Forthcoming in MER issue 297 "Health and the Body Politic"
Nihal Kayali 11.24.2020
For the last six years, Turkey has hosted more refugees than any other country in the world. Since the beginning of the Syrian civil war in 2011, over half of the 6.6 million refugees who left Syria have sought refuge in Turkey.
Situated between a Europe wary of refugees and smaller regional neighbors weary of refugees, Turkey has proved relatively generous in both the scope of rights provided to Syrians and the scale of its refugee reception. While access to public health care is a central pillar of Turkey’s refugee efforts, the persistent language barrier coupled with bureaucratic obstacles, discrimination, overburdened facilities and changing state policies have laid bare the challenges Syrian refugees face in the existing system.
Syrians’ legal status in Turkey was systematized in 2014 with the establishment and application of the Temporary Protection Regulation (TPR) under the Law on Foreigners and International Protection, which extended free education and health care as well as the right to legal work to all Syrian nationals who registered. Despite shifting political tides, TPR has remained the backbone of Turkey’s refugee response over the past six years. The Turkish state’s most notable subsequent effort to ease access to care for Syrians has been the establishment of Migrant Health Centers staffed by Syrian doctors, a project buttressed by the infusion of European Union funds in 2016.
But a focus on the top-down transformation of refugee health care provision by the Turkish state misses two additional important and related aspects of refugee care. First, it overlooks the plight of the sizeable unregistered refugee population in Turkey, which is not served by the state system. Second, it misses the dynamic landscape of nonstate, often informal, refugee health care, sustained in large part by Syrian doctors and professionals to meet refugees’ needs.
To understand how health care provision outside the public care system has evolved over time I conducted interviews with Syrian refugees, Syrian doctors and Syrian clinic managers across ten refugee-run clinics in Istanbul from 2017–2019. During this period, there were a variety of informal health clinics in Istanbul operated by Syrian doctors for refugees. Some were run by registered non-governmental organizations (NGOs) while others operated on a smaller scale. The assumption was that these clinics would be temporarily tolerated until the Turkish health system could adapt to meet refugees’ health care needs. Yet Syrian-run clinics have not merely served as temporary substitutes for state services. Rather, a fragmented terrain of private clinics, some of which remain informal, has continued to serve as a complementary set of providers that address the residual health care needs of refugees in Istanbul. Refugees and health care professionals alike navigate this space strategically as the politics of refugee reception oscillates between tolerant, inclusionary and exclusionary.
The existence of Syrian-run clinics has allowed the state to relegate the needs of unregistered refugees into an increasingly expensive private realm and an increasingly precarious informal realm. In order to prevent the retreat of refugee care further into the shadows, accessible health care options for unregistered refugees must be regularized. Increasing financial support for advocacy NGOs and further strengthening their ties with health care providers would help facilitate free or subsidized care for those refugees shut out of the state system. Such an effort would both benefit public health and affirm the right to health for all of Turkey’s residents as enshrined in the country’s constitution.
The Emergence of Informal Health Care Providers
While the Temporary Protection Regulation established registered Syrians’ right to free health care in the state system, an updated 2015 circular laid out the legal criteria for the provision of care, including regulations for NGOs. Providers were required to register with the Ministry of Health and apply for renewal every six months, health care services were to be free and beneficiaries were expected to be registered, except in situations where emergency care was required or patients constituted a public health concern. A number of Syrian-run clinics—including seven that I spoke with in Istanbul—registered as Turkish associations and applied for legal provider status. Yet the provider regulations were never systematically implemented or enforced. In practice, the registered clinics charged nominal fees for services (20–30 Turkish Lira, or about $6–8 at the time), employed Syrian doctors without Turkish certification equivalency and treated refugees both with and without legal status. Six months after the initial registration, none of the 17 officially registered NGO clinics across Turkey had their legal status formally renewed. Many of the clinics, however, continued to practice informally with the tacit acceptance of the state.
Smaller private clinics also began to emerge throughout Istanbul around 2015. These clinics, run by Syrian professionals and tucked into apartments and commercial complexes, operated without attempting to register with state agencies. Many Syrian doctors worked in both types of clinics, dropping by a small private clinic to treat a patient and then walking across the neighborhood to see more patients in a larger NGO clinic.
Doctors and managers pointed to the language barrier at state providers as the overriding reason for the operation of informal clinics. The language barrier permeated all aspects of seeking care, including navigating the bureaucracy of the Turkish referral-based system, the possibility of miscommunication and the risk of being subject to discrimination by Turkish health care personnel. These concerns came up repeatedly in my interviews with Syrians. One 38-year-old woman described a traumatizing experience in which she believes she was subjected to an unnecessary cesarean section birth, describing the ordeal as “violent” and “inhuman.” Due to the language barrier, there was no way to communicate the reasons for the procedure, and she was left to try to make sense of the scarring encounter on her own. She noted that even though she would prefer to utilize free care, for now she would only go to fee-for-service Syrian clinics to avoid the risk of another negative encounter in a Turkish hospital.
While the demand for Arabic-language care was critical to the formation of Syrian-run clinics, so too was the presence of Syrian doctors in Istanbul who were eager to practice. Doctors, some of whom had fled Syria after their clinics and hospitals were targeted or destroyed in the war, arrived unable to practice their professions. Though they lacked Turkish certification, doctors were also acutely aware of the fact that their skills were in high demand by Syrians facing the barriers of the Turkish health care system. Informal health care provision provided relatively more dignified employment than other work options for Syrians, which, despite the introduction of work permits, remained by and large in the informal sector. One Syrian doctor recounted that he had been practicing for 38 years and was a specialist for 33. “We can’t go from being a doctor to working in a factory,” he explained. “It is beneath us.” The clinics provided a venue where doctors could resist being deskilled by Turkey’s employment regime, thereby maintaining their status in a professional—albeit informal—class.
The refugee-run NGO clinics provided substantial employment opportunities for Syrian professionals. Some clinics employed upward of 40 doctors in addition to nurses and staff. One manager noted that a primary goal of his clinic was “to employ as many Syrians as possible,” and that they actively tried to find opportunities within the organization for qualified individuals who approached them. The smaller clinics also served as a space for other professionals to salvage what they saw as respectable careers. One engineer who helped manage a clinic said that the fact that qualified Syrian doctors could not open their own legal clinics was an “injustice to doctors.” His wife, who never had to work back in Syria, now worked long hours in the clinic as an assistant to help make ends meet. Syrian-run clinics emerged where the supply of professionals shut out of the formal labor market coincided with demand for culturally and linguistically accessible care, employing Syrians in the process.
Refugee Health Care Preferences
Syrian refugees, even when registered and informed about their health care rights in Istanbul, sometimes prefer to seek out care in refugee-run clinics. Even as translators were incorporated into state facilities and after the Migrant Health Centers staffed by Syrian doctors opened, the preference for walk-in secondary outpatient care at times trumped the bureaucracy of the primary care-based state health system for many refugees.
Syrians often navigated their options strategically, opting for free state services in situations where care would require more involved procedures or costlier interventions. In situations that called for quick diagnoses or the expertise of a specialist, individuals often paid the nominal fee of a Syrian clinic. One 26-year-old woman explained how she navigated care in Istanbul: For her prenatal check-ups she saw a Syrian gynecologist at a local Syrian-run clinic, which was more comfortable than seeing a Turkish doctor. But for the birth, she went to a Turkish hospital equipped for the more involved procedure. When her infant daughter had a skin reaction, she again went to a Syrian clinic for immediate care. The informal clinics took on the role of a flexible supplemental outpatient clinic.
Yet for other Syrians, there is no choice. Those Syrians who are unregistered or reside in provinces different from their province of registration must seek out alternatives to state care. One respondent explained that when she approached the local authorities to register her family in Istanbul, officials suggested that they instead drive two hours to Yalova province to register due to local backlogs. After the ensuing bureaucratic ordeal, they realized that she, her husband and four daughters could not use the state services in Istanbul. As a result, they only went to Syrian-run clinics. Even though they heard that sometimes state providers were lenient with registration irregularities, they did not want to risk being charged excessively for care. Despite arriving in 2015, when registration was somewhat easier for Syrian refugees, this family was unwittingly excluded from the state system.
Problems accessing health care multiplied in 2018, when Istanbul and a number of border provinces with large refugee populations all but stopped registering Syrians. According to a Human Rights Watch report from July 2018, individuals were turned away at the border, forced to return to Syria in violation of international law and refused emergency medical services due to lack of registration. This tightening of Turkey’s refugee reception regime did not mean that Syrians stopped entering Turkey and settling in these provinces; it just meant that those who did enter could not usually register and therefore could not access formal health care.
The Introduction of Migrant Health Centers
Recognizing the health care challenges faced by Syrians in the Turkish system, the Ministry of Health gradually adapted its refugee care provision. In 2015, the Public Health Institution of the health ministry called for the establishment of Migrant Health Centers in areas with large refugee populations. Initially staffed by Turkish doctors, and therefore hardly an improvement for Syrians, the Migrant Health Centers were reinvigorated with European Union funding following the EU-Turkey Deal in 2016. In exchange for stricter control of refugee migration into Europe, the EU pledged €6 billion for refugee support programs in Turkey, with €300 million to fund the Turkish government’s SIHHAT project to improve Syrian refugee access to health care. In conjunction with the World Health Organization, the Ministry of Health trained Syrian doctors and nurses to staff 178 Migrant Health Centers and 790 migrant health units (one doctor and one nurse) in provinces with large refugee populations. These clinics were opened gradually beginning in 2018 and continued to open well into 2020, with translators, technicians, psychologists and other support staff increasingly incorporated into state health care institutions.
Yet, even as Syrian doctors and nurses trained to work in these new MHCs, informal clinics continued to operate. Gradually, authorities began to shut down the larger Syrian-run NGO clinics in 2018 and 2019 that had been tolerated for some time, though smaller informal clinics continue to operate, as do Syrian doctors working with private Turkish providers. Though the Migrant Health Centers effectively reduced language barriers at the level of primary care, their establishment did not wholly replace the existing terrain of refugee-run clinics.
One reason for their continuation is that some doctors had dismissed the SIHHAT project trainings since they had little interest in being relegated to the role of primary care giver, writing prescriptions and referring patients all day. As one doctor explained, “I spent a third of my life studying surgery. I will not be a GP, I would rather be jobless.” While some avoided the trainings as an insult to their years of specialized training, others participated only to realize that their salaries as MHC doctors were lower than their Turkish primary care physician counterparts. Formal employment, though legally stable, entailed a pay cut for those who had been working regularly in the informal clinics. The pull of informal but more autonomous work remained for some doctors.
But the continued provision of refugee-run care on the margins is not merely a supply-side phenomenon. Patients still seek out the clinics. One manager operating a clinic in 2019 explained that Syrians, both registered and unregistered, still came to the clinic frequently. “It’s not just people without ID, everyone comes…but it is the only place for people without ID.” Another clinic manager noted that in 2018, more Syrian refugees arrived in Istanbul fleeing violence in Ghouta and Daraa but were unable to register and regularize their status. He noted that even as some of their patients started frequenting MHCs after they opened, unregistered patients and newly arrived doctors largely replaced those who transitioned to the state system.
Even from the perspective of the Migrant Health Centers, informal care still had a place in Istanbul’s health care landscape. The Turkish supervisor of one MHC mentioned that if Syrians without official identification came to the clinic for care, they would send them either to emergency care or to trusted Syrian-run clinics in the city. She then noted that Syrian-run dentistry clinics have even drawn Turkish patients because of their low cost. In this sense, Syrian clinics were becoming established as one option among a diverse terrain of care providers in Istanbul.
New Restrictions on Refugees Impede Health Care
The role of nonstate providers evolved in 2019, as Turkey’s refugee policies became explicitly restrictive. A severe economic downturn in 2018 led simmering discontent toward Syrians to boil over into the political sphere. Refugees, and the state’s generous policies, proved a convenient scapegoat for the country’s economic woes. The insidious tropes of Syrian refugees as job stealers and a drain on state finances were harnessed by multiple political parties in the 2019 municipal elections. Realizing the growing resentment toward refugees within its own constituency, the incumbent Justice and Development Party (AKP) also tempered its relatively generous disposition toward refugees by tightening legal status enforcement practices. In the summer of 2019, the Istanbul provincial governor released a statement demanding that unregistered Syrians leave and register in other provinces. Those who did not comply were threatened with deportation. During this politically volatile period, reports of forced deportations to Syria proliferated.
The increased threat of deportation as well as the generalized rise in hostility toward Syrian refugees reverberated in the realm of health care. Personnel at state providers were advised to report unregistered patients to authorities for deportation. Referring to the new coercive policies, one administrator who helped implement the SIHHAT project noted, “So what happens now? The numbers of refugees [seeking care] are reduced. We don’t have that many refugees who are coming to get services.” For unregistered individuals, or those whose province of registration does not match their province of residence, state health care providers have come to be seen as a space of state enforcement and policing to be avoided. Aside from prohibitively costly private care, informal clinics are the only option for these increasingly precarious individuals.
With the crackdown on informal health care, some NGO clinics have attempted to legalize and privatize. At least one Syrian-run NGO clinic has been transformed into a private health care clinic with Ministry of Health approval, and others have looked into the feasibility of state-approved privatization but are currently closed. Meanwhile, peppered throughout Istanbul, one can still find informal Arabic-language care, albeit in smaller spaces than the NGO clinics that once operated. These clinics, known primarily through word of mouth rather than visible placards or active Facebook pages, are part of an increasingly fragmented private realm of refugee health care for those excluded from the TPR regime.
And while refugee health care has always been prioritized as a public health issue, even in the original text of the Temporary Protection legislation, the COVID-19 pandemic has brought into focus the importance of making care available to all individuals regardless of legal status. State providers, which by 2019 were a place actively avoided by unregistered refugees, have now opened their doors to all individuals for treatment in an effort to contain the spread of the coronavirus.
A government order passed in April 2020 provides free COVID-19-related care, including protective equipment, testing and treatment, regardless of registration status. Nevertheless, NGOs report that refugees who fear deportation continue to avoid state health care, and some are wary that a positive COVID-19 test would trigger removal from their jobs or their homes. As a result of persistent anxiety about deportation, unregistered refugees continue to seek care at informal providers.
Informal clinics staffing refugee doctors will continue to exist in urban centers so long as unregistered refugees lack accessible or affordable care options and doctors disillusioned with their limited professional opportunities remain. Despite the state’s recent efforts to crack down on both informal care provision and unregistered refugee populations, the reality across migrant-receiving countries is that crackdowns on legal status push individuals and their informal activities further underground. In the context of health care, such pressure goes against domestic public health interests, particularly in the midst of a pandemic.
Both the state and NGOs can play an active role in preventing the retreat of refugee care into the shadows. First, clinics that can demonstrate adherence to the Ministry of Health’s standards of care provision should be legalized as private providers, a transformation that already has local precedent. Second, Migrant Health Centers should be given official authorization to accept unregistered refugees. Third, the next stage of the SIHHAT project, which has been extended to 2023, should give Syrian doctors a path to provide the specialized care they were trained in and ensure salaries on par with Turkish counterparts. Finally, the links between advocacy NGOs, health care providers and the unregistered refugee population should be strengthened and streamlined to facilitate subsidized care for unregistered individuals. Together these changes can help diminish demands for informal care and ensure better health for all residents within Turkey’s borders.
[Nihal Kayali is a PhD candidate in sociology at the University of California, Los Angeles.]
 Basak Bilecen and Dilara Yurtseven, “Temporarily Protected Syrians’ Access to the Health care System in Turkey: Changing Policies and Remaining Challenges,” *Migration Letters *15/1.
 The number of irregular migrants in Turkey is estimated to be around 500,000 as of April 2020, with an estimated 55,236 of those from Syria, as cited in the June 8, 2020 “Situational Brief: Report on Forced Migrants and COVID-19 Pandemic Response in Turkey” by Ozge Karadag Caman, Erva Nur Cinar, Muge Cevik, F. Deniz Mardin, Ali İhsan Nergiz, and Selma Karabey. The exact number of unregistered refugees, however, is impossible to know and may be higher.
 I thank Radia Androun for her translation assistance with Arabic language interviews.
 I owe this idea to Dr. Yeşim Yasin, who discussed with me at length the possible policy and organizational solutions to the challenges of providing care to unregistered refugees.
 F. Deniz Mardin, “Right to Health and Access to Health Services for Syrian Refugees in Turkey,” *MiReKoc Policy Brief Series, *March 2017.
 Ceren Ark Yıldırım, Ayşegül Komşuoğlu and İnanç Özekmekçi, “The Transformation of the Primary Health Care System for Syrian Refugees in Turkey,” *Asian and Pacific Migration Journal *28/1.
 Interview, July 31, 2017.
 Interview, December 24, 2017.
 Interview, August 16, 2018.
 Interview, August 3, 2017.
 Interview, July 31, 2017.
 Interview July 27, 2017.
 Derya Özkul, “COVID-19 Salgını süreci ve sonrasi için göçmen, sığınmacı, ve mültecilere yönelik politika önerileri,” *Politika Raporu: Istanpol-Friedrich Ebert Stiftung, *September 2020.
 Interview September 6, 2018.
 Interview November 11, 2019.
 Interview August 16, 2018.
 Interview September 5, 2018.
 Interview September 17, 2019.
 Migrant Health Centers are often lenient and accept unregistered refugees, but this lenience depends on the generosity of individual clinics and doctors.
 “COVID-19 Salgını Döneminde Mülteci ve Göçmenlerin Durumlarına İlişkin Rapor” Sevgi ve Kardeslik Vakfi, June 1, 2020. “COVID-19 Krizi Sürecinde Türkiye’deki Mültecilerin Durum Analizi,” Refugee Support Center, May 18, 2020.
 Burcu Karakaş, “Göçmen ve mültecilerin pandemi günlerinde Türkiye’de sağlık hizmetlerine erişimi,” Heinrich-Böll-Stiftung, May 18, 2020.