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employability of refugee Syrian health-care

professionals in Turkey

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Abstract

This field assessment of factors affecting the employability of Syrian health professionals included 101 employed or unemployed Syrian doctors and nurses from five migrant health training centres in Ankara, Gaziantep, Hatay, Istanbul and Şanlıurfa. Of these, 53 (52.5%) were currently employed by the SIHHAT project and 48 (47.5%) were not. Semi- structured interviews were used to collect data between 11 and 22 February 2019. Most employed interviewees had been delighted to find a job in their chosen profession and were happy with their working conditions. Despite daily challenges related to family settlement, children’s education and keeping in touch with relatives abroad, most were highly satisfied with the relative stability, peace and security of life in Turkey. In contrast, unemployed interviewees were disappointed with the lack of job opportunities and uncertain about their future prospects. Many relied on family support, savings, part-time jobs and odd jobs. The main concerns were cultural barriers, long working hours, high workloads, lack of vacation time, the employment of specialist physicians as general practitioners, higher living costs in larger cities and distance from the Syrian Arab Republic.

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Photo coverpage: © SIHHAT Design and layout: 4PLUS4.dk Document number:

WHO/EURO:2021-2409-42164-58097

Keywords

SYRIAN ARAB REPUBLIC SYRIAN DOCTORS HEALTH CARE NURSES EMPLOYMENT REFUGEE

REFUGEE HEALTH

REFUGEE HEALTH SERVICES TURKEY

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employability of refugee Syrian health-care

professionals in Turkey

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Contents

Preface ... iv

Acknowledgements ... v

Abbreviations ... v

Executive summary ... vi

Background ... 1

Objective ... 1

Methods ... 2

Results and discussion ... 3

Current status and working conditions of Syrian health-care professionals ... 3

Challenges to employability for Syrian health-care professionals ... 4

Recommendations to improve the employability of Syrian health-care professionals ... 5

Conclusions ... 7

References ... 8

Annex 1. Interview questions for employed Syrian health-care professionals ... 9

Annex 2. Interview questions for unemployed Syrian health-care professionals ... 10

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iv

Preface

The conflict in the Syrian Arab Republic has caused one of the world’s largest and most dynamic displacement crises, affecting millions of lives. WHO is supporting the response to the crisis through its operations in Turkey, which comprise a cross-border response from the field office in Gaziantep and a health response to refugees in Turkey, coordinated by the WHO Country Office in Ankara. In north-western Syrian Arab Republic, WHO is implementing interventions such as the delivery of vital medicines and medical supplies and providing support for the operational costs of health facilities and capacity-building of health staff. Through the Refugee Health Programme in Turkey, efforts have been made to strengthen the national health system through integrating Syrian health workers and translators, building capacity for mental health care, providing linguistic and culturally sensitive health services, and supporting home care for older refugees and those with disabilities.

Activities of the Programme are defined within the scope of the Regional Refugee and Resilience Plan 2018–2019, a broad partnership platform for over 270 development and humanitarian partners to provide coordinated support in countries bordering the Syrian Arab Republic that are heavily impacted by the influx of refugees. This platform capitalizes on the knowledge, capacities and resources of humanitarian and development actors to provide a single strategic, multisectoral and resilience-based response. Supported by several donors, WHO’s activities are complementary to the Ministry of Health-implemented SIHHAT

(Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities) project that is funded by the European Union (EU). This project operates under the EU Facility for Refugees in Turkey and focuses on strengthening the provision of primary and secondary health-care services to Syrian refugees, building and supporting a network of migrant health centres across the country, and employing additional health personnel, including Syrian doctors and nurses.

In November 2018 the Refugee Health Programme conducted the Workshop on Refugee and Migrant Health in Turkey: Survey and Research Consultation to identify gaps in the information and evidence required for Programme development and adaptation and for informing policies on migrant health in Turkey. The Workshop brought together more than 57 national and international experts from academia, the Ministry of Health, United Nations agencies and WHO collaborating centres and led to the formulation of the Programme’s research framework. Within this framework, a series of studies was implemented in the fields of mental health, health literacy, women and child health, health workforce, and noncommunicable diseases. This study, Factors affecting the employability of refugee Syrian health-care professionals in Turkey, is one of the studies implemented within the Refugee Health Programme’s research framework. It was implemented within the scope of the Improved access to health services for Syrian refugees in Turkey project with funding from the EU Regional Trust Fund in Response to the Syrian Crisis.

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Acknowledgements

Dr Omur Cinar Elci of the Refugee Health Programme, WHO Country Office in Turkey, designed the study, directed the interviews and authored the report. Special thanks go to Ms Habibe Özdemir of the Migration Health Department of the General Directorate of Public Health, Ministry of Health, and Ms Elif Goksu of the Refugee Health Programme, WHO Country Office in Turkey, for their role in coordinating and implementing the field work.

Members of the WHO Refugee Health Programme team contributed to the preparation of the report. Details of the research plan and the final report were reviewed and approved by the Migration Health Department of the General Directorate of Public Health, Ministry of Health.

Abbreviations

EU European Union MHC migrant health centre MHTC migrant health training centre

SIHHAT Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities (project)

This document was produced with the financial assistance of the European Union.

The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

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vi

Executive summary

Since 2011, Turkey has hosted increasing numbers of Syrian refugees. The current total of 3.6 million represents the largest number of refugees hosted by a single country since the Second World War. The country has shown exemplary openness and made considerable efforts to support Syrians, despite the strain on its social services.

Health service provision for refugees is provided through the comprehensive Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities (SIHHAT) project, funded by the EU. The project employs eligible Syrian health-care workers in primary health-care settings after they complete the WHO adaptation training programme. In December 2018 93.3% of WHO-trained support staff, 95.1% of nurses and 76.7% of trained Syrian doctors were employed through the SIHHAT project in Turkey. However, factors such as previous professional experience, residence, gender, family settlement, cost of living, refugee status affect the employability of Syrian health-care workers.

The WHO Country Office in Turkey conducted a field assessment to better understand the core obstacles and contextual barriers to the employability of Syrian health-care professionals.

The field assessment included 101 Syrian doctors and nurses who had completed adaptation training (and had or had not been employed in the SIHHAT project) from five of the seven migrant health training centres (MHTCs) in Ankara, Gaziantep, Hatay, Istanbul and Şanlıurfa). Of these, 53 (52.5%) were currently employed by the SIHHAT project and 48 (47.5%) were not. In collaboration with the Department of Migration Health of the General Directorate of Public Health, Ministry of Health, data were collected between 11 and 22 February 2019 through semi-structured interviews using two questionnaires: one for Syrian health professionals who had been employed in the SIHHAT project (i.e. employed) and the other for those who had not (i.e. unemployed).

In all, 61 (60.4%) of the 101 participants were men and 40 (39.6%) were women. There was no significant

difference in gender distribution between the employed and unemployed groups of participants. Most of the employed health-care professionals were happy with their current working conditions. After their initial delight in obtaining a job relevant to their professional background after moving to Turkey, they had

experienced daily challenges, such as the settlement of family members, their children’s education, and keeping in touch with relatives in the Syrian Arab Republic and other countries. However, the overwhelming majority were highly satisfied with the relative stability, peace and security of life in Turkey. Owing to factors such as political uncertainty and lack of security, only a few of the health-care professionals would like to return to the Syrian Arab Republic, even after the war is over.

Employed doctors noted very clear differences in working environments between Turkey and the Syrian Arab Republic: there is a higher patient load, longer working hours, limitations on private practice and less social support in Turkey than in the Syrian Arab Republic. These differences affected their job satisfaction, income level and social status.

Furthermore, unemployed health-care professionals were disappointed with the lack of employment opportunities, and had become fearful and uncertain about their future. Many relied on financial support from family members, savings and odd jobs or worked part-time in the Syrian Arab Republic, including in private practice, Syrian hospitals or Syrian Service Corps hospitals in Afrin and the Euphrates Shield territory, Syrian Charity hospitals and nongovernmental organizations. Although very few admitted to working privately as doctors or midwives, rumours suggest that informal employment is often sought, with consequent health and safety risks to health-care providers and patients related to poor hygiene and medical malpractice.

In general, Syrian health-care workers reported that factors affecting their employability were cultural barriers, long working hours, high workloads, lack of vacation time, the employment of specialist physicians as general practitioners, higher living costs in bigger cities and distance from the Syrian Arab Republic.

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Based on the findings of the study, recommendations were presented classified into three categories:

administration, health services, and social and working conditions. Some recommendations require amendments in policies and operations.

Recommendations related to administration are to:

increase the number of refugee health units per migrant health centre (MHC) establish population- based services by providing one refugee health unit per 2000–3000 refugee population, and strengthen communication with beneficiaries through the Directorate General of Migration Management and Red Crescent offices to make better use of the existing facilities;

establish open communication channels to provide information on the status and future of the SIHHAT project to ensure accurate information flow for health professionals;

adjust salaries to cover the higher costs of living in larger cities;

schedule adaptation training programmes to coordinate with the availability of positions; and

streamline the acquisition of professional equivalency certificates, incentivize internships in MHCs as a route to future employment in the national health system, and provide a waiver for health-care professionals with sufficient years of experience.

Recommendations related to health services are to:

increase the number of specialized services in MHCs, including women’s health and reproductive health, psychiatry and mental health, obstetrics and gynaecology, physical therapy and rehabilitation, X-ray, dental, pharmacy, and laboratory services;

employ preclinical specialist doctors in relevant laboratories and allow specialist doctors and midwives to practise their specialty;

introduce a small payment for each service to reduce unnecessary service utilization;

strengthen the current medical recording system by improving the infrastructure and recruit support staff to help complete the medical records effectively;

scale up efforts to register undocumented Syrian refugees and capture the total population size to improve the quality of health services;

provide more health education programmes for Syrian refugees;

organize continuing medical education, professional meetings, joint education and training activities between Turkish and Syrian staff to improve their professional interactions;

introduce night services and increase home-care services to ease the workload, improve employment opportunities and, therefore, improve the quality of services;

recruit Syrian doctors and nurses to state hospitals.

Recommendations related to social and working conditions are to:

consider family unity and residency locations when planning employment allocations;

establish child-care and transportation services;

include occupational safety and health services in MHCs, and provide the necessary education, training, and monitoring and evaluation;

improve the current building structure and infrastructure;

inform health professionals about their social security benefits and support mechanisms; and

provide Turkish language education courses to facilitate the acquisition of professional equivalency certificates and employment opportunities in family health centres.

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Background

Since 2011 Turkey has faced one of the largest refugee crises of any country since the Second World War, and currently hosts over 3.6 million registered Syrian refugees. Turkey has shown exemplary openness and made considerable efforts to support Syrians, despite the strain on its social services. It has facilitated the access of refugees to vital public services, including health, housing, education and social assistance services (1–3). However, refugees cannot rely solely on social and financial support for their livelihoods:

they also need employment opportunities. According to estimates from the Turkish Disaster and Emergency Management Agency and the Ministry of Health, at least half of working-age Syrians are employed in informal work (2). In January 2016 Turkey adopted the Regulation on Work Permit of Refugees under Temporary Protection, which grants Syrian refugees access to formal employment opportunities. To implement this regulation and address the increasing need for health-care services, the WHO Country Office in Turkey (in collaboration with the Ministry of Health and with financial support from the EU Regional Trust Fund in Response to the Syrian Crisis), the German KfW Development Bank, and European Civil Protection and Humanitarian Aid Operations initiated an adaptation training programme for eligible Syrian health-care providers, including doctors, nurses, community health support staff, translators, social workers and psychologists. The initiative aimed to increase access to quality and equitable health care for refugees and impacted local populations, including culturally appropriate care services by recruiting trained Syrian health-care providers into formal, structured health-care services. The adaptation training programme consists of five days of theoretical adaptation training on the Turkish health-care system and six weeks of practical training in primary health-care settings. After training, health-care workers are included in the recruitment process to work in the SIHHAT project.

In December 2018 93.3% of Syrian support staff, 95.1%

of Syrian nurses and 76.7% of Syrian doctors who had received WHO training were employed in the SIHHAT project in Turkey. To improve employment opportunities for Syrian health-care providers, salaries were increased in 2018; however, the effects of factors such as

previous professional experiences, place of residence, gender, family, cost of living and refugee status on employability have not been evaluated. Employability relates to an individual’s ability to function at work and in the labour market throughout their working life (4). As such, it impacts on the social and cultural integration of refugees into the host community (5). No simple structured solution has been found to mitigate the core obstacles to the professional integration of refugee doctors and nurses into host countries (5). Therefore, it is vital to identify the contextual barriers to employment.

Understanding the disincentives for institutions to promote formal employment, for employers to offer formal employment and for workers to seek formal employment is essential for setting out realistic expectations of regulatory changes and investments.

Therefore, the WHO Country Office in Turkey undertook a field assessment with the aim of improving the quality of the adaptation training programme and the effective use of resources, facilitating beneficiary participation, and ensuring accountability of the programme.

Objective

The objective of the study was to obtain the opinions of trained Syrian doctors and nurses on which factors contribute to their employability.

This is the first step toward understanding the factors affecting the employability of Syrian health-care professionals and which actions can be taken to improve their employability. The collected information will be used to develop study questions for other studies on sustainable solutions for the employment of Syrian health workers.

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2 Factors affecting the employability of refugee Syrian health-care professionals in Turkey

Methods

The field assessment included trained Syrian refugee doctors and nurses (both employed and unemployed) from five of the seven MHTCs: those in Ankara, Gaziantep, Hatay, Istanbul and Şanlıurfa. Owing to the sensitivity of the topic and differences in context, participants were divided into two groups according to their employment status:

employed doctors and nurses

unemployed doctors and nurses.1

At the Ankara MHTC, there were no unemployed health-care professionals, so only employed doctors and nurses were interviewed. Table 1 shows the total number of participating doctors and nurses in each province.

1 In this report, the term unemployed relates to Syrian doctors and nurses who received adaptation training within the SIHHAT project but have not yet been employed in MHCs.

The Department of Migration Health of the Directorate General of Public Health, Ministry of Health, invited unemployed and employed Syrian doctors and nurses to participate in the study on a voluntary basis. Each participant was personally invited by telephone; those who accepted were fully informed about the study content and methodology and were asked to sign a standard WHO informed consent form. Semi-structured interviews were used to collect information from all participants. To guide interviews, two questionnaires (one for employed and one for unemployed health-care workers) were prepared, reviewed and translated into Arabic. Interviews were held in Arabic and translated by trained translators working at the respective MHTC.

Voice recordings and interview notes were also collected. After each MHTC visit, the field assessment team met to compare notes and then drafted a summary report. After all visits had been completed (a total of nine interview sessions), all field notes were compiled into a field evaluation report.

Table 1. Distribution of participating doctors and nurses by employment status and province

Province Employed Unemployed Total

Doctors Nurses Doctors Nurses

Ankara 5 5 0 0 10

Gaziantep 5 5 4 10 24

Hatay 8 3 3 7 21

Istanbul 8 6 5 4 23

Şanlıurfa 4 4 7 8 23

Total 30 23 19 29 101

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Results and discussion

Current status and working conditions of Syrian health-care professionals

In all, 61 (60.4%) of the participants were men, with no significant difference in gender distribution between the employed and unemployed groups. Most of the employed health-care professionals were happy with their current working conditions and had been delighted to find a job relevant to their professional background after moving to Turkey. Despite their daily challenges (e.g. settlement of family members, children’s education, and keeping in touch with relatives in the Syrian Arab Republic and other countries), the overwhelming majority were highly satisfied with the relative stability, peace and security of their life in Turkey. However, employed health-care professionals were still unsure about some of their working conditions: they are not well informed about the workings of the employment lottery and state-based job appointment system in Turkey and they do not have a point of contact for this information. In addition, they had no information about the continuity of the SIHHAT project and did not know what would happen to them beyond 2019. Specialist doctors and midwives who were working as general practitioners were concerned about their working conditions, given that they cannot work in their own specialty area without a professional equivalency certificate. As such, they were uncertain how long they would feel comfortable working as general practitioners.

When asked to compare their current working conditions in Turkey with their prewar working

conditions in the Syrian Arab Republic, employed health- care professionals highlighted the following differences.

1. The workload is much higher in Turkey (working week of 40 hours and 50–90 patients per day) than in the Syrian Arab Republic (working week of 18–

20 hours and no more than 20 patients per day).

2. They acknowledged that the health-care system is much better organized in Turkey than in the Syrian Arab Republic, but highlighted disparities in workload between standard MHCs and MHTCs.

Standard MHCs employ only general practitioners,

whereas MHTCs employ both general practitioners and specialist physicians. Therefore, MHTCs are perceived as hospitals and Syrian refugees tend to bypass MHCs and demand health services from MHTCs. Furthermore, service organization is not population based in most provinces, which creates an unbalanced workload for health-care professionals working at MHTCs.

3. In the Syrian Arab Republic, specialist doctors and midwives could work in their specialty area, whereas in Turkey they are limited to working as general practitioners. Moreover, In the Syrian Arab Republic, they were allowed to treat private patients in addition to their public hospital or clinic work and could, therefore, earn a higher income and achieve a higher social status. Government hospitals in the Syrian Arab Republic also provided social support for health-care professionals, such as child-care facilities and transportation.

However, unemployed health-care professionals were greatly disappointed in their employment status. They had started their adaptation training with great hopes but, owing to the lack of foreseeable employment opportunities, had become fearful and uncertain about their future. Some were still not employed in the SIHHAT project a year after completing the training course. They supported themselves in various ways, as follows.

Most female health-care professionals relied on their husbands or other family members for their livelihood.

A few supported themselves with savings or received financial support from family members in the Syrian Arab Republic or other countries.

Most male nurses reported working up to 14 hours per day in odd jobs (e.g. as porters, construction workers, maintenance workers, or by selling various goods or vegetables at market). Some said that they are not always paid because they are not registered workers.

All Syrian doctors from border provinces reported having a part-time job in the Syrian Arab Republic, including in private practice, Syrian hospitals or Syrian Service Corps hospitals in Afrin and the

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4 Factors affecting the employability of refugee Syrian health-care professionals in Turkey

Euphrates Shield territory. Unemployed doctors in Istanbul reported working for Syrian charity hospitals and nongovernmental organizations.

Although clinicians and midwives are rumoured to treat private patients, few participants confirmed this during interview. One MHTC staff member said that some Syrian doctors and midwives have all of the equipment they need for their work (e.g. ultrasound scanner and small surgical tools). Therefore, as well as financial and social problems, their lack of formal employment creates serious problems related to poor hygiene, medical malpractice and patient safety.

When asked to explain why they were unemployed, participants gave the following reasons.

A few female participants said that their husbands do not approve of them working.

Some said that they were accustomed to working close to home in the Syrian Arab Republic and have refused jobs away from home in Turkey.

Some said that they had refused employment in MHCs because of the longer working hours and shorter vacation time than in the Syrian Arab Republic.

A few specialist physicians had refused to work as a general practitioner.

Some said that they had refused to accept the offer of a job in a bigger city because the salary did not cover the expenses of living in a large city.

Some had applied for jobs and were waiting for the response.

Overall, Syrian health-care providers had mixed feelings about returning to the Syrian Arab Republic. Only a few said they would like to return to the Syrian Arab Republic, even after the war is over, because of the political uncertainty and lack of security. Even fewer are willing to move to a third country because of uncertainty of living conditions, cultural differences, the greater distance to the Syrian Arab Republic, reports of poor living conditions, and lack of job opportunities as health- care professionals. Only a very few would be willing to go wherever they could find a job.

Challenges to employability for Syrian health-care professionals

When asked about their perceived challenges to employability, participants reported that the main challenges were related to cultural and professional differences between the health-care systems, working arrangements and health-care service organization in the Syrian Arab Republic and Turkey.

The greatest challenge for Syrian health-care professionals was to obtain work near to home.

This is what they were accustomed to in the Syrian Arab Republic and they would prefer the same working conditions in Turkey. In particular, those living in border provinces did not want to move away for work. Living near the Syrian border has advantages such as easy access to family and friends in the Syrian Arab Republic and additional income from part-time work in the Syrian Arab Republic.

Female Syrian health-care professionals in particular said that they had refused job offers because of the lack of support structures such as sufficient vacation time, child-care services and transportation support. A few said that they would spend most of their income on transportation to and from work, so it is not worthwhile to accept the

job.Another deterrent to employment is that the same salary scale applies to both smaller provinces and larger metropolitan areas (such as Istanbul and Izmir). Some participants had refused to move to larger cities because of the higher cost of living.

Another challenge is that services are not population based. Currently, the organization of most MHC services is not based on a defined population size. Syrian refugees have different perceptions of standard MHCs and MHTCs. Since MHTCs have specialist doctors, they are perceived to be hospitals; therefore, most refugees bypass standard MHCs and go directly to MHTCs, which increases the workload for MHTCs. Furthermore, although it was initially planned to have one migrant health unit (comprising one doctor and one nurse) for every 4000 refugees, one refugee health unit now serves 6000 refugees. Health-care professionals think that this number is too high and suggest decreasing the workload to one refugee health unit for every 2000–3000 refugees, which would increase service quality, as well as their employment prospects.

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Some Syrian health-care providers thought that favouritism and nepotism were still a problem in job recruitment. They also alleged that some previous employment lotteries had been cancelled, which they took to indicate that the Ministry of Health no longer needs to recruit Syrian health-care professionals.

Unexpectedly, Syrian health-care professionals perceived a lack of proficiency in Turkish to be another barrier to employment. They thought that they would have more job opportunities if they were competent in Turkish (e.g. in Turkish family health centres).

Syrian health-care professionals perceived their lack of Turkish citizenship to be a major barrier to employment. They considered citizenship a license to work freely in Turkey, but complained that the bureaucratic process is too long and cumbersome.

In addition, the time taken to complete the citizenship process differs across provinces.

Recommendations to improve the employability of Syrian health- care professionals

Syrian health-care professionals believed that employability is closely related to working conditions and that, therefore, working conditions should also be targeted. Participants in the field assessment made recommendations for changes in the following areas:

administration

health services

social and working conditions.

Recommendations related to administration are to:

increase the number of MHCs and available migrant health units – as some regions with large Syrian refugee populations do not have a local MHC or health-care facility, opening new MHCs would increase their opportunities while reducing the patient workload and increasing service quality;

establish population-based services by providing one unit per 2000–3000 refugee population, and strengthen communication with beneficiaries through the Directorate General of Migration Management, Population Administration and Red Crescent offices to make better use of the existing facilities;

expand the SIHHAT project beyond the current 29 locations, and establish open communication channels for the SIHHAT project via the MHC administration to provide up-to-date information on the status and future of the SIHHAT project;

increase the salary scale for health-care workers in larger metropolitan areas to cover the higher costs of living, since the high cost of living has been a major deterrent to accepting job offers in these areas;

schedule adaptation training programmes to coordinate with the availability of jobs – many health-care professionals had completed the training programme and applied for jobs (some have even signed employment contracts) and then waited for a job allocation for more than a year, so resolving this problem would significantly improve the morale of Syrian health-care providers; and

streamline the acquisition of professional equivalency certificates, incentivize internships in MHCs as a route to future employment in the national health system, and provide a waiver for health-care professionals with sufficient years of experience.

Recommendations related to health services are to:

increase the number of specialized services in MHCs, including women’s and reproductive health, psychiatry and mental health, obstetrics and gynaecology, physical therapy and rehabilitation, radiology, dental, pharmacy, and laboratory services;

employ preclinical specialists (e.g. biochemists and microbiologists) in relevant laboratories and allow specialist doctors and midwives to practise their specialty;

introduce a small cost for each service to reduce unnecessary service utilization;

strengthen the current medical record system by purchasing more computers, ensuring a more reliable electricity supply and Internet services for MHCs and recruiting more support staff to help doctors and nurses to complete medical records effectively;

scale up efforts to register undocumented Syrian refugees and capture the total population size to improve the quality and humanitarian impact of services, especially for Syrian children;

provide more health education programmes for Syrian refugees to increase their health literacy and help them to use health services more effectively;

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6 Factors affecting the employability of refugee Syrian health-care professionals in Turkey

organize continuing medical education, professional meetings, and joint education and training activities with Turkish health-care professionals to increase their employment opportunities and improve their professional interactions with Turkish health-care professionals;

introduce night services in MHCs and provide more home health-care services to ease the workload and improve the employment opportunities of health- care workers and improve the quality of services;

andrecruit Syrian doctors and nurses to state hospitals to help Arabic-speaking patients and improve the quality of health-care services.

Recommendations related to social and working conditions are to:

consider cultural issues such as maintaining family unity and working close to home when planning employment allocations;

establish child-care and transportation services for female health-care professionals with children;

include occupational safety and health services in MHCs, and provide the necessary educational, training, and monitoring and evaluation;

improve the current structure and infrastructure of MHC buildings, where necessary, in particular in relation to sanitation, insulation, water and electricity supply, and Internet provision;

inform health professionals about social security benefits and support mechanisms; and

provide Turkish language courses to facilitate the acquisition of professional equivalency certificates and their employment opportunities in family health centres.

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Conclusions

The employability of Syrian health-care professionals who have completed WHO/Ministry of Health training for recruitment by the SIHHAT project is a matter of concern for the Ministry of Health, WHO and EU as the financial donor of the SIHHAT project. This field assessment demonstrated that employability is also a matter of concern for the Syrian refugee population. Although employed and unemployed Syrian health-care professionals had different concerns and perspectives, all had the common goals of stability and sustainability and hope for a more secure future. Their recommendations were categorized into three groups related to administration, health services, and social and working conditions. Although not all recommendations might be feasible or practical to implement, keeping communication channels open, reviewing the recruitment process and health system organization from a culturally sensitive perspective, and increasing integration activities between the Syrian and host communities are critical to improving the employability of Syrian health-care professionals.

The field assessment helped the WHO Refugee Health Programme to develop relevant study questions for the continued investigation into long-term solutions for the employment and integration of Syrian health workers.

This study was implemented within the scope of the Improved access to health services for Syrian refugees in Turkey project with funding from the EU Regional Trust Fund in Response to the Syrian Crisis.

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8 Factors affecting the employability of refugee Syrian health-care professionals in Turkey

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Annex 1. Interview questions for employed Syrian health- care professionals

1. How do you feel about the job recruitment process for MHCs/other?

a. What were your expectations before starting work?

b. Do you feel satisfied with the process and result?

2. How do you like working as a doctor/nurse in the MHC/other?

a. How does your experience compare with your work in the Syrian Arab Republic?

b. Would you prefer to work somewhere else or in another job?

3. What are the most important factors that make you happy working in the MHC/other?

a. Explain why.

b. How would you rank them (from 1 to 5)?

4. What are the most important factors that make you unhappy working in the MHC/other?

a. Explain why.

b. How would you rank them (from 1 to 5)?

5. How do you like the working environment and working conditions?

a. What conditions would you like to keep as they are?

b. What conditions would you like to change?

6. What factors do you think would increase the employability of Syrian doctors/nurses?

a. Explain why.

b. How would you rank them (from 1 to 5)?

7. What are the current obstacles to the employment of Syrian doctors/nurses?

a. Explain why.

b. How would you rank them (from 1 to 5)?

8. If you were offered a job in the Syrian Arab Republic, what working conditions would you need to accept?

a. How would you feel about working in the Euphrates Shield territory?

9. If you were offered a job in another country, what conditions would you need to accept?

a. Explain why.

b. How would you rank them (from 1 to 5)?

10. Would you like to say anything else about the employability of Syrian doctors/nurses?

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10 Factors affecting the employability of refugee Syrian health-care professionals in Turkey

Annex 2. Interview questions for unemployed Syrian

health-care professionals

1. How do you feel about the job recruitment process in MHCs/other?

a. What were your expectations at the start of the process?

b. Do you feel satisfied with the process and the outcome?

2. Where would you like to work as a doctor/nurse?

a. How do you compare your present experiences with your work in the Syrian Arab Republic?

3. What are the most important factors that would make you happy working in a MHC/other?

a. Explain why.

b. How would you rank them (from 1 to 5)?

4. What are the most important factors that would make you unhappy working in a MHC/other?

a. Explain why.

b. How would you rank them (from 1 to 5)?

5. What kind of working environment and conditions would you prefer?

a. What working conditions would you definitely not accept?

6. What factors do you think would increase the employability of Syrian doctors/nurses?

a. Explain why.

b. How would you rank them (from 1 to 5)?

7. What factors do you think would decrease the employability of Syrian doctors/nurses?

a. Explain why.

b. How would you rank them (from 1 to 5)?

8. If you were offered a job in the Syrian Arab Republic, what conditions would you need to accept it?

a. How would you feel about working in the Euphrates Shield territory?

9. If you were offered a job in another country, what conditions would you need to accept?

a. Explain why.

b. How would you rank them (from 1 to 5)?

10. Would you like to say anything else about the employability of Syrian doctors/nurses?

(21)
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The WHO Regional Office for Europe

The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves.

Member States

World Health Organization Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø Denmark

Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int Albania

Andorra Armenia Austria Azerbaijan Belarus Belgium

Bosnia and Herzegovina Bulgaria

Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany

Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway

Poland

Portugal

Republic of Moldova Romania

Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine

United Kingdom Uzbekistan

Document number:

WHO/EURO:2021-2409-42164-58097

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