Health in Syria
Health indicators improved considerably in the Syrian Arab Republic over the past three decades according to data from the Syrian Ministry of Health with life expectancy at birth increasing from 56 years in 1970 to 73.1 years in 2009; infant mortality dropped from 132 per 1000 live births in 1970 to 17.9 per 1000 in 2009; under-five mortality dropped significantly from 164 to 21.4 per 1000 live births; and maternal mortality fell from 482 per 100 000 live births in 1970 to 52 in 2009. The Syrian Arab Republic was in epidemiological transition from communicable to non- communicable diseases with the latest data showing that 77% of moralities were caused by non-communicable diseases. Total government expenditure on health as a percentage of Gross Domestic Product was 2.9 in 2009. Despite such low public investment access to health services increased dramatically since the 1980s, with rural populations achieving better equity than before.
Despite the apparent improved capacity of the health system, a number of challenges prevail which need to be addressed to reduce inequities in access to health care and to improve the quality of care; these include, addressing validity of the data, overall inequity, lack of transparency, inadequate utilization of capacity, inadequate coordination between providers of health services, uneven distribution of human resources, high turnover of skilled staff and leadership, inadequate number of qualified nurses and allied health professionals. More recently there has been an uncontrolled and largely unregulated expansion of private providers, resulting in uneven distribution of health and medical services among geographical regions. Standardized care and quality assurance and accreditation are major issues that need to be addressed; a recent study revealed that mortality rates among critically ill patients admitted to the intensive care units with severe 2009 H1N1 influenza A was 51% in Damascus compared to an APACHE II predicted mortality rate of 21% with a standardized mortality ratio of 2.4 (95% confidence interval: 1.7–3.2, P-value < 0.001).
Syria is experiencing a protracted political and socioeconomic crisis that resulted in a severe deterioration of living conditions which has also significantly eroded the health system.
The violent conflict in Syria has taken a heavy toll on life of the Syrian people and is resulting in large outflow of refugees. The estimated death toll has exceeded 250,000 people (as per the UN); and a recent report by the Syrian Center for Policy Research (SCPR) put the death toll to 470,000. One million two hundred thousand people were injured and many more displaced. The latest UNHCR statistics reveal that half of the Syrian population has been forcibly displaced, with an estimated 7.6 million internally displaced persons (IDPs) and 4.8 million registered refugees (UNHCR, 2016). In addition, 900,000 asylum applications were filed by Syrians in Europe during 2011-February 2016. The Refugee Protection (3RP) and humanitarian program (UN) estimated that there were 4.8 million Syrian refugees in February 2016 in the neighboring host countries alone (Egypt, Iraq, Jordan, Lebanon, and Turkey).
The conflict has significantly damaged the country’s public and private assets including health, education, energy, water and sanitation, agriculture, transportation, housing and other infrastructure. The World Bank’s Damage and Needs Assessment report (conducted for six governorate capitals namely, Aleppo; Dar’a; Hama; Homs; Idlib; and Latakia) estimated the total damage for the six cities to be in the range of $3.7 to 4.5 billion as of [December 2014]. The SCPR estimated that, for the whole country, the destruction of physical infrastructure amounted to $75 billion. The UN estimated that it would need an investment of $180 billion to bring Syrian GDP back to pre-conflict levels.
The GDP is estimated to have contracted by an annual average of 19% in 2015 and is projected to continue to contract in 2016, by 8%. After rising by nearly 90% in 2013, inflation is estimated to have increased by 30 in 2015 and is estimated to grow by 25% in 2016 because of continued trade disruption, shortages and sharp depreciation of the Syrian pound.
Public finances have worsened since the start of the conflict. The overall fiscal deficit increased sharply by an average of 12% of GDP during the period 2011-14 and is estimated to worsen to 20 and 18% of GDP in 2015 and 2016, respectively. Total revenue fell to an all-time low of below 7% of GDP during 2014-15 due to the collapse of oil revenues and tax revenues. In response, government spending was cut back, but not by enough to offset the fall in revenues. Reduction in outlays on wages and salaries were not far-reaching enough, while military spending increased.
The severe decline in oil receipts since the second half of 2012 and disruptions of trade due to the conflict put a pressure on balance of payments and the exchange rate. Revenues from oil exports decreased from $4.7 billion in 2011 to an estimated $0.22 billion in 2014, and are estimated to have declined further to $0.14 billion in 2015 as most of Syria’s oil fields are under control of opposition forces of ISIS. Therefore, current account balance is estimated to continue its trend and reached a deficit of 22 and 15% of GDP in 2015 and 2016, respectively. As a result of the civil war, it is estimated that total international reserves have declined from $20 billion at end-2010 to $0.7 billion by the end of 2015. Depressed export revenue and declining international reserves have caused a significant depreciation of the Syrian pound from 47 pounds per USD in 2010 to 375 pounds per USD at end-February 2016.
The medium-term macroeconomic prospects hinge on containing the war and finding a political resolution to the conflict, and rebuilding the damaged infrastructure and social capital. Violence continues to disrupt the production and distribution of goods and services, and impedes economic activity. Barring a cessation of the conflict, the country’s human and physical capital stock is expected to continue to shrink. Physical harm, poor nutrition and health services, unemployment, poverty, and the breakdown of public service delivery will continue to weigh heavily on the population.
- Vital infrastructure has been compromised or destroyed, resulting in a lack of shelter and energy sources, deterioration of water and sanitation services, food insecurity and serious overcrowding in some areas.
- Access to health care is severely restricted, hampered by security factors. Maternal and child health services at the primary health care (PHC) level are disrupted. The consequences for maternal and child morbidity and mortality, among deliveries that took place during the conflict period remains unclear.
- Specific concerns remain for the chronically sick. It is estimated that more than half of those chronically ill have been forced to interrupt their treatment. These concerns are exacerbated by the virtual halt of referrals of ordinary patients outside the conflict areas as life-threatening injuries receive higher priority in an overwhelmed health care system. Elective surgery and nonurgent routine medical interventions are delayed or interrupted indicating that a growing number of patients, mainly with chronic conditions are facing a dire situation, while awaiting treatment.
- The quality of health care has been further affected by the deterioration in the functionality of medical equipment due to the lack of spare parts and maintenance shortages of drugs and medical supplies due to sanctions. Routine operations are affected and many elective interventions suspended.
Very few assessments were taken place to assess the status of health care services at the conflict areas; the World Health Organization (WHO) completed a rapid assessment in late June to assess the availability and functionality of health services and resources in affected areas. The survey included 342 primary health care centers (PHC) and 38 hospitals in several affected provinces: Rural Damascus, Homs, Hama, Idleb, Der El Zor, Dara’a, and Tartous. The first six provinces were selected to assess the effect of the current unrest on health services, while Tartous was selected to assess the degree of overburdened health facilities, due to high numbers of internal refugees from other affected provinces. It was found that about 43% of PHCs are partially functioning, and 2% of PHCs are nonfunctioning, 13% PHCs are inaccessible due distance of PHC from patients (50%, mostly in Idleb); lack of safety (34%, mostly in Homs and Hama); difficulties in public transportation (8%, mostly in Tartous) or temporary relocation of patients (2%) while only 50% of hospitals are fully functioning due to lack of staff, equipment and medicine. The report showed an urgent need for infant incubators in some hospitals, CT scans, Doppler, echography, anesthesia equipment, and ambulances. Antibiotics, anti-ulcer medication, sterilizers and antidotes are also urgently needed. The major obstacles are a lack of safety related to the current situation, long distances to hospitals, and difficulties in available public transportations (12.5%). These issues exist mainly in Rural Damascus, Daraa, Homs and Der El Zor provinces. The majority of PHCs and hospitals also count on the national water supply system as a main source of water (88%, 87%, respectively). A large proportion of PHCs have no available sanitation system (mostly in Hama, Der El Zor and Dara′a). Only one-tenth of PHCs have usable generators; the majority has usable blood pressure apparatuses (94%); Availability of nebulizers, fetoscopes and suction machines are 44%, 30% and 18%, respectively. This assessment is limited due security issues, the dynamic situation and the rapid escalation of the crisis, it is expected the needs are at larger scale after the recent escalation in the last 2 months.
There is a need for a larger assessment and evaluation of health services in the affected areas. Prompt coordinated efforts and proactive solutions of health care services for displaced people are necessary in order to mitigate the serious and negative outcomes. Multiple interventions have been attempted by the WHO in response to the crisis including the distribution of surgical kits and equipment of mobile health units in Homs and rural Damascus.
After the crisis: Post-conflict needs assessment
In the postcrisis phase, there will be an urgent need for a development process designed to examine and assess the health situation in the country using a holistic approach; one that encompasses the health sector, socioeconomic status, the determinants of health, and upstream national policies and strategies that have a major bearing on health.
Post-conflict needs assessments (PCNAs) are multilateral exercises that should be undertaken by the international organizations in collaboration with the national government of Syria. The Syrian International Coalition for Health with its affiliates (Syrian American Medical Society, Syrian British Medical Society, Middle East Critical Care Assembly and others) along with its experts and specialists will play a major role in the PCNAs and in the development and implementation of strategies and needed projects. PCNAs are increasingly used by national and international actors as an entry point for conceptualizing, negotiating and financing a common shared strategy for recovery and development in fragile, post-conflict settings. The PCNA includes both the assessment of needs and the national prioritization and costing of needs in an accompanying transitional results matrix. The assessment will evaluate the capacity and functionality of the health system in addition to the following points:
- Complications and permanent disabilities for people with traumatic injuries and hearing impairment caused by explosions due to inappropriate follow-up and treatment.
- Potential risks for women who went into labor as well as infants born during the crisis period associated with the lack of appropriate care during labor, delivery and postpartum.
- Complications and excess mortality in patients with chronic diseases due to suspension of treatment and delayed access to health care.
- Epidemic outbreaks of water and food-borne diseases due to limited access to clean water and sanitation and a weak public health surveillance system.
- Outbreaks of vaccine-preventable diseases due to interrupted vaccination programs.
- Psychological trauma and mental health problems particularly upon children due to the effects of the conflict, ongoing insecurity and lack of protective factors.
- Deterioration of health and nutritional status leading to increasing morbidity and mortality due to a further decline in socioeconomic and security conditions and in the quality of health care.
- The extent of vulnerable groups (elderly, pregnant women, and children) or individuals who are severely affected by the emergency, having reduced coping mechanisms and limited access to appropriate services or support networks.
- The magnitude of restricted access to specialized tertiary care.
The Syrian International Coalition for health is determined within its scope and limitation to do all what it is possible not to allow a repeat of what has happened in other countries of the region, namely a total collapse of existing health infrastructure and systems.
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