Evaluating the healthcare access of Syrians in Turkey: a mixed-method analysis

Turkey hosts one of the world's largest refugee populations, making refugee healthcare access a significant public health challenge and a contested policy issue. While Turkey provides free healthcare services to Syrians under Temporary Protection Status (TPS), scholarly debate continues regarding whether health equity has been achieved. Some studies suggest potential overutilization of services, while others identify persistent barriers to equitable access, particularly for Syrians without formal protection status.

This mixed-methods study employed a sequential design combining quantitative and qualitative data. The quantitative component analyzed household survey data from 2,497 face-to-face interviews (1,258 Syrian and 1,239 Turkish respondents) across 20 Turkish provinces in 2022. Healthcare utilization was measured through doctor visits and emergency department visits in the previous 12 months. The qualitative component included 20 semi-structured interviews with Syrians in Istanbul and Gaziantep conducted in 2023-2024, capturing diverse registration statuses and ethnic backgrounds. The analysis was guided by the Behavioral Model of Health Service Use, examining predisposing, enabling, and need factors affecting access to healthcare.

The quantitative analysis revealed no significant difference in predicted doctor visits between Syrian (79.8%) and Turkish (80.8%) respondents. However, Syrians showed significantly lower probability of emergency department utilization (25.4% vs. 31.75%). Among Syrians, income was a significant predictor of emergency care use, while Turkish proficiency and longer duration of stay were associated with increased healthcare utilization. Qualitative findings revealed stark disparities based on registration status: registered Syrians in their province of registration reported satisfaction with healthcare access, while those facing registration obstacles experienced severe barriers. Those with registration obstacles relied on expensive private care or informal Syrian clinics, creating distinct healthcare access hierarchies determined by legal status and economic resources.

While Turkey's policy framework appears successful for registered Syrians residing in their provinces of registration, significant inequities persist. The restrictive TPS registration system creates a vulnerable subpopulation largely excluded from equitable healthcare access, particularly hospital care. Recent intensification of migration enforcement has exacerbated these disparities, indicating how migration policies directly undermine health equity. Rather than overutilization, the study found underutilization of emergency services by Syrians, contradicting popular narratives about refugee healthcare burden.