Original Article Syrian Refugees in Hatay/Turkey and Their Influence on Health Care at the University Hospital

Int J Clin Exp Med 2016;9(9):18281-18290 www.ijcem.com /ISSN:1940-5901/IJCEM0027188

Original Article Syrian refugees in Hatay/Turkey and their influence on health care at the university hospital

Nazan Savas, Evrim Arslan, Tacettin İnandı, Arif Yeniçeri, Mehmet Erdem, Meryem Kabacaoğlu, Ersin Peker, Ömer Alışkın

Department of Public Health, Medical Faculty, Mustafa Kemal University, Antakya, Hatay, Turkey Received February 21, 2016; Accepted August 13, 2016; Epub September 15, 2016; Published September 30, 2016

Abstract: Background: Refugees have been exposed to severe health problems due to the influences of negativi- ties they experienced in their countries, migration process and low standards of living. Health care workers are not prepared and educated enough for such circumstances, even though they are the very witnesses of changing circumstances and an essential part of providing required services. Our aim is to investigate how Syrian civil war and refugees in Turkey influenced health care services. Methods: This cross-sectional study was conducted in 2015, involving health care workers in the university hospital in Hatay. The survey was applied to 102 doctors and 108 nurses/health technicians. Chi-square test and Mantel-Haenszel test were used. Results: The highest need concerning refugee patients was intensive care capacity for 65.6%, in patient care for 64.6% and 55.5% stated complications develop more in refugees. This was similar among workers at internal and surgical departments (P>0.05). 85.7% stated that workload, 67.1% stated that working hours and 71.6% stated that patient waiting time had increased. Increase in working hours was higher for doctors; increase in patient waiting time was higher in surgical departments and alloted time to patient s increased more for nurses/health technicians (P<0.05). Regarding what is insufficient; it was intensive care capacity for 76%, the number of beds for 68.3% and medicine/blood/blood- products for 34.8%. 37.6% experienced a dangerous situtation, 88.1% do not feel secure and 58.9% of participants’ desire to work decreased. The rate of feeling in secure was higher among nurses/health technicians, decrease in the desire to work was higher among doctors (P<0.05). The most common diagnosis was gunshot wounds for 38.4% of internal department workers and 68.8% of surgical department workers (P<0.05). The most common communicable disease was found to be nosocomial infection (45.9%). Conclusion: The university hospital in Hatay had been negatively influenced by Syrian civil war in terms of refugee patients. Peace is a precondition for proper health care.

Keywords: Syrian refugees, health care, university hospital, Turkey

Introduction to the press release issued by the Governor of Hatay in January, 2015, there are 229,617 reg- The first mass population movement from Syria istered Syrian refugees living in the province to Hatay occured in April, 2011 due to the fact [3]. According to the data provided by the that conflicts and internal disorder began in Republic of Turkey Disaster and Emergency March, 2011 in Syria leading to a state of chaos Management Authority (AFAD) in May, 2015, in the country [1]. Turkey held an open-door 15,082 refugees live in the camps [4]. Refug- policy towards the population movement and ees who live in and outside camps constitute gave “temporary protected status” to Syrian approximately 16% of Hatay’s population [5]. citizens within the context of international refu- The issue of refugees’ health status and the gee law and customary internional law. Thus, it concern to meet the health requirements suffi- is aimed to supply all the needs for Syrian refu- ciently have generated a crucial public health gees [2]. issue [6].

The overwhelming majority of the refugees in It is a health requirement to be fulfilled that Hatay have been living in the city centre and Syrian citizens wounded in civil war and brought the rest in five camps built for them. According to Turkey need preventive and therapeutic Syrian refugees and health care in Turkey treatment [7]. On top of that, Syrian refugees’ Syrian Civil War and what differences they needs for preventive and curative health care is have experienced afterwards in terms of pro- expected to be higher than the pre-war situa- viding health care. tion in Syria because of many deprivations [6]. For, even in the absence of war, the migration Methods process, drawbacks they encounter in their country and poor living conditions unavoidably This cross-sectional study was made in 2015 create serious health problems, either infec- June-July period and applied to the health care tious or not [8, 9]. workers in Hatay Mustafa Kemal University Faculty of Medicine Training and Research According to Cousins’ report, infectious diseas- Hospital. Hatay province is located in East es such as malnutrition and leishmaniasis, Mediterranean Region with a population of measles, tuberculosis, scabies, bronchiolitis, 1,519,836, that is constituted by the citizens of hepatitis A are found widespread in Syrian refu- the Republic of Turkey (T.R) and it has the bor- gees [10]. Doosy S. et al detected in their der with Syria. Universe of the study are all research conducted in Jordan that, one non- health staff in the hospital. There were 460 communicable disease, such as hypertension, health care workers by the time the study was arthritis, diabetes, COPD, coronary artery dis- conducted and 236 of them were medical doc- ease and cancer, was found in one family mem- tors. Sampling was made by first stratifying the ber in more than the half of Syrian refugee universe according to branches and 50% of the households [11]. Another health problem seen occupational groups in every stratum was in Syrian refugees is traumatization caused by selected by random method. 210 health work- civil war and increased necessity of urgent ers in total participated in the study; as 102 health care [7]. To illustrate, according to the medical doctors (62 faculty members, 40 study made by Akküçük S. et al in Hatay, 159 research assistants) (43.2%), 108 allied health Syrian refugees with gunshot wounds contact- personnel (89 nurses, 19 health technicians) ed to general surgery department of the univer- (48.2%). The ones who were off duty and on sity hospital in 2011-2012, after the civil war. In leave could not be reached. Data was obtained addition, according to the study of Aras M. et al, from the survey, prepared by the researchers, 186 refugees with gunshot wounds contacted through face to face application. The question- to neurosurgery department of the same hospi- naire was constituted of 50 questions, three of tal between the years 2011 and 2013 [12, 13]. them were open-ended and four of them were five-level Likert-type, involving participants’ Health care workers are not prepared and edu- sociodemographic features, health care and cated enough for such circumstances, even hospital services parts which are related to though they are the very witnesses of changing Syrian refugees. Descriptive statistics, Chi- circumstances and an essential part of provid- square test and Mantel-Haenszel test were ing required services [14]. Escalation in refugee used for the statistical analysis of data, P<0.05 movements and alteration of patient types was considered significant. Ethics committee have increased health care workers’ workload approval and informed voluntary consent were and effected their work environment [7]. Also, taken. the fact that their awareness and experience about the special needs of asylum seekers and Results refugees is not satisfactory has an impact on the health care given, along with the problems 210 healthcare workers participated in the related to language, communication and cul- research. 43.2% of them were medical doctors tural differences [15-17]. In addition to these, (62 faculty member, 40 research assistants) lack of trained specialists in many public hospi- and 48.2% of them were allied health person- tals and the inadequate infrastructure to cope nel (89 nurses, 19 health technicians). The with growing demand may result in disruption average age of participants is 31.8±8.3 of health services [10]. (min.19-max.55) and 55.2% were women; as 53.3% working in internal medicine depart- This study’s purpose is to determine how the ment, 44.3% surgical department and 2.4% University Hospital in Hatay Province and its basic sciences department. They have been health care workers have been influenced by working in the hospital for an average of

18282 Int J Clin Exp Med 2016;9(9):18281-18290 Syrian refugees and health care in Turkey

Table 1. Changes experienced by health care workers due to Syrian refugees and influences With the impact of Syrian refugee patients Number (%) How was your daily workload effected? Decreased 2 (1.0) Unchanged 28 (13.3) Increased 179 (85.7 How was your daily working time effected? Decreased - Unchanged 69 (32.9) Increased 141 (67.1) Did alloted time to patients change? Decreased 96 (46.4) Unchanged 72 (34.8) Increased 39 (18.8) Did patients’ waiting time change? Decreased 12 (5.8) Unchanged 47 (22.6) Increased 149 (71.6) How do you consider the number of emergency admissions to your department compared to the previous? Decreased 53 (25.4) Unchanged 45 (21.5) Increased 111 (53.1) Have you experienced a change in the number of T.R citizen patients you see? Decreased 135 (65.6) Unchanged 62 (29.7) Increased 12 (5.7) Did undergradute-graduate-postgraduate studens’desire to be trained in the hospital change? Decreased 111 (54.1) Unchanged 84 (41.0) Increased 10 (4.9) Did your income change? Decreased 65 (31.0) Unchanged 140 (66.7) Increased 5 (2.3)

4.6±3.4 years (min.1-max.14). The units they periencing difficulty in communication was nei- work most were services (46.7%), operating ther a difference between medical doctors and theaters (15.7%), outpatient clinics (14.8%) and allied health personnel nor among the ones in intensive care units (13.3%) respectively. internal and surgical departments (P>0.05).

The median number of the T.R citizen patients Participants were asked to scale their difficul- that participants encountered each day was 15 ties in communication from 0 to 5 points (as 0 (min.1-max.100) and of Syrian refugees was 10 means ‘never’ and 5 means ‘very often’) and (min.1-max.200). The median number of T.R the reasons with 5 points were turned out to be citizen patients relatives that they communi- language for 77.7%, of participants, refugees’ cated each day was 18 (min.0-max.150); and lack of information about health care for 46%, of Syrian refugee patient relatives was 10 cultural differences for 45.5% and timidity of (min.0-max.160). For the 20% of the partici- refugees related to the issues such as violence, pants communication with refugees was par- abuse, etc. tially challenging; for the 72.4% it was very challenging and 13.8% used an official translator 85.7% of the participants stated that their and 53.9% used an unofficial translator. Ex- workload, 67.1% stated that working hours,

18283 Int J Clin Exp Med 2016;9(9):18281-18290 Syrian refugees and health care in Turkey

Table 2. Health Care Workers’ Evaluation of Syrian Patient Profile Concerning Syrian refugee patients Lower (%) Similar (%) Higher (%) How do you evaluate the need for patient care compared to T.R citizen patients? 10 (4.8) 63 (30.1) 136 (65.1) How do you evaluate the need for inpatient treatment compared to T.R citizen patients? 6 (2.9) 68 (32.5) 135 (64.6) How do you evaluate the rate of complications compared to T.R citizen patients? 18 (8.6) 75 (35.9) 116 (55.5) How do you evaluate the need for intensive care compared to T.R citizen patients? 4 (1.9) 68 (32.5) 137 (65.6)

students’ desire to be trained in the hospital had declined afterwards Syrian refugees.

Another question to be illuminated was the most common reasons of Syrian refugees’ admissions to the hospital they first came to Hatay. 61.9% of the participants declared that refugees were suffering from gunshot wounds. In addition, 38.4% of internal department workers Figure 1. Infectious Diseases Diagnosed in Syrian Refugees at Health Care and 68.8% of surgical depart- Workers’ Departments (N=210) (multiple response). ment pointed out that the most widespread diagnosis 71.6% stated that patient waiting time were had been gunshot wounds among refugees increased and 46.4% stated that the time allot- from the beginning of the civil war (P<0.05). ed to patients was reduced with the impact of Syrian refugee patients (Table 1). Daily working Furthermore, participants were asked to com- time of 76.2% of the doctors was found to be pare Syrian patient profile with T.R citizen prolonged, whereas the working hours of 58.7% patients and 65.1% answered that need for of the nurses/health technicians were found patient care and 64.6% answered that in to be increased (P<0.01). This difference bet- patient treatment requirement were higher; ween two groups did not change when it was and 55.5% underlined a larger number of com- analyzed by controlling department (P<0.01). plications than T.R citizen patients and 65.6% Patient waiting time was also found to be underlined the higher need for intensive care increased in 79.3% of the surgical departments (Table 2). Each four circumstances resembled and 65.8% of the internal medicine depart- one another among internal and surgical ments (P<0.05). Inaddition, alloted time to the departments (P>0.05). It was found that 26.1% patients for nurses/health technicians was of participants encountered a health problem observed to be increased (P<0.05). Moreover, that they have seen for the first time while 52.7% remarked that the number of emergency examining Syrian refugees according to the admissions to their departments had increased statements of 40% of research assistant physi- due to Syrian refugees. The increase observed cians, 29% of faculty member physicians and in emergency admissions was not a difference 19% of nurses/health technicians (P<0.05). between internal and surgical departments (P>0.05). Participants were also asked through a mutiple choice and multiple response question that Observations of participants were asked con- which communicable diseases they had diag- cerning the impressions of patients and stu- nosed in Syrian refugees. The answers were dents in terms of preferring the hospital: 65.6% nosocomial infection by the 45.9%, viral hepati- of the participants stated that there had been tis by the 42% and tuberculosis by the 36.1% a decrease in the number of T.R citizen pati- (Figure 1). Nosocomial infection cases were ents contacted to hospital and 54.1% stat- diagnosed more frequently in surgical depart- ed that undergraduate-graduate-postgraduate ments, whereas gastroenteritis and leishmani-

18284 Int J Clin Exp Med 2016;9(9):18281-18290 Syrian refugees and health care in Turkey

Table 3. Evaluations of health care workers on the issue of Syrian civil war and refugees in terms of hospital services Due to the civil war in Syria and refugee patients Number (%) Have you experienced a dangerous situation in the hospital? No 131 (62.4) Yes 79 (37.6) Do you feel safe in the hospital? No 185 (88.1) Yes 25 (11.9) Did your desire to work in the hospital change? Decreased 123 (58.9) Unchanged 82 (39.2) Increased 4 (1.9) Has anyone resigned from your department? No 161 (78.9) Yes 43 (21.1) Is the number of health care workers sufficient? No 193 (92.3) Yes 16 (7.7) Did your department recruit a temporary or permanent health care worker? No 177 (85.9) Yes 29 (14.1) Is the number of hospital beds sufficient? No 140 (68.3) Partially 53 (25.9) Yes 12 (5.9) Is the capacity of intensive care sufficient? No 155 (76.0) Partially 43 (21.1) Yes 6 (2.9) Are the needs for edicine, blood and blood products satisfied? No 71 (34.8) Partially 87 (42.6) Yes 46 (22.5) Is the need for consumables satisfied? No 85 (41.7) Partially 83 (40.7) Yes 36 (17.6) asis cases were diagnosed more frequently in the fall of grenade from a wounded refugee internal medicine departments although they patient brought to the emergency. In addition to were all infectious diseases (P<0.05). Viral that, 37.1% of participants were subjected to hepatitides, tuberculosis and sexually trans- verbal violence and 6.7% to physical violence mitted diseases were detected at similar rate (Table 3). Experiencing a dangerous situation in internal and surgical departments (P>0.05). was more common among research assistant physicians, while verbal and physical violence 37.6% of participants experienced a dangerous were more widespread among nurses/health situation emerged in a relation with Syrian civil technicians (P<0.05). The question “Have you war. It was asked through an open-ended ques- ever used violence against refugees”? was tion and the most common answer (24%) was responded positively as 9% of the answers

18285 Int J Clin Exp Med 2016;9(9):18281-18290 Syrian refugees and health care in Turkey were referring to verbal violence and 1.9% were 92.4% of the health workers had difficulty in referring to physical violence. their communication with refugee patients, however 13.8% of them used official translator. 88.1% of participants do not feel safe in the The most common causes of having trouble in hospital and 58.9% of participants’ desire to communication were language difference, refu- work had been declined. Feeling unsafe was gees’ lack of information in terms of health ser- more widespread among nurses/health techni- vices, cultural differences and refugees’ timidi- cians, while declining willingness to work in the ty due to reasons such as abuse respectively. hospital was more commonly found among According to Turkish Medical Association’s research assistant physicians (P<0.05). Be- report, language difference causes severe sides, 78.9% of participants declared that problems related to accession to public servic- there had been several resignations in their es, communication and social life, and espe- departments. The rate of resignations in inter- cially health care services [7]. In addition, Lloyd nal and surgical departments were similar states that language barriers and trust issues (P>0.05). create anxiety for refugees; while from a service provider perspective, main problematic Furthermore, participants were asked to evalu- issues are time constraints and unfamiliarity ate hospital services within the perspective of with refugee health issues [18]. Furthermore, in refugee patients. 92.3% stated that the num- terms of health information, this situation has ber of health care workers, 68.3% stated that implications effecting the ability of health ser- the number of beds and 76% stated the ca- vice providers to deliver information, or even it pacity of intensive care were insufficient. Also may lead to information avoidance [19]. Another the 34.8% remarked the unsatisfied need for significant issue appears as cultural beliefs medicine, blood and blood products and 41.7% that has been identified as creating barriers to remarked the unsatisfied need for consum- health information [18]. Murray and Skull sug- ables. Insufficiency of the number of health gests that information-seeking in relation to care workers was not a difference among occu- health and wellness may be inhibited by pre- pational groups (P>0.05). Qualification statutes existing cultural beliefs and by culturally rein- of the number of health care workers and beds, forced attitudes towards health care providers the capacity of intensive care and medicine/ [20]. blood/blood products were similar between internal and surgical departments (P>0.05). Moreover, it was detected in our research that Inadequacy of supplying needs for consum- health care workers’ workload increased due to ables was higher in surgical departments refugee patients; and especially for medical (P<0.05). doctors. According to AFAD’s legislative regula- Finally, an open-ended question was asked in tions, refugee patients were able to benefit order to find out what kind of arrangements from health care services provided from univer- were made in the hospital due to Syrian refu- sity hospitals without any payment and referral gees. The most common answers are as fol- chain until June, 2015 [21, 22]. Yet, this result- lows; hanging signboards in Arabic, rearranging ed in refugee contacts to hospitals exceeding the eating places for patient attendants, rear- staff’s capacity. As a matter of fact, although a ranging the admissions unit, preparing contact significant decrease was observed in the num- forms at some departments, increasing the ber of refugee patients in June, the proportion number of beds, placing extra beds to the of refugee patient and patient relative commu- rooms, giving priority to refugees, enhancing nicated per day was found to be 60.6%. Also it the intensive care unit and opening the refugee was remarked by 92.3% of the participants that service. the number of health care workers was not sufficient. This problem is reported to be valid in Discussion state hospitals as well [23].

The median proportion of Syrian refugee Another result reached by the study was the patients and their relatives with whom health decrease of the alloted time to patients and the workers get in communication per day was increase of patient waiting time especially in found to be 60.6%. It was determined that surgical departments. However, alloted time to

18286 Int J Clin Exp Med 2016;9(9):18281-18290 Syrian refugees and health care in Turkey patients was found to be more for allied health (2.0%) respectively. According to research re- personnel compared to medical doctors. Thus, sults achieved by Petersen et al, many of the it can be supposed that patient care and proce- infections found in Syria like leishmaniasis, dures take more time. Moreover, admissions to tuberculosis and brucellosis have a long incu- emergency was another thing observed to be bation time and refugees bring them along with increased due to refugee patients that was not the risk of reintroducing them in neighboring a difference between internal and surgical countries. “Epidemics of bacterial meningitis departments. With respect to this, Döner et al and gastrointestinal infections like hepatitis A, state that doctors face very difficult situations enterovirus and Giardia can be expected” [28]. to manage. They work for long hours and man- Leismaniasis cases observed in refugees are age several urgent cases. As a nurse explained noticed not only in Turkey but also in Lebanon to them, it is not just wounds caused by bombs as well [29, 30]. Thus, “the sudden increase in or bullets that need treatment, but also spiritu- Leishmaniasis cases in Lebanon in 2013 is al wounds, fears and pains need to be healed attributed to the increasing numbers and wide [24]. distribution of Syrian refugees in Lebanon” [30]. High rate of infectious diseases observed We asked our participants to evaluate the refu- in refugees “highlights not only the destruction gee patients profile in comparison to T.R citizen of health care facilities and the difficulties in patients. Top priority in terms of meeting unsat- treating injured people, but also describes the isfied needs was stated as patient care by absence of childhood immunizations in many 65.1% of the participants, inpatient treatment areas, lack of pharmaceuticals including antibi- by 64.6% and intensive care by 65.6%. Also, otics and the lack of access to clean water and 55.5% of the participants remarked that com- surge in diarrhea cases” [28]. plications more often develop in refugee patients. In addition, 61.9% stated that the Our research showed the decrease in 58.9% most common reason of the admissions to of health care workers’ desire to work in the their departments was gunshot wounds; and hospital, especially the research assistant doc- similarly, 68.8% of the workers in surgical de- tors. 78.9% confirmed that there had been res- partment indicated that the most frequently ignations in their departments due to Syrian diagnosed health problem in refugees had civil war and refugee patients. Also, 54.1% stat- been “gunshot wounds” since the beginning of ed that undergraduate-graduate-postgraduate the civil war. Many research have been pub- students’ desire to be trained in the hospital lished that reports different organ wounds decreased as well. These results are not sup- resulted from being subjected to gunfire dur- posed to be merely about the increase of working the civil war, regarding Turkey’s provinces load and working hours, but also shaped by the which are neighboring to Syria [12, 13, 25-27]. factors that were illuminated by our study as According to Özdoğan and Karateke, thousands follows: feeling unsafe at the hospital (88.1%), of seriously injured trauma patients from Syria experiencing dangerous situations related with were brought to Turkey for emergency opera- the civil war and refugees (37.6%), being sub- tions and postoperative intensive care. With jected to verbal (37.1%) and physical (6.7%) vio- respect to this, the wards had been overstrec- lence by refugees. Döner et al supports this by thed because of the increased demand for sur- underlining that health care workers appear as gical care. They also remarked that the most another side of the situation who are experienc- common problem faced in intensive care area ing the consequences of current events while was gunshot wounds during the same period prodiving services to vulnerable refugee popu- [27]. lation [24]. Similarly, Korkmaz’s study shows that many nurses and allied health personnel The questions related to communicable diseas- had to resign from the State Hospital in Kilis -a es indicated that the most commonly diag- neighboring province to Syria-due to the nega- nosed diseases in refugees were nosocomial tive impacts of the current situation on their infection (45.9%), viral hepatitides (42%), tuber- work environment [7]. As a matter of fact, culosis (36.1%), gastroenterititides (24.9%), regarding nurses, cases of resignation or will- leishmaniasis (12.7%), sexually transmitted dis- ingness to resign can be directly related with eases (12.2%), marsh fever (3.9%) and measles their work environment. For that matter, In-

18287 Int J Clin Exp Med 2016;9(9):18281-18290 Syrian refugees and health care in Turkey ternational Council of Nurses (ICN) specified intensive care, medicine/blood/blood produ- their theme as “Secure Environment-Secure cts and consumables. Feeling insecure at the Employment” in 2006 [31]. hospital was observed in the majority of health workers; decrease in more than the half of Another important point touched by our study health care workers’ desire to work and medi- was capacity problems and unsatisfied needs. cal vocational high school students’ desire to Participants declared that the capacity of in- be trained in the hospital were observed as tensive care (76%), the number of beds (68.3%) well. Major serious health problems found in and the capacity of medicine/blood/blood refugees were detected as gunshot wounds, products (34.8%) were insufficient. The need nosocomial infection, viral hepatitides, gastro- for consumables was stated by 41.7% of the enterititides, tuberculosis and leishmaniasis. participants to be insufficient, especially in sur- Finally; incidence of complications are more gical departments. Center for Middle Eastern frequent in refugee patients, and their need for Strategic Studies’ report in 2015 touched upon inpatient treatment, patient care and intensive this as well by stating that nearly 30-40% of the care are determined to be higher compared to total services provided in state hospitals were T.R citizen patients. directed to refugees in order to meet their needs but this resulted in capacity problems in Acknowledgements the end [32]. This research was supported by Mustafa Kemal According to the answers given by health care University hospital administration and we personnel to the open-ended question; sign- would like to thank senior consultant Prof. Dr. boards in Arabic were hung, eating places were Yunus Dogramaci for valuable contribution on arranged for patient attendants, admission unit our research. was rearranged, contact forms were prepared, refugees were given priorities, the number of Disclosure of conflict of interest beds was increased, extra beds were placed in the rooms and the intensive care unit was None. enhanced. It was aimed by making these kind of rearrangements in the university hospital to Authors’ contribution prodive convenience for refugees in terms of benefiting from health care services and to The survey was designed by Savas N, Yeniceri increase the effectivity. However, such rear- A, Inandi T. Savas N initiated the study and she rangements are also crucial in relation with the coordinated the study. The survey was applied requirements of the proper humanitarian by all researhers. The statistical analysis was health care since health and access to health- conducted by Savas N, Erdem M, Arslan E. care are basic human rights. That is why, it is Savas N wrote the manuscript. All authors essential to satisfy the requisitons and require- approved the final manuscript. ments effectively for refugees within the perspective of human rights [33]. Parkinson also Address correspondence to: Dr. Nazan Savas, De- argues in their article that she “advocates for partment of Public Health, Medical Faculty, Mustafa the incorporation of situated forms of knowl- Kemal University, Antakya, Hatay, Turkey. E-mail: edge into humanitarian healthcare practices [email protected] and the development of an understanding of References healthcare access as nested in the larger experience of everyday refugee life” [34]. [1] İÇIŞLERI BAKANLIĞI GÖÇ İDARESI GENEL Conclusion MÜDÜRLÜĞÜ; Goc.gov.tr. (2016). İçişleri Bakanlığı Göç İdaresi Genel Müdürlüğü. ��[online] Available at: http://www.goc.gov.tr/icer- After Syrian civil war and within the context of ik3/turkiye%E2%80%99de-gecici-koru- refugees major changes experienced by the ma_409_558_1097 [Accessed 22 Oct. 2015]. healthcare workers of the university hospital in [2] ÜLKEMIZE SIĞINAN SURIYE VATANDAŞLARININ Hatay were determined as the increase in work- BARINDIKLARI ÇADIRKENTLER HAKKINDA loads, extension of patient waiting time and the İNCELEME RAPORU -3- https://www.tbmm. emergence of incapacities in terms of beds, gov.tr/komisyon/insanhaklari/belge/ulke-

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