HEALTH SITUATION As the Syrian conflict enters its eighth year, around 6.1 million people inside Syria have been displaced, many of them repeatedly as they flee shifting lines of conflict. Another 5.5 million Syrians have sought refuge in other countries. Hundreds of thousands of internally displaced people (IDPs)are living in rudimentary conditions in collective shelters, where they have very limited access to clean water, health care and other necessities of life. The lack of clean water and sanitation greatly increases the risk of waterborne diseases such as acute watery diarrhoea. In 2017, measles outbreaks were reported in all 14 governorates of Syria, and an outbreak of circulating vaccine-derived poliovirus was detected in March 2017, indicating the need for emergency mass vaccination campaigns to restore high levels of population immunity. Overall, the health situation is similar to that at the end of 2016. More than 50% of public hospitals and primary health care (PHC) centres are still out of service or functioning only partially, and the health workforce has been severely depleted. Attacks on hospitals and health care workers continue. Noncommunicable diseases (NCDs) were estimated to account for 46% of total deaths in Syria in 2014. The disruption of the country’s pharmaceutical industry has left many Syrians unable to obtain regular life-saving medications to treat NCDs. As the conflict continues, increasing numbers of Syrians, including children, are likely to be suffering from severe depression and anxiety, while mental health services are not readily available. Malnutrition among children and infants has risen sharply. Many Syrians who have undergone unnecessary amputations because they were unable to reach hospitals in time will require lifelong rehabilitative care. According to the 2018 Humanitarian Response Plan for Syria, two thirds of Syrians are living in extreme poverty. Access to people in need in hard-to-reach and besieged areas remains a major obstacle to WHO’s emergency response. WHO has advocated for sustained, unimpeded access to all areas of Syria to deliver health supplies, ascertain health needs, review the status of health care facilities, assess and treat patients and refer them for specialized care when required. HEALTH POLICIES AND SYSTEMS Previously, the public health sector in Syria was the main provider of health services, which were given free of charge. With more than half the country’s health care facilities either closed or functioning only partially, millions of Syrians, especially those in besieged and hard-to-reach areas, have very limited access to health care. Before the conflict began, most of the country’s medicines were produced domestically. The disruption of the domestic pharmaceutical industry has led to shortages of many medicines, including those to treat chronic diseases. The pharmaceutical sector is rebuilding its factories and gearing up to reach pre- conflict productivity, but production levels remain low due to shortages of staff and raw materials. In the meantime, the MoH and WHO are collaborating on the production of an annual Essential List of Medicines that sets out the priority medicines to be procured and the quantities required. This helps determine which medicines can be procured nationally and which will need to be procured internationally until the pharmaceutical industry is restored to full capacity. To mitigate the impact of the disrupted national disease surveillance system, the Ministry of Health (MoH) has worked with WHO to establish an emergency disease surveillance system (EWARS) to monitor and respond to disease outbreaks and avert their further spread. EWARS is managed jointly by the MoH and WHO. Over 1700 health care facilities throughout Syria are reporting to EWARS. Other challenges to the country’s health system include the continuing sanctions placed on Syria, which mean that spare parts cannot be imported to repair essential hospital equipment. The country has lost around 60% of its health workforce. Dozens of hospitals have been forced to close due to the conflict. State-of-the-art medical equipment has been lost, operating theatres have been damaged, and medical specialists have left the country. The MoH is taking concrete steps to respond to many of these challenges . In the biennium 2016-2017, it implemented emergency vaccination campaigns that reached millions of children nationwide and is working to restore routine vaccination services in PHC centres. It is integrating mental health services into PHC centres across the country and, with support from WHO, is launching a mental health programme in Syrian schools. Nutritional screening services have been established in PHC centres to detect malnourished children and ensure they receive specialized treatment when required. COOPERATION FOR HEALTH The MoH has begun the process of post-conflict planning and has set three main priorities for 2018- 2019: 1) develop a long-term plan to rehabilitate and reform the health system; 2) establish a skilled health workforce; and 3) strengthen the national programme for the prevention and control of NCDs. To support efforts to improve PHC services, WHO will assist in setting standards and providing technical guidance on the minimum basic health care services and medicines to be provided in PHC centres. This will help ensure that Syrians are able to obtain quality health care services, based on internationally accepted standards, in an equitable manner. WHO will also support efforts to strengthen referral services at PHC level, ensuring that Syrians can be rapidly transferred to secondary and tertiary health care levels for specialized treatment when required. To help the country rebuild its workforce, WHO will support the development of a national plan to build human resources for health (HRH), including an HRH information system and a continuous professional development plan for all health personnel. WHO will support a strengthened NCD programme by lending its technical expertise, strengthening NCD surveillance systems, integrating the management of NCDs into PPHC services, and support the establishment of national reference centres to promote research on the NCDs that account for the main burden of disease in Syria. Syrian Arab Republic http:// www.who.int/countries/en/ WHO region Eastern Mediterranean World Bank income group Lower-middle-income Child health Infants exclusively breastfed for the first six months of life (%) (2009) 42.6 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2017) 67 Demographic and socioeconomic statistics Life expectancy at birth (years) (2015) 69.9 (Female) 59.9 (Male) 64.5 (Both sexes) Population (in thousands) total (2015) 18502.4 % Population under 15 (2015) 37.1 % Population over 60 (2015) 6.4 Poverty headcount ratio at $1.25 a day (PPP) (% of population) () Literacy rate among adults aged >= 15 years (%) (2007-2012) 84 Gender Inequality Index rank (2014) 119 Human Development Index rank (2014) 134 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 3.25 Private expenditure on health as a percentage of total expenditure on health (2014) 53.69 General government expenditure on health as a percentage of total government expenditure (2014) 4.80 Physicians density (per 1000 population) (2016) 1.546 Nursing and midwifery personnel density (per 1000 population) (2014) 2.302 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2016) 8.9 [6.5-12.8] Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2016) 17.5 [13.6-24.6] Maternal mortality ratio (per 100 000 live births) (2015) 68 [ 48 - 97] Births attended by skilled health personnel (%) (2009) 96.2 Public health and environment Population using safely managed sanitation services (%) () Population using safely managed drinking water services (%) () Sources of data: Global Health Observatory May 2017 http://apps.who.int/gho/data/node.cco WHO COUNTRY COOPERATION STRATEGIC AGENDA (on-going ) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Develop a long- term national vision for health development and reforming and upgrading the health system Support the development and implementation of updated primary health care (PHC) services; this includes defining the specific roles, responsibilities and functions of different services involved in the PHC referral system. Strengthen the supply chain. Strengthen national capacity to analyse health information and use it to underpin policy, planning and management. STRATEGIC PRIORITY 2: Strengthen the national system for human resources development through evidence-based policy formulation, better coordination and strategic partnerships In consultation with national authorities and key stakeholders, support the development of a national plan to build human resources for health (HRH), including an HRH information system and a continuous professional development plan for all health personnel. Strengthen the accreditation system for educational institutions involved in HRH, and review/assess their curricula. Support the strengthening of national regulatory systems, reinforced by appropriate legislation, to certify, register and license health personnel. STRATEGIC PRIORITY 3: Upgrade the national programme for the prevention and control of noncommunicable diseases Monitor and evaluate noncommunicable disease prevention and control efforts , including strengthening surveillance systems. Promote research for the prevention and control of noncommunicable diseases through the establishment of national reference centres and networks. Promote partnerships for the prevention and control of noncommunicable diseases through cross - sectoral approach and collaboration with relevant professional associations. Upgrade health care delivery and incorporate the control and management of noncommunicable diseases into the PHC system, supported by the establishment of a disease-specific registry. Please note that the 3rd generation CCS 2014-20g finalize © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Syria Updated May 2018
HEALTH SITUATION As the Syrian conflict enters its eighth year, around 6.1 million people inside Syria have been displaced, many of them repeatedly as they flee shifting lines of conflict. Another 5.5 million Syrians have sought refuge in other countries. Hundreds of thousands of internally displaced people (IDPs)are living in rudimentary conditions in collective shelters, where they have very limited access to clean water, health care and other necessities of life. The lack of clean water and sanitation greatly increases the risk of waterborne diseases such as acute watery diarrhoea. In 2017, measles outbreaks were reported in all 14 governorates of Syria, and an outbreak of circulating vaccine-derived poliovirus was detected in March 2017, indicating the need for emergency mass vaccination campaigns to restore high levels of population immunity. Overall, the health situation is similar to that at the end of 2016. More than 50% of public hospitals and primary health care (PHC) centres are still out of service or functioning only partially, and the health workforce has been severely depleted. Attacks on hospitals and health care workers continue. Noncommunicable diseases (NCDs) were estimated to account for 46% of total deaths in Syria in 2014. The disruption of the country’s pharmaceutical industry has left many Syrians unable to obtain regular life-saving medications to treat NCDs. As the conflict continues, increasing numbers of Syrians, including children, are likely to be suffering from severe depression and anxiety, while mental health services are not readily available. Malnutrition among children and infants has risen sharply. Many Syrians who have undergone unnecessary amputations because they were unable to reach hospitals in time will require lifelong rehabilitative care. According to the 2018 Humanitarian Response Plan for Syria, two thirds of Syrians are living in extreme poverty. Access to people in need in hard-to-reach and besieged areas remains a major obstacle to WHO’s emergency response. WHO has advocated for sustained, unimpeded access to all areas of Syria to deliver health supplies, ascertain health needs, review the status of health care facilities, assess and treat patients and refer them for specialized care when required. HEALTH POLICIES AND SYSTEMS Previously, the public health sector in Syria was the main provider of health services, which were given free of charge. With more than half the country’s health care facilities either closed or functioning only partially, millions of Syrians, especially those in besieged and hard-to-reach areas, have very limited access to health care. Before the conflict began, most of the country’s medicines were produced domestically. The disruption of the domestic pharmaceutical industry has led to shortages of many medicines, including those to treat chronic diseases. The pharmaceutical sector is rebuilding its factories and gearing up to reach pre- conflict productivity, but production levels remain low due to shortages of staff and raw materials. In the meantime, the MoH and WHO are collaborating on the production of an annual Essential List of Medicines that sets out the priority medicines to be procured and the quantities required. This helps determine which medicines can be procured nationally and which will need to be procured internationally until the pharmaceutical industry is restored to full capacity. To mitigate the impact of the disrupted national disease surveillance system, the Ministry of Health (MoH) has worked with WHO to establish an emergency disease surveillance system (EWARS) to monitor and respond to disease outbreaks and avert their further spread. EWARS is managed jointly by the MoH and WHO. Over 1700 health care facilities throughout Syria are reporting to EWARS. Other challenges to the country’s health system include the continuing sanctions placed on Syria, which mean that spare parts cannot be imported to repair essential hospital equipment. The country has lost around 60% of its health workforce. Dozens of hospitals have been forced to close due to the conflict. State-of-the-art medical equipment has been lost, operating theatres have been damaged, and medical specialists have left the country. The MoH is taking concrete steps to respond to many of these challenges . In the biennium 2016-2017, it implemented emergency vaccination campaigns that reached millions of children nationwide and is working to restore routine vaccination services in PHC centres. It is integrating mental health services into PHC centres across the country and, with support from WHO, is launching a mental health programme in Syrian schools. Nutritional screening services have been established in PHC centres to detect malnourished children and ensure they receive specialized treatment when required. COOPERATION FOR HEALTH The MoH has begun the process of post-conflict planning and has set three main priorities for 2018- 2019: 1) develop a long-term plan to rehabilitate and reform the health system; 2) establish a skilled health workforce; and 3) strengthen the national programme for the prevention and control of NCDs. To support efforts to improve PHC services, WHO will assist in setting standards and providing technical guidance on the minimum basic health care services and medicines to be provided in PHC centres. This will help ensure that Syrians are able to obtain quality health care services, based on internationally accepted standards, in an equitable manner. WHO will also support efforts to strengthen referral services at PHC level, ensuring that Syrians can be rapidly transferred to secondary and tertiary health care levels for specialized treatment when required. To help the country rebuild its workforce, WHO will support the development of a national plan to build human resources for health (HRH), including an HRH information system and a continuous professional development plan for all health personnel. WHO will support a strengthened NCD programme by lending its technical expertise, strengthening NCD surveillance systems, integrating the management of NCDs into PPHC services, and support the establishment of national reference centres to promote research on the NCDs that account for the main burden of disease in Syria. Syrian Arab Republic http:// www.who.int/countries/en/ WHO region Eastern Mediterranean World Bank income group Lower-middle-income Child health Infants exclusively breastfed for the first six months of life (%) (2009) 42.6 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2017) 67 Demographic and socioeconomic statistics Life expectancy at birth (years) (2015) 69.9 (Female) 59.9 (Male) 64.5 (Both sexes) Population (in thousands) total (2015) 18502.4 % Population under 15 (2015) 37.1 % Population over 60 (2015) 6.4 Poverty headcount ratio at $1.25 a day (PPP) (% of population) () Literacy rate among adults aged >= 15 years (%) (2007-2012) 84 Gender Inequality Index rank (2014) 119 Human Development Index rank (2014) 134 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 3.25 Private expenditure on health as a percentage of total expenditure on health (2014) 53.69 General government expenditure on health as a percentage of total government expenditure (2014) 4.80 Physicians density (per 1000 population) (2016) 1.546 Nursing and midwifery personnel density (per 1000 population) (2014) 2.302 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2016) 8.9 [6.5-12.8] Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2016) 17.5 [13.6-24.6] Maternal mortality ratio (per 100 000 live births) (2015) 68 [ 48 - 97] Births attended by skilled health personnel (%) (2009) 96.2 Public health and environment Population using safely managed sanitation services (%) () Population using safely managed drinking water services (%) () Sources of data: Global Health Observatory May 2017 http://apps.who.int/gho/data/node.cco WHO COUNTRY COOPERATION STRATEGIC AGENDA (on-going ) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Develop a long- term national vision for health development and reforming and upgrading the health system Support the development and implementation of updated primary health care (PHC) services; this includes defining the specific roles, responsibilities and functions of different services involved in the PHC referral system. Strengthen the supply chain. Strengthen national capacity to analyse health information and use it to underpin policy, planning and management. STRATEGIC PRIORITY 2: Strengthen the national system for human resources development through evidence-based policy formulation, better coordination and strategic partnerships In consultation with national authorities and key stakeholders, support the development of a national plan to build human resources for health (HRH), including an HRH information system and a continuous professional development plan for all health personnel. Strengthen the accreditation system for educational institutions involved in HRH, and review/assess their curricula. Support the strengthening of national regulatory systems, reinforced by appropriate legislation, to certify, register and license health personnel. STRATEGIC PRIORITY 3: Upgrade the national programme for the prevention and control of noncommunicable diseases Monitor and evaluate noncommunicable disease prevention and control efforts , including strengthening surveillance systems. Promote research for the prevention and control of noncommunicable diseases through the establishment of national reference centres and networks. Promote partnerships for the prevention and control of noncommunicable diseases through cross - sectoral approach and collaboration with relevant professional associations. Upgrade health care delivery and incorporate the control and management of noncommunicable diseases into the PHC system, supported by the establishment of a disease-specific registry. Please note that the 3rd generation CCS 2014-20g finalize © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Syria Updated May 2018