Background

Refugees’ healthcare access is not only a global public health challenge [1]. but also a discursive battlefield of welfare chauvinism [2, 3]. In this regard, national regulations governing healthcare access can be understood as reflecting the broader migration governance framework of the host country [4]. Turkey, hosting approximately 3.5 million registered Syrians at the time of our data collection in 2022 [5]Footnote 1, has been internationally lauded for providing free-of-charge healthcare services. Yet, the extent to which health equity has been achieved for the Syrian refugee population remains contested in the literature. While some scholars raise concerns over Syrians’ potential overutilization of Turkish healthcare services due to the generous regulations [6,7,8], others focus on persistent barriers to healthcare access [2, 3, 9,10,11,12,13,14].

This study contributes to this debate in two ways. First, it systematically compares the healthcare utilization between Syrians and the Turkish host population. Second, it comprehensively analyzes the role of national migration governance – specifically the restrictive assignment of Temporary Protection Status (TPS) – in shaping (in)equitable access to healthcare services.

In the existing literature, no study has combined a population-level comparison with an analysis of how migration governance shapes healthcare access in the Turkish context. To address this gap, we employ a mixed-methods research design that combines data from a large-scale national survey of Syrians and their Turkish host population with 20 in-depth interviews of Syrian migrants. Our analysis of this novel empirical evidence is based on a theoretical framework that integrates the existing knowledge on the healthcare structures, regulations and barriers shaping Syrians’ access to healthcare in Turkey.

The remainder of this paper is structured as follows: The current literature on Syrian’s healthcare access in Turkey is reviewed in the following section, before we outline our theoretical model and empirical approach. In the subsequent sections, we present the quantitative and qualitative findings separately, before synthesizing them in the Discussion.

Healthcare access regulations for Syrians in Turkey

Initially, Turkey’s response to forced migration following the outbreak of the Syrian civil war in 2011 was framed as a temporary humanitarian crisis. Consequently, the Turkish Disaster and Emergency Management Authority (AFAD), was tasked with coordinating urgent healthcare delivery for those fleeing the war to the Turkish-Syrian border region. Over time, however, neither the Syrian conflict nor the resulting displacement proved temporary, and the Syrian population in Turkey continued to grow.

The steady growth of the Syrian population, particularly in border regions, placed additional strain on an already understaffed Turkish healthcare system. The overall impact on the national healthcare system and its quality appeared limited. But in provinces bordering Syria—where a majority of Syrians resided—Syrians under TPS constituted over 20% of patients in public, predominantly secondary, healthcare services as of 2014 [15]. In 2015, clinics and hospitals in these provinces received an estimated 30–40% more patients than before [16], reducing the quality of care for all [17].

In response, expanding healthcare infrastructure and incorporating Syrian health professionals into service delivery became essential. As the Syrian population increased and more Syrians settled in urban areas outside border camps, a circular that expanded free-of-charge healthcare access to Syrians holding identity cards was issued by AFAD in 2013 [10]. This arrangement was formalized with the 2014 Law on Foreigners and International Protection (LFIP), which remains the key document governing healthcare provision for non-citizens under international protection in Turkey. Under this framework, Syrians under TPS are covered by health insurance in accessing primary and secondary healthcare services.

In 2016, the first EU-funded healthcare project, SIHHAT, was launched, allocating €300 million to the Turkish Ministry of Health to improve healthcare provision for Syrians in Turkey. Designed specifically for Syrians under TPS, the project aimed at establishing a systematized and centralized primary healthcare delivery. SIHHAT led to the creation of 790 health units (each consisting of one doctor and one nurse) across 177 Migrant Health Centres (MHCs) nationwide. These centers employ 790 doctors, 790 nurses, 300 support staff, 84 technicians, and 960 patient guides [18]. Following the completion of SIHHAT I in 2021, SIHHAT II was introduced with a budget of €200 million [19].

In the newly established MHCs, Syrian health professionals – after receiving special training and certification from WHO migrant health training center, were permitted to treat Syrian patients. While most MHCs provide primary healthcare through employed General Practitioners (GP) only, approximately 42 Extended Migrant Health centers (EMHCs) offer specialized services such as specialized dental, gynecological, pediatric care, X-ray or ultrasound [20]. Services are typically provided in Arabic and operate on a first-come, first-served basis during weekday daytime hours.

Syrian doctors are employed in MHCs und a special one-year contract with the Ministry of Health, which restricts them to providing primary care regardless of their specialization. Workloads are significantly above recommended levels: while the Turkish Medical Association suggests 20 patients per day, physicians in the MHCs reportedly see between 50 and 80 patients per day [20]. Such high patient loads likely compromise the depth and quality of care, reducing opportunities for thorough medical assessments and detailed communication, and potentially diminishing patient’s confidence in the care received. In addition, the employment restrictions further contribute to quality concerns by underutilizing specialized skills; physicians with specialized training are confined to providing primary care, which may result in suboptimal management of complex conditions requiring specialized expertise. Despite these challenges, official evaluations of the SIHHAT project conclude that the project was meeting the health needs of the Syrian population in Turkey, and increased demand for as well as availability and accessibility of healthcare services [20].

Nevertheless, the question remains whether the existing legal framework and healthcare infrastructure ensure equitable access to healthcare, or whether persistent barriers continue to prevent Syrians from benefiting fully from healthcare services [3, 10].

Syrians as a threat to the national healthcare system?

A significant body of literature has focused on the infectious disease-burden and vaccination status of Syrians [7, 21,22,23,24], often framing them as a potential threat to the health of Turkish citizens. Another strand of research examines the utilization of the healthcare services and the potential demand-shock posed to the Turkish healthcare infrastructure, assuming that national policies and regulations enables Syrians to access services easily [6,7,8].

Several studies have drawn on diverse datasets – especially from the early years of Syrian displacement to Turkey – to quantify healthcare visits and expenditures [25, 26] But none of these systematically compared healthcare utilization between adult Syrians and the host population at the national level. One study compared Syrian and non-Syrian children and found that Syrian children presented more frequently with high acuity to the Emergency Departments (ED) in the researched hospital in Istanbul, resulting in higher hospitalization rates and longer stays compared to Turkish children [27].

While understanding the challenges of meeting the healthcare needs of a rapidly growing refugee population—including the potential impacts on the host population—is indisputably important, framing the disease burden, fertility rates, and healthcare utilization patterns of Syrians primarily as a threat to the health and healthcare access of the Turkish population warrants critical examination. Such framings evoke discourses within broader dynamics of welfare chauvinism and medical racism. Ozaras et al. [28] therefore argue that academic, policy, and public debate should be grounded in empirical epidemiological evidence rather than prejudice.

Beyond fears of Syrians posing risks to public health, public discourse the funding of migrants’ healthcare as a public policy issue [2, 3]. Growing anti-migrant sentiment among Turkish citizens has been linked to the belief that their tax payments are used to finance Syrians’ healthcare [2]. This perception that persists despite the fact that a considerable share of healthcare and welfare payments for Syrians are funded by international actors, particularly the EU. According to Siviş [3], this reflects a broader pattern of conditional welfare distribution: Syrians are perceived as not belonging to Turkish society and are therefore constructed as less deserving of social welfare in general, and healthcare in particular. This nativist attitude toward healthcare provision appears especially pronounced in Turkey, where a strained healthcare system struggles to meet the needs of both citizens and non-citizens [29].

Persistent barriers to equitable healthcare access

Kargin [30], reports that most Syrian refugee interviewees were satisfied with the free-of-charge healthcare provided – despite some facing poor treatment and negative attitudes. But substantial evidence points to unmet health equity due to persistent structural barriers to formal healthcare services.

First, MHCs provide only “first stage diagnoses” and corresponding treatment [31]. Even when trained in a medical specialty, Syrian physicians working in the MHCs are restricted to practicing as general practitioners [20]. Access to specialized healthcare, as for Turkish citizens, requires referral from a primary healthcare service (e.g. a GP in an MHC) or independently seeking an appointment via online services or phone calls. However, these services – and often consultations themselves – are conducted in Turkish only.

Language barriers are consistently identified as the primary obstacle to accessing adequate healthcare [9, 11,12,13,14]. Even within MHCs, shortages of Arabic-speaking staff – particularly female doctors – persist. Social workers, psychologists, and dentists often lack sufficient Arabic proficiency [20]. Beyond the MHC-setting, language barriers prevent appointment booking in public hospitals [32], ) and access to health information needed to navigate secondary care [2, 33]. They also complicate communication with healthcare professionals in hospitals, increasing the risk of misdiagnoses and over- or under-prescription of care [34,35,36]. Although qualified bilingual patient guides funded by the SIHHAT project are employed as “patient referral personnel” in some public hospitals, their numbers remain insufficient [2, 20, 31, 37] or their skills are inadequate for medical translations [13].

Furthermore, reports document discriminatory incidents against Syrians seeking secondary and tertiary care in public hospitals [2, 13]. Combined with language barriers, such experiences contribute to mistrust towards the Turkish healthcare infrastructures [12]. An assessment run by Doctors of the World further identified the issue of distance and transportation costs restricting healthcare accessibility, primarily for Syrians in rural areas [11].

Most critically, primary healthcare services in the MHCs and secondary and tertiary healthcare in the public healthcare infrastructures are limited to Syrians registered under TPS in their province of registration [4, 9, 10, 12]. Under the LFIP, unregistered Syrians and those seeking care outside their province of registration are entitled only to emergency health services and the treatment for communicable disease that pose a risk to the general population. Yet, fears of being reported to the police and consequently deported prevent many unregistered Syrians from seeking care in public hospitals [31]. Moreover, without TPS, Syrians must pay for treatment in private and public hospitals, at rates three to six times higher than those charged to Turkish citizens because they are subjected to the Regulation Concerning International Health Tourism and Tourist Health [31].

Due to these structural barriers, many Syrians, especially in urban areas, turn to informal clinics run by Syrian healthcare professionals, despite their fee-for-service nature [13, 38]. These clinics remain informal due to the operating physicians being denied licenses (in their specialty) in Turkey. For Syrians facing registration struggles, those informal clinics are essential to receive any medical care, as they require neither proof of identity nor registration [31]. Even for those under TPS, such informal clinics are a popular alternative over the hard-to-navigate state-run medical services [38].

The threat to health equity posed by access barriers related to Syrian’s registration status have further increased since 2022, when the Turkish government started significantly restricting and complicating registration of Syrian refugees [32]. In some districts, registration had already been halted as early as 2017 [39]. Karadağ and Tatar [40], characterize Turkish migration governance, including the TPS registration procedures, as not only arbitrary but intentionally “powered by secrecy”. Consequently, ever-growing registration struggles of Syrians seemingly manifest in service exclusion [12] and thus predominant structural health inequity.

Sweeping policies: closed districts, increased checkpoints, deactivated IDs

The first comprehensive law on international protection, the 2014 LFIP, states that Syrians are required to approach the provincial directorates of the Presidency of Migration Management (PMM), of their own choosing, to obtain a temporary protection identity card. Once they receive their ID specified with their city of registration, they gain access to healthcare and education, but not to work permits. Hence, once Syrians are registered, they must reside within their city of registration and apply for travel a permit from the PMM to move to another city. Likewise, their access to healthcare, education and any other public services is restricted to their province of registration [31].

Despite the legal architecture of Turkish protection regime aiming to internally tie Syrians to their provinces of registration, Syrians tend to move to other cities, albeit without travel permit, to find jobs in the informal sector in bigger cities. Although such internal mobility is difficult to quantify, a field study conducted by the PMM and IOM in 2018–19 estimated that approximately one million Syrians were living in Istanbul, while only 496,000 were officially registered in the city [41]. Other reports similarly indicate that large numbers of Syrians relocated to access informal market and that they had managed to access healthcare using their IDs, as internal mobility was largely tolerated until 2019 [18, 31].

After 2019, however, internal mobility of Syrians – particularly toward metropolitan cities – became increasingly securitized, a trend that intensified after 2021 [42]. Following the surge of public backlash against refugees in the summer of 2021, driven in part by the radical right party (ZP), the government declared sweeping policies in 2022. These included halting registration and ID renewal processes in many provinces and districts [43]. Registration and renewal restrictions were followed by regular home visits by authorities to identify those not residing in their provinces of registration. Syrians under TPS who were living outside of their registered provinces - in the thousands - were given 45 days to relocate households, workplaces and children’s schools to their registered city and complete re-registration. Otherwise, they risked losing their TPS and having their IDS cancelled [42]. For thousands of Syrian families, 45 days were impossible to rebuild a new life in another city, forcing them to risk becoming irregular. These so-called sweeping policies aimed to reduce overcrowding in metropolitan cities, completely close certain districts to Syrians, increase checkpoints and highly tighten control over inter-city travel that had previously been tolerated, and ultimately decrease the total number of registered Syrians by introducing continuous obstacles to registration and renewal procedures.

The last stage of sweeping policies was the official announcement of “big return plan of Syrians”. The President Tayyip Erdoğan announced plans to reconstruct residential and industrial zones in northern Syrian under Turkish control, to facilitate the “voluntary” return of one million Syrians [44]. Government officials further indicated that the international projects and funding would be directed toward these areas, Afrin, al-Bab, Aza, Jarabulus, and Idlib [45].

This study, employing a mixed-methods research design and providing a population-level comparison additionally makes significant contribution by accounting for the consequences of recent sweeping policies that have notably deteriorated Syrians’ access to the healthcare and health equity.

Methods

Theoretical framework

Assessing whether a population enjoys equitable healthcare access poses a number of conceptual and empirical challenges. Merely observing a population’s healthcare seeking behavior (i.e. its realized healthcare access) provides limited information about remaining barriers to access, as we lack information on the ideal, unimpaired healthcare utilization. We need to thus model the various factors influencing individual healthcare use to identify those that indicate structural barriers in healthcare access.

To do so, we employ the well-established theoretical framework of the Behavioral Model of Health Service Use (BMHSU) developed by Ronald Andersen [46] and subsequently advanced [47] and applied to the study of healthcare access of many subpopulations, including migrants [48, 49]. In its most commonly employed form, the BMHSU models individual healthcare use as a result of the interplay of predisposing (e.g. demographic characteristics, social status, health practices), enabling (resources such as income, health insurance or a nearby source of care) and need factors (subjective and objective health status). Following Andersen’s argumentation, equitable healthcare access would be achieved if individuals’ realized healthcare use is determined by their demographic characteristics and their healthcare need, not by e.g. their membership in a particular social group or their financial resources.

In their adaption of the BMHSU to the study of immigrant healthcare utilization, Yang & Hwang [49], further emphasize the particular importance of macrostructural factors in determining the healthcare access of migrant populations. These can include the structure of the healthcare system (e.g. the establishment of MHCs), healthcare and immigration policies (e.g. rights and restrictions related to TPS), as well as the general conditions under which migrants arrived in the context under study (e.g. forced displacement).

In the present analysis, we are primarily focused on how the predisposing factor of being Syrian in Turkey relates to healthcare utilization, i.e. whether Syrians enjoy equitable healthcare access in Turkey. As evidenced in the literature described above, macrostructural factors play a pivotal role in shaping Syrian healthcare access in Turkey and thus represent a particular focus in our analytical framework. On the policy level, the introduction of TPS and the enforcement practices regarding the registration of Syrians are key macrostructural factors, as they regulate whether an individual falls within the group of those registered under TPS (predisposing factor) which, in turn, provides the enabling resource of free healthcare access in the province of registration. Key macrostructural factors on the healthcare system level considered in our analysis are the introduction of the MHCs the continued existence of Syrian-run informal clinics as well the dual-system of public and private hospitals, the latter of which are not required to control for patient’s registration status. Further factors particular to the healthcare access of Syrian in Turkey and thus included in our analytical framework is the enabling factor of Turkish proficiency and the predisposing factors of prior experiences of discrimination and duration of stay in Turkey, the latter of which may affect individuals’ familiarity with the (formal and informal) healthcare system in Turkey and hard-to-measure social resources. An overview of our analytical framework is provided in Fig. 1.

Fig. 1
Fig. 1
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Analytical framework based on Behavioral model of healthcare service use (BMHSU), own illustration adapted from Yang and Hwang [49]

Mixed-methods design

In order to trace the complex interplay of macrostructural, predisposing, enabling and need factors, our analysis follows a mixed-methods approach that incorporates both qualitative and quantitative data sources in a complementary, sequential design.

The first data source used, is a quantitative survey including 2497 face-to-face interviews collected in the TRANSMIT project across Turkey in 2022 among both Syrians and the majority population in the same neighborhoods. This data allows us to systematically compare the utilization rates of the Syrian and Turkish respondents across three levels of care. However, the relative anonymity of a standardized survey often does not allow for particularly sensitive subjects surrounding e.g. individual’s legal status. Additionally, despite the deliberate sampling method, combing stratified area sampling with random walks, it is possible that unregistered Syrians, owing to their more precarious legal status, were less likely to agree to be interviewed, resulting in an under-sampling of the non-registered Syrian populationFootnote 2.

Taking this into account, we combine the quantitative evidence with a set of 20 semi-structured interviews conducted in 2023/2024 with Syrians residing in Gaziantep and Istanbul, with some of those not being registered under TPS or being registered in another province. These more recently collected qualitative data allows us to learn more about the intertwined struggles of registration and healthcare access. These struggles are particularly interesting amid the since 2018 intensifying threats and enforcement of deportation of Syrians, putting many in a position of losing their TPS registration. [40]. The semi-structured interviews were also conducted several months after the devastating earthquake that hit Turkey and Syria on February 6 2023 and that was shown to amplify pre-existing inequalities and vulnerabilities for the Syrian population in Turkey [50].

Quantitative analysis

The quantitative analysis is based on survey data collected across 20 Turkish provinces in November and December of 2022 as part of the TRANSMIT project [51]. As such, its stratified random area sampling strategy has been described in Gundacker et al. [51]. The resulting study sample contains 1258 Syrian and 1239 Turkish respondents between the ages of 15 and 92.Footnote 3 Computer assisted personal interviews (CAPI) were conducted by a native speaker in Arabic for the Syrian and Turkish for the host sample.

Dependent Variables were selected to capture potential differences in accessibility across different levels of care and measure realized healthcare utilization across two distinct domains. Our first outcome measure captures individual’s consultation with any medical professionals, regardless of institution or specialty. It is coded as a binary variable that is equal to one if respondents reported that they saw a medical doctor about their health in the last 12 months. This measure also captures consultations in informal clinics run by Syrian doctors, an important source of healthcare for some Syrians. The second outcome measure captures people’s utilization of emergency care services in hospitals. It is also binary and equal to one if respondents report that they received care in an emergency department in the last 12 months. Emergency care represents a more resource intensive form of care that is only available in formal public or private hospitals.

Independent Variable selection was based on common operationalizations of the BMHSU for quantitative analysis (see Table 1 for variable specifications). Since it makes use of individual, cross-sectional data, from one point in time our quantitative analysis cannot capture variations in macrostructural factors such as the design of the national health insurance scheme or the nation cost-of-living crisis. They are thus not part of our statistical model.

Table 1 Specification of dependent variables
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The statistical analysis, given the binary nature of our dependent variables, employs logistic regression to model healthcare service use. To account for our area sampling design, we cluster standard errors at the neighborhood level. Missing values in the independent variables are adjusted for using Multivariate Imputation by Chained Equations [52] as employed in the mice package in R [53]. In as first step, we model healthcare use among Turkish and Syrian respondents based on the BMHSU, to identify differences in healthcare access between the two groups. For ease of interpretation in the presence of nonlinearities and interactions, results of this regression model are presented as predictive margins [54], i.e. the average predicted annual probability of utilization, estimated separately and pooled across the 10 imputed datasets via Rubin’s Rules [55].

Spoken Turkish proficiency, years since arrival in Turkey and discrimination experiences cannot be meaningfully compared between Turkish and Syrian respondents. Instead, in a second step, we run separate models among the Syrian sample only. Consistent with the first analysis, results for the three Syrian-specific variables are presented as marginal effects, i.e. changes in predicted annual probability of utilization. Full regression results (in adjusted Odds-Ratios) can be found in the Supplementary Materials.

Qualitative analysis

In our qualitative data, 20 in-depth and semi-structured interviews were conducted with Syrians living in Turkey, between January and February 2024. The interviews were carried out face to face in two provinces of Turkey, Istanbul and Gaziantep, which host the largest number of Syrians (Istanbul = 529,944; Gaziantep = 429,935, as of August 2024), and which were also included in the sampling frame for the quantitative Survey. In both provinces, districts and neighborhoods with the dense concentration of Syrians were visited and respondents from these areas were approached through the purposive snowballing. In the city of Istanbul, 10 respondents were interviewed in the districts of Küçükçekmece, Sultangazi, Çağlayan, Fatih and Şişli while another 10 respondents were approached in the neighborhoods of Akyol, GATEM, Ünaldı and Karşıyaka in Gaziantep. The interviews were conducted either through home visits or at workplaces.

In our qualitative study, we aimed to capture the differences in the Syrian community in terms of their ethnic and gender-based subjectivities as well as legal status in order to observe potential hierarchies in access to healthcare. Among 20 interviews, there are 4 Kurdish Syrians, 3 Turkmen Syrians and 13 Arabic Syrians. Out of total numbers of respondents, there are 15 men and 5 women.

Regarding their registration status, there are 9 Syrians (3 in Istanbul, 6 in Gaziantep) who reside in their provinces of registration without having registration obstacles. Additionally, we have 4 interlocutors who are earthquake victims of the city of Hatay and currently reside in Istanbul. While 2 of these four respondents were able to obtain travel permits along with their family members, the other 2 had become unregistered for various reasons and, consequently, refrained from leaving their homes due to fear of being apprehended by the police. The remaining 7 out of the total 20 individuals had become unregistered in both cities for various reasons.

During our qualitative study, one of the authors (SK) conducted interviews and did participant observations in the houses or workplaces of respondents. Her already established network within the Syrian community strengthened our capacity to reach our respondents and to build trust relations. Interviews were conducted in Turkish, Arabic and Kurdish later to be transcribed and translated into English. During Arabic and Kurdish interviews, Syrian civil society actors and experts did the simultaneous translation. The data was collected after well-informed and explicit consent of the respondents.

For the qualitative analysis, data from in-depth interviews was analyzed with MAXQDA. Each transcript was reviewed separately by two qualitative experts of the research team, each creating a separate analysis file for comparison. After reviewing each transcript, similar descriptions, phrases and concepts were grouped into categories. Once qualitative researchers agree on categories and sub-categories, these were subsequently linked into themes to get a sense of diverseness and nuance in responses by paying attention to their legal, socio-economic, and ethnic-based differences in their access to healthcare.

Results

Quantitative analysis

Descriptive results

Descriptive characteristics of the Syrian and host samples can be gleaned from Table 2. Unsurprisingly, the two samples somewhat differ in their demographic make-up with the Syrian sample being on average younger, more likely to be male and married than the host sample. With a lower average educational attainment, a higher chance of being employed in precarious day labor and lower household savings and current income, Syrians in our sample further present as having a lower socioeconomic status than the host population. With regards to the healthcare needs, we find self-rated health to be comparable between the two samples, while the PHQ-score implies a substantially higher mental health burden among the Syrian sample. Another noteworthy observation in Table 2 is the higher number of missing values in the host sample. Based on field observations these are likely a result of a more common reluctance to share information that is perceived as personal among Turkish respondents. Since we impute missing values using multiple imputations, variables with high missingness rates will exhibit slightly wider confidence intervals and reduced statistical significance, while mitigating bias in point estimates that would result from listwise deletion.

Table 2 Sample distribution of Independent variables by sample strata
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The distribution of our dependent variables in Table 3 shows no significant difference in the probability of having seen a medical doctor in the last 12 months. However, Syrians appear significantly less likelyFootnote 4 to have visited an emergency department in the last 12 months.

Table 3 Sample distribution of dependent variables by sample strata
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As outlined above, descriptive statistics on healthcare utilization alone do not allow for meaningful inference regarding differences in healthcare access. We thus turn to the results of our statistical analysis.

Regression model

Figure 2 displays the predicted annual utilization rates by sample and income group controlling for need, predisposing, and enabling factors (see Table 1) and largely confirms the descriptive findings (detailed coefficients and confidence intervals for all variables included in the regression are provide in the Supplementary Materials Table S1). While Syrian respondents display a slightly lower probability of having seen a medical doctor in the last 12 months (79.8%) than their Turkish counterparts (80.8%), the difference is not statistically significant. Income is also not a significant predictor of access to medical doctors for either Syrian or Host respondents.

Fig. 2
Fig. 2
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Predicted probability of healthcare use by strata and income group, controlling for sample characteristics

Meanwhile, for visits to the emergency department, Fig. 2 shows that, all else equal, being Syrian is associated with a significantly lower probability of use (25.4%) than being Turkish (31.75%). This Syrian under-utilization relative to the host population appears to be somewhat compensated for by income. Syrians with a monthly income higher than 6000 TL display a probability of visiting the ED of 30.6%, compared to 24.1% for those below the income threshold. In contrast, for the host sample this relationship is reversed and insignificant, indicating that income is only a relevant predictor of emergency service use among Syrians.

Figure 3 presents the results of the analysis run in the Syrian sample only, which allows us to study the relationship of years since arrival in Turkey, spoken Turkish proficiency and experiences of verbal discrimination with predicted healthcare utilization rates. For doctor visits, only a longer duration of stay on Turkey shows a significant relationship with utilization, with an additional year of tenure in Turkey increasing the average predicted probability of use by 1.3% points.

Fig. 3
Fig. 3
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Marginal effects of years in Turkey, Turkish speaking proficiency and verbal discrimination on probability of healthcare use

Meanwhile, the probability of having visited the ED is significantly correlated with both experiences of discrimination and spoken Turkish proficiency. Syrian respondents who rate their ability to speak Turkish as good or very good have a 10.2% points higher probability of visiting the ED at least once a year. An increased frequency of verbal discrimination experiences is associated with a 2,9-percentage-point decrease in the probability of having an ED visit. The years of stay in Turkey do not appear to impact ED use in any significant way.

Qualitative analysis

Testimonies given by Syrian respondents in the interviews describe significantly restricted healthcare access due to institutional and structural experiences of discrimination. In the following, we will examine the substantial influence of TPS regulation and registration enforcement policies (macrostructural), the individual’s registration status (predisposing), financial resources and language skills (enabling) on equitable access to healthcare for Syrians in Turkey.

Temporary Protection status (TPS) policies and individual legal status

The qualitative part of the study details how, on one hand, the individuals’ legal status, plays a key predisposing role in access to healthcare. On the other hand, in the midst of sweeping operations and narrative of return plan, securitizing TPS regulation and registration enforcement policies can be identified as a powerful macrostructural factor shaping healthcare utilization.

Participants residing in their city of registration indicated their satisfaction with healthcare access. “Healthcare is the best thing, generally works very well” (R1) was the general framework emphasized by the respondents who have their IDs in TPS and reside in their city of registration. In both cities, Istanbul and Gaziantep, participants who have their IDs issued in their city of registration did not mention any obstacles they face in accessing MHCs or public hospitals. Those having chronic diseases or serious operations, such as diabetes, coronary disease, appendicitis and intestinal surgery, noted their overall contentment regarding healthcare access. Nevertheless, overcrowding, waiting time, and violent conflicts are likewise experiences reported to be made in public hospitals. Testimonies describe it to be “a matter of luck” (R13) and that not only Syrians, but “Turkish citizens are also complaining about the [public] hospitals” (R11). Accordingly, if they have the legal status and the opportunity to choose, Syrians might opt for private healthcare to receive high-quality and preferred health services (e.g. female doctors for female patients).

Our findings reveal that in case of Syrians who do not reside in their city of registration, access to healthcare is no longer possible. A testimony from a 45-year-old Arabic-speaking Syrian father, registered in Istanbul but with two unregistered children due to Istanbul’s closed registration policy. His account highlights the stark contrast between him and his children:

It was a fantastic service; they cared well about me. If I did not have an ID card, it would have been different, of course […] They [his children] did not get severely sick, to the degree that I had to take them to hospital. But, if they got too sick, I would take them to a private hospital or to hidden Syrian clinics.”(R10)

The only condition to access healthcare in a province where you are not registered is to obtain a valid travel permit. Travel permits became particularly relevant for victims of the earthquake. For them, travel permits valid for 3 months were promptly issued but had to be renewed thereafter. An Arabic Syrian, aged 32, father of 2 children who was an earthquake victim in Hatay and had to bring his family to Istanbul after the earthquake noted that: “I went to the hospital, when they saw my ID registered in Hatay, they asked for a travel permit to Istanbul, then they accepted me.” Since their arrival after the earthquake, he renewed his travel permit a couple of times, and the current one was valid for 2 more months: “we never know if they will give us new permission to stay in Istanbul or ask us to go back to Hatay. No one knows.” (R5).

Testimonies of our respondents show that for Syrians who do not reside in their city of registration, emergency departments appear as a solution to access healthcare.

They try to enter from emergency. They can enter the emergency room, but for example, sometimes they say that we are not specialists, you will make an appointment, the specialist will take a look, in that case they will have to go to a private hospital. That’s right, now most of the people who do not have a travel permit go to the private sector. (R3)

Our qualitative data indicates that especially in the midst of sweeping operations, Syrians might witness multi-faceted obstacles regarding their registration and IDs. An illustrative case is that of R6, a 22-year-old Arabic-speaking Syrian male. Although officially registered in Hatay, he had resided and worked in Istanbul for several years without any problem, despite the absence of a travel permit. In January 2023, fifteen days prior to the devastating earthquake, he was detained by authorities for lacking travel permit. Following his release under the condition of returning to Hatay and regularly giving signature to local authorities, he tragically lost his entire family in the disaster. Despite these circumstances, upon returning to Istanbul to stay with relatives, he was detained again six months after the earthquake. This time, authorities confiscated his ID and mandated proof of residence in Hatay – an impossible requirement given the city’s devastated infrastructure. During our interview, he described living under de facto house arrest at his uncle’s residence, noting that he would buy medications from the pharmacy which is the only way for those lacking ID.

Another respondent was detained and returned to Syria in 2019. He came back to Turkey but lived without his ID since then due to the registration restrictions. Likewise, he lives in a prison-like situation in his home in Istanbul. Regarding his healthcare use, he narrates:

I just take medications from pharmacy. I have an arm ache, but I am just taking a painkiller. Recently, I got severely sick, I was in bed for 10 days. But, I could not go to the doctor because of my legal situation […] It was a severe flu. I could not get treatment because I have no ID. I do not want too many things, only ID to feel I am a human like people going out, having a job. I want to work to support my family. I feel embarrassed because my family is supporting me, it should be the opposite. I am a young man who can work and do too many things. But because of the ID issue I am imprisoned, I cannot do a thing. (R7)

The case of a married Kurdish Syrian woman (R20) in Gaziantep illustrates how sudden administrative actions and home visits can severely disrupt healthcare access. Registered without issue along with her four children until 2021, her family had been established members of their neighborhood for twelve years, with their standing verified by both the mukhtar (local administrator) and neighbors. Despite this community recognition, she was abruptly arrested from her home on unsubstantiated terrorism allegations. Following a year-long detention in a removal center, she was released under the condition of regular check-ins with authorities. Notably, no formal evidence supporting the accusations was ever provided. The revocation of her identification documents during this process has had severe consequences. She described being completely excluded from formal healthcare services, including during childbirth:

It was a private hospital. […] My husband borrowed money. I went to the state hospital, but they did not take care of me. I had to go to a private hospital. My daughter stayed in the hospital for a while after she was born. They charged 3,000 TL each day. At first, they wanted 5 thousand for each day. But we had no chance to pay that much. I told them to come and look at our house, it is a hell and we do not have any money. They said 3,000 was enough […] My baby was hospitalized for a week. My husband is still paying for them. […] No, I cannot go [to hospital]. My feet hurt, I have asthma, but I could not go. I cannot afford medicine. My tooth hurt, I had it pulled for 500 TL. I have another tooth that hurts, but they want 3,000 TL. How can I pay that money? And I have small children. (R20)

Our qualitative data indicates that in the post-2019 period – intensified with sweeping policies - Syrians and Syrian families face diverse registration obstacles. Some become de facto irregular when their IDs are cancelled because they cannot relocate to their city of registration. Earthquake victims are unable to renew their travel permit due to renewal restrictions. Others cannot register their children or face unproven accusations and detention orders after increased checkpoints that result in the loss of their IDs. The in-depth interviews reveal a wide range of cases in which Syrians risk losing their registered status under the increasingly severe implementation of sweeping policies. Therefore, under the macrostructural factor of TPS regulation, legal status appears to be a key predisposing role in access to healthcare.

Financial resources and economic capital

Most participants residing in their province of registration reported that while they continue to access free primary healthcare services, they have been required to contribute to medication costs since 2023. As one respondent explained: “Medications were fully covered before 2023, but now we must pay for them” (R3). This policy change has created additional financial burdens, particularly for those requiring specialized treatments. A participant noted: “My brother suffers from immune deficiency syndrome, but we must purchase his expensive medications ourselves as they are not covered” (R8). Hence, even in the case of Syrians living in their city of registration, free access to healthcare might need additional financial resource for specific medications since they are not covered by the system.

When it comes to Syrians facing any registration obstacle, healthcare options are severely limited to emergency services, private hospitals, or informal Syrian clinics (for which they must pay out-of-pocket). Those residing outside their registered province can only access secondary healthcare in public hospitals through emergency departments by presenting identification and covering the full costs. Notably, these fees are substantially higher than those charged to Turkish citizens, as they are calculated according to the Regulation Concerning International Health Tourism and Tourist Health [31], which sets prices at three to six times the standard rate.

This financial burden was highlighted by a 55-year-old Kurdish male registered in Istanbul but residing in Antalya:

We paid for services. We went to private hospitals. We went when we were ill and needed medication. But always on a paid basis. Because were not in our registered province to receive healthcare. (R4)

For those with sufficient financial means (and ID), expensive treatment in private hospitals remains an accessible option regardless of registration status or location. Respondents without valid ID documents (unregistered, deactivated or lost ID etc.) are in practice limited to informal Syrian clinics. In both cases, all expenses must be covered out of pocket. Accordingly, individuals lacking financial resources report significant barriers to adequate care.

Those facing both ID and financial constraints often resort to self-medication through pharmacies. As our research revealed, pharmacies in migrant-concentrated districts serve a dual function as both medication dispensaries and de facto primary care providers (R2). Since they cannot access MHCs or public hospitals due to lack of formal status, nor afford private hospitals or informal clinics, their only option is to rely on a neighborhood pharmacy as their sole source of healthcare.

Language

Our qualitative data indicates that the significance of language appears as a prominent factor especially in secondary healthcare in hospitals. Despite efforts to employ translators in public hospitals and Syrian doctors in MHCs, fieldwork study demonstrates considerable barriers in language and communication.

The Turkish formal healthcare system does neither provide multilingual healthcare services nor a sufficient number of qualified interpreters (so-called patient guides) for migrant communities seeking healthcare beyond MHCs. Since the whole bureaucratic system, including referral procedures, is even complicated for Turkish citizens to navigate, it becomes almost inaccessible for non-Turkish speaking Syrians.

In the absence of bilingual patient guides and referral guidance, neighbors, children and friends often accompany Syrians to hospitals. In our sample, ethnic diversity among Syrian community played a key role to reveal discrepancies between Arabic, Turkmen and Kurdish Syrian communities. While Turkmen Syrians are the most advantageous group because of their Turkish language proficiency, the most vulnerable group appears as Arabic Syrians regarding language barriers in healthcare.

A 48-year-old Kurdish Syrian respondent, registered in Istanbul and father of three, highlighted healthcare as the most beneficial service available to him. However, due to linguistic challenges, his daughter—currently enrolled in a Turkish high school—accompanies the family to medical appointments to facilitate communication with healthcare providers (R1). Similarly, a 32-year-old unregistered widow residing in Istanbul reported relying on informal Syrian clinics because of her unregistered status, while her registered brother accesses public hospitals by bringing a Turkish-speaking acquaintance to interpret (R8).

This reliance on neighbors or family members was further emphasized by a registered Kurdish Syrian woman in Gaziantep, who stated, “I take my daughter with me, she translates. When my daughter is not there, I go with my neighbor” (R18). Parallel experiences were echoed by a 35-year-old Arabic-speaking mother of four, also registered in Gaziantep, who explained, “We try to find someone who knows Turkish to translate for us like the neighbor. Sometimes we depend on ourselves and try to use our limited Turkish skills” (R19). As a result, testimonies report misdiagnoses and mistrust towards the healthcare system.

Notably, during field research, greater satisfaction with healthcare services was observed among Turkmen Syrian respondents, largely attributable to their Turkish language proficiency. A 45-year-old registered Turkmen Syrian woman in Gaziantep, married with four children, revealed disparities in treatment due to linguistic barriers: “That is exactly different, because they do not know the language, they [doctors] say go and get an interpreter.” (R17). The respondent further elaborated:

I swear I didn’t see any difficulties, but some people don’t understand the language and it is so difficult for them. Alhamdulillah, I did not see any problems. Neither in hospitals nor in such things, I did not see any problems. I don’t know if it is because my language is very good. (R17)

Beyond her own experiences, she reported frequently serving as an informal interpreter for Arabic-speaking Syrians during hospital visits. She described the dynamic as follows:

One of them approaches and asks, do you speak Turkish? I say I do; I will interpret for you […] At times, hospital staff in the women’s department even request that I translate for Arabic-speaking patients. They don’t know the language, so sometimes I translate it for them. I go in and out with them [into doctor’s examination room] […] I translate 1–2 of them until it is my turn. I say it is a pity they do not speak the language, there is nothing for them (R17).

Despite the presence of somebody translating, testimonies describe discriminatory treatment when using healthcare services. A 23-year-old Arab Syrian student, employing his acquired Turkish skills to translate for his brother in a public hospital after a severe motorcycle accident, narrates how, upon first seeing the patient, the physician proposed to amputate the brother’s leg without careful examination and consideration given to less invasive options “because [they] are Syrians” (R12). He then “managed to stop the blood and then took him to a private hospital. They had surgery, he recovered well, and the surgery was successful. […] Now he stands up and walks. He can even run” (R12).

Discussion

This mixed-method study aimed to analyze healthcare accessibility and utilization of Syrians in Turkey and to investigate whether the policy measures taken succeeded in ensuring equitable access to healthcare services for Syrian refugees. Therefore, we studied the complex interplay of macrostructural, predisposing, enabling and need factors as specified in the adaptation of Andersen’s Behavioral Model of Healthcare Service Use (BHMHSU) [49] for migrant populations as displayed in Fig. 4. By studying both doctor and ED visits and through the interaction of our qualitative and quantitative results, distinct barriers to health equity and coping strategies to navigate them emerge. The empirical evidence demonstrates how, in the exemplary case of Syrians in Turkey, healthcare becomes an arena of tightening anti-migrant policies.

Fig. 4
Fig. 4
Full size image

Empirical findings of key factors for Syrian healthcare utilization, based on the Behavioral model of healthcare service use (BMHSU), own illustration

At first glance, the results of our mixed-methods analysis may suggest that Syrians in Turkey indeed enjoy equitable healthcare access regarding their ability to consult medical doctors. The quantitative results show no significant difference in medical doctor visits between Syrian and host respondents. In addition, testimonies from TPS-holders in our qualitative interviews emphasize the quality of healthcare services. Yet our mixed-method approach allows for a more nuanced interpretation.

First and foremost, the positive perception of healthcare access in the qualitative interviews is only found among respondents who are registered under TPS and reside in their province of registration. Informed by these insights provided by the qualitative interviews, the interpretation of our quantitative results also appears less equitable than the mere Syrian-coefficient in the regression analysis may suggest. For doctor visits, our quantitative analysis finds no enabling effect of either Turkish proficiency or (lack of) discrimination experiences. This pattern, which does not occur for ED visits, seen in the light of our qualitative evidence and the reviewed literature (e.g. [38]) suggests that medical consultation may primarily be realized through Syrian doctors working in MHCs and Syrian-run informal clinics. In Syrian-run clinics neither language barriers nor fear of discrimination are expected to affect healthcare seeking behavior. Yet this form of care remains strictly informal as the government aimed to transfer all healthcare provision to the “central authority” of the Ministry of Health [31] and thus lacking any form of quality control.

The qualitative analysis further reveals the flexible navigation between the formal and informal healthcare systems not to be motivated by the search for high quality healthcare, but as a necessity arising from nuanced healthcare access hierarchies predisposed by legal status, just as enabled (disabled) by ethnic subjectivities and (the lack of) financial resources. The ability requires a considerable amount of familiarity with the different formal and informal healthcare institutions, which may explain why the duration of stay in Turkey emerges as a significant predictor of Syrian doctor visits in the quantitative analysis (see Fig. 3).

Particularly, once hospital care is required, the inequitable healthcare access for Syrians becomes evident. Our quantitative analysis shows that for Syrians considerable barriers to accessing services in EDs remain. Notably, we identify income as a significant enabling factor of ED visits for Syrian respondents; a result likely driven by the share of respondents facing registration struggles in our survey sample. Testimonies in our qualitative analysis demonstrate: For Syrians without valid registration in their place of residence, private hospitals and EDs present the only, yet very limited, options to receive advanced healthcare. Both options are associated with very high out-of-pocket cost due to the Regulation Concerning International Health Tourism and Tourist Health [31]. Consequently, those individuals lacking TPS must entirely rely on their financial resources to access hospital care. Thus, a concerning interaction between the predisposing factor of registration status and income emerges, the former amplifies the enabling role of the latter. This creates a distinct healthcare access hierarchy where economic capital determines not solely the quality, but more existentially the access to medical services.

Among Syrians in Turkey, this dynamic acquires particular urgency, as they face a dual disadvantage. First, lacking work permits, general fear of registration enforcement and increasingly widespread immigration sweeps structurally depress their earning potential [56], resulting in more constrained financial resources and higher levels of socio-economic precarity relative to Turkish nationals. Second, lack of TPS exposes them to disproportionately high healthcare costs. Taking this into consideration, we must expect numerous Syrians opting for non-treatment due to the lack of financial means despite pronounced medical needs.

As is commonly reported [9, 11,12,13,14], Turkish proficiency emerges as another key enabling factor in both our quantitative and qualitative analyses. While Syrians appear to be able to navigate language barriers with regards to primary healthcare, thanks in large part to the Syrian doctors working in the MHCs and informal clinics [13, 38], formal hospital care is considerably harder to access for those lacking Turkish proficiency. Only a minority of the testimonies in our qualitative analysis reported that they had been taking advantage of a SIHHAT-funded formal translator employed in a public hospital. Instead, respondents stated that they relied on their own social networks e.g. a neighbor, a child, or an acquaintance. Even though this allows for communication between the service provider and the patient across language barriers, the pitfalls of lay translators, especially when emotionally close to the patient, are well-studied and are non-conducive to quality of services [34, 57, 58]. Furthermore, the ability to receive medical care is thus limited by the individual’s social bridges with the host population [59], or their human, cultural, and social capital.

Regarding this reliance on cultural and social capital, the qualitative analysis exposes a subordinate impact of the individual’s ethnic subjectivities on their language skills and, consequently, their healthcare utilization. Turkmen Syrians, compared to Arabic and Kurdish Syrians, report greater satisfaction with healthcare services, largely attributable to their familiarity with the Turkish languageFootnote 5. While experiences of discrimination, within and notably outside the healthcare sector, beyond language, are not described in detail here, they are prevalent in the interviews.

It is the integration of quantitative and qualitative analyses, that reveals important nuances that are essential for understanding how significant hierarchies shape healthcare utilization among the Syrian population in Turkey. In doing so, this research contributes to more differentiated narratives about refugee populations, moving beyond the dominant discourse that tends to generalize, for example by portraying refugees as overusing healthcare services [6,7,8]. The integration of the two methodological approaches reveals the complexity of phenomena that remain obscured within any purist methodological framework.

In summary, individuals with TPS-registration in their province of residence and those with sufficient financial, cultural and social capital appear to have healthcare access comparable to that the Turkish population. Yet many Syrians face considerable language barriers in navigating the healthcare system. In addition, those lacking formal registration status are forced to rely on informal service provision and face steep, often-prohibitive costs, particularly when accessing hospital services. Unfortunately, these inequities have only worsened in recent years, with the emergence of new and opaque registration enforcement policies and widespread immigration sweeps that push a growing number of individuals into irregularity and thus further away from equitable healthcare access.

Policy implications

Our analyses suggest that the decision of the Turkish government to make healthcare free of charge as well as investments in the healthcare infrastructure as part of the EU-funded SIHHAT project proved relatively successful in extending healthcare access, particularly to primary care services, to Syrians registered under TPS in their province of residence. Relative here meaning both compared to the situation in other Syrian-hosting countries [60] and compared to other integration policies within Turkey such as the lack of housing and labor market access [56, 61, 62].

But by tying this access to individuals’ location and registration status the government created a whole sub-population that is largely denied the basic human right to healthcare. As described above recent intensification in registration enforcement has further exasperated this situation, demonstrating how migration policy and enforcement can immediately translate into a threat for health equity and as such pose significant risk to health and wellbeing by creating an environment of in-transparency, mistrust and fear [40]. This deteriorating impact on healthcare access is particularly concerning as similar strategies of opaque migration enforcement, regularization and weaponization of deportation can be observed in numerous migrant hosting countries [63]. Our data shows that these sweeping policies immediately translate into a threat for health equity. Syrians access to healthcare services, including medication, is severely restricted the moment they are unable to present a valid TPS (plus a valid travel permit, in case of seeking for care outside the province of registration).

Our analysis has further provided evidence that, in contrast to popular narratives [6,7,8], the free provision of healthcare to registered Syrians has not resulted in a disproportioned overuse of healthcare resources by a disease-burdened refugee population relative to the Turkish population. Rather, Syrian respondents to our quantitative survey report similar (physical) health as their Turkish counterpart. Yet theyunderutilize scarce healthcare resources such as EDs, even though it presents one of the only ways for unregistered Syrians to access care in public hospitals.

Limitations

Our mixed-methods study design faces important limitations. First, qualitative data collection took place a year after the quantitative survey was conducted. While this approach enabled the inclusion of recent changes in migration enforcement within our analysis, the sequential design limits comparability between the two data collections. Second, due to ethical and privacy concerns, the quantitative survey did not elicit individual’s registration status. While the mixed-methods design was explicitly employed to rectify this limitation of the quantitative method, we are unable to quantify to which degree the utilization patterns observed in the statistical analysis are informed by individual’s registration status. Third, due to practical constraints on the length of the quantitative survey questionnaire, we lack information on which channels respondents used to facilitate their doctor visits, i.e., whether they visited informal clinics, MHCs, private or public hospitals. We hope this nuanced information can be gathered in future research.

Conclusion

Through the decision to provide free health coverage to TPS holders and aided by sizable EU-investments, Turkey made significant strides in ensuring healthcare access for Syrians. Despite persistent language barriers, Syrians’ access to primary healthcare appears to be on par with that of the Syrian host population. Yet, our mixed-methods analysis reveals that restrictive migration policies in Turkey are creating distinct hierarchies in healthcare access determined by individual’s legal status and economic resources, leaving Syrians without formal registration reliant on informal or costly private providers; and those lacking financial means, forgoing needed hospital care all together. Rather than improving, this state of health inequity appears to be worsening because of intensifying and in-transparent migration enforcement by the Turkish government.