Dimensions of choosing a health provider

Interviewees reported the existence of multiple providers, both public and private, reasonably close to their locations. The majority of them had no difficulty accessing either type of institution, indicating that accessibility played a positive role in their ability to receive the care they needed. They became aware of the healthcare providers and their services through recommendations from friends, family members, online sources, insurance company’s list of covered institutions, and rarely through the institutions’ information dissemination campaigns. Their awareness of the healthcare system increased as they stayed longer in Turkey. However, when it came to selecting a healthcare provider, availability and affordability emerged as the most significant dimensions influencing their decisions. More than half of the interviewees preferred private health institutions, but some used both public and private institutions. In certain categories, interviewees reported visiting MHCs.

Interviewees who preferred private health institutions primarily referred to the availability dimension (e.g., supply, quality, and abilities of health personnel; facilities of the hospital; technology for healthcare) and explained the reasons for their preferences as follows: “being able to communicate with physicians and health personnel,” “not waiting in the hospital too long,” “receiving immediate care when necessary,” “not being in a very crowded environment while receiving healthcare,” “for the physician to take his time and carefully examine,” “because private healthcare is more effective and better,” and “because there are very good physicians in private hospitals.” Those who sought public health services, on the other hand, mainly referred to affordability and explained that they preferred public health institutions because “it was free,” “it costs very little,” or “it costs nothing in the emergency room.”

Migrants who settled in Turkey with work and residence permits referred to availability and affordability as the main influencing dimensions in their access to healthcare. Some interviewees also referred to accessibility, especially in emergency situations. Most explained that they preferred private hospitals because they wanted to receive “proper” care:

While some private hospitals charge very high fees for their services, others may offer more affordable healthcare services. In line with this dynamic, the majority of regular migrants, including those with middle and low income levels, expressed a preference for private hospitals within their budget:

International students attending private and public universities adopted different strategies in accessing healthcare. All who attended private universities received healthcare only from private health institutions. They referred to the dimension of accessibility and explained that they chose private health service providers according to their locations: they preferred those located closest to either their school or their dormitories. Conversely, students from public universities referred to the dimension of affordability and indicated that their hospital choices were guided by their insurance type. Their primary preference was for public hospitals as they were covered by GSS. However, they occasionally received healthcare from private hospitals as well, due to reasons of availability. They visited them when they could not make timely appointments in public hospitals, or when they needed specific healthcare, such as dental treatment or psychological counseling. Similar to students at private universities, they referred to accessibility, too; however, they also referred to awareness. They stated that their preference for public or private hospitals depended not only on location but also on their knowledge of these institutions.

Among all migrant categories, spousal migrants and international retirement migrants demonstrated a higher level of awareness of the availability of healthcare services and navigation within the health system. Their awareness enabled them to make informed decisions when accessing healthcare services. Spousal migrants, in particular, preferred specific physicians over hospitals and typically received services from private health institutions catering to high-income patients. However, when they faced a serious problem or heard about a specialized physician working in a public hospital, they preferred that public hospital. Their access to services was facilitated by the personal relationships, know-how, and family networks of their spouses. This social capital played a crucial role in enabling them to access better healthcare services, placing them in a more advantageous position compared to other migrant groups. Spousal migrants benefited from the fact that their spouses were sometimes physicians, had physician friends or relatives, or their relatives knew good physicians or how to access better health services:

Retirees also had a high level of awareness about the Turkish health system due to their health concerns and personal experiences. Based on their knowledge of the system, they utilized both public and private healthcare providers. Almost all of them visited public family health centers for free primary care on a regular basis. They reported having positive relationships with their family physicians and expressed high levels of satisfaction with the services. For secondary and tertiary care, some visited only private hospitals, paying a premium to their GSS insurance schemes, while many others preferred public hospitals. They referred to availability and noted that the treatment and qualifications of the physicians were not different in public and private hospitals, but the reception, attention, care, and hygiene were far better in private hospitals. Another important point was that health providers, both public and private, seemed to approach international retirement migration as a business opportunity, targeting retirees as “health consumers” of medical services. While private hospitals offered medical services tailored more specifically for the elderly, such as recruiting experts on hip replacement or offering cataract or prostate operations at reduced fees, both types of institutions worked with interpreters to facilitate access.

Unlike all other migrants, irregular migrants’ primary concern was their legal status while accessing healthcare. All stated that they visited private hospitals and clinics although the costs were steep. They explained that public hospitals asked for identification documents and had police officers in them, and they were afraid that they would be deported. This first concern was followed by affordability and awareness as they chose the private hospitals or services that they knew and could afford.

Another observation was that the provision of private health services to them was common. Some private healthcare providers did not turn them away or inform authorities. Instead they adopted informal methods, like treating them after visiting hours or without formal registration, even using the passports of regular migrants accompanying them. While physicians often approached this issue with humanitarian concern and voiced concerns about turning away the ill, the private health institutions’ stance was not based on the belief that every individual, regardless of official papers, should access healthcare. Contrarily, in line with the marketization and commodification in Turkey’s healthcare system, they viewed irregular migrants as another “health consumer” group in need of their services. Recognizing that these patients sought care informally, they engaged with these communities and raised awareness about their services by offering reduced rates. As such, during the time of data collection, irregularities in migrant status did not necessarily obstruct their access to healthcare services, provided they could afford to pay. All the same, due to being undocumented, they were very vulnerable vis-à-vis private health providers. They could not complain when they were misdiagnosed or mistreated, even for medical malpractice. While informal service provision allowed them the ability to access healthcare, it also exposed them to the risks of further vulnerabilities and abuses.

Interviews with refugees and asylum seekers, particularly Syrians, revealed that they had developed an awareness of Turkey’s healthcare system. They knew about different types of health institutions, and also shared information about hospitals and doctors amongst themselves. They mentioned that they would have preferred private health institutions. However, the cost of private healthcare services was out of reach for them. As a result, their choice of healthcare institutions was primarily guided by affordability, leading them to seek care at MHCs, informal clinics, and rarely family health centers for minor issues. They turned to public hospitals when they required comprehensive care:

Syrian refugees have also emphasized availability and acceptability in shaping their preferences for healthcare institutions. MHCs employed Arabic-speaking healthcare workers, while informal clinics were operated by Syrian healthcare workers, offering primary and secondary care. Interviewees explained that they chose MHCs and informal clinics in order to overcome the language barriers, receive healthcare from physicians who understood their illnesses, avoid long waiting times for appointments, and pay less for the services. Additionally, as informal clinics operated without licenses, outside the oversight of the MoH there was no need to provide identification and registration. Furthermore, referring to acceptability, Syrian refugees explained that they opted for both MHCs and informal clinics to avoid mistreatment, discrimination, and hostility when seeking care.

Affordability: limited health insurance, SGK agreements with private providers, and varying fees

In line with the LFIP’s requirements, nearly all of our interviewees, except refugees and irregular migrants, were covered by health insurance. The overwhelming majority had private health insurance plans designed specifically for migrants that could only be used in some private hospitals. These plans had very limited coverage; therefore, though these interviewees had insurance plans, in reality many of them were underinsured. Needless to say, this affected the affordability of healthcare negatively.

Several interviewees mentioned that despite paying minimal amounts for their annual health insurance plans (as little as 25 USD as of 2019), they only realized the limitations of their plans upon visiting a hospital. They were shocked when they had to pay high out-of-pocket expenses in private hospitals. Others shared that they knew it was limited, but they took it anyway because it was a requirement. These health insurance plans seemed primarily designed to fulfill a necessary requirement in residence permit applications. Offering such health insurance plans for migrants seems to have become a business for insurance companies and, unfortunately, this is another area where migrants are abused.

Examining the interviews according to migrant categories, we see that all spousal migrants had GSS through their Turkish spouses. In addition, almost all of them had private health insurance covering inpatient treatment in private hospitals. Therefore, their affordability of healthcare was very high.

Regular migrants with work permits had GSS, while several also held private health insurance. Majority of the regular migrants with residence permits, on the other hand, had private health insurance, except for one who registered himself under GSS. Notably, two interviewees with residence permits mentioned that their European health insurance was valid in Turkey. The comprehensiveness of private health insurance depended on their income levels; while those with higher incomes had comprehensive coverage, those with mid-level or lower incomes had limited plans. The plans of international students, on the other hand, differed. Students attending public universities on government scholarships were covered by GSS and their premiums were paid by the government. These students told us that their insurance “covered everything” in public hospitals and that they could visit them “like Turkish citizens” without any barriers. Students attending private universities, on the other hand, found their own cheap and limited private health insurance. Several students reported that they were unaware of the three-month registration rule causing them to lose their chances of GSS coverage. They noted that international students should be informed more clearly about these policies.

Though health insurance is not required for the residence permit applications of migrants older than sixty-five years, all but one of the interviewed retirees had health insurance plans. Interviewees told us that they had been living in these coastal towns of Turkey for some time and that they had private health insurance plans in the past but more recently registered themselves for GSS. This allowed them to visit family health centers in their neighborhoods and public hospitals for free, and they could also benefit from GSS-contracted private health institutions with discounts. Many of them chose a combination of these services. Their main concern was that SGK had very recently annulled its contracts with several health providers and they could no longer get discounts from those institutions. They were confused and questioned the rationale of being registered for GSS if they were unable to get discounts from the private health institutions they had previously used. Several interviewees were still covered by their home country’s public insurance and they benefited from GSS under bilateral social security agreements between their home countries and Turkey.

International protection applicants and status holders have GSS coverage for a year, while temporary protection status grants GSS coverage to Syrian refugees without time limitation upon registration. Syrians are by far the largest group of refugees; however, there are also significant numbers of Afghans, Iranians, and Iraqis facing serious challenges and additional barriers in accessing healthcare in the country. This differentiated access to healthcare, characterized by distinct insurance arrangements for international protection applicants and status holders on one hand, and Syrian refugees under temporary protection on the other, has worsened their vulnerabilities and contributed to unjust disparities in accessing healthcare services. In light of these complexities, it is crucial to highlight that all of our refugee and asylum-seeker interviewees were highly vulnerable. Though they developed an awareness of the institutions and services, they did not fully understand the legal mechanisms through which costs were paid in the health system. Only one Syrian refugee mentioned that he had acquired private insurance coverage for his pregnant wife. None of the other Syrian interviewees had any form of insurance apart from what was provided through temporary protection.

As described above, private health institutions charged varying fees for their services. In addition, the interviewees reported that these institutions charged migrants higher fees, consistently higher than those charged to Turkish citizens. This affects the affordability of healthcare services negatively. Moreover, though many explained that they were satisfied with the quality of the facilities, services, and health personnel, the varying fees and inflated rates made the system unreliable in their eyes.

Accommodation: interpretation services, patient accompaniment, and aftercare

According to most interviewees, the most important obstacle in accessing healthcare in Turkey is the language barrier. Interviewees reported that due to the lack of interpretation services, they faced language barriers not only when communicating with physicians but at all stages of access, such as making appointments, entering the hospital and getting directions from reception, or accessing test results. Many interviewees noted that even though the Central Physician Appointment System website offered options in English, Arabic, and Russian for public hospitals, they still had difficulty in making appointments on their own. These difficulties arose mainly because of differences in patient cultures, which reduced migrants’ health literacy when they moved.

Retirees reported very few or no problems in this regard. They underlined the importance of communication while receiving healthcare, but explained that interpretation services were offered by several interpreters in private hospitals, while staff at information desks and also physicians spoke English. Apart from ordinary interpreters, there were also “health interpreters” in private hospitals. Though the interviewees in Fethiye said that there were interpreters in the public hospital, too, interviewees in Alanya reported that they were accompanied by interpreters if they had health insurance. Family physicians in both districts were reported to know English, but this was not sufficient for the retirees in Alanya, who, unlike those in Fethiye, did not come from countries where English is spoken.

Interviews in İstanbul revealed that although they are discussed in reference to accommodation, interpretation services also traverse the dimension of availability as most of the interviewees who received healthcare from private hospitals chose those institutions because they had interpreters. Similarly, some interviewees noted that physicians in especially well-known private hospitals had been trained abroad and could therefore speak fluent English, and that they preferred these hospitals to be able to communicate directly with physicians instead of relying on interpreters:

Interviewees stated that finding an interpreter in public hospitals was almost impossible. As public hospitals could not accommodate the interpretation needs of migrant patients, migrants devised different strategies: they were sometimes accompanied by a neighbor, a neighbor’s child, or a friend. Sometimes, another patient acted as an interpreter, or sometimes a migrant who had already passed through these stages now spoke Turkish and knew the health system. Younger interviewees also noted that they used a translation tool when needed (interview D_K3, December 8, 2018):

Spousal migrants again had the advantage of having family networks. They reported that family members made appointments for them, accompanied them during their visits to hospitals or clinics, and helped them with all kinds of communication needs in the hospital. Though their spouses and family networks provided them with an advantage in overcoming the language barrier, some interviewees underlined that this still implied a deficiency in the accommodation of health services. They, too, needed interpretation services to be independent and have privacy about their health problems.

Interviewees mentioned encountering mainly Arabic-speaking and rarely Persian-speaking freelance interpreters in public hospitals, available for daily hire. They made appointments, accompanied migrants and refugees in hospitals, and interpreted their communications with physicians and nurses, diagnoses, and test results. Their mobile numbers and information were shared via social media channels and could also be found on posters hung on trees or walls around hospitals. As the interviews revealed, following the mass migration of Syrian refugees, this has become a line of business for some people who can speak both Turkish and Arabic. Though freelance interpreters could help refugees overcome the language barriers in accessing healthcare, this practice also provided grounds for exploitation:

Patient accompaniment and insufficient aftercare were other themes mentioned when migrants spoke about accommodation in health services. Family support for inpatients in the form of patient accompaniment is common practice in Turkey. Social and cultural reasons, as well as the inadequacy of hospital services and staff, are the main reasons for this. In some hospitals, family members are expected to give psychosocial support to the patients; in others, they are expected to undertake their medical aftercare. Interviewees from Western societies or former Soviet countries were particularly unfamiliar with this practice, and health institutions, both public and private, failed to accommodate the aftercare needs of these migrants. Many did not have family members to accompany them when they were hospitalized. Consequently, they were left without aftercare and felt helpless and isolated:

Acceptability: changing perceptions about migrants

Acceptability involves positive or negative perceptions in interactions between patients and healthcare providers. Our findings revealed a decline in acceptability, especially for Syrian refugees. Among all interviewees, almost all Syrian refugees shared experiences of encountering discrimination when seeking healthcare. Existing research already indicates that they face several challenges, including language barriers (Assi et al. Reference Assi, Özger-Ilhan and İlhan2019), cultural differences, and confusing regulations regarding registration (Ekmekçi Reference Ekmekçi2017). Moreover, they find navigating a new healthcare system daunting and overwhelming (Bilecen and Yurtseven Reference Bilecen and Yurtseven2018). During research, Syrian refugees reported facing mistreatment and obstacles in accessing healthcare, primarily due to their Syrian identity. These experiences were rather attributed to nurses, other hospital staff, and even Turkish patients. Instances were shared where hospital staff and patients united in expressing negative sentiments towards Syrian refugees, leading to verbal abuse and marginalization within hospital waiting rooms:

The forms of discrimination varied widely, ranging from refusal to give information in the hospitals to physical violence. The experiences of Syrian women in accessing reproductive health, particularly during pregnancy and childbirth, evolved beyond discrimination. Given that Syrian refugees were already in a precarious position, the discrimination and mistreatment they experienced led many of them to avoid seeking care until their health situation reached a critical stage. They visited health institutions only when they had a pressing problem, such as acute appendicitis, unbearable tooth pain, or excessive bleeding. One interviewee stated that she would only go to the hospital “while she was dying.” In recent years, rising xenophobia, anti-Syrian sentiment, and the stigmatization of Syrian refugees have further exacerbated their access to healthcare (Regional Refugee and Resilience Plan 2023).

Differently from the Syrian refugees, most of the migrants in other groups reported positive interactions with medical professionals and did not perceive discrimination while accessing healthcare. Interviewees who received healthcare from private institutions responded negatively when asked if they had experienced discriminatory behavior, while most of those treated at public hospitals felt the same way:

They believed they were treated similarly to Turkish citizens. However, the interpretation of “how Turkish citizens were treated” varied among them, highlighting the influence of socio-economic factors on healthcare access. Those who could visit private hospitals offering services to high-income patients stated that they received the same treatment as Turkish citizens, entailing the same high-quality health services and good reception. Interviewees who received healthcare from affordable private hospitals or public hospitals, on the other hand, complained that “just like Turkish citizens” they also waited in the hospitals or nurses “grumbled” at them as well. Additionally, some of the interviewees stated that the physicians in public hospitals had such limited time that they did not even inquire whether they were migrants.

A similar conclusion was drawn from the interviews with physicians. A physician working in a public hospital stated that due to the patient volume, he could spend a maximum of ten minutes per patient, and half of that time had already passed once he asked about the patient’s complaints. Physicians working in private hospitals and private clinics, on the other hand, stated that foreign patients were an important source of income for their hospitals. Therefore, they tried to be more welcoming and attentive. Furthermore, all interviewed physicians stated that patients were patients, irrespective of ethnic or national affiliation, and the only problem they reported was the need for interpreters to communicate with them.

Though the issue of varying fees was discussed in reference to affordability, it also traversed the dimension of acceptability as an overwhelming majority of interviewees felt they were treated differently when it was time to pay for services. They reported that they were always overcharged because they were foreigners, suggesting that, despite their earlier claims of equitable treatment, there is discrimination when it comes to payment. But they did not conceptualize it as such:

Finally, about one-quarter of our non-Syrian interviewees were aware that anti-immigrant sentiments had been growing. According to the majority of interviewees, the arrival of Syrian refugees made migrants more visible, increased the demand for public services, and strained access to healthcare. Interviewees revealed that with the mass migration of Syrian refugees, the way that Turkish society viewed migrants changed in a negative way, which, they hinted, might impact their access to healthcare services in Turkey:

As these anti-refugee, anti-immigrant sentiments were growing in Turkish society, interviewees from various Middle Eastern countries mentioned that they made sure to emphasize that they were not Arabs. Individuals from other Arab nations, on the other hand, attempted to distinguish themselves from Syrian refugees when seeking healthcare. Additionally, a considerable number of interviewees revealed that they had heard accounts from friends or relatives regarding the discrimination faced by Syrian refugees within the healthcare system. Given the increasing xenophobia and anti-Syrian sentiments, it would not be wrong to assume that recent socio-economic developments, international crises, and shifts in the political atmosphere have worsened the situation and affected acceptability negatively, further hampering migrants’ access to healthcare services.