Who is (un)deserving? Differential healthcare access and the interplay between social and symbolic boundary-drawing towards Syrian refugees in Turkey

ABSTRACT

Although the degree to which social services should be extended to migrant groups by the state has occupied migration and welfare scholars’ agenda for a long time, how perceptions of deservingness on migrant groups’ social welfare entitlements can show a constraining character and rigidify boundaries have not yet received the full attention it deserves. Based on a qualitative case study with Turkish citizens in Adana, this paper explores how differential policies on healthcare access can shape insiders’ narratives on outsiders and grounds for social and symbolic boundaries; and how boundary work interacts with insiders’ perceptions of welfare deservingness. The findings indicate that, facing unequal access to healthcare, host society members define institutionalised worthiness between Turkish citizens and Syrian refugees. The mobilisation of institutional worthiness with regards to differential healthcare access, therefore, not only forges host society members’ perspectives towards Syrians, but also the degree of deservingness regarding who contributes more to the national well-being and who deserves more benefits.

KEYWORDS:

• social and symbolic boundaries
• welfare deservingness
• healthcare policies
• Syrian refugees
• Turkey

Introduction

Respondent: “How many are you in your family?”

Interviewer: “Four of us.”

Respondent: “Okay, you are four people. How would you feel if you were treated as a stepchild in your own house?”

Interviewer: “I would feel excluded.”

Respondent: “We (Turkish nationals) feel the same because, in our country, we have become just like people who are excluded in their homes. You (the president of Turkey) say ‘I will grant Syrians citizenship’. However, they (Syrians) are already more privileged than us without granting citizenship. We’re already behind them (in terms of social rights). Isn’t it true? Is there any other explanation beyond this?” (male, 57, taxi driver)

The taxi driver’s statement above echoes two important academic questions which have occupied migration and welfare scholars' agenda for a long time: To what degree should the state extend social services to migrants and how does easy access to welfare programmes affect social and symbolic boundaries between insiders and outsiders? Whilst some scholars justify migrants’ access to the welfare state by highlighting their economic contributions (Facchini and Mayda 2009), others argue that easy access imposes a financial burden on the state and leads to competition between natives and migrants (Escandell and Ceobanu 2009). How immigrants’ welfare access influences host society attitudes towards migrants has been widely studied. But how perceptions of deservingness on migrants’ social welfare entitlements can rigidify boundaries has received little attention. In recent years, the ‘welfare deservingness’ debate has led to a reconsideration of the principles that affect people’s perceptions of welfare deservingness. Therefore, asking ‘who should get what and why’ (van Oorschot 2000, 34) has a prominent role in understanding what the citizens of a given country think about allocating social rights to migrant groups. Such questions also encourage us to revisit the literature on boundary work to understand how perceptions of deservingness regarding migrant groups’ social welfare entitlements contribute to the construction of insider-outsider relationships (Bloemraad et al. 2019).

This article explores how perceptions of allocated social rights reinforce the interplay between social and symbolic boundaries towards outsiders, and how these, in turn, shape perceptions of welfare deservingness. Drawing on welfare deservingness and boundary-drawing literature, this study demonstrates how unequal access to and distribution of material and/or non-material resources (i.e. differential healthcare entitlements), framed by the state, can reinforce boundary-drawing. This forges social actors to deploy different individual evaluations and justifications at the intersubjective level even though reasoning is based upon the same institutional framework. Understanding the role of institutionally driven social differences between social groups is important because they do not only affect host society members’ perspectives towards Syrians, but also the degree of deservingness. Based on a qualitative case study with Turkish citizens in labour-intensive sectors in Adana, this article examines how (1) institutional elements (differential policies on healthcare access) can shape insiders’ narratives on outsiders and ground for social and symbolic boundaries and (2) boundary work interacts with insiders’ perceptions of welfare deservingness. Syrian refugees in Turkey are categorised as ‘outsiders’ here since Turkish citizens, attributing ‘insider’ status to themselves, portray Syrians as ‘foreigners’ regarding access to and exercise of social rights.

The article is structured as follows. I firstly bind the two different but intertwined sociological concepts – welfare deservingness and boundary work – to demonstrate how differential healthcare access can inhibit insiders’ narratives towards outsiders. Secondly, I provide an overview of the Turkish healthcare system and explain healthcare policies designed for Syrians who are under temporary protection. After discussing the methodological framework, I next present empirical data to discuss the relationship between boundaries and constructions of welfare deservingness through the eyes of Turkish nationals. To conclude, I discuss this study’s theoretical contributions.

Boundary-drawing and welfare deservingness

While the link between immigration and public attitudes toward the welfare state is not a recent phenomenon, it maintains sociological complexity because of divergent perceptions of deservingness on welfare distribution. Studies from an institutional perspective investigate the role of constructions of deservingness in policymaking (especially in the United States), showing that how beneficiaries are portrayed directly impacts policy decision-making (Ingram and Schneider 2005; Schneider and Ingram 1993). While portraying immigrant welfare beneficiaries as worthy or needy may make public support more likely (Cook and Barrett 1992), mobilising negative conceptions of immigrants, as threats, burdens, non-contributors, and morally deficient, may prevent them from gaining public assistance (Yoo 2008). Such negative conceptions can then be used to justify excluding a group of people from welfare (Horton 2004).

How immigrants are framed influences constructions of deservingness. At the intersubjective level, there is a growing literature on the perceived deservingness of beneficiaries of welfare support (van Oorschot 2000; Petersen et al. 2010; Reeskens and van Oorschot 2013). Welfare deservingness theory argues that citizens deploy five criteria, known as the CARIN criteria: control over neediness (i.e. perception of having little or no personal control over the situation of needy people), people’s attitudes (i.e. the tendency to support welfare for those who are regarded as compliant, docile or grateful), degree of reciprocity (i.e. perception of individuals’ past, present and future contributions to society), identity (i.e. the sense of belonging to the in-group), and the level of need (i.e. greatly being in need of support) (Laenen, Rossetti, and van Oorschot 2019; van Oorschot 2000; van Oorschot and Uunk 2007). Identifying the constitutive elements of deservingness criteria is as important as understanding public perceptions of deservingness since the conditions for deservingness are not uniform. People may attach importance to different principles of social benefits and services while deciding on the type of welfare provision to offer, and accordingly provide justifications why some societal groups are regarded as more deserving of welfare support than others (Laenen, Rossetti, and van Oorschot 2019).

Beyond identifying the criteria for accepting welfare redistribution, welfare deservingness research also explains why some societal groups are regarded as more deserving of welfare support than others. For example, van Oorschot (2006) shows that, across European societies, immigrants are seen as the least deserving group whereas elderly people are regarded as most deserving, followed by sick and disabled people, and the unemployed. From the perspective of welfare studies, it is unsurprising that individuals are less likely to support welfare distribution to migrant groups (see Kootstra 2016; van Der Waal, Koster, and van Oorschot 2013). What is interesting here, however, is that host societies do not completely favour denying immigrants access to social rights. Instead, they support recognition of their rights to welfare benefits as long as they meet certain conditions, such as citizenship or reciprocity, before actually benefitting. This tendency for conditional welfare distribution is common in states with both less (e.g. Czechia and Hungary) and more comprehensive welfare systems (e.g. Denmark and Finland) (Reeskens and van Oorschot 2012). Previous studies also emphasise the role of uncontrollable events in shaping deservingness frames towards migrants (Jensen and Petersen 2017; Slingenberg 2021). Citizens thus favour granting social services to those who migrate involuntarily, such as war refugees, as they are perceived to be victims of uncontrollable events. In contrast, those who are in need of social benefits because of controllable events such as unemployment, are deemed less deserving of help (Jensen and Petersen 2017).

Given the welfare deservingness literature’s current deductive approach, there remains theoretical and empirical room to explore ‘which deservingness criteria people actually apply when deciding who should get what from the welfare state, how these criteria are applied, and what they really mean to people’ (Laenen, Rossetti, and van Oorschot 2019: 193). Recent welfare deservingness scholarship, therefore, adopts a more inductive approach while addressing how and in which contexts welfare deservingness judgments are made (see Kremer 2016; Osipovič 2015; Ratzmann and Sahraoui 2021).

From a boundary-making perspective, Lamont and Molnár point to the role of symbolic sources ‘in creating, maintaining, contesting, or even dissolving institutionalized social differences’ (2002, 168). To understand the interaction between symbolic sources and social differences, it is crucial to distinguish between symbolic and social boundaries.

Symbolic boundaries refer to the evaluative distinctions made between groups of people (class, ethnoracial, religious, and gender groups […]) or through practices […]. Social boundaries refer to patterns of associations as manifested in degrees of separation and proximity between groups. (Bloemraad et al. 2019, 90)

This distinction is necessary to explain the tensions between more inclusive national membership and exclusionary social citizenship (Bloemraad et al. 2019) as symbolic boundaries are circulated intersubjectively while social boundaries manifest between groups as a form of separation (Lamont and Molnar 2002). Therefore, the role of institutions in constructing positive or negative definitions of groups requires attention. Organisational and institutional actors, like the state, provide institutional scripts through legislation, policies, and social programmes. For instance, the state can significantly contribute to legitimising systems of categorisation by extending social rights to different segments of society, which creates a legal framework defining who is more or less worthy (Ruhs 2013). Such actions can systematically disadvantage some groups, depending on the access to material and non-material resources and the recognition of social groups through laws and policies (Bloemraad et al. 2019; Lamont, Beljean, and Clair 2014). Yet, one should not forget that the state can also produce contradictory frames of deservingness through its different bodies by engaging in inclusionary/exclusionary actions. To illustrate, healthcare professionals can implement inclusive healthcare policies at the same time as other parts of the migration regime may carry out exclusionary policies, e.g. easing deportations.

Given the state’s influential role in defining groups, state policies can be powerful enough to strengthen and weaken groupness, shape everyday interactions, and trigger social inequalities. Therefore, categories created by state policies can mediate boundary work, which ‘both opens and closes opportunities and enables and constrains individuals’ life trajectories’ (Lamont, Beljean, and Clair 2014, 14). For instance, Ingram and Schneider argue that ‘laws are not just bundles of advantages or disadvantages but are also messages about who matters and who does not’ (2005, 106). The institutional and legal context, therefore, influences insider-outsider relationships and constructions of deservingness regarding the distribution of social rights. By combining the two theoretical strands, this article extends our knowledge of how state policies influence social boundaries, how this influence reinforces symbolic boundaries, and how the interplay between social and symbolic boundaries shape variations in the constructions of frames of deservingness. Focusing on differential healthcare access between Turkish citizens and Syrian refugees, I demonstrate (1) how unequal access to healthcare and its unequal distribution creates a category of institutionalised worthiness (social boundary) between Turkish citizens and Syrian refugees; (2) how this categorisation reinforces boundary work; and (3) how it shapes variations in host society members’ perceptions of welfare deservingness towards refugees.

Healthcare policies in Turkey

In Turkey, the Ministry of Health is the main public body responsible for orchestrating the healthcare system. Both public and private healthcare institutions exist. Turkish healthcare institutions are categorised as primary, secondary, and tertiary care units. Their status is determined on the basis of size, facilities, healthcare personnel, and equipment, regardless of being a private or public healthcare provider (Bilecen and Yurtseven 2017). Primary healthcare is provided by family physicians, nurses, midwifes in family practice centres, counselling centres, tuberculosis dispensaries, community health centres and migrant polyclinics (Mardin 2017). Secondary healthcare, including out – and inpatient treatments, is provided in public and private hospitals by medical specialists. And because tertiary healthcare requires specialised training and equipment, only training and research hospitals fall into this category (Bilecen and Yurtseven 2017).

In April 2008, Turkey adopted more universal healthcare provisions to establish ‘a high-quality and effective healthcare system based on equity, where, in principle, all citizens would have access to healthcare services by contributing to the financing of the services to the extent of their financial power’ (Erus et al. 2015, 100). Accordingly, the Social Insurance Institution (Sosyal Sigortalar Kurumu) for wage earners, the Retirement Fund for Civil Servants (Emekli Sandığı), and the Pension Fund for the Self Employed (Bag-Kur) were united under the Social Security Institution (SSI), which functions as a single insurance payer (Yıldırım and Yıldırım 2011). The SSI operates under the Ministry of Labour and Social Security and is responsible for implementing the General Health Insurance Scheme (GHIS) that took effect in 2012.

Thanks to this healthcare reform, the new universal coverage ensures that all individuals who legally reside in Turkey can access healthcare services. Foreign nationals seeking to obtain a Turkish residence permit must buy private health insurance but can then be covered by general health insurance once formally employed in Turkey. In contrast, the status of those under temporary protection is enacted by separate legislation which I detail below. Registration for GHIS is mandatory and dependants are automatically insured as long as they have a formally-employed family member. GHIS is financed mainly by social insurance contributions as well as state contributions and out-of-pocket payments (Erus et al. 2015). Social contributions come from employees’ gross income as employers (7.5%) and employees (5%) are required to contribute 12.5% of it (Yıldırım and Yıldırım 2011). Accordingly, employers must register their employees with the health insurance scheme, SSI, which automatically deducts the employees’ contribution from their salary. The state contributes 3% through taxation revenue, and pays premiums for individuals whose monthly income is below one-third of the gross minimum wage (Adaman and Erus 2017). Individuals who cannot afford the premiums can still access healthcare but must either pass the administrative means testing or purchase healthcare services in public hospitals (Erus et al. 2015).

The SSI also sets the out-of-pocket payment amounts for medical treatment. While primary care is free of charge to everyone in family practice centres, all citizens with or without a public health insurance are charged a contributory payment for secondary and tertiary healthcare services, except for vulnerable groups (e.g. pregnant women, veterans, and disabled people). Those covered by GHIS pay 6 TRY (0.45 USD) in public and 7 TRY (0.52 USD) in university hospitals. Uninsured individuals can still access healthcare but have to pay an examination fee of at least 35 TRY (2.62 USD) in public hospitals which does not include the medical analysis costs (SSI 2020). There are also additional charges of 10–20% for prescribed medicines if covered by the SSI. This is deducted from the monthly salaries of those who are formally employed whereas retired people, widows, and orphans are only charged 10% for prescribed medicines.

Differential healthcare access as a source of (un)deservingness and social boundaries

Although Turkey is one of the signatory countries of the 1951 Geneva Convention Relating to Status of Refugees and the 1967 Protocol, it does not grant refugee status to asylum seekers from outside Europe owing to the geographical limitation. With the 2013 Law on Foreigners and International Protection and introduction of the Temporary Protection Regulation (TPR) in 2014, all Syrians in Turkey are treated under the international temporary protection scheme and can access basic rights including health services just as Turkish citizens do (Article 27, TPR). The Ministry of Health is the main authority responsible for providing healthcare services to refugees (Alawa, Zarei, and Khoshnood 2019; Yılmaz 2019). Under its supervision, Syrians under the temporary protection regime have the right to benefit from primary health services, including family healthcare, vaccinations, mother and child healthcare, contraception, and immunisation. Emergency and primary healthcare services, including treatments and medication, are free of charge (Article 27/b, TPR). Syrians can also access secondary and tertiary health services in public, research, and university hospitals if referred to a specialist by a primary care provider (Alawa, Zarei, and Khoshnood 2019; Mardin 2017). The three main healthcare services in public hospitals are polyclinics, emergency, and inpatient care. Patients must book an appointment for polyclinic services and pay an additional contribution fee, determined by the SSI for the beneficiaries of GHIS. Since 2018, in accordance with protocols that set an annual fixed lump sum price agreed by the Ministry of Health, the Presidency of Migration Management (PMM)¹ pays the contribution fee, which was previously paid by the Prime Ministry Disaster and Emergency Management Authority (AFAD), for Syrians with temporary protection status (Ministry of Health 2018; Yılmaz 2019).

Following negotiations between Turkey and the EU in late 2016, the Ministry of Health established Migrant Health Centres in areas heavily populated by Syrians. These centres, funded by the EU and coordinated by the Ministry of Health, are responsible for providing primary care services to Syrian refugees with the aim of overcoming language and cultural barriers and reducing pressure on Turkey’s public health facilities (Ministry of Health 2020). In December 2019, the TPR was amended in relation to healthcare services. The statement that the ‘Patient contribution fee shall not be collected for primary and emergency health services and the respective treatment and medication’ (TPR, Article 27/b) was replaced by ‘The contribution fee can be applied for primary and emergency health services and the respective treatment and medication determined by the Ministry’ (Resmi Gazete 2019). This implies that, depending on their financial means, beneficiaries of the GHIS might be required to make co-payments for treatment and medications at the point of service.

Yet, ‘guaranteeing full access to the healthcare services through regulations does not necessarily indicate equity in access due to the practical challenges in Turkey’ (Bilecen and Yurtseven 2017, 119) since Syrians continue to encounter problems in access to healthcare in the course of everyday life. For instance, only those with a valid identity card can access healthcare services. Those who are not registered with Turkish authorities or fail to comply with changes regarding their identity cards cannot benefit from healthcare services (Rottmann 2020). Another challenge is the language barrier. Lack of language proficiency and translators causes difficulties while making appointments or receiving medical treatment (Bilecen and Yurtseven 2017). Kaya (2020) notes that local transportation is another obstacle in accessing healthcare owing to the size of cities such as Ankara, Istanbul and Izmir. Cultural barriers may also limit access to healthcare. Some Syrian women refuse treatment by male doctors, but finding female doctors is not always possible (Rottmann 2020).

Acknowledging Turkey’s efforts to provide Syrian refugees with fundamental services like healthcare, one should not ignore the other side of the picture, which is that Turkey’s contribution-based health coverage leads to differential treatment between Turkish citizens and Syrians refugees regarding access to healthcare services. Currently, 30.60% of working age Turkish citizens are not registered with the SSI² (SSI 2020), which means they must pay premiums out of their own pocket. Indeed, approximately 10 million of them have failed to pay their premiums (BirGün 2021). If those owing payments to the SSI cannot pay back their debt or be means-tested by December 2022, they will no longer be able to access to healthcare services in either public or university hospitals (Resmi Gazete 2022). This situation creates a difference between registered Syrians, whose contribution fees are fully covered by the PMM, allowing them to benefit freely from secondary and tertiary healthcare services, and Turkish citizens who cannot because they are not registered with SSI. This differential access to healthcare between Syrian refugees and Turkish citizens creates two issues: (1) Turkish citizens with health insurance are obliged to pay a contribution fee to access polyclinic services in public hospitals whereas Syrians do not; (2) general health insurance automatically covers Syrians under temporary protection while Turkish citizens who are neither formally employed nor meet the income threshold for exemption have to pay their own premiums. Due to both (1) and (2), premiums and co-payments are an issue for Turkish citizens but – at least officially – not for Syrians under temporary protection. Differential healthcare access, thus, triggers discontent among Turkish citizens and provides the basis for social boundaries they draw vis-a-vis Syrians. But despite wide displeasure due to differential healthcare access, interviewees varied in how much they saw Syrians as (un)deserving of healthcare support.

Methodology

This qualitative-driven study reports the findings of 47 semi-structured in-depth interviews and three naturally occurring focus groups³ with Turkish citizens from different ethnic and religious backgrounds working, as employer or employee, in labour-intensive economic sectors. Adana was selected as a research site for this study due to the city’s large number of Syrians, high informal economy rate, and heterogenous demography.

Adana, 221 km away from the border with Syria, is located in the Eastern Mediterranean part of Turkey (see Figure 1). Like many provinces in Turkey, Adana, with a population of 2.237.940 (PMM 2022), is inhabited by individuals with diverse ethno-cultural and ethno-religious backgrounds. It hosts significant numbers of internal migrants, mostly Kurds coming for seasonal work from Turkey’s South-East, as well as local people such as Turks, Arabs, and Roma people (TUIK 2020). Migration is therefore not new to the city but its patterns have changed in recent years due to the Syrian refugee inflows. Adana province hosts the fifth-highest number of Syrian refugees in Turkey. As of March 2022, the province is home to 256.196 registered Syrians which accounts for 11.32% of the local population (PMM 2022). Beyond its geographical proximity to Syria, numerous job opportunities, are one of the reasons why Syrians are attracted to the city.

Figure 1. Location of Adana Province in Turkey.

I conducted all interviews and focus groups face-to-face between November 2017 and June 2018, these lasted from twenty minutes to two hours. 37 interviews and two focus groups were recorded on tape whereas I took notes for ten interviews and one focus group since some interviewees were unwilling to be recorded. I also made ethnographic observations in the first month after arriving in Adana to identify neighbourhoods and occupational categories that were mostly populated by Syrians. Then, I began to contact potential Turkish employers and employees who might be interested in being interviewed through gatekeepers, snowballing and introducing myself to potential respondents during ethnographic field visits. I shall note that being a native speaker and Turkish citizen facilitated both access to the field and conducting more fluid and deeper interviews.

Regarding the participants’ profile, all came from labour-intensive occupational categories such as agriculture, textile, construction, and manufacturing. These not only provide job opportunities to Syrian refugees, but also exhibit high rates of informal market economy which, for working age Turkish citizens, stood at 38% in Adana-Mersin region in 2020 (SSI 2020). This is crucial to understand the role of the structural dynamics of Adana’s labour market in shaping deservingness frames, especially as ten employers (out of 30) stated that they struggled with paying their and their employees’ social security taxes and four employees’ social security taxes (out of 17) were not paid by their employers, meaning they were informally employed and had to pay premiums out of their own pocket (if they can afford). These occupational categories are mostly dominated by male employers and employees, the sample is thus gender-imbalanced (39 male and 8 female). Interviewees’ aged ranged between their early 20s and early 70s (at the time of the interview). Considering their education profile, only 4 interviewees graduated from university while the remaining held either high school or primary/secondary education degrees.

As this article is one output of a wider research project, interview questions are not formulated to specifically reveal links between healthcare deservingness and boundary-making, but rather to uncover varying forms of boundary-drawing towards Syrians in everyday informal work life (i.e. taking part in unregistered employment as either employer or employee). Therefore, interviews consist of multiple sets of questions, including but not limited to participants’ self-presentation, profession and economic activity, work experiences and interactions with Syrians, and insights into participants’ understanding of culture, citizenship, and nationhood in relation to the presence of Syrians in Turkey. The core findings of this article derive from the interview questions focusing on how ordinary citizens of Turkey perceive and interpret the Turkish Government’s policies towards Syrian nationals who are under temporary protection. These questions probed interviewees’ knowledge and thoughts about rights granted to Syrian refugees such as access to healthcare services or education and their feelings about sharing public spaces with Syrians. There was thus no exclusive focus on access to healthcare services while asking interviewees’ views on the social rights granted to Syrian refugees in Turkey. On the contrary, 32 of the 47 respondents and the participants of two focus groups themselves chose to highlight healthcare-related factors as the core of their boundary-drawing among others without asking any probing questions. This already hints at how unequal access to and distribution of (im-) material resources can take priority over the course of ordinary citizens everyday life.

Ethical approval of research involving human participants was obtained from the university with which I was affiliated before commencing fieldwork in order to ensure the protection of all human subjects who directly or indirectly took part in this research project. Given the possibility that the recent political atmosphere in Turkey, where citizens may hesitate to explicitly share their views on sensitive topics, might have discouraged participants to be interviewed, the informed consent of each interviewee, guaranteeing anonymity and confidentiality, was taken orally, not in writing, before interviews began. As for naturally occurring focus groups, I had to follow a different strategy for obtaining informed consent. While I was conducting an interview with interested respondents, their next-door neighbours (owners of other shops or workplaces), customers and colleagues spontaneously showed up. Every time a new person came in, I had to explain the aim of the research, the interview, and the presence of a recording device and to seek their consent to be recorded while this was already happening.

All interviews were fully transcribed, systematically coded, and analysed using NVivo 12. I adopted an inductive analytical approach to find out local community members’ multiple forms of boundary-drawing towards ‘outsiders’, focusing on the role of differential policies in creating social differences between groups, reinforcing boundary-drawing, and shaping variations in perceptions of welfare deservingness.

The constructions of (Un)deservingness

As the most influential institutional actor, the state can affect ‘the macro patterns of distribution of material and non-material resources, and the recognition of diverse social groups’ by establishing institutional frameworks through legislations and social programmes (Lamont, Beljean, and Clair 2014, 13). Such institutional frameworks can determine varying degrees of groupness while institutionalised worthiness shapes people’s narratives, and, in turn, informs their perceptions of deservingness. While the views on (un)conditionality of welfare distribution and perceptions of deservingness are interconnected, the way such views are framed can be distinct and layered. Individuals tend to develop different deservingness frames and apply distinct principles and norms of deservingness depending on which groups they refer to, especially regarding immigrants (see Kootstra 2016; van Der Waal, Koster, and van Oorschot 2013). Host societies can even apply different principles and norms to the same social group. What makes Turkish citizens deserve more and Syrians less or vice versa? How does differential healthcare access inform boundaries between Turkish citizens and Syrian refugees? Equally important, how do boundaries contribute to framing varying levels of welfare deservingness? The findings indicate that, facing unequal access to healthcare, host society members define institutionalised worthiness between Turkish citizens and Syrian refugees. The mobilisation of institutional worthiness with regards to differential healthcare access, therefore, not only forges host society members’ perspectives towards Syrians, but also the degree of deservingness regarding who contributes more to the national well-being and who deserves more benefits. Accordingly, the respondents make deservingness judgements in three distinct discourses: unworthiness, reservations against preferential treatment, and universalism. The ‘unworthiness’ discourse was widely discussed in reference to being an insider on the basis of citizenship and the extent to which one, as insider, contributes to national well-being. This automatically makes Syrians as less deserving in the eyes of the respondents. The second discourse-related criterion, ‘reservations against preferential treatment’, was emphasised regarding Turkish citizens’ and Syrian refugees’ unequal access to healthcare. Even though Syrians are viewed as unbelonging in both discourses, the emphasis, in the second discourse, was not the prioritisation of Turkish citizens in healthcare as in the first discourse, but the objection to differential treatment which privileges Syrian refugees over Turkish citizens. The last discourse, ‘universalism’, was reflected in the call to make access to healthcare equal for all as it is a basic human right. In interviewees’ opinions of the Turkish government’s healthcare policies towards Syrians, the dominant discourse concerned ‘reservations against preferential treatment’. However, although differential healthcare access made interviewees feel that ‘Syrians are more privileged than Turkish citizens’, perceptions of ‘deservingness’ varied widely from fully deserving to less deserving. Such divergent perceptions of differential healthcare access among respondents are driven by those who view Syrians as outsiders or less worthy also being the ones who are more disturbed by Syrians’ preferential access to healthcare. That is, the state’s differential healthcare access policy towards Syrian refugees creates a social boundary, what I call institutional worthiness, which goes hand in hand with further stigmatisations of Syrians in the context of healthcare deservingness. Thus, the intersubjective circulation of both social and symbolic boundaries as espoused by interviewees affects their perceived degree of deservingness and informs divergent welfare perceptions.

‘Unworthiness’ as grounds for becoming less deserving

In this part, I pay particular attention to how the link between unbelonging and unworthiness creates a less deserving discourse from the perspective of Turkish citizens as Syrians are not seen a part of the established group. Thus, 16 interviewees (out of 47) claimed that ‘Turkish citizens shall be prioritized’ regarding access to healthcare benefits since they regard themselves as ‘legitimate owners of the state and territory who should have the right to a privileged seat in the theatre of society’ (Wimmer 1997, 30). They justified this view by referring to their insider position and their contributions to Turkish society in reference to their citizenship. For some respondents, the question ‘Are you one of us?’ (van Oorschot 2000, 38) is the main deservingness criterion. From both a welfare deservingness and boundary work perspective, this question is important as it marks the role of, first, identity and, second, reciprocity. Identity signals ‘people perceived as belonging to one’s in-group being deemed more deserving’, while reciprocity implies that ‘those perceived to have made higher contributions to society in the past, or who will do so in the present or future, are deemed to be more deserving of social welfare’ (Laenen, Rossetti, and van Oorschot 2019, 192). My data indicates that identity and reciprocity are closely intertwined, given how much Turkish citizens feel they have contributed to the country through their hard work and regular tax payments. Some respondents deploy their intertwined appearance as a fundamental condition of belonging to Turkish society. It is also where boundary work intervenes: their understanding of worthiness for welfare services is associated with hard work and regular tax payments as a duty of citizenship, which simultaneously signals who is an insider or not, and who deserves public assistance. Therefore, some respondents took a very reserved approach to Syrians’ access to healthcare, seeing them as unbelonging to Turkish society and hence less deserving of welfare benefits (see Sahraoui 2021 for a similar argument in the case of undocumented pregnant women in Mayotte). Respondent 1, a farmer who is in debt to the SSI, exemplifies this attitude:

Interviewer: “What does it mean for you that Syrians are entitled to the same rights as Turkish citizens?”

Respondent 1 (male, 52) “It means my rights fall by half.”

Interviewer: “Do you know what kinds of rights Syrians can benefit from in Turkey?”

Respondent 1: “I do not really know but they are prioritized in healthcare.”

Interviewer: “How would you feel when you share common spaces such as hospitals?”

Respondent 1: “To me, it means an upstart has come in and tries to oust the old-timers. Turkish citizens should be prioritized.”

According to Respondent 1, Syrians are ‘foreigners’ who have recently arrived and are trying to take Turkish citizens’ place. What is interesting here is that one of the employees on his farm at the time was a Syrian. He appreciated Syrians’ presence in the job market to overcome labour shortages in his economic sector. Nevertheless, he saw them as outsiders who do not belong to the national majority regarding access to certain welfare services in Turkey. He explicitly showed his reluctance to Syrians’ accessing healthcare services and sharing hospitals with them. He engaged in boundary-drawing by associating himself with the established group, defined by citizenship intertwined with national identity in his understanding. And because Syrians are not part of this group, his construction of deservingness means that Turkish citizens access to healthcare should be prioritised over theirs.

Respondent 22 (male, 47, metal products shop owner/ pawnbroker, with social health insurance) also emphasises that he feels like a second-class citizen in his own country as a result of differential healthcare access favouring Syrian refugees. This also gives rise to the imposition of symbolic ideas regarding Syrians (e.g. free healthcare means more Syrian-born babies):

(S)he goes to the hospital and does not pay the fee as if they are first-class citizens. But when we go, you pay for the examination fee. You wait your turn. You pay for medicine. Like a slave! And if you do not have insurance, you are charged more! Especially if you are not insured … But they (Syrians) are special, they go to hospitals, they receive treatment. As they suffer torment, they will make a baby every year … So, you have escaped the war and you have come here. When you go out, if one hundred women pass by, eighty of them are pregnant. I mean speaking of Syrians. Do you think they can have children if they do not find all this comfort?

Respondent 22 not only emphasises that differential healthcare access creates inequality between Syrians and Turkish citizens but also that such policies enable Syrians to live a comfortable life. This allows them to have children in Turkey despite escaping the war in Syria. His disagreement with the government’s healthcare policies towards Syrians is accompanied by concerns about the increasing number of Syrian babies in Turkey. He used boundary-making to mobilise a less deserving discourse in two ways: having children should not be the primary concern of those who have fled from a war because it is a privilege, not a right in this context; and Syrians’ free access to healthcare services creates the perception that they would not have children so readily if they had to pay for healthcare services.

Another interviewee, who works as janitor, cynically approached differential healthcare access by sharing his personal queueing experience in the hospital:

Respondent 36 (male, 27, with social health insurance):

The state gives them money, does not tax them (Syrians), pays their social insurance taxes … I even myself want to be a Syrian in this country (cynical laugh). Priority is given to Syrians in hospitals. My wife was pregnant. I took her to the hospital. She forgot her identity card. Even though she knew her ID number, they did not accept her. I was looking around and saw three Syrians. They took them directly. You do not treat me in this way although I am your citizen, I am the one who pays you taxes but you prioritize Syrians!

Like other interviewees, Respondent 36 primarily argued that citizenship obliges him to fulfil citizen responsibilities like paying taxes regularly. He views paying taxes not only as his civic duty to the state, but also his investment in his country. However, he did not think his contributions have been reciprocated enough given the rights granted to Syrians:

They can have some rights; I would not mind. My concern is that they are granted more rights than we have. For example, my people (Turkish citizens) who are poor and sleep on the streets cannot receive a salary from the state; they (Syrians) receive it. They receive money from the state and then they beg as well. They are not charged for medicines and hospital expenses. Now I will give you an example: X person is very poor. He does not work, and he has a disability. This person goes to the hospital and gives money. When this person goes to a pharmacy, he pays for medicine. No income, nothing �� He is unable to work and homeless. I mean Syrians are really more advantaged than us in terms of rights!

Giving the example of an unemployed, homeless, disabled Turkish citizen, Respondent 36 deploys both identity and neediness discourses to justify why Syrians should be less eligible for welfare benefits because they are not insiders, resulting in ‘an underlying battle over whose presence is legitimate and who is deemed deserving of healthcare’ (Sahraoui 2021, 480). This makes Syrians less worthy than an average Turkish citizen in terms of accessing welfare provision. These interviewees’ views on prioritising needy people who belong to Turkish society also supports van Oorschot’s claim that individuals tend to support welfare distribution to needy people if they belong to ‘us’ (2000). As the comments show, Syrians are viewed as less deserving despite being in need. The interviewees’ main narrative, regarding access to healthcare services is that less is demanded from Syrians than from Turkish citizens since they consider that their citizenship status should advantage, not disadvantage them. Therefore, they not only question who matters and who does not in the eyes of the state but also introduce justification logics for why Turkish citizens should matter more than Syrian refugees.

Reservations against ‘preferential treatment’

Unequal access to healthcare services leads to different degrees of deservingness in the eyes of Turkish citizens. Thus, interviewees vary in how they view Syrians’ access to healthcare services, engage with the deservingness frame, and develop reservations against ‘preferential treatment’, which was the most frequently used narrative. In contrast to the interviews discussed above, the deservingness consideration is not determined by the extent to which ‘Syrians are one of us’, but by ‘why differential treatment is the case’. 19 interviewees claim that Turkish citizens are treated differently than Syrian refugees in their access to healthcare. The interviewees feel excluded due to two issues: contribution payments for healthcare and prioritisation in healthcare centres.

Turkish citizens are required to make co-payments for healthcare whereas the PMM covers Syrians’ contribution and prescribed medicine fees. This fuels these respondents’ perception of injustice towards Syrians:

Why doesn’t the state charge them? Also, why don’t they pay for medicines whereas I have to? Aren’t I a citizen of this country? I am required to pay taxes but they (Syrians) no! Medicine is free for them. On the contrary, I am charged for the examination fee to be able to buy medicine. The value of medicine is 5 Turkish liras, but it becomes 50 Turkish liras together with the examination fee, for instance. (Focus group with minibus drivers)

These concerns over Syrians’ preferential conditions of accessing healthcare indicate that the Turkish state’s current healthcare policies make these respondents feel ignored. Such feelings also constrain their narratives about Syrians to focus on being a burden on Turkish institutions and threatening the social order and national belonging. Differential healthcare policies operated at the state level thus not only influence how people perform boundary work but also affect its importance for broader conceptual distinctions.

The second issue regarding perceptions of preferential treatment is the prioritisation of Syrians’ treatment in hospitals. Some respondents claimed that Syrian patients are prioritised in the waiting queues in family practice centres and public hospitals. However, this claim does not reflect reality. Although there is no prioritisation policy (Ministry of Health 2020),⁴ some reported experiencing such differential treatment, which encourages more reserved attitudes towards Syrians. Respondent 35 (female, 40, cleaner, with social health insurance) offers a particularly representative comment:

Of course, when you go to hospital, priority is given to them (Syrians). I witnessed something, where was it? Ah, I went to hospital with my sister-in-law to see a gynaecologist. For example, they did not queue with us there. There was a separate unit upstairs, only for Syrians. They even had such privileges. All people there were talking about how important Syrians are. What I want to say is why that much discrimination?

Even though there is no prioritisation policy in waiting queues between Turkish and Syrian nationals, the interviewee claimed that Syrians were prioritised in the hospital she went to. It is possible that the Syrian she encountered in the same hospital could fall into the exceptional patient category owing to age, physical disability or so, but she probably misinterpreted this situation and chose to generalise this experience. The respondent's concern is thus not whether Syrians should be entitled to healthcare services but about a differential healthcare access that has created unequal access to and distribution of healthcare services between citizens and Syrian refugees:

If there was no discrimination, we would not mind. There should be equality. I mean, I get sick, they (a Syrian) may get sick as well, but they have to wait for their turn, just as I wait even though I suffer because there are some occasions when people may die due to severe heavy pain. But nobody wants to give their place to anybody. But when Syrians come, they can let them in. It’s everywhere.

With the queueing example even though it does not reflect the reality, she also touched on her understanding of social order in public hospitals. From her perspective, there are unwritten, culturally accepted procedures that everyone has to follow in public hospitals, such as waiting your turn. However, what she witnessed in some public hospitals challenged her understanding of what she was accustomed to so far, which she interpreted as a threat to the existing social order. Unsurprisingly, such experiences are coupled with the notion that Syrians gain healthcare opportunities that are not provided to Turkish citizens, which influences the construction of deservingness frames. In particular, the interviewees believe that Syrians are advantaged because they face fewer requirements than Turkish citizens to access healthcare. The current healthcare policy appears to favour Syrians while inconveniencing Turkish citizens:

Respondent 43 (male, 23, metal factory worker, with social health insurance):

If something happened here, I would go to a different country, so the same rights will be granted to me as well. The problem is that here, Syrians are put first. However, you should not behave unjustly toward this country’s citizens. The state does not really care about it. Since Syrians are war immigrants, there is such a right. I do not know if it is because of international law or the United Nations … If it is an international right and if such rights are granted in other countries as well, then such rights should be allocated. However, this country’s citizens should not be treated unjustly, in hospitals or somewhere else.

Previous studies demonstrate that ambivalent healthcare policies can fuel citizens’ resentment towards migrants (Sahraoui 2021). That current healthcare policy treats Syrians preferentially, as argued by the respondents, also deepens the sense of groupness in their daily lives. How respondents apply the deservingness frame is closely related to such differential healthcare access because the healthcare policy’s structure and content seems their main concern rather than the right to healthcare itself. Because the PMM pays Syrians’ hospital contribution fees, the Turkish state has created an inclusive environment for registered Syrians in line with universal human rights, whereas Turkish citizens feel excluded because their citizenship cannot guarantee access to healthcare services. This creates a feeling of ‘otherness’ among Turkish citizens which, in turn, is coupled with subjective evaluations of Syrian refugees. This lets Turkish citizens stigmatise everyday encounters in hospitals (e.g. Syrians may be prioritised in hospitals due to the regular medical priority, not nationality). Such narratives play a crucial role in rationalising constructions of deservingness.

‘Universalism’ as grounds for unconditional deservingness

When asked about policies concerning Syrians’ access to healthcare services in Turkey, six respondents (out of 47) mentioned its universal aspect since healthcare is considered a fundamental human need. For them, the right to access healthcare services is not shaped by host society members’ preferences. Rather, healthcare is viewed as a basic human right that everyone should be able to exercise regardless of their nationality, race, and/or ethnicity. Here, the deservingness framework has a different discourse whereby providing healthcare services to Syrians is regarded as a moral issue. Respondent 8 (male, 30, barber shop owner, without social health insurance) stated his position clearly:

Interviewer: “Do you know what kinds of rights Syrians benefit from in Turkey?”

Respondent 8: “For example?”

Interviewer: “Healthcare?”

Respondent 8: “You have to provide them with healthcare services. Likewise, education … These are good things. I do not have any issues with such policies.”

Respondent 8 considers both healthcare and education as necessary services catering to Syrians’ basic needs in Turkey. Such welfare policies should therefore aim at treating citizens and non-citizens equally because education and healthcare are fundamental human rights. In a similar manner, Respondent 16 (male, 50, with social health insurance), who owns a construction company that employs both Turkish and Syrian nationals, took a strongly moral approach when asked about Syrians’ access to healthcare in Turkey:

He (a Syrian) is sick. You cannot say anything about this. This is a humanitarian situation. So, I am not against this. As I say, you have to look at the situation from the point of view that they are first of all human beings, then you can take care of loose cannon people among them, but firstly they are human.

While discussing the universal aspect of the right to healthcare, Respondent 16 also distinguishes between good and bad Syrians. However, this does not mean that treatment should depend on personality qualities. Rather, he emphasises that, regardless of personal traits, Syrians should be treated equally in terms of healthcare since health is a basic human need. According to Respondent 16, one can debate whether a Syrian’s personality should be a determining factor regarding their stay in Turkey only after their basic needs have been met.

For these respondents, moral considerations and universal values go hand in hand to guide their evaluation of the Turkish state’s healthcare policies towards Syrians. Instead of having reservations against preferential treatment, they interpret the healthcare policies implemented for Syrians under temporary protection as a guarantee of access to healthcare services in Turkey. The mere condition of being human is sufficient justification to narrate these Syrians as a group ‘worthy’ of access to healthcare. The respondents also show us that the deservingness frame can be deployed unconditionally, especially when individuals are driven by the idea that healthcare is indispensable and should be provided equally regardless of citizenship status.

Conclusion

This article elucidates the importance of institutional frameworks in the emergence of social boundaries and the role of social boundaries in triggering symbolic boundaries and in shaping the perceived deservingness of access to healthcare. This single-case study of Adana has sought to answer how differential healthcare access creates social differences between Turkish citizens and Syrian nationals and how these social differences forge not only host society members’ perspectives towards Syrians but also Syrians’ and their own perceived degree of healthcare deservingness. The differential treatment in healthcare leads to a form of separation between Syrians and Turkish citizens which deepens when individuals are exposed to its practical consequences in their daily life (e.g. paying contribution fees). This separation rigidifies social boundaries and becomes coupled with further narratives regarding Syrian refugees, such as cutting the queue for healthcare, not contributing to society, and threatening the social fabric, which results in varied perceptions of welfare deservingness.

The analysis indicates that respondents make deservingness judgements in three different discourses: unworthiness, reservations against preferential treatment, and universalism. In the unworthiness discourse, respondents utilise their insider positionality to justify their welfare preference for Turkish citizens over less-deserving Syrian refugees. References to identity and reciprocity are intertwined with a sense of insider positionality and insiders’ past contributions to society. This not only tells us what welfare deservingness criteria are applied but also how they are utilised to justify excluding Syrian refugees from healthcare. Therefore, those who are against Syrians being treated as belonging to regular society also object to their entitlement to welfare provision. In the preferential treatment discourse, respondents emphasise the fact that Turkish citizens and Syrians do not have the same access conditions to healthcare services. This creates demands of conditional deservingness, in which respondents criticise the preferential treatment of Syrians, both because of their insufficient contribution to Turkish society, and because Turkish citizens face stricter conditions in accessing healthcare. Such unequal treatment sharpens groupness because the state’s preferential treatment makes Turkish citizens feel excluded. In the universalism discourse, the right to healthcare is constructed on the basis of being human rather than any insider position. As Syrians are seen both as refugees in need and human beings with dignity, respondents interpret their preferential access to healthcare as a necessity. Importantly, these varying conceptions of deservingness do not originate solely in the state’s differential healthcare policies towards Syrian refugees, although it is clear that these policies increase groupness. Instead, these conceptions are further linked with how Turkish citizens assign worthiness to themselves and Syrian refugees. Specifically, common narratives, informing who is contributing more to national well-being and who deserves more benefits, support and rationalise citizens’ constructions of deservingness.

This article makes three contributions. First, it documents how differential policies on healthcare access create a category of institutionalised worthiness between Turkish citizens and Syrian refugees which reinforces boundary work and how the interplay between social and symbolic boundaries shapes citizens’ perceived deservingness of healthcare towards Syrian refugees. Even if a social boundary derives from the same reason (i.e. differential healthcare access), social actors can engage in different constructions of deservingness frames. Second, welfare deservingness scholarship demonstrates that those who are forcibly displaced are seen as more deserving of help since they cannot be blamed for their fate (Jensen and Petersen 2017). However, this study shows that even victims of uncontrollable events are not always perceived as fully deserving by host society members. Third, existing studies on the perceived deservingness of beneficiaries of welfare support (van Oorschot 2000; Petersen et al. 2010; Reeskens and van Oorschot 2013) still leave empirical room to explore ‘how and in which context welfare deservingness judgements are made’ (Kremer 2016; Laenen, Rossetti, and van Oorschot 2019; Osipovič 2015). Addressing this gap, this article qualitatively extends our knowledge regarding how, in the context of a new immigration country, citizens conceptualise refugees’ (un)deservingness to healthcare benefits. Institutionalised worthiness derives from the differential healthcare access which drives the respondents to question who is worthier in the eyes of the state and, in turn, forges the social boundary. Self-worth appears as a differentiation strategy which enables host society members to make their deservingness judgements depending on the lens through which they approach Syrian refugees’ healthcare entitlements in Turkey.

Acknowledgements

I am deeply grateful to the field supervisor, İlke Şanlıer Yüksel, and supervisors, Renee Luthra and Yasemin Soysal for their mentorship and persistent support. I also specially thank to Johanna Römer, Marius Mehrl and Nando Sigona for their insightful comments on earlier versions of this article. I further thank the two anonymous peer reviewers for their rigorous feedback.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 In October 2021, the name of the institution was changed from Directorate General of Migration Management (DGMM) to the Presidency of Migration Management (PMM).

2 The percentage of informal employment ranged between 33.42% and 42.05% in 2011–2019.

3 Focus groups in naturally occurring setting are defined as ‘places where people would gather whether or not a focus group was taking place’ (Brown 2015, 86–87). They take place spontaneously, especially in public and semi-public social settings such as schools, workplace, and individuals’ homes, which enables others to easily join the conversation.

4 Syrians as well as Turkish patients are prioritized in hospitals when they qualify for the exceptional category, due to being older than 65, younger than 7, disabled, pregnant, an emergency, etc.