Health Policies of Turkey and Neighboring Countries for Syrian Asylum Seekers

Turkey is a transit and final destination for many asylum seekers, refugees and immigrants because of its geographical location, cultural issues and hospitality. The following article is aimed to present the health policies applied to Syrian citizens who escaped the Syrian Crisis in 2011. To evaluate the topic in detail, legal basis of health policies of Turkey and the neighboring countries who accept Syrians as asylum seekers or refugees were evaluated. As the right of human access to health is vital and it is thought that this study will help the researchers and policy makers to understand the results of their efforts and compare the health care needs and access to health care of Syrian asylum seekers.


INTRODUCTION
People who are worried about their lives due to war, conflict, assault, natural disaster, or need and demand protection because of religious, social, political or national identity issues are called asylum seekers. Several terms such as asylum seeker, refugee or immigrant are also used to identify these people in the literature. If the asylum seeker's request for protection from a country of asylum is accepted; these people are called refugees (1). The main difference between a refugee and an immigrant is that the immigrant voluntarily leaves his country with the desire to obtain a better living condition for economic or social reasons (2). Geneva Agreement signed by the United Nations in 1951 asylum seekers/refugees have to prove that they flee from war or persecution and the country of asylum has to accept these people while it is the country's initiative to accept immigrants. Also the country has the authority to deport the immigrants who do not have legal documents or are involved in a crime. As a signer of Geneva Agreement Turkey give the refugee status to individuals from Europe instead of asylum seeker status. However; Turkey gave Syrian asylum seekers a special status which they can benefit from the same rights with European refugees (3).
From its geographical structure and position Turkey always has become a country of asylum for refugees and immigrants (4). Since March of 2011, after the crisis in Syria; Turkey took a large number of Syrian asylum seekers who demand international protection and still provides temporary protection to them. Turkey applies open-door policy to ensure the security of Syrian's and provide them security, nutrition, education and health services (4,5). The issue of Syrian asylum seekers should be considered as a problem of all the countries of the world and the aspects of health policies towards Syrian refugees should be investigated deeply and developed (6). Limited number of evidence on health policies for Syrians is available in the literature (5). In the following article; health policies of Turkey and the neighboring counties who accept Syrian's as a transit or final destination were evaluated historically from 2011 to 2019. Therefore, it is thought that this study will provide a basis for the health needs and further solutions on the topic.

METHODS
A comprehensive search was performed to determine the health policies and healthcare services provided for Syrian asylum seekers in Turkey and neigboring countries. In addition to reviewing and analysing peer-reviewed articles, governmental policies and reports of national/international/intergovernmental organisations were examined. The information obtained from the literature was categorised into the following themes: (a) health policies of Turkey and Neighboring Countries for Syrian Asylum Seekers (b) healthcare services provided for Syrian asylum seekers and (c) challenges and restructuring efforts in Turkey.

RESULTS
Health policies of Turkey for Syrian asylum seekers Turkey cover shelter, nutrition, education and health needs of Syrian asylum seeker who escaped from their homeland because of the 2011 crisis of Syria. There are several policies that are planned for Syrian citizens in Turkey and their implementations have been appreciated by all the countries (4). There is a legal basis for each of the health policies. These legal bases are given below in chronological order 6  • AFAD and the Ministry of Health Protocol 2016 (01.01.2016) According to the AFAD and Ministry of Health Protocol in 2016 and further regulations, Turkish government pays for the provision of health care for asylum seekers by insurance premiums paid by AFAD according to agreements between AFAD and Turkish Ministry of Health (4). The scope and rules of health services for Syrian asylum seekers is given in Table 1. Table 1. The scope and rules of health services for Syrian asylum seekers in Turkey. 1 Those who have not completed registration can only benefit from contagious and epidemic prevention services and emergency health services. 2 Health services cannot be provided except for services determined for those who have general health insurance.

3
For the treatment to be covered, no contribution is required except from those who have taken a work permit and thus been covered by social security institution (SSI) 4 It is essential that those under temporary protection receive health services in the province they have been registered. 5 It is essential that applications be made to the primary healthcare institution. 6 If treatment is not available in the province the person has already been registered, he/she can be referred to the most appropriate health facility in any province with a referral certificate. 7 It is not possible to apply directly to private health institutions except for emergency and compulsory cases. 8 Health service fees, including secondary and tertiary health services, cannot exceed the rates set by the Health Practices Statement. 9 With the exception of vaccinations, services that are not covered by SSI are not given. 10 Treatment costs related to lost limbs and organs formed before entering Turkey cannot be met.

11
The healthcare institution that makes the treatment arranges the bill for the governorship in which the person is registered.
UN Refugee Agency declared that the majority of all Syrian refugees (over 63,3%) are registered in Turkey and Turkey has opened it's doors to 3.630.575 From 2011 April; Syrians who have temporary identification numbers can benefit from the same public health services without incurring any costs as Turkish citizens in all provinces of Turkey. The Turkish government pays for the provision of health care for asylum seekers by insurance premiums paid by AFAD according to agreements between the AFAD and the Turkish Ministry of Health Syrians (5). The unregistered Syrians are able to take emergency care and necessary primary healthcare services free-of-charge and later send for registration (4-6). GMJ 2020; 31: 90-94 Farook and Ilhan 92 To provide this huge workload 50 interdisciplinary refugee healthcare centers working in collaboration with Community Health Centers including standard health workers, social workers, psychologist and translators are established in 13 provinces of Turkey (4). These centers provide screening tests for phenylketonuria, hypothyroidism, congenital deafness and micronutrient supplements such as Vitamin D and iron for newborns and vaccination calendar is followed for the Syrian infants and children free of-charge (7). Reproductive health services in primary and refugee healthcare centers provide free iron and Vitamin D supplement for pregnant and postpartum refugee women during their pregnancy addition to health counseling for reproductive system and contraceptive materials are distributed free of-charge (4. 7).
In contrast to other neigboring countries, language barrier is one of the biggest problem in providing qualified health care in Turkey. The Ministry of Health has established an 'Interpreter Line for International Patients' and employed translators in the refugee health care centers (4. 5).
In addition to Turkey's Governmental efforts there are several national and international non-profit organizations offering special helps to the Syrians in Turkey (4). Moreover; projects jointly executed by the Ministry of Health and the European Union are launched. 'SIHHAT Project' is one of the expanded and well-structured one which is planned to be completed in 36 months by 1st December 2019 that aims to increase the quality of health care services, health care understructure and qualification of the professionals working with Syrians in Turkey (6). Health policies of neighboring countries of Syria for Syrian asylum seekers From the first days of Syrian crisis a total of 5.4 million people have become asylum seekers. The distribution of Syran asylum seekers from December 2017 due to country is shown in Table 2. Turkey along with several countries has a regional Refugee and Resiliency Plan (3RP) for the Syrian asylum seeker. This plan which includs Turkey, Lebanon, Jordan and Iraq is an international call to increse awarness on protection needs, humanitarian needs of asylum seekers and the long term socio-economic effects on the countires of asylum. Within the objectives of this call, many countries provide many assistance and services for Syrian asylum seekers. Health care is one of these services. The Syrian Crisis Report of the 3RP Regional Refugee and Resilience Plan provides services for Syrian asylum seekers is based on data from January 2017 to July 2019. This report summarizes the health services that countries have implemented since the date of the Syrian refugee influx (4. 6). Iraq According to data from the World Health Organization, the Iraqi Government has provided comprehensive support in the camps with the support of humanitarian partners Dohuk and Anbar Health Directorates and Iraqi people in order to improve the health status of Syrian refugees and to provide safe food and drinking water to the health services. In addition, the Iraqi Government provides services in camps through existing health care centers and hospitals for those living outside the camps (6)., According to the data received from UNHCR in July 2017; In Iraq which hosts 244.605 Syrian refugees, access to primary health care services is free for Syrian asylum seekers. In addition, the Iraqi government provides vaccination and growth monitoring services for children, reproductive health services for women and family planning and mental health services for all asylum seekers. Table 4 presents the number of health services provided by Iraq between March 2011 and December 2017 for Syrians. In addition, it is known that Iraq provides measles vaccination to 2.942 asylum seekers under 1 year of age and polio vaccination to 115.88 asylum seekers under 5 years of age. In addition, 196 health workers under the 3RP were assigned to serve asylum seekers (6).

Egypt
It is known that the Egyptian Government has provided no social assistance other than granting asylum seekers access to education in public schools and health services in public hospitals. At the same time the World Health Organization in a similar way support the routine supplementary vaccination programs like in Turkey and follow-up the asylum seekers. According to data of 3RP Syrian Crisis Program Report in 2017; 434 health workers have been assigned to the 3RP Program. 239 of which are health professionals and the other 195 are public health workers. In addition, 1.267 home visits were made in order to provide health care services to 143 hospitalized patients. Table 5 presents health services for Syrian asylum seekers in Egypt between December 2011 and 2018 (4,8,9).

Jordan
During the first period of the influx of Syrian refugees, the Jordanian Government guaranteed free access to primary and secondary health services for Syrian asylum seekers. However, due to the high number of asylum seekers applying for health services and the increase in costs due to the provision of these already expensive services in the country, access to these services was abolished in November 2014. Jordan is home to more than 655.000 Syrian asylum seekers, has also provided humanitarian assistance to asylum seekers (6, 10, 11). Table 6 shows Jordan's health care services for asylum seekers from March 2011 to December 2017. Table 6. Number of health care services given to Syrians in Jordan.

Lebanon
In Lebanon, primary health care services for Syrian asylum seekers is provided free of charge. These services are to be provided in public and private sectororiented health care centers and hospitals. In addition, epidemiological surveillance, vaccination against polio and measles, medication for chronic diseases, health services for tuberculosis, HIV / AIDS and reproductive health are also available (12.13). Table 7 presents the health care services for Syrian asylum seekers in Lebanon between March 2011 and 2018.

DISCUSSION
It is known that the amount of budget separated for aids for Syrian asylum seekers in Turkey is gradually increasing (4). Turkish government declared that this amount is over 84 billon Turkish Liras and 16 billon Turkish Liras were spent just for the health needs of Syrians (4)(5)(6). Moreover, it is mentioned that the health and education services are unlimited and the cost of the assigned personnel is also a big budget for Turkey (5). Psycho-social supports given to the Syrians are also another part of the health services provided for them (4). Moreover, re-spreading of some diseases such as measles and polio in border regions is an important public health problem (7).
According to the results of Tastan, even if 3% of the Syrians use public hospitals, Turkish citizens in the regions where asylum seekers mostly live declared that it is harder for them to reach public health services (14,15). Additionally, giving the Syrians the right to apply health services in every province of Turkey free of charge decreased the intensity of the public health services which previously affected the workload and the satisfaction of the health professionals negatively (4.6.16).
According the report of Turkish Medical Association report, to raise awareness of the health professionals on protective services, acute and chronic disease, emergency health services, medication, home based health care services, detection of infectious diseases such as malaria, measles and orient boils is seen important to protect the public health (8.17).
In spite of all these similar problems, it is thought that it is a humanitarian duty of every country to help the asylum seekers/refugees who are victims of war. Turkey is the second country after USA which gave highest level of humanitarian aid to Syrians. According to the data taken from separate reports, Turkey is followed by Britain and Germany. Turkey has been selected as "World's Most Generous Country by separating it's 0.75 % of national income for humanitarian aid (4,6,17,18).

CONCLUSION
Turkey has taken an intense number of asylum seekers from Syria since the Syrain internal crisis in April 2011 (4,6). Turkey's open-door policy and tolerant approach is an important example of humanitarian aid against Syrian asylum seekers. It is known that Turkey offers free access to shelter, education and health care for more than 5 million Syrians (4). As a public health issue, health of Syrians and their access to health care are very important for Turkey and various countries in Syria's border (6). This study presents the health policies for health care services offered to Syrian asylum seekers in various countries.
Turkey is an end country and also a transition country for Syrians who want to migrate to other European counties. Because of cultural simillarities and the easy traveling conditions, Syrians prefer to migrate to Turkey, Egypt, Jourdan and Lebanon more and this stuation increased the responsibilies of these counties. Even if it is hard to manage for the country of asylum, the people seeking for asylum are threatened. Therefore, the issue of asylum seekers is actually considered as a problem of all the countries of the world. From a point of view it is true that asylum-seekers are financially a big burden for the host country but it is also a conscience matter for the human beings.
Syrians stay in Turkey under temporary protection status but they are provided the rights of refugee status. But this status is not approved by the international law yet and Turkey has the right to cancel this status anytime. Another point is the continuous flow of Syrians. Huge number of Syrians changed the health needs of the proviences of the given counties and increased the human resourse and financial needs. Moreover, social and rehabilitative services for Syrians are still insufficent in the given countries. Another importatnt issue is the EU Readmission Agreement, which is based on reciprocal obligations between the EU and non-EU countries to facilitate the return of people residing irregularly in a country to their country of origin or to a country of transit. According to this agreement Syrains in EU countires can be readmitted to the given countires and this can increase the number of Syrian in these transit countires.
There are some barriers like un-experienced health care workers, limited financial support, change in the health needs of the host country population cover the positive results of all work done for the Syrian people in the given countries. Beyond the given reasons, it is thought that national and international collabrations in interdisciplinary team work may facilitate the quality of service delivered to Syrain asylum seekers.