication was needed, the child’s stay in hospital was extended.
“They cannot go to other departments to get the results of tests, for example they do not know where the X ray department is, so sometimes they leave the hospital without picking up their results.”

The Izmir representative of Dev Saglık Is health workers union reported the same problem, “The language problem is important, in particular when families bring their children to the hospital. When there are failures of communication because of the language problem, they become more agitated.”

SES Hatay Branch Committee member and Family Practitioner Gulmez Pancar states,

“A department has been set up to deal with the language problem, and people have been appointed. However, some of those appointed do not actually know the language and this is a problem. There are problems both during diagnosis and with explaining how medicines are going to be used. We have to find someone in the hospital who knows the language or get help from other patients.”

SES Izmir Branch Committee member Gulistan Kılıc, pointed out another aspect of this problem and said that health workers should be paid a language premium.

“Language bonus should be paid for all languages other than the official language, including Kurdish. While those who know English get a language payment, health staff who know local languages are not receiving a language payment.”

A SES member working in Mardin Kızıltepe stated,

“Equal and free health services must be provided in the patients’ mother tongue. It should be compulsory to provide health services in a language that the refugees can understand and there should be a 24 hour interpreting service.”

In Mardin, when it became known that a doctor was able to communicate with refugees in Kurdish, demand for the doctor, and consequently his workload, increased greatly.

Problems with preventative health care

Preventative health care is only given to refugees who apply themselves to health service providing institutions. There is not any home or community health care. For this reason, cases of pregnant women, babies and children not being monitored, or vaccinations being partially or completely missed have been observed among refugees. Virtually no patients are being followed up. Everything is left to the refugee’s own initiative.

The provision of preventative health care being dependent on personal applications means that monitoring, control and evaluation are not being performed.

While there are serious problems about access to birth control, baby food and nutritional support for children are not being provided.

A health worker, member of the SES Izmir branch, said,

“Pregnancy monitoring is not being done, addresses are not recorded. Continuity of the vaccination program is important, but it is not being done.”

Women and children’s health

In the course of this study, women stated that they had received no help with family planning or their own health. Among the obstacles to this kind of care were migrants’ ignorance of where they could obtain such services and the fact these service were not being provided in the localities where the migrants lived.

We came across many refugee children who were obliged to work under age. It was observed that these children worked under more onerous conditions, in more crowded and insanitary workplaces than children who were Turkish citizens. It was observed that the psychological and physical health of children was threatened by being sent out to work by senior members of their families who were having difficulties find work, or, in some cases, work they considered not appropriate to their previous status. For example, a father who had been working in Syria as a professional engineer, and did not regard the work he could find as suitable to his status, sent his two under age daughters to work in a garment factory.

It was observed that children who are not working, as a result of language problems in the place where they are living and social exclusion, did not leave the house much, and preferred to remain at home with relatives, not forming relationships with local children. However, in localities where Syrians were concentrated together, children would form friendships and play with other Syrian children in the locality.

Infectious diseases

Health workers interviewed stated that the risk of infectious diseases has increased, indeed that for some previously unknown infectious diseases they were undergoing new training. “Diseases such as Leishmaniasis were unknown, now we are having training courses on them.” Especially in the areas where Syrians are concentrated, the risk of epidemics is said to be rising.

In the camps, vaccinations are performed as part of the registration process and there is support for developing immunities. However, for those living outside the, camps there is insufficient access to these services. This has a particular negative effect on women and children. Polio has been observed in some provinces. Because Syrians were not being vaccinated on arrival until 2013, many caught measles.

SES Hatay Branch committee member Gulsen Pancar:

“One of the results of this war, the result of imperialist intervention, is migrations, the other, for us health workers, is fear of epidemics. At this stage preventative health services need to intervene. However, in Hatay, where first stage vaccinations are from time to time not even given to citizens of Turkey through lack of health staff, vaccinating unregistered Syrian refugees becomes impossible. The majority do not have a permanent address, so it is not possible to track and ensure continuity in immunisation services.”

A SES İzmir Branch member and health worker:

“We see a lot of patients with infectious diseases. Even when these illnesses would normally respond well to treatment with drugs, for the Syrians these are serious illnesses.”

A SES member in İzmir stated that the negative impact of poor housing and living conditions meant that these illnesses were more serious. Syrians were only seeking medical help at the hospitals when their illnesses were well advanced, meaning that treatment took longer and was more difficult. “Pregnancies are not being tracked, no-one takes responsibility for that, Follow-up vaccinations are important, but they are not being done.” In addition to these problems, repeated changes of address make follow-ups difficult.

It is not possible for migrants to access social services or services for the old, and for the disabled. SES Hatay Branch ex-President, Ibrahim Sayman, said about this, “The Prime Minister’s office issued a decree for orphans, disabled and the aged. Service is being provided in accordance with the decree, but there were not many applications. Apart from that there is no social services support for the families.”

The Turkish Doctors Union’s statement on this matter also drew attention to this state of affairs:

Providing All Refugees with Integrated and Locally Delivered Health Services. We want to draw attention to the realities of the refugee problem that is growing in our country day by day. The size of the refugee population not being reached by government services is growing continuously. Refugees without any kind of resources are living in parks, in poor districts, in abandoned and half demolished buildings. Survival is difficult for those living outside the camps. They have serious problems, primarily with housing, food and securing an income, but also in the fields of health and education. When the living conditions of the refugees are taking into account, it is clearly vital that protective services are continuously provided to those living outside the camps. No-one should be surprised if the outbreaks of measles, malaria, leishmaniasis that we saw last year are repeated on a larger scale. There is serious potential for the emergence of diseases like typhus, dysentery and polio. If the condition facing refugees do not improve, deaths of mothers, babies and children and complication in chronic diseases will be inevitable. It is necessary to provide, immediately, an integrated health service to refugees, delivered locally. The report prepared by the peoples health team of the Turkish Medical Union, including observations and recommendations, and written after a study in the border provinces where refugees are concentrated, will be issued shortly.”

Turkish Medical Union Central Committee, “Our prioritised proposals for averting the threat of epidemics” Press Release of 8 November 2013
“1. It is vital to start taking, without delay, measures regarding immunity in the at-risk groups in accordance with World Health Organisation guidelines, especially in the border provinces.
2. Education and training of health workers is of vital importance. During the measles outbreak, nearly 90 health workers caught measles. The sick cannot deliver services, and will infect those they attempt to serve.”

SES Mardin branch made a press statement about this issue stating that for the first time for many years they were facing cases of poliomyelitis and that the infection had been brought in by people coming from outside Syria as fighters. The SES branch drew attention to the risk of the infection spreading in society, because the government was ignoring warnings and not giving the necessary medicines and vaccination support.

The attitude of health workers to the refugees

Among the problems faced by refugees in their access to health services are discrimination both by health workers and by the local population.

The increasing patient load on the hospitals has been a cause of discrimination. This has led from time to time to tensions between refugees and local people and between health service workers and patients. Among Turkish citizens, the numbers of those complaining of bad treatment are on the rise. This is at its worst in Hatay.

Refugees have complained the health care institutions and health workers have not shown the necessary interest and that, on occasion, doctors have behaved badly towards them.

A teaching hospital doctor in Izmir:

“There are prejudices that come from not knowing the refugees well enough. We need to break down these prejudices. Some health workers have prejudices such as, “The government are spending our money on them, they are living in luxury camps. These Arabs are dirty and carry diseases.” and also claim, “They are increasing our workload.”

SES Izmir branch secretary Umit Dogan:

“Hospital personnel reflect their own political preferences. When the patient is Kurdish, their faces turn sour. Appearance, dress and cleanliness all affect health personnel when providing services.”

Hatay SES branch executive committee member Merve Nur Varhan:

“Local people are reacting to what they see as priority being given to Syrians and hold the Syrians responsible for locals not being able to find beds in hospitals. In fact, the priority given to Syrians is being given to those arriving with gunshot wounds. Other Syrians are being treated equally with locals.
At the hospital where I work 75% of patients are Syrians. Because of the large numbers of refugees, Turkish citizens have mostly moved over to private hospitals. Those Turkish citizens with green cards or without social security are particularly indignant, saying, “If we were Syrians, you would treat us.”

Dev Saglik Is health workers union Izmir representative:

“Subcontract workers see the Syrians as a potential threat. They fear that tomorrow the Syrians will take their jobs from them.”

Hatay SES branch ex-president Ibrahim Sayman:

“Local people objected to health services not being given to themselves with the same ease as Syrians and stoned ambulances. The stoning happened after the Keseb attack.”

Hatay SES branch executive committee member Gulsen Pancar:

“70% of the patients in the maternity home are Syrian refugees. Turkish citizens have all fled to the private sector hospitals. Another reason for the flight to the private hospitals is the fear that the Syrians are carrying infectious diseases.”

Charges for medicines

While refugees who were interviewed said that they had not paid for hospital treatment, all of those interviewed in Izmir reported that they had paid for their medicines. On the other hand, in Hatay, some refugees reported paying for medicines, while others had not.

When refugees were asked for their most urgent demand from the government, some refugees, particularly those living in Izmir, said that free medicines were their priority.

In particular, for patients with chronic illnesses that require continuous drug treatment, those with cancer and diabetes, having to pay for medicines has increased their suffering. Some patients requiring regular medication have been observed to have given up taking their medication.

From our investigations it emerged that charges for medicines were a major obstacle to uptake of health services.

President of the Association for Solidarity with Syrian Refugees, Muhammed Salih Ali stated,

“Because drugs are charged for, in particular the chronically ill are unable to get their medication.”

Psychosocial support for refugees

War conditions have affected refugees’ mental health and psychological condition adversely. It has been determined that refugees living outside the camps have received no services oriented to their mental health.

Health workers say that more than 50% of refugees need psychological support and that, “for these reasons the numbers of psychologists in the camps and in the hospitals need to be increased as the current staff levels are inadequate.”

One woman refugee was living close to a military area in Izmir, and when she heard shooting during military training in the camp, believed that the war had spread to Turkey, and hid her children inside the house and waited until morning.

Another woman refugee had thought that the sound of a firework display was an exploding bomb and become very frightened. There are many examples of this kind.

A refugee interviewed in Izmir:

“I came with my wife, son and daughter. There bombs were falling and I use to turn up the television sound so as not hear the sound. Now we are sometimes hungry, but at least we are not frightened here. One month after we arrived here, there was a rainstorm and I hid in a corner, I could not move and I was crying. When they made a flight display over the army house I was frightened that they had come here. Every loud noise paralyses me. We are frightened, we cry. My daughter never goes out and talks to no-one. She wets the bed. We have no money and no work. Life is difficult.”

To deal with problems of adjustment arising from dislocation and the trauma of war, medical support and also advice and social support need to be put in place.

The effects of migration on Health workers

Working conditions and intensity of work

In interviews with health workers, the greatest of the problems being encountered was the increase in work load. In cities where Syrians were concentrated, this problem was being felt more intensely.

For a longish time, with the justification that this is an exceptional period, health workers have been made to work under arbitrary conditions, in breach of the rules. Health workers are working long hours and have not been able to get any overtime payments. In time, they have become, by the nature of their job, health workers who continue to work without making any demands.

SES Hatay Branch Womens’ Secretary:

“During the first period we were receiving war wounded patients, and we did not know about treating war wounds, we also had communication problems because of language, were getting exhausted as lots of patients were arriving. Previously we had two nurses and one doctor in emergency, there weren’t any new staff. You don’t know the language and patients are arriving all the time, calling for you all the time and you can’t understand what they are saying. We weren’t able to keep up with the patients. To start with, we said that this situation would end in two or three months. Then we realised that it hadn’t ended and was continuing. We don’t get war wounded any more. We just get normal refugees who are ill.
Despite the increase in workload we didn’t get any extra staff. We were given some intern doctors as support. At nights we had an internal transfer of nurses from within the hospital. Because we have so many patients, we work two or three hours overtime. The hospital administration is not pressuring us to stay late, but we can’t just leave them. We do not get paid overtime for these extra hours. I could say that the staff have got used to this new situation. It has become to seem normal. Health care staff have started to learn a bit of Arabic.”

SES Hatay Branch ex-President İbrahim Sayman:

“Workload has increased a lot; this is why there is a reaction. In addition there is no benefit to staff in the performance evaluations, which increases the reaction.”

Health Worker and Academic:

“The fact that diagnoses of refugees are not counted in performance assessments affects doctors negatively.”

Psychological problems

It has been established that, particularly in the Hatay region, health care staff have experienced severe mental health problems. There must be a provision of psycho-social support for doctors and health care staff

SES Hatay Branch Womens’ Secretary Merve Nur Varhan:

“Treating war wounded is not easy. Seeing wounded patients all the time is a really hard situation. Part of their body is missing, this is traumatic for us, too. After Aleppo we lived through this trauma again. There is nervousness that we will see this again. Wounded children were particularly difficult for us. Colleagues with children of their own were badly affected.

The health and safety of health care staff

One of the biggest problems of health care staff in the first years was health and safety. The risk that wounded Syrians were carrying weapons, from time to time the hand grenades they were carrying, worried health care staff and made them nervous.

SES Hatay Branch Womens’ Secretary Merve Nur Varhan:

“In the first period, the war wounded were carrying hand grenades on them. We were frightened that these could explode at any moment. We had no security.”

On 18 February 2015 a very dangerous incident occurred when a hand grenade fell from a patient who had been brought to the Mustafa Kemal University Hospital in Reyhanli, Hatay by ambulance and was being given first aid by a member of the SES union.

While there was no loss of life in the incident, on 19 February SES members made a press statement in front of the hospital protesting the dangers to their personal security.

The SES statement included these sentences:

“When we were treating a patient brought into Mustafa Kemal University Medical Faculty Hospital by 112 ambulances, because explosives fell onto the floor we had to record a note and inform the security forces. It became clear that the explosive material was a hand grenade.
In this situation emergency workers responding to a 112 call and providing first aid have as little personal security as the medical teams performing medical interventions. The precaution necessary to ensure personal safety for health workers who are being forced to perform extremely difficult tasks and work for excessively long hours.
We will continue to struggle day and night to provide quality health care that respects the human dignity of our patients, while we also struggle against the ignored problems of health workers and fight for safe working conditions, an end to violence in our working environment and a working environment that respects our human dignity, too.”

It was determined that incidents where armed Syrians had verbally and physically threatened hospital workers had occurred.

Another problem that has been making health workers nervous is the presence of chemicals on wounded Syrians and that they have been accepted into operating theatres in non-sterile military uniforms. For a long time health workers have been worried that they, too, will be affected by this situation.

Hatay SES branch ex-president Ibrahim Sayman:

“In the first years of the war, during the first period when fighters were arriving, there was pressure put on health workers who were Alevis. Special health personnel were assigned to look after the fighters.

The personal security of health workers was under threat, they were saying, “we do not know what will happen to us tomorrow”.”

SES Hatay Branch President Atıf Yılmaz:

“The Jihadists were being allowed into the emergency wards and operating theatres in their non-sterile military clothing. This increased the risk of infection.
There was a worry that the wounded had been exposed to chemical weapons. When we communicated our worries to the provincial health directorate they replied, “We are doing chemical checks at the border”. There was threat to the health and safety of health care staff.
Some jihadists were found to have hand grenades in their pockets.
The Syrians who were coming here were Sunni Arabs. For this reason they did not want some of the nurses to touch them. For a short period, some of them were saying, “I don’t want Alevi nurses to touch me, I don’t want to be cared for by Alevis.”

SES Hatay Branch ex-President reported that during one period armed people were coming occasionally to the Hospital, which was making health care staff uncomfortable, but they were too frightened to say anything about it.

İbrahim Sayman ex-President of the SES union Hatay Branch:

“After the explosion in Reyhanli, (11 May 2013) health workers started to express their reactions. Since the explosion, armed individuals no longer come to the hospital.
Until the Reyhanli bombing health care staff were being subject to transfers and there was administrative pressure. After Reyhanli these pressure did not continue and the situation returned to normal.”

Problems of General Practitioners

It appears General Practitioners have encountered different problems to those encountered by other health care workers. General Practitioners have not been able to get an appropriate increase in their income to compensate for their increased workloads and increased patient numbers.

A General Practitioner from Hatay explains the problems faced:

“General Practice works in this way. A population of 3–4,000 is determined and a General Practitioner provides health services for this population. But refugees are excluded from this calculation. While the number of refugees is increasing, the resulting income does not increase. In some areas the number of refugee patients has increased greatly. Despite this, no budget has been set for them. The increased work load means that the health care worker needs an additional income, but this is not forthcoming. Although our work load has increased substantially, we have been given neither extra staff, nor extra payments.
Normally, patient records are held on computer. However, we cannot enter the information on the “temporary identity cards” given to Syrian refugees into the computer system. For this reasons General Practitioners are unable to keep records. When the refugees are unregistered they cannot be treated. Sometimes patients arrive without any identity papers, not even the “temporary identity card” and for this reason record cannot be kept and patients cannot be followed up.
No supplies, lots of work, no budget. Under these conditions Family Health Centres cannot provide adequate health care.
We drew this situation to the attention of the Provincial Health Director, but the problem was not resolved.
In the Family Health Centre family planning service is at a very low level, and is not being provided properly. Refugees do not know where they can get this service. There should be a separate unit for the refugees.”
If only we had Health Centres!

Under the Renewal in Health Care program the Health Centres that used to operate have been closed and in their place the Family Doctor system has been instituted. The closure of the Health Centres has had various negative effects for citizens of Turkey, and in addition has created problems for refugees as well.

One General Practitioner in Hatay expressed these views:

“If the Health Centres had not been closed, there would not have been a limitation of numbers of health personnel by population and it would have been possible to employ more health care workers. There would not have been a limit on medical supplies. Now when a vaccination is asked for, you are cautious, because if the generator fails, the vaccines may be made useless. If the vaccines are destroyed, the General Practitioner has to pay the cost. In addition, the doctor gets warning penalty points. In the past there was no such fear and no such need for a cautious approach. The General Practitioner has to account for every dose of vaccine all the time. We are obliged to vaccinate the Syrian refugees, but we cannot account for it.
For reproductive health it would have been possible to employ staff, now legally this cannot be done. Too much work, too few people. This, in short, is what ‘Renewal in Health Care’ really means.”

The SES union Hatay branch president Atıf Yılmaz said that after the problems encountered by health workers and patients, particularly in Hatay, had been discussed with representatives of public institutions, and as a result of these negotiations, some problems had been solved:

“Our branch had meetings with the Provincial Health Director, the Medical Directors of hospitals, and the General Secretary of the Association of Public Hospitals. In meetings with officials we put the problems such as long working hours, lack of staff and personal safety to the agenda. After these interventions by our union some problems were partially solved.”

Performance System

In so far as the health services provided to Syrian refugees are taken into account in performance evaluation of all health care staff, the doctors get points and the hospital average multiplier rises. The average rises, but because there is a ceiling for “auxiliary health care staff” they do not, in practice, benefit from this rise. As a consequence, auxiliary staff see no increase in their performance pay from services to refugees. Only the doctors benefit from the performance system. On the other hand, performance pay is not reflected in the levels of pensions.

The fact that health care workers apart from doctors do not see any concrete result in their performance evaluations from the services given to Syrians, affects health care workers negatively. They cannot get the financial reward for their increased work load.

In practice auxiliary health staff receive no benefit from the performance system and so the income of auxiliary health staff does not rise with rising patient numbers.

UNION POLICIES

The SES Health Workers Union Izmir branch committee member Gülistan Kılıç, outlined, as union policy, the following findings and demands:

We must increases consciousness among health care workers, and give an open answer to the question “where did they come from”, expose pro-war policies, emphasise the humanitarian dimension.
We have once again seen the importance of preventative medicine.
Syrian refugees should have the same rights to health care as the population living in Turkey.
Equal, free, health care should be delivered in the patients’ mother tongue.
It is imperative that health care be delivered in a language in which the patients can express themselves.
There should be 24 hour uninterrupted translation support.

The representative of Dev Saglik Is health workers union, as union policy:

There should be an end to unregistered, uninsured employment. Every employee should be registered and have their social security payments credited and be receiving a living wage.
There must be an effort to overcome discriminatory ideas among our members, we have to explain that the people who are coming are the victims of war.
We must defend everywhere the idea that humane living conditions are their right, too, we must defend this right for them.
The union must not be part of the imperialist war.

Conclusion and proposals

In interviews conducted with Syrian refugees and health care workers, it was established that, in the first years of the flow of refugees, there were more serious problems of access to health services, and the legal infrastructure was insufficient. There has been some improvement since then and some steps have been taken to ensure access to health care services, while, even today, some problems remain.

In particular it appears that the health care problems of those living outside the camps persist to a large degree.

Confusion remains on the question of payment for medicines. Whether or not medicines are being paid for varies from province to province.

There has not been an increase in the numbers of health care workers appropriate to the increased work load. It is clear that the existing situation is not sustainable. There is an emergency situation in the provision of health care.

There is the need for the establishment of new health care units along with an increase in the numbers of health care workers.

It appears that some refugees have no identity papers at all. It also appears that some refugees are thinking of returning to Syria and, for this reason, do not want to register themselves in Turkey. They are frightened that their registration details will pass into the hands of the Assad regime and that the fear that they will have problems when they return is widespread. Some even believe that the Syrian secret services have them under surveillance.

Registration should not be made a condition for the provision of health care services. Insisting on registration as a pre-condition for the provision of health care services will prevent the solution of the problem of health care provision for refugees.

There needs to be a an arrangement that will ensure accessible, quality health care of every kind, free of charge, and in suitable quantities, for refugees.

Health services should be taken to the areas where there are concentrations of refugees and mobile services should be provided.

The language problem is one the most important problems encountered in the health sector. Not knowing the language as with other factors is a serious factor obstructing access to health services. The fact that refugees do not know Turkish, together with the absence of an understanding in the public sector of the necessity of multi-lingual service provision is an important factor impeding access to public services in general and health services in particular.

In this study we observed that not knowing the language caused problems at every stage of access to health services, from registration to communication with the doctor, to giving information about problems and the carrying out of necessary tests. The fact that refugees do not know enough Turkish along with the lack of staff knowing Kurdish or Arabic in the service providing institutions obstructs access to health services.

Language problems are violating patient confidentiality, leading to third parties learning information that patients may not want known.

-END-

Appendix: The views of SES about access to health services by Syrian refugees

Millions of people have been forced to abandon the lands where they were born by causes like human rights violations, war and poverty. Since April 2011, as a result of the continuing conflict in Syria, we are witnessing one of the largest migrations of the last 20 years. A large portion of the Syrian population has been forced to migrate within the country and also to seek refuge in neighbouring countries such as Turkey, Lebanon, Iraq and Jordan. According to data from the United Nations High Commission on Refugees (UNHCR) dated 14 January 2015, 3.8 million people have been forced to leave Syria and seek refuge in other countries. Of these 1,622,000 are in Turkey, 1,160,000 in Lebanon, 622,000 in Jordan, 230,000 in Iraq and 136,000 in Egypt.

Until recently for many refugees Turkey was a pathway to a legal or illegal passage to the USA, Canada or the EU countries. However, as the border regimes of these desirable regions and countries change, Turkey is now becoming more of a final destination for refugees. The most important consequence of the increased border security measures by the EU is to increase the risks that refugees take. One of these risks is death. Alongside this, as controls get tighter the activity of crossing borders requires an international network and crossing has been transferred into a “service” whose price is increasing by the day. What was for a long time an individual effort to cross the border has now become a source of profit and an avenue for exploitation.

The 91st article of the Foreigners and International Protection Law, which came into effect in April 2014 defines “Temporary Protection” status. In October 2014, the Temporary Protection Directive was promulgated and Syrian refugees were defined as falling under the provisions of Temporary Protection. It is in this way that a legal framework was created from refugees arriving from Syria. However, because this new legislation did not remove the “geographical exception” applied to Turkey’s accession to the 1951 Convention on the Legal Status of Refugees, refugees in Turkey do not have the legal status of “refugees”. This is one of the most important obstacles to refugees’ access to public services. As a result of the inadequacy of identification of the population the nutritional and living conditions are not fully known. Health is directly related to living conditions and nutrition, and problems in these two areas are, to a large degree, ongoing. The lack of legal employment rights is worsening many problems.

Problems with Health Services:

From the first day that clashes started, Turkey opened its borders, and in a short space of time more than 2.5 million Syrians had entered Turkey. Turkey’s open border policy meant that entries and exits were not restricted to the official border posts, but took place along the whole of the border in a continuous and uncontrolled way.

Among those seeking refuge in Turkey there are patients in need of continuous care, pregnant women, people with disabilities, small children and old people. Insufficient accommodation, defective hygiene practices and poor nutrition contribute to increasing health risks. When the overcrowding of many people into single houses the risk of rapid spread of infectious diseases and epidemics is increased. Some refugees are camping in the parks of the towns where they are staying, or in improvised tented accommodation. Despite having insufficient provisions for hygiene and health, housing is let to refugees for high rents. It is clear that basic needs such as heating and warm winter clothing are not being met.

As a result of the inadequacy of identification of the population the nutritional and living conditions are not fully known. Health is directly related to living conditions and nutrition, and problems in these two areas are, to a large degree, ongoing. The lack of legal employment rights is worsening many problems.

From the health perspective, the lack of information about at risk groups (babies, children, pregnant women, old people, people with chronic illnesses, sufferers from malnutrition, people with mental difficulties, people living alone, women under threat of domestic violence or sexual exploitation) is an important problem area. Because arrivals across the border are often obliged to change place frequently, there are serious problems in following up vaccinations and tracking pregnancies. Also the needs for social services support and education have not been adequately determined by the relevant public authorities. There is a serious problem about the provision of protective services. In 2014, the year of the most intense inward migration, preventative care was only given to those who presented themselves at a health institution (such as family health clinic or social health clinic). Our union commission observed that refugees could not get services based on the address where they were residing. For these reasons the commission identified a large number of refugees who were women of childbearing age, pregnant women, babies and children who had not been observed continuously, not vaccinated or not fully vaccinated.

As we stated in our introduction, the absence of legal refugee status is the biggest obstacle to access to public services for refugees. Alongside this, the importance of demands by SES for free, quality public services provided in the mother tongue has once more been shown. The failure to provide health, education and social services in clients’ mother tongue increases and reproduces human rights violations. Especially in the psycho-social area this can lead to even more serious problems. There is no accepted standard for social services and public authorities lack a people centred approach. Even for registered refugees, having to pay for services and pharmaceuticals is another serious problem. At every level and in every field, lack of personnel is negatively affecting the quality of services. To identify these problems and generate solutions a comprehensive field study is necessary, but there is no such effort and there is no comprehensive plan for the provision of public services.

Around 250,000 refugees are staying in camps affiliated to AFAD. The remain more than 2 million refugees are trying to stay alive with their own resources outside the camps. Since there is no possibility for NGOs to investigate the operations of the camps, we have no chance to identify problems or develop solutions for refugees there. SES has been directly involved in organising the provision of health services to refugees in tent cities set up by local councils in areas close to the border. In these camps, alongside health treatment, preventative health care has also been offered. These camps mostly accommodate Syrian Kurds and Yezidis from Iraq and were set up while the attacks on Rojava and in Iraq were at their most intense. Subsequently, as a result of people returning or the lack of further need, the provision of these services was ended. Far from supporting these operations the attitude of the public authorities was to keep the local councils running these camps on a largely voluntary basis funding these camps from their limited resources under pressure, with arrests, even of the severely wounded.

The Effect of Migration on Health and Social Services Workers:

Since the political crisis began in Syria, as a result of the open door policy, there has not been a planned public intervention on the refugee question. The numbers of Syrians and Iraqis seeking refuge in Turkey has varied in accordance with the intensity of the fighting. In addition, the irresponsible attitude of the government to this flow of refugees has increased the problems in the health and public service sectors. Health workers who already faced long working hours, especially in the border areas, faced an ever increasing work load. The indeterminacy in the regulations concerning refugees and contradictory practices frustrated the provision of public services. The numbers of personnel able to speak Arabic and Kurdish are few and well below the numbers required to meet needs. Neither the Ministry of Health nor the Ministry for Family and Social Policy have carried out any work to overcome these problems.

In the field of social services provision permanent locations for the provision of service are very important, but because the refugees lack permanent accommodation of good quality, ensuring continuity of service is not possible. The design of preventative health services and preventative social care in accordance with needs and problems of refugees is particularly important. It is necessary to take steps to ensure the adaptation of health and social services workers to these conditions. However, because the approach of the Ministries to this question has been problematic and wholesale, health and social services workers have been physically and emotionally worn down.

Union Policies and Practices

The problems in quality of and access to health and social service provision created by the flow of refugees resulting from the Syrian civil war is on SES’ agenda. In particular, in the provinces where refugees are concentrated, we have tried, alongside other people centred health organisations to make problems visible and develop proposals for solutions. We have done all we can to increase awareness among our members and expose existing problems.

As they cross the border people who were “citizens” are transformed into “illegals” with no rights at all, or refugees with very restricted rights. After crossing the border, for those either have no legal status or limited legal status, the most important problems concern claiming or obtaining rights. In the dominant understanding of human rights, human rights are essentially for those who are citizens. This approach, which covertly excludes those who are not citizens, needs to be comprehensively questioned, particularly in the world after the 90’s, in which international migration has both increased and become more varied. With the loss of citizenship, full participation in political life, and legal activity to secure improve and enjoy rights becomes virtually impossible.

The majority of organisations that have conducted activities concerning refugees have looked at them wholesale, thus failing to consider the particular problems experienced by women, children and LGBT refugees.

Naturally the worst affected by the difficulties that they face, of all the refugees in Turkey are the children. They are poorly nourished, grow up in social isolation, are victims of the reflection of the psychological problems experienced by their parents, fail to get appropriate treatment for their illnesses, are sexually abused, and if their parents cannot find permanent accommodation, are unable to exercise their right to education.

Women refugees, forced by violence and poverty to leave the place where they live, in the places to which they arrive face encounter a deepening of their psychological wounds, increasing poverty, discrimination, and increasing violence against women. Multilingual centres should be set up where refugees and particularly women refugees, can apply for help on their needs, oriented to the need of women and children. Ensuring access to quality public services by refugee women is a subject that needs to be taken up concertedly by all NGOs. While the services available to refugees are very restricted, in Turkey, where LGBTi reality is not recognised, the problems of LGBTi refugees are even less visible. LGBTi refugees have even more problems in gaining access to health services. The difficulties in obtaining treatment of trans people who changed their sexual identity in İran are compounded when we consider the regulations in Turkey about access to health services.

It is very important that we are insistent in implementing refugee rights, and ensuring the effective operation of mechanisms for the prevention of violations of those rights. Our union will continue its rights based efforts to expose violations of the rights of refugees, a particularly vulnerable group, especially in the fields of social and health services.

*This report was made possible through support from PSI’s Swedish affiliate Kommunal.

A Flickr album can be seen here: https://www.flickr.com/photos/psi_isp_iska/albums/72157662143803103

A news story on the release of the report can be read here: http://www.world-psi.org/en/psi-releases-report-syrian-refugee-crisis-and-its-effect-public-services-turkey