Introduction
The Syrian civil war precipitated a mass movement of Syrians into Turkey that occurred in a rather different political and institutional context from that described in humanitarian studies. First, the volume of unplanned migration as a result of the Syria crisis has been unprecedented. Second, the host country has been relatively stable and has relatively strong, intact, welfare institutions in some domains such as health care and social assistance. Third, the gradual erosion of the international refugee protection regime (Zetter, Reference Zetter2007) allowed Turkey and other host countries to avoid granting refugee status to Syrian migrants.
The Syrian civil war started in 2011. Seven years later, humanitarian assistance programmes are still providing emergency support for Syrian refugeesFootnote 1 in Turkey. It is eminently clear that the current situation in Turkey can no longer be treated simply as an emergency situation. A recent survey of Syrian refugees in Turkey found that almost 90 per cent of Syrians want to return to Syria when the war is over. But, if that is not possible, 85 per cent reported that they would like to stay in Turkey (Fabbe et al., Reference Fabbe, Hazlett and Sinmazdemir2017). There is a growing awareness that most Syrian refugees will continue their lives in Turkey for the foreseeable future, which necessitates a long-term and rights-based plan for the socio-economic integration of Syrian refugees (e.g. Kirişçi, Reference Kirişçi2014; Erdoğan, Reference Erdoğan2015; İçduygu and Şimşek, Reference İçduygu and Şimşek2016; Eder and Özkul, Reference Eder and Özkul2016; Asik, Reference Asik2017; The Economist, 2017).
This paper seeks answers to the following questions: What are the defining characteristics of the emerging welfare mix for Syrian refugees in Turkey? How do humanitarian assistance programmes and the Turkish welfare system interact in this process? It focuses on three policy domains to explain the main features of the nascent welfare mix for Syrian refugees: social assistance, employment and health care. These domains are selected to represent the varied levels of maturity among different components of the Turkish welfare system. Employment is a domain where the welfare system remains relatively weak. Social assistance is a small part of the welfare system, but behind it there is a significant state capacity to deliver. Health care is a domain where the Turkish welfare system is relatively well established.
To answer these questions, this paper starts with an analysis of the humanitarian assistance programmes and domestic social policies that emerged in response to the Syria crisis. The analysis relies on the 2015 and 2016 activity reports of professionalised and well-funded domestic and international NGOs working in the field of humanitarian assistance and government policy documents on public sector programmes for the refugees.
The paper is divided into four sections including this introduction. The second section introduces the theoretical approach to the examination of the welfare mix for Syrian refugees in Turkey. The third explains the context at the time the refugees began to arrive. The fourth section investigates the existing public and humanitarian assistance programmes in the selected domains. Finally, conclusions are drawn with respect to the defining characteristics of the welfare mix for Syrian refugees in Turkey and the modes of interaction between humanitarian assistance programmes and domestic social policies.
Bridging social policy and humanitarian assistance
With the separation of refugee and migrant categories in the 1950s (Long, Reference Long2013), the literature on the social rights of migrants has been bifurcated. While social policy applies to issues arising especially from economic migration in the context of mature welfare systems, humanitarian studies deal with the questions around the welfare of refugees and asylum seekers.
Social policy literature on immigration and welfare includes research on immigrants’ social rights (e.g. Sainsbury, Reference Sainsbury2006), welfare generosity for immigrants (e.g. Leerkes, Reference Leerkes2016) and immigrant integration and its impact on the attitudes of citizens of the host country towards welfare programmes and redistribution (e.g. Emmenegger and Klemmensen, Reference Emmenegger and Klemmensen2013). In terms of welfare generosity related to immigrants, there are two dominant scholarly perspectives: the generosity perspective and the dualisation perspective. One group of scholars (Sainsbury, Reference Sainsbury2006; Joppke, Reference Joppke2010; Römer, Reference Römer2017) suggests that the rights of immigrants converge with the rights of citizens in comprehensive welfare states. Another group (Castles, Reference Castles2011; Leerkes, Reference Leerkes2016) observes the differentiation of social citizenship rights between immigrants and citizens, and between registered immigrants and undocumented immigrants in comprehensive welfare states. Leerkes (Reference Leerkes2016), for example, suggests that archaic practices of poor relief for unauthorised immigrants coexist with modern welfare programmes for those who are legally eligible (citizens, residents and refugees) in Western European countries. The literature so far details the level of welfare state generosity towards immigrants, in terms of whether the overall welfare systems are comprehensive or rudimentary. This level of abstraction and generalisation, however, renders the potential differences between social entitlement programmes available to immigrants in separate social policy domains largely invisible.
Studies on the interaction between humanitarian assistance programmes and domestic social policies are limited. Deacon and Stubbs’ work (Reference Deacon and Stubbs1998) on post-conflict Bosnia-Herzegovina is an exception. They underline ‘the difficulties of a shift from humanitarian relief to sustainable social protection’ in the context of ethnicised social relations and the lack of a centralised state (Deacon and Stubbs, Reference Deacon and Stubbs1998). Deacon and Stubbs frame the humanitarian assistance programmes of international non-governmental organisations (INGOs) and their local partners in post-conflict Bosnia-Herzegovina as ‘an implicit social policy through their activities in the spheres of social regulation, social redistribution and social provision’ (Reference Deacon and Stubbs1998: 109). They suggest that the weak links between humanitarian assistance activities and social policy development could lead to a policy vacuum when emergency relief programmes come to an end. In another study, Stubbs takes his argument a step further and argues that humanitarianism’s disregard of social policy development leads to ‘residual, privatised social policy’ and ‘focus[es] not on structures of welfare governance, but on aid to specific vulnerable groups’ (Stubbs, Reference Stubbs2002: 325). Previous attempts at bridging ‘the humanitarian-development gap’ in the humanitarian studies literature (Buchanan-Smith and Maxwell, Reference Buchanan-Smith and Maxwell1994; Moore, Reference Moore1999) largely failed to address the interplay between humanitarian programmes and domestic social policies, as they mainly focused on economic development and paid little attention to the social protection dimension.
Boundaries between humanitarian assistance and social policy are fairly porous, and the relationship between the two has not attracted much academic interest. Several reasons may account for the disconnect between studies on humanitarian assistance and social policy. First, while social policy assumes that a state is interested in social protection, humanitarian assistance generally occurs in contexts where the state is either not interested in social protection or has failed to provide it. Second, the state is the leading party in at least financing and regulating the major components of the social policy. While NGOs have always been part of the social policy nexus as service providers in affluent countries (Bode, Reference Bode2006), the role of the state is still dominant in regulating and financing key components of welfare systems. In humanitarian assistance financing, however, it is not host states but donor states that are the pivotal actors, and NGOs assume a key role in providing humanitarian assistance. Third, the concept of social policy is historically associated with the social protection systems of countries with high and upper-middle economic development, whereas countries of the Global South have traditionally been the receivers of humanitarian assistance. Fourth, social policies are usually intended to be long-term, while humanitarian assistance is first and foremost a response to an emergency situation. Finally, humanitarian assistance programmes – with the exception of protection programmes –work with an absolutist approach to human needs and are even defined as ‘an expression of global governance’ (Duffield, Reference Duffield2001). Social policy in comprehensive welfare state contexts, however, generally takes a relativist approach that defines human needs in terms of living standards in the society under consideration and according to prevailing social norms about minimum acceptable living standards.
Contemporary changes taking place in the international refugee protection regime, including the current fractioning of the refugee status (Zetter, Reference Zetter2007), necessitates a rethinking of this split between social policy and humanitarian assistance programmes. Temporary protection gained increasing prominence especially after the 1990s (Fitzpatrick, Reference Fitzpatrick2000). While some scholars (e.g. Koser and Black, Reference Koser and Black1999) suggest granting temporary protection status instead of refugee status has undermined the international refugee protection system, others (e.g. Hathaway, Reference Hathaway and Handmaker2001) argue that ‘the right kind of’ temporary protection may lead to the strengthening of the international refugee protection system. In both scenarios, changes in the international refugee protection regime would have an impact on the division of labour and responsibilities among different actors in offering protection and assistance, especially for international forced migrants.
The case of Syrian migration to Turkey provides fruitful ground for such an academic endeavour to rethink the above-mentioned disconnect between humanitarian assistance and social policy. First of all, when the migration movement of Syrian refugees to Turkey began, Turkey already had relatively strong welfare institutions in some domains of social policy such as health care, but it lacked an immigration regime. Second, Turkey is an upper-middle income country, which makes it neither a typical example of the Global South nor of the Global North. Third, both Turkey and external donor states such as individual European Union (EU) member states and the United States assumed a significant role in financing the policy response to this humanitarian crisis. The diversity of actors is also mirrored on the delivery side, as the response relied on both the public sector and third sector institutions.
It is against this backdrop that the present study suggests that a holistic approach that includes both humanitarian assistance programmes and domestic social policies is required for the delineation of the emerging welfare mix for Syrian refugees in Turkey. The notion of the welfare mix, which was coined in the social policy literature in the 1990s to systematically examine diverse institutional configurations of welfare delivery services in different countries (e.g. Evers, Reference Evers1995; Vogel, Reference Vogel1999), is useful in challenging the social policy/humanitarian divide. Relying on the welfare mix approach, the article examines the main features of the welfare mix and modes of interaction between humanitarian assistance programmes and domestic social policies.
The humanitarian response and the development of social policies for Syrian refugees in Turkey
Turkey, while a party to the 1951 Geneva Convention, maintains its geographic limitation and does not accept refugees from non-European countries. Turkey has long been on the migration route from Middle Eastern, Central Asian and African countries to Europe and North America. After the outbreak of the Syrian civil war, Turkey implemented an open-door policy to Syrian immigrants. This policy, along with its growing public expenditures on humanitarian assistance for Syrian refugees, is touted by the Justice and Development Party (AK Party) in power as a source of national pride (The AK Party Presidency of Social Policies, 2017).
As of March 2017, according to the Directorate General of Migration Management data (DGMM, 2017), roughly three million Syrian refugees were living in Turkey, making Turkey the world’s largest refugee host country in absolute numbers (UNHCR, 2016). The refugees are concentrated mainly in the southeast of the country in cities near the Turkey–Syrian border: Kilis, Şanlıurfa, Hatay, Gaziantep and Mardin. Significant numbers also reside in western and southern cities, including İstanbul, İzmir, Bursa, Adana and Mersin (DGMM, 2017). Roughly nine per cent of Syrian refugees reside in temporary accommodation centres (refugee camps) in the southeast run by the Disaster and Emergency Management Presidency (AFAD), whose conditions have been lauded in the international media (McClelland, Reference McClelland2014; Lancashire, Reference Lancashire2015). The overwhelming majority, however, live in urban settings (DGMM, 2017).
Syrian refugees in Turkey benefit from a group-based temporary protection regime (Refugee Rights Turkey, 2015). While scholars (Rygiel et al., Reference Rygiel, Baban and Ilcan2016) argue that temporary protection status offers a limited scope of social rights, this article suggests that the distinguishing feature of temporary protection regime, as it is practised in the Turkish case, is not the restricted set of social entitlements it entails but the fact that it creates ambiguity with respect to long-term integration. In fact, the Council of Ministers is the sole authority for granting and lifting temporary protection status.
Granting temporary protection status instead of refugee status put the Turkish government in a powerful position vis-à-vis international organisations and humanitarian actors for two main reasons. First, with this decision to grant temporary protection, Turkey became immune from its legal responsibilities, derived from international refugee law, towards Syrians. The legal status of Syrian refugees has, thus, largely become an endogenous affair for Turkey. Moreover, this phenomenon gained international recognition with the widely criticised agreement between Turkey and EU member states to end the flow of irregular migration from Turkey to EU member states in March 2016 (European Commission, 2017a).
Second, contrary to the optimistic accounts of temporary protection leading to a formalised regime, the Turkish case demonstrates that it allows political discretion for governments to manage legal statuses of refugees, which sometimes makes refugees a bargaining chip in foreign policy (Memisoglu and Ilgit, Reference Memisoglu and Ilgit2017). Scholars, for example, suggest that the discourse of ‘voluntary return’ and ‘burden share’ started to replace the previous discourse of the open-door policy and humanitarian generosity of Turkey as a result of Turkey’s foreign policy changes towards Syria (Aras and Mencutek, Reference Aras and Mencutek2015). Similar shifts are observed in political discourses about naturalisation. While the temporary protection order does not offer a naturalisation option, the President of Turkey alluded to granting citizenship to Syrian refugees in 2016 (Aljazeera, 2016) and then raised the issue again in 2017, suggesting this time that only skilled Syrian refugees would be offered this option (Aljazeera, 2017).
The Law on Foreigners and International Protection, ratified in 2013, regulates the rights and obligations of persons under temporary protection (Republic of Turkey, 2013). According to this law, Syrian refugees have access to primary and secondary education, social assistance and services, and universal health insurance, all on an equal footing with Turkish citizens (Republic of Turkey, 2013). Despite the positive developments in the policy domains covered in this legislation, not all these positive developments at the policy level have been put into practice so far (Yıldız and Uzgören, Reference Yıldız and Uzgören2016).
Education policy, for example, is key to a successful integration strategy, especially given that almost half of Syrians in Turkey are school-age children (Çelik and Erdoğan, Reference Çelik and Erdoğan2017). However, the latest research demonstrates that refugee children still have limited access to public schools in Turkey (UNICEF, 2015: 53). Children in low-income and larger families are in an especially disadvantaged position (Uyan-Semerci and Erdoğan, Reference Uyan-Semerci and Erdoğan2018: 41). In addition to the problem of access to schools, the monolingual character of public schools contributes to the social exclusion of Syrian children (Çelik and İçduygu, Reference Çelik and İçduygu2018: 11). Refugee children’s access to special education opportunities has also remained unsatisfactory (Bircan and Sunata, Reference Bircan and Sunata2015: 235). Finally, only around three per cent of university-age Syrians is attending university (Hohberger, Reference Hohberger2018: 33).
Syrian refugees were not granted the right to work until 2016 (Republic of Turkey, 2016), and that came with significant caveats that would limit their integration into the formal labour market. Syrian refugees can exercise their rights after they register with the Turkish authorities, obtain temporary protection status and report their residency address in Turkey. Refugees can exercise these rights only in the province where they are registered; opportunities for mobility within the country are limited.
Financing humanitarian assistance for Syrian refugees in Turkey has been at the centre of domestic and international political debates. The widely criticised agreement between Turkey and EU member states has made the humanitarian financing for the Syria response in Turkey subject to bumpy diplomatic negotiations between the two parties. As part of the agreement, the EU committed to releasing three billion Euros in funding for humanitarian assistance activities for three years under the programme entitled Facility for Refugees in Turkey (European Commission, 2017b). The EU is expected to release another tranche of three billion Euros in 2018 (European Commission, 2018). Turkey reported a contribution of roughly six billion dollars in 2016 (Development Initiatives, 2017). While Turkey certainly spends considerable sums, the reliability of the Turkish figures is unknown as it suffers from a lack of publicly available breakdown of expenditures.
The development of the welfare mix for Syrian refugees is an ongoing, conflict-ridden political process within which donors, donor states, the Turkish state, international organisations, INGOs and NGOs all have different stakes. International actors cannot dictate the terms of the relationship between international and domestic actors as is generally suggested in the humanitarian studies literature. INGOs, for example, are required to apply for a work permit from the Ministry of Interior to operate in Turkey, a laborious and complex political process. Turkish authorities largely refrained from collaborating with international and domestic NGOs in dealing with the deepening humanitarian crisis in the early years of the crisis (Research Centre on Asylum and Migration, 2013). Still, both international and domestic NGOs performed a significant function in this period in supporting refugee populations, the overwhelming majority of whom live in urban settings, while state funding was mainly channelled into the temporary accommodation centres. More recently, the relationship between the Turkish government and INGOs has become tense mainly due to foreign policy concerns. The Turkish government summarily cancelled the work permits of INGOs such as the Mercy Corps and Médecins Sans Frontières (MSF) (Sanchez, Reference Sanchez2017). These government decisions spread the fear of mass expulsion from Turkey among INGOs. This altered the content of both the international response and Turkey’s response to the Syria crisis within Turkish borders and increased the roles of public sector and domestic NGOs at the expense of INGOs. While a recent study on Sultanbeyli, a district of Istanbul, has argued that the relationship between domestic NGOs and the Turkish state is now based on loyalty to the state and common religious values (Danış and Nazlı, Reference Danış and Nazlı2018: 2), this conclusion is still case-specific and does not fully capture the diverse modes of relationship between a diverse set of domestic NGOs and the state.
Social assistance
Social assistance policies have traditionally been one of the least developed policy domains of Turkey’s welfare system. The introduction of the first nationwide social assistance programmes, which provided cash transfers for people with disabilities and the elderly living under the official poverty threshold, dates back to the late 1970s. With the Turkish development paradigm transforming from import-substituting industrialisation to export-oriented growth after the 1980 military coup, economic growth failed to increase formal employment opportunities on a par with the increase in the working-age population. Coupled with the increasing domestic migration from rural to urban areas, a new urban poverty emerged (Buğra and Keyder, Reference Buğra and Keyder2006).
The policy response to the increase in poverty rates was the introduction in 1986 of discretionary and irregular in-kind and cash social assistance schemes for those who are not in employment and are living under the official poverty threshold. After the 2001 economic crisis, Turkey, in collaboration with the World Bank, introduced conditional cash transfers for households with children with an income that was below the official poverty threshold (Buğra and Keyder, Reference Buğra and Keyder2006). Since the beginning of the AK Party period in 2002, the share of public expenditure on social assistance schemes and the scope of these schemes have increased substantially (Yentürk, Reference Yentürk2013). The government launched new social assistance schemes such as a targeted scheme for widows, for example, and introduced cash-for-care schemes in the case of households with a disabled family member in need of care. The main feature of social assistance programmes in Turkey is their categorical feature targeting ‘the deserving poor’.
Since the early days of the Syria crisis, social assistance has been one of the largest domains of NGO emergency field activity. Various NGOs distributed food and non-food aid (e.g. winterisation) and supplied e-voucher cards. NGO social assistance programmes differed in their perspective and scope. For example, the Human Relief Foundation (IHH), a faith-based humanitarian assistance NGO based in Turkey, distributed food on religious holidays (IHH reached out to more than 80 thousand households during the Muslim feast of sacrifice in 2015), while the Support for Life Association, a secular humanitarian assistance NGO based in Turkey, implemented a cash transfer programme that reached out to approximately 54 thousand households in the same year.
The Emergency Social Safety Net (ESSN), which is a EU-funded emergency aid programme implemented by Turkish Red Crescent in collaboration with the Ministry of Family and Social Policies and World Food Programme, is an unconditional cash benefit programme for Syrians under temporary protection and other refugees under international protection in Turkey (The Emergency Social Safety Net, 2017). The ESSN replaced most of these NGO programmes to become the main basic needs programme, thanks to the financial resources it receives from the EU’s European Civil Protection and Humanitarian Aid Operations (ECHO), its reliance on public sector capacity and the large number of beneficiaries. The EU promotes this programme as ‘the biggest ever humanitarian aid programme’ it has funded (European Commission, 2016).
Implementation of the ESSN programme started in December 2016. With funding secured for two years, it is expected to reach a total of 1.3 million people by the end of 2018. The programme relies on the social assistance infrastructure of the Ministry but, to facilitate the implementation of the ESSN, the Turkish Red Crescent opened application centres in provinces with a high concentration of Syrian refugees.
To apply for the ESSN, refugees must have registered for temporary or international protection in Turkey and have a registered residency address. They must also fall into one of the following categories: women living alone, single-parent households, elderly individuals over age 60 without any younger family member in the household, households with a disabled family member, households with four or more children, or households with a high share of people in need of care (dependency ratio 1.5 or higher). The total amount of cash is provided monthly to the applicant through a debit card, which provides a fixed sum per household member. As part of the programme, each household receives 120 TL (approximately 18 Euros after the 2018 devaluation of the Turkish lira) per person monthly (Anadolu Agency, 2016). Unlike the European trends, cash transfer for refugees relies not on activation perspective, which aims at increasing the labour market participation of social assistance recipients, but mainly on unconditional income support.
Social assistance has been one of the key components of the Syria response within Turkey. The launch of the ESSN programme in 2016 led to the scale-up of the social assistance component of the response, which shifted the centre of gravity from NGOs to domestic public actors including the Turkish Red Crescent. Concerning its programme design, the ESSN is in line with the recent trend in the Turkish welfare system towards categorical cash transfer schemes.
Employment
The employment rate in Turkey is relatively low (around 45 per cent as of January 2017), primarily because only about one-third of women are in the labour force. Turkey implements a nationwide minimum wage policy, but the fact that the share of informal employment in the total employment is about one-third (32.5 per cent as of January 2017) (TURKSTAT, 2017) limits the state’s capacity to enforce a minimum wage policy effectively. The Turkish Employment Agency (ISKUR), founded in the late 1940s, is tasked with matching job seekers with potential employers. Its overall effectiveness has been limited so far. The incidence of child labour in Turkey was around 6 per cent in 2012 (TURKSTAT, 2013), before the number of Syrian refugees increased.
Nearly 1.8 million Syrian refugees in Turkey are of working age (DGMM, 2017). Turkey granted Syrian refugees the right to work in 2016 (Republic of Turkey, 2016). According to the regulation, employers willing to employ a Syrian refugee who has resided in Turkey for more than six months can apply for a work permit on behalf of the refugee. Work permits are valid for one year and are renewable annually. A 10 per cent cap is imposed on the number of Syrian refugees employed in a given enterprise. Between January and July 2016, roughly five thousand Syrian refugees were granted work permits (Hurriyet Daily News, 2016) and thus work in formal jobs. But recent research indicates that many more are employed informally in labour-intensive sectors (Tumen, Reference Tumen2016) that are pathways to precarity (Baban et al., Reference Baban, Ilcan and Rygiel2017). In addition, NGO reports suggest that a significant portion of Syrian children have started to work in Turkey (Yalçın, Reference Yalçın2016).
This discrepancy between the number of work permits granted and their integration into the informal economy clearly demonstrates the failure of domestic employment policies as well as humanitarian livelihood programmes to integrate refugees into formal employment. This was not surprising in the early years of the crisis when emergency assistance was needed and Syrian refugees had not yet been granted the legal right to work.
NGOs, however, started projects that would facilitate the integration of Syrian refugees into the labour market even before the right-to-work legislation came into being. In late 2013, a number of humanitarian assistance NGOs opened community centres in cities with a high concentration of Syrian refugees to offer vocational training courses in addition to other assistance and protection activities. For instance, in 2015, the Yuva Association offered vocational training to around 1.4 thousand Syrian refugees. The Norwegian Refugee Council implemented 16 vocational training programmes in five training centres and supported participants with a generous daily allowance of 30 Euros a day. The International Medical Corps, which was closed down by the Turkish government in April 2017, launched the Istanbul Maharat Center, which offered skill training and career counselling for Syrian refugees. The Maharat Center supported entrepreneurial initiatives of Syrian refugees, providing an incubation centre and career fairs to bring together the refugee population with companies willing to employ refugees. In addition, Rizk for Professional Development offers vocational training for Syrian refugees in İstanbul, Gaziantep and Şanlıurfa. Rizk for Professional Development declares it has succeeded in placing around ten thousand refugees in jobs since 2014 (Balkan, Reference Balkan2017).
The public sector response was rather late in granting work permits (five years after the first arrivals), and it offered no effective mechanisms to discourage refugees from entering the informal economy. Unlike the shift of gravity from NGOs to Turkish public sector in social assistance, NGOs are still the main actors in employment, yet the overall effectiveness of their activities in a largely unregulated labour market remains weak. Unlike the Jordan Compact (European Commission, 2017c), neither the international community (especially the EU) nor the Turkish government has brought forward an economic development plan with a significant potential of decent job creation for the local and refugee communities. Scholarly accounts still emphasise supply-side policies to increase formal employment among the refugee population (İçduygu and Diker, Reference İçduygu and Diker2017), but the prospect for their success in the Turkish case looks rather bleak due to limited formal job creation especially in the provinces where the majority live.
Health care
Health care is one of the mature components of Turkey’s welfare system (Buğra and Keyder, Reference Buğra and Keyder2006). As early as the 1940s, Turkey devised occupational status-based health insurance schemes that covered the majority of the population by the 1970s and have succeeded in developing a substantial public capacity for health care delivery. Similar to the situation in other developing countries, its social insurance-based model of health care financing created outsiders, whose number increased with the weakening relationship between economic growth and the generation of formal employment after the 1980s. In response, in the 1990s, Turkey introduced tax-funded health insurance coverage (only for inpatient services) for those living below the official poverty threshold. The 2003 reform introduced a compulsory public health insurance scheme with equal benefits packages for all (Yıldırım and Yıldırım, Reference Yıldırım and Yıldırım2011). Although the benefits package has been broadly defined, it does not cover long-term psychotherapy and psychosocial support services (Yılmaz, Reference Yılmaz2012).
The health care needs of the Syrian refugee population were met largely by a combination of transitory informal health clinics staffed by Syrian doctors, NGO clinics, and the Turkish health care delivery structure. According to the Law on Foreigners and International Protection, Syrian refugees are granted access to universal health insurance on an equal footing with Turkish citizens (Republic of Turkey, 2013). With this regulation, the public sector became the major actor in the provision of health care for the refugee population, which gradually replaced the informal health clinics and NGO clinics. Health care utilisation figures of Syrian refugees between 2011 and 2016 (Anadolu Agency, 2017) imply that health care is the most commonly used public service among the refugee population. Health care services for Syrian refugees are financed by the AFAD in line with annual protocols signed by the Ministry of Health since July 2015 (AFAD, 2015). These protocols set an annual fixed lump sum price to be paid by the AFAD for the Ministry of Health-provided services, which equates to roughly 120 million Euros in 2018 (The Ministry of Health, 2018).
Until the end of 2015, Syrian refugees were able to apply for primary health care services at all public hospitals. Then, as of late 2016, the Ministry launched migrant health centres, with the objective of providing primary health care services for the Syrian refugee population in their mother tongue, thus easing the burden on public facilities, especially in provinces where the concentration of Syrian refugees is high (Daily Sabah, 2017). The EU provided the funding for the establishment of these centres. In fact, one-fifth of the total EU funding was granted to the Ministry of Health for the establishment of over 500 health care facilities and rehabilitative mental health services (European Commission, 2017b: 13). The Ministry expects to establish a total of 500 migrant health centres, each of which will serve approximately 4,000 to 7,000 refugees. The centres are mostly staffed by Syrian physicians, who have received training by the Ministry of Health in collaboration with the World Health Organisation.
Despite the ability of the state to offer health care insurance and provide health care services for the Syrian refugee population, the relative weakness of Turkish mental health services, the inability to offer services in the mother tongue of the refugee population and the centrality of the use of mother tongue in mental health services leave the mental health needs of the refugees – which increased with post-migration experiences (Cantekin, Reference Cantekin2018: 8–12) – largely unmet. The Ministry of Family and Social Policies offers psychosocial support services mainly in temporary accommodation centres (Hürriyet, 2017). Humanitarian NGOs, on the other hand, concentrate on the provision of mental health and psychosocial support services for Syrian refugees living in cities. NGOs such as the Union of Medical Care and Relief Organizations International (UOSSM), in collaboration with Médecins Sans Frontières (MSF), provided these services in a mental health clinic setting established in Hatay, but others such as the Association for Solidarity with Asylum Seekers and Migrants (SGDD/ASAM) offered them in multi-service community support centres in different provinces.
While Syrian refugees have been able to access the medical equipment through their public health insurance, most pharmacies and medical equipment suppliers refuse to serve the refugee population because of the instability of public reimbursement. Additionally, the required co-payments might have created an obstacle to refugees who would otherwise use public health insurance (Hürriyet, 2016). To address this shortcoming, NGOs such as Doctors Worldwide also supplied medical equipment to the refugee population.
Health care has been one of the strongest components of the Syria response in Turkey. By including the refugee population in its public health insurance, by granting refugees free access to health facilities and by strengthening its service delivery capacity with new primary health care facilities, the public sector has a dominant role in health care. Unlike Jordan, which had to reverse its policy of offering free health care services to Syrian refugees in 2014 (Francis, Reference Francis2015: 24) due to the relatively high share of refugees within the general population, the financially sound compulsory public health insurance programme in Turkey and the relatively low share of refugees within the general population enabled the country to absorb the financial burden of free health care services for the refugee population.
Nevertheless, the Turkish health care system falls short in its ability to address the mental health needs of the refugee population, a lack that has been partially compensated for by the mental health and psychosocial support services of humanitarian NGOs. Humanitarian programmes in mental health care, therefore, complement the public sector response and are located in a service domain where the public sector response is lacking, which has led to the emergence of a de facto division of labour between two actors.
Conclusion
Challenging the humanitarian/social policy divide in the literature, this paper has taken a welfare mix approach to exploring domestic social policy and humanitarian assistance programmes for Syrian refugees in Turkey. To this end, it examined the modes of interaction between humanitarian assistance programmes and domestic social policy responses in the area of social assistance, employment and health care that emerged as part of the response internationally and by Turkey to the Syria crisis within Turkish borders.
The welfare mix for Syrian refugees, a joint product of humanitarian assistance programmes and domestic social policy programmes, is still a work in progress. In the early years of the crisis, the welfare mix for Syrian refugees in three selected domains was essentially a patchwork of social policies and humanitarian assistance programmes that could hardly be said to constitute a coherent response. The Turkish government concentrated its resources on a small group residing in temporary accommodation centres, and international and domestic humanitarian NGOs provided in-kind and in-cash social assistance programmes, mental health and psychosocial support, and medical aid to those living in cities. Despite these efforts, because of the high number of Syrians arriving in Turkey and the late response of both international and domestic bodies, the scope of humanitarian assistance remained limited when the total number of refugees living in Turkey is considered.
The division of labour among different actors in the welfare mix has changed over time. Three major factors explain the current structure of the welfare mix: granting of temporary protection status, the EU-Turkey agreement, and the strengths and weaknesses of institutional capacity in the Turkish welfare system. Especially after the ratification of the Law on Foreigners and International Protection and the EU–Turkey agreement, public sector actors (including the Turkish Red Crescent) started overtaking the activity domains of international humanitarian NGOs, especially those working in social assistance and health care. On the one hand, this trend restricts opportunities for policy learning in the public sector, which largely lacks the humanitarian sector’s know-how about working with refugees, particularly with respect to protection issues. On the other hand, the expansion of the public sector role provides an opportunity to scale-up a sustained response to refugee needs.
Despite the overall tendency to rely on the public sector, the main characteristics of the emerging welfare mix for Syrian refugees vary significantly across different policy domains covered in this paper. The public sector gained dominance in social assistance and health care, where it had an institutional capacity, but NGOs are the key actors in vocational training and mental health service provision; areas where the Turkish welfare system has been traditionally weak. The expansion of the public sector role reached its natural limits while also shaping the humanitarian response scene.
The inclusion of the refugee population in Turkey’s public health insurance may support the generosity approach in the literature, which suggests that the rights of immigrants will converge with the rights of citizens. While this claim has been made for comprehensive welfare states only, this paper argues that the convergence of the rights of immigrants and citizens may well occur in mature components of less comprehensive welfare states.
Social assistance and health care for Syrian refugees in Turkey have received the most attention and funding. But the funding sources for these domains differ. While the contemporary reliance on international humanitarian aid in social assistance may pose an obstacle to the shift from humanitarian relief to sustainable social protection, the use of public funding in health care may guarantee refugees’ access to health care services in the future.
Employment, however, has been essentially ignored, both in humanitarian assistance programmes and in social policies aimed at Syrian refugees. The humanitarian NGOs focus only on vocational training courses but the prospects of long-term economic integration of the Syrian refugee population are dire. This is due to the absence of a demand-side approach in the employment component in the EU’s Facility for Refugees in Turkey, the limited employment creation capacity of the Turkish economy and Turkey’s historical failure to regulate its labour market.
Improvement in employment conditions for Syrian refugees requires a concerted effort on the part of the Turkish government to develop a domestic policy that will create decent work opportunities for all and better regulate the labour market. The regulation of the labour market, however, must be combined with demand-side measures (e.g. job creation, employment subsidies for refugee employment and a reduction in the tax burden on employment) in order not to hamper the employment prospects of Syrian refugees. Otherwise, humanitarian NGO livelihood programmes will be doomed to failure if they place the overwhelming majority of beneficiaries in informal, temporary and low-paid jobs. In the absence of a clear strategy for economic integration, the current humanitarian and policy responses may end up relegating Syrian refugees into the ‘deserving poor’ category in Turkey, whose deservingness may be contested by hostile domestic political actors in the near future.
Acknowledgements
I am grateful to my research assistant Ayşe Meryem Gürpınar Akbulut for her help. I thank my colleague Talita Çetinoğlu who provided insight and expertise that greatly assisted the research. The study was funded by Boğaziçi University Research Fund Grant Number 12723.
