World Health Organization Syrian Arab Republic: annual report 2016

ANNUAL REPORT 2016 World Health Organization Syrian Arab Republic WHO Country Office (Damascus, Syrian Arab Republic) Elizabeth Hoff, WHO Representative hoffe@who.int WHO Country Office (Damascus, Syrian Arab Republic) Noha Alarabi, Donor and Reporting Officer alarabin@who.int WHO Headquarters (Geneva, Switzerland) Cintia Diaz-Herrera, Team Leader, Resource Mobilization for Appeals WHO Health Emergencies Programme diazherrerac@who.int Photo credits for cover photo: Aleksander Nordahl WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean World Health Organization Syrian Arab Republic annual report 2016 / World Health Organization. Regional Office for the Eastern Mediterranean p. ISBN: 978-92-9022-202-6 ISBN: 978-92-9022-203-3 (online) 1. Health Status - Syria 2. Health Services Accessibility - Syria 3. Delivery of Health Care 4. Emergency Medical Services 5. Financial Support 6. Annual Reports I. Title II. Regional Office for the Eastern Mediterranean (NLM Classification: WA 300) © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. 54 Photo Credits: WHO CONTENTS Foreword 1. Situation in 2016 2. Highlights 3. WHO’s response in 2016 • Leading the health response • Bridging the political divide - Working with the International Syria Support Group • Accessing people in need • Working with partners • Attacks on health care • The tragedy of Aleppo • Public health areas of focus 4. Funds received in 2016 5. Funding requirements for 2017 6. WHO offices and hubs • Inside Syria • Gaziantep • Amman Annex 1: activities and outputs by public health area of intervention 6 8 9 12 12 13 13 14 16 16 18 20 28 29 30 31 31 31 32 76 “As the conflict continues, more lives are lost every day, not just due to the violence, but as people become victims of a failing health care system that can no longer provide them with the health services they need to stay alive.” Dr Ala Alwan, former WHO Regional Director for the Eastern Mediterranean Photo Credits: WHO 98 Syria is entering its sixth year of conflict, and there is no end in sight. Access to health care remains severely compromised. More than half of hospitals and health care facilities in Syria are either closed or functioning only partially, and there are severe shortages of staff, equipment and supplies. Over half the country’s health care personnel have left the country since the crisis began. In 2016, there were confirmed reports of 338 attacks on health care facilities across Syria. Many hospitals and health care facilities have been damaged beyond repair, depriving people of health care just when they need it most. In addition, around 30 000 people each month are injured in the conflict. Without timely and appropriate treatment, many of them will suffer lifelong disabilities. The long-term economic and health consequences to the country are incalculable. A quarter of the population in Syria lives in besieged and hard-to-reach locations. Throughout 2016, WHO continued to advocate for regular access to people in these areas. To some extent, its efforts have paid off. WHO and its humanitarian partners were able to deliver humanitarian assistance to all besieged areas in Syria for the first time since the conflict began. However, access remained sporadic, and government forces continued to confiscate essential medicines and surgical supplies from inter-agency convoys. Moreover, the government continues to withhold approvals to evacuate critically ill patients from besieged areas. Only two of WHO’s 18 requests to evacuate critically ill patients from the besieged areas of Madaya, east Aleppo and Foah were authorized. Diplomatic efforts to end the conflict continue. WHO has strongly supported the work of the International Syria Support Group (ISSG) , whose mandate is to negotiate a political solution to end the crisis. The ISSG led the efforts to negotiate increased access to besieged and hard-to-reach areas. Moreover, it was instrumental in gaining all parties’ acceptance of the detailed medical evacuation plan for east Aleppo that was prepared by WHO on behalf of its UN partners. A WHO team remained in Aleppo throughout December 2016 to oversee its implementation. WHO and staff from the Syrian Arab Red Crescent monitored the departure of the remaining residents of east Aleppo to make sure that all parties complied with the terms and conditions of the evacuation plan. Thanks to this meticulous planning and monitoring, around 35 000 people were safely evacuated in just over one week. WHO’s painstaking work in Aleppo will serve as a blueprint for similar operations in the future. In 2017, WHO will continue to advocate for unimpeded access to all parts of Syria to assess health care needs and ensure that people receive appropriate health care and follow up. Seriously ill patients in besieged areas must be promptly evacuated for proper medical care, and their safe return to their homes and families must be guaranteed. WHO extends its heartfelt thanks to all staff and partners for their commitment, collaboration and trust. I wish to pay particular tribute to the Syrian Arab Red Crescent for its dedication and support. In a year full of tragedy, it suffered its own devastating losses in the bombing at Orem Al-Kubra in November 2016. Elizabeth Hoff FOREWORD Photo Credits: Aleksander Nordahl 1110 Intense hostilities continued across many parts of Syria in 2016. The situation remained characterized by widespread violence, indiscriminate attacks on civilian populations, serious human rights violations and mass population displacements. As a result, an already catastrophic humanitarian situation deteriorated yet further. By the end of 2016, more than 300 000 people had been killed and over 1.5 million had been injured since the crisis began. A total of 13.5 million people were in need of humanitarian assistance, 6.5 million people had been forced from their homes, and around 4.8 million had sought refuge in other countries. Almost one million people remained trapped in besieged areas, and almost four million were living in hard-to-reach areas, including one million who were militarily encircled. More than 80% of the population is living below the poverty line. Many children have known nothing but conflict. In February 2016, the situation offered a glimmer of hope with the International Syria Support Group’s adoption of the Munich Declaration setting out the terms of a cessation of hostilities. UN Security Council resolution 2268, adopted later that month, endorsed the Munich Declaration and also demanded a cessation of hostilities. These initiatives resulted in a short-lived reprieve, but the violence soon resumed, with devastating impacts on civilian populations. In the absence of a political solution, the conflict looks set to continue in 2017. Thanks to sustained diplomatic pressure, access to besieged and hard-to-reach areas improved • Over 11 million treatments delivered across Syria, of which over 1.7 million were delivered through cross-border operations. • Essential medical equipment and ambulances distributed to hospitals and health care facilities. • Children in besieged and hard-to-reach areas vaccinated against childhood diseases. • All 18 besieged areas reached with humanitarian health assistance. • 34 cross-border missions conducted to besieged and hard-to-reach locations. significantly in 2016 compared to the previous year. By the end of the year, WHO and its UN partners were able to reach all besieged locations with desperately needed humanitarian assistance. However, government forces continued to systematically remove life-saving medical and surgical supplies from cross-line inter-agency convoys, and medical evacuations continued to be obstructed by the parties to the conflict. Impact of crisis on health care delivery The destruction of hospitals and health care facilities has deprived millions of people of access to even basic health care. Around half of Syria’s public hospitals and health care centres are either closed or only partially functional. Those that remain operational have suffered daily power cuts, and only 12% of them have back-up generators. In some areas, the prevailing insecurity remains a major obstacle to accessing health care. As a result of lack of access to timely trauma care, up to one third of those injured in the conflict will suffer life-changing disabilities and will require long-term care. Many pregnant women have no access to life-saving obstetric care or essential reproductive health care. Patients with untreated chronic diseases face the prospect of death or disabilities. The mass exodus of health care professionals and the collapse of the national health information system have compounded the dire health situation. • 1618 sentinel sites across the country reporting to the disease early warning and response system/ network. • Nutritional surveillance services for children under five expanded to 445 health care centres. • Health care facilities across the country continually assessed. • More than 41 000 health care staff trained on a wide range of topics including trauma care, first aid, primary health care, reproductive health, and the management of noncommunicable diseases. • Over US$ 43 million mobilized in funding support. 1. SITUATION IN 2016 2. HIGHLIGHTS Photo Credits: WHO 1312 Thirteen year old Bakry is from east Aleppo. He has congenital deformations in both feet, and cannot walk without assistance. Miraculously though, he can ride a bicycle. Bakry’s father and his two brothers left home four months ago to buy food. That was the last time he ever saw them. He wants to know what happened. He dreams of them all the time. Along with thousands of others, Bakry and his mother were forced to leave their home during the evacuation of east Aleppo in December 2016. Due to poor health, Bakry’s mother couldn’t carry her son. Bakry had to ride his bike. Bakry and his mother trudged and cycled for ten hours through the snow to reach the checkpoint. They were greeted by chaos, as hundreds of families waited to leave the city. Bakry and his mother endured a night of sub-zero temperatures before they were allowed to get on one of the buses. They finally reached Jibreen collective shelter 22 hours later. Sadly, the journey through east Aleppo had taken a toll on both Bakry and his bike. His feet were swollen and injured, and his bike was damaged beyond repair. A team of volunteers in the shelter inspected Bakry’s feet and referred him to a local hospital for observation. He was discharged two days later, happy to be reunited with his mother but downcast at the loss of his bike. However, thanks to a private donation from an Italian donor, and to Bakry’s immense joy, WHO replaced his bike. It is impossible not to admire the bravery of children like Bakry who survive the horrors of war. His story is a lesson in courage. A BOY AND HIS BIKE Photo Credits: WHO 1514 3. WHO’S RESPONSE IN 2016 LEADING THE HEALTH RESPONSE WHO leads and coordinates more than 80 health partners including UN agencies, international NGOs, the International Committee of the Red Cross, the International Federation of Red Cross and Red Crescent Societies, and the Syrian Arab Red Crescent (SARC). Its main office in Damascus and its hubs in Gaziantep and Amman regularly convene meetings of health partners to plan, implement and monitor the overall health response. WHO coordinates strategic planning and operational reviews, leads the process of assessing humanitarian health needs and oversees the preparation of the health component of the annual humanitarian response plan for Syria. BRIDGING THE POLITICAL DIVIDE On behalf of all health partners, WHO has consistently advocated at the highest diplomatic levels for unhindered access to all areas in the country. The Organization maintains close links with the International Syria Support Group, the Office of the Special Envoy for Syria, the Syrian Arab Red Crescent (SARC), the International Committee of the Red Cross, and community and religious leaders across the country.It continually advocates with senior government representatives for unhindered access to all parts of Syria. Although its advocacy efforts are highly visible and politically sensitive, it has remained firmly neutral in presenting arguments driven by humanitarian needs and the obligation to treat all people equally regardless of their political affiliations. The UN Security Council (UNSC) has played a key role in facilitating WHO’s interventions in Syria. Several UNSC resolutions have called on the Syrian government to permit all parts of the country to access humanitarian Working with the International Syria Support Group WCO/Syria has strongly supported the work of the International Syria Support Group (ISSG), whose mandate is to find a diplomatic solution to the Syria crisis. The ISSG is co-chaired by the US and Russia and includes senior representatives of over 20 governments. WHO has used several health initiatives to support the ISSG’s efforts to rebuild trust among the different communities in Syria. For example, the In 2016, health partners focused on four core functions: coordination, health information, health systems, and filling gaps in health care delivery. WHO and its partners prepared joint contingency plans, improved information sharing, and strengthened cross-line and cross-border operations. WHO worked closely with the UN country team led by the Humanitarian Coordinator and with the Water, Sanitation and Hygiene, Nutrition and Logistics clusters to plan operations and pool resources. aid. Resolutions 2165 and 2191 authorizing cross- border operations have been instrumental in allowing aid to be delivered to people who cannot be reached by WHO’s office in Damascus. WHO has also drawn on international health agreements, treaties and legal instruments and declarations such as the International Health Regulations, international humanitarian law, the Geneva Conventions and the UN Declaration on Noncommunicable Diseases. In November 2016, the head of the WHO country office in Syria briefed the UN Security Council on the health situation in Syria, via video link, during the Council’s meeting on the situation in the Middle East. She outlined the dire health situation inside Syria and the challenges it presented for WHO’s work on the ground, and appealed to the Council to use every last ounce of its influence to bring an immediate end to attacks on health care facilities and the suffering in Syria. Organization has prepared detailed plans for mass vaccination, and has suggested that these campaigns be used to help bring different communities together. The ISSG was instrumental in helping negotiate the government’s acceptance of the detailed medical evacuation plan for east Aleppo that was prepared by WHO on behalf of its UN partners. WHO Representative giving a speech to the Security Council on attacks of health facilities. Photo Credits: WHO ACCESSING PEOPLE IN NEED Distribution of NGOs More than a quarter of Syrians live in areas that are classified as besieged or hard to reach. Many of these areas are off limits to UN agencies, and they are often those where the acute needs are greatest. WHO relies heavily on national NGOs to deliver essential health care services in these locations. In 2016, thanks to inter-agency convoys, WHO was able to deliver life-saving supplies to Darayya (Rural Damascus) for the first time in almost four years. Other long-besieged towns also received life-saving Government security forces continued to remove medical supplies, particularly trauma kits, surgical supplies, anaesthetics and antibiotics, from inter- agency convoys. Medical supplies were confiscated from more than three quarters of these convoys. By the end of the year, the national authorities had confiscated 75 tons of medicines and medical supplies. Moreover, attempts to deliver aid to besieged areas were deliberately obstructed or delayed. Between January and December 2016, WHO submitted 41 Q4 Q3 Q2 Q1 Number of treatments rejected Number of treatments approved 176,140 328,177 49,188 618,125 71,713 820,015 25,345 979,217 Medicines and supplies delivered via inter-agency convoys in 2016 assistance. For example, on 10 June 2016, an inter- agency convoy of 38 trucks laden with humanitarian supplies entered the besieged town of Duma for the first time in more than two years. By the end of 2016, inter-agency convoys had delivered aid to all besieged locations in Syria. WHO participated in 69 inter-agency convoys and undertook 34 cross-border missions to hard-to-reach and besieged locations. On behalf of its health partners, it consolidated lists of medical supplies and equipment to be included in convoys and monitored their safe delivery. requests to national authorities to deliver medicines and supplies to 117 locations in 11 governorates. Fewer than half of these requests were approved; the remainder went unanswered. WHO reports all incidents of rejected and confiscated items and government withholding of approvals for the delivery of humanitarian aid to the UN Security Council and to donors. WHO has steadfastly advocated for the safe delivery of all medical supplies to all area in Syria. Damascus Dar'a Quneitra As-Sweida Lattakia Tartous Al-Hasakeh Deir-ez-Zor Ar-Raqqa Idleb Rural Damascus Homs Hama Aleppo 1716 Hard to reach areas Headquarter 68 Health center (dispensary) 125 Dialysis center 7 Mobile clinic 13 Hospital 10 Beisiged areas Pharmacy 9 Psychiatric clinic 1 H H H H H H H H 1918 WORKING WITH PARTNERS WHO leads and coordinates health sector agencies working on the emergency response. WHO’s network of national and local partners includes academia, professional associations, NGOs and students. The WHO country office in Damascus draws on approximately 70 NGO partners who deliver essential health care in hard-to-reach and besieged areas. These NGOs have undergone stringent vetting by the WCO and by the United Nations Office of the Special Envoy for Syria. As much as 30% of WHO’s humanitarian budget is dedicated to supporting its NGO partners. The Organization has established rigorous mechanisms to assess potential NGO partners, train them, and monitor their performance. WHO’s network of focal points throughout Syria assesses needs, monitors ongoing activities, and reviews health facility and NGO records to ensure that WHO’s supplies are reaching end beneficiaries. This has allowed WHO to operate effectively, delivering humanitarian supplies based on real-time needs assessments conducted by those who are able to witness the situation on the ground at first hand. WHO staff talk to children at Al-Mabara NGO in Aleppo. MEDICAL EVACUATIONS FROM BESIEGED AND HARD-TO-REACH LOCATIONS The blockage of urgent medical evacuations results in unnecessary civilian deaths and suffering. WHO has consistently advocated for the regular medical evacuation of critically ill people (and accompanying family members) for life-saving medical care, together with guarantees for their safe return following treatment. In early 2016, as a result of WHO’s sustained advocacy, the national authorities agreed to authorize medical evacuations from besieged and hard-to-reach areas. As an immediate consequence hundreds of people were evacuated for urgent medical treatment. Since then, however, medical evacuations have been approved only sporadically. Moreover, the SARC’s plan to deploy mobile clinics to besieged and hard- to-reach locations on a permanent basis, submitted to the national authorities several months ago, has yet to be approved. In 2016, the government approved only two of WHO’s 18 requests to evacuate critically ill patients from the besieged areas of Madaya, east Aleppo and Foah. Even when patients are evacuated, they do not always receive treatment in time. Moaz and Nawras Hashash, conjoined twins from Eastern Ghouta, were just two of the children requiring urgent medical care in 2016. They were evacuated, but later died. Photo Credits: WHO 2120 ATTACKS ON HEALTH CARE The number of attacks on hospitals and health care facilities in Syria continued to rise despite intense international attention and media reports. Syria is now the most dangerous country in the world for health care workers. Hundreds have been killed. Thousands more have courageously chosen to stay behind and fulfil their oath to save lives. Some have literally gone underground to keep providing care. In 2016, there were confirmed reports of 338 attacks on health care facilities across Syria. Over 30 health care workers were killed and almost 100 were wounded. WHO has repeatedly condemned these attacks in the strongest possible terms . Nonetheless, they continue unabated. More than half the country’s hospitals and health care facilities have either closed http://www.emro.who.int/media/news/whocondemns-multiple-attacks-on-health-facilitiesin- the-syrian-arab-republic.html Attacks on health care facilities and workers have enormous impacts on the communities that they serve. For example, before three hospitals in rural Western Aleppo were attacked, they provided more than 10 000 consultations and 1500 surgeries per month. Every attack on the health care system has a domino effect. Its immediate consequence is to deprive people of urgently needed care when they need it most. The long-term consequences include the need to rebuild and re-equip hospitals and train new doctors and other health care professionals. The The remains of a burnt-out truck containing WHO medicines and supplies destined for Orem Al-Kubra. associated costs can run to hundreds of millions of dollars. Moreover, the health of the population can be severely affected. People with chronic diseases go without treatment, children are not vaccinated, and those who suffer traumatic injuries often die or are left with life-changing disabilities. The overall costs to the country are incalculable. WHO is working to document attacks on health care facilities in Syria and around the world, and recommend concrete actions including national legislation and policies to reduce the risk of attacks during conflicts and other emergencies. or are only partially functional. Hospitals and other health care facilities in east Aleppo have been almost obliterated. The dangers faced by health care workers were starkly illustrated in November 2016, when a SARC convoy with UN supplies headed for Orem Al- Kubra in Aleppo was destroyed while offloading 31 UN-contracted commercial trucks carrying flour, medicines and supplies, winter clothes and blankets for 78 000 people. The SARC warehouse and most of the trucks were destroyed. At least 18 people including the head of the SARC in Orem Al-Kubra were killed. WHO alone lost nine tons of emergency medicines and supplies destined for hospitals and health care centres in Aleppo and Orem Al-Kubra. 2322 THE TRAGEDY OF ALEPPO In 2016, Aleppo, a city of 1.8 million people, became the most visible face of Syria’s suffering. Throughout the year, there was severe, sustained fighting between government and opposition forces, with control of several parts of east Aleppo passing back and forth between them. Tens of thousands of people in east Aleppo were trapped and living in dire conditions, without electricity and with severely limited access to food, water and health care. Hundreds of people were killed and thousands more were injured as the heavy ground fighting and bombardments continued. West Aleppo came under sustained mortar and rocket attacks. Its hospitals were overwhelmed and working round the clock to handle the huge numbers of wounded patients, many of whom were severely injured and required emergency surgery and follow up care. WHO deployed additional staff to west Aleppo and donated more than 700 tons of medical supplies. In early December 2016, government forces escalated their military operations in east Aleppo. Around 90 000 residents fled the area and sought refuge in other locations, including government- designated collective shelters in the western part of the city. WHO deployed six mobile clinics to west Aleppo, and distributed around 300 tons of medicines and supplies to the hospitals, health care facilities and NGO partners responding to this new wave of displacements. Senior staff from WHO including the head of the office in Damascus spent several weeks in west Aleppo to monitor the unfolding situation and prepare for a mass evacuation of the remaining residents of east Aleppo. Humanitarian access to east Aleppo remained severely restricted. WHO repeatedly called for the immediate and safe evacuation of the sick and wounded out of east Aleppo, and the safe passage of medicines and medical supplies into the area. The Organization worked closely with UN partners to prepare detailed medical evacuation plans based on different scenarios. It continued to work with the International Syria Support Group to negotiate a ceasefire that would be honoured by all parties and allow it to implement its plans. In the absence of a sustainable ceasefire, and despite brief reprieves, the situation in east Aleppo continued to deteriorate. By the end of September 2016, the situation was increasingly desperate. Most of east Aleppo’s hospitals and health care facilities had been destroyed, and supplies of food, water, medicine and fuel were dwindling rapidly. WHO staff inspect the rubble of a PHC centre in east Aleppo destroyed by bombardments. WHO had been supporting this centre since 2014. People newly displaced from east Aleppo wait to be seen at a mobile clinic in west Aleppo donated by WHO. In December 2016, more than 20 000 people were treated at the six mobile clinics donated by WHO. Almost 1400 people were referred to hospitals for advanced care. Photo Credits: WHO Photo Credits: WHO 25 By 13 December 2016, just 35 000 people were left in a handful of neighbourhoods in east Aleppo. The government announced that it would begin evacuating them according to the UN’s painstakingly negotiated humanitarian medical evacuation plan. Between 15 and 22 December, the remaining residents of east Aleppo were evacuated in a meticulously orchestrated operation. Families were loaded into waiting buses at an agreed checkpoint and taken across the city to a second checkpoint, from where they departed for the opposition-controlled areas of Idleb and rural western Aleppo. Several hundred WHO staff meet with the vaccination team at Hanano collective shelter in west Aleppo. The team is responsible for making sure that all children under five years of age evacuated from east Aleppo are vaccinated against polio. seriously ill patients were evacuated by ambulance. WHO, the ICRC and the SARC monitored the evacuation, and ensured that the seriously ill and wounded were referred to hospitals in Idleb and rural western Aleppo on arrival. The health cluster in Gaziantep deployed more than 150 ambulances to transport the ill and injured. WHO pre-positioned emergency medicines and supplies in referral hospitals in western rural Aleppo and Idleb, and set up medical checkpoints to assess and treat patients. More than 20 mobile clinics along the route to Idleb were on standby to provide health care. By 22 December 2016, around 35 000 people had been successfully evacuated. WHO also supported three multi-antigen vaccination campaigns that reached over 800 000 children in besieged and hard-to-reach locations. Primary health care Primary health care (PHC) services are generally the point of entry for patients seeking health care. When PHC services are disrupted, patients cannot obtain ongoing health care or be assessed and if necessary referred to hospitals or specialized health care centres. In 2016, WHO trained over 20 000 health care workers to provide basic PHC, donated medicines and supplies to support PHC centres, and purchased ambulances to strengthen referral services. Given the heavy burden of noncommunicable diseases (NCDs) including diabetes and kidney diseases, much of WHO’s efforts focused on procuring medicines to treat NCDs and supplies for haemodialysis centres. Vaccination coverage rates in Syria: 2009-2016 100 90 80 70 60 %50 40 30 20 10 0 Polio 3 Measles2 DTP3 2009 99 99 91 97 78 75 67 60 62 66 68 66 64 60 51 57 63 68 64 2010 2011 2012 2013 2014 2015 2016 Photo Credits: WHO 24 PUBLIC HEALTH AREAS OF FOCUS Trauma care Trauma is a leading cause of mortality and morbidity in Syria, with 30% of trauma cases resulting in permanent disabilities requiring long-term rehabilitative care. WHO has donated trauma care medicines, surgical supplies and kits, equipment for operating theatres and intensive care units, and prosthetic devices. The Organization has trained health care workers on basic trauma care, and supported the strengthening of physical rehabilitation services across the country. Childhood vaccination Vaccination rates have dropped sharply since the conflict began (see chart below). The polio outbreak in Deir ez-Zor at the end of 2013 served as a dramatic reminder of the importance of vaccination. In 2016, WHO, UNICEF and other partners implemented five mass vaccination polio campaigns, each of which reached an average of 2.3 million children under five years of age. Thanks to these interventions, Syria has remained polio-free for the last three years. 2726 Secondary health care Because of the widespread destruction of health care facilities, many people who need specialist medical care can no longer access it. They face long-term health consequences that have significant costs for the health care system. In 2016, WHO donated emergency equipment and supplies to support hospital operating theatres and intensive care units, and other specialist supplies to support haemodialysis sessions. Mental health Despite, or perhaps because of, the challenges, mental health services in Syria are becoming more widely available. WHO has trained health care staff in primary health care facilities on its Mental Health Gap Action Programme (mhGAP), which aims to scale up services for mental, neurological and substance use disorders in countries with scarce resources. Mental health care is now being offered in primary and secondary health care facilities in some of the most affected governorates in Syria. In contrast, before the conflict began, mental health care was provided in hospitals in just two cities Nutrition Malnutrition rates are rising across the country, especially in besieged and hard-to-reach locations where people face acute shortages of basic life necessities. WHO has worked with UNICEF to support the establishment of nutrition stabilization centres and the revitalization of the national nutrition surveillance system. WHO continues to promote breastfeeding promotion and appropriate infant and young child feeding practices in line with WHO and UNICEF guidelines. Disease surveillance and response The maintenance of epidemiologic surveillance and response to communicable disease outbreaks is of utmost public health importance. WHO’s disease early warning and response system/network (EWARS/N) serves as the primary mechanism for monitoring and responding to disease outbreaks in Syria. WHO has trained health care staff on EWARS/N, and donated laptops, mobile phones and other equipment to strengthen timely reporting. In 2016, the number of health care facilities reporting to EWARS/N rose from 1512 to 1618. No major disease outbreaks were reported in Syria in 2016. Health information Throughout 2016, WHO published regular information on the status of health care facilities in Syria. These data are crucial to inform decision making and help ensure that scarce resources are directed to where they are needed most. According to WHO’s Health Resources Availability Mapping System (HeRAMS), the number of medical doctors working in public hospitals dropped by almost 3% between May and November 2016 alone. Water, Sanitation and Hygiene (WASH) Sufficient quantities of clean water are essential to the safe and efficient functioning of hospitals. Clean water is necessary for simple things like hand washing, bathing patients and preparing food. It is needed for sterilizing surgical instruments. It must be rigorously purified for use in haemodialysis. In 2016, WHO’s specialist water engineers installed equipment to provide safe and reliable water supplies for five hospitals in Aleppo. This included drilling and equipping five groundwater wells, and installing water filtration and purification equipment, solar generators and water storage tanks. This ensured that each hospital would have at least a three-day supply of clean water to support its essential functions. Nine-year old Wafaa was at home with her father when their house in east Aleppo was rocked by a huge explosion. Wafaa screamed in pain as her body was set alight by the flames that ripped through the house. Her father covered her with blankets in a desperate attempt to staunch the flames, and took her to the nearest hospital. She was immediately transferred to a hospital in western Aleppo, and later referred to a specialist hospital in Turkey, where she remained for almost two months. Wafaa’s life has been saved, and her vision and hearing are unimpaired, but this once joyous little girl has been deeply scarred, both inside and outside. WAFAA’S STORY When the family recounts what they have been through, their grief and despair are evident. Wafaa’s mother Duaa had lost her own mother and all of her siblings during the conflict in Aleppo. She recalls how she broke down when she saw her daughter lying in a hospital bed, covered in bandages. Wafaa’s father had feared for his wife’s sanity when she followed her daughter to Turkey. Duaa has spent hours praying for her little girl to be restored to health. “Her burned face is the trigger for traumatic flashbacks. Wafaa suffers tremendously from other children’s taunts. They call her ‘deformed’, ‘ugly’, a ‘monster’.” Duaa would do anything to have her beautiful girl restored to a normal existence. Wafaa has four wishes. She would like to get medical treatment to restore her face and body. She would like to become a teacher so that she can help other children. She wants her mother to get well and not cry any more. And she wants God to forgive her friends and the people who hurt her and her family. Wafaa’s wishes are slowly coming true. Surgeons in Damascus will soon begin the long and painful process of cosmetic reconstruction. Her father has noticed a change in his daughter. “She grew up very quickly after her accident. She has gone back to school, and is determined to learn. And, for the first time in a very long time, my wife has begun to smile again.” Photo Credits: WHO Photo Credits: WHO 2928 3130 4. FUNDS RECEIVED IN 2016 5. FUNDS REQUIRED FOR 2017 WHO would like to thank the following donors for their generous support in 2016: Donor USAID Norway ECHO Pooled Fund -OCHA Kuwait DFID China Spain Japan Amount contributed (in US$) 17 500 000 8 550 015 6 726 457 5 861 180 2 000 000 1 578 947 1 000 000 335 196 100 000 43 651 795 WHO has requested a total of US$ 163 748 100 to implement the following interventions under the Humanitarian Response Plan for Syria for 2017: • Enhancing trauma care, mass casualty management and physical rehabilitation: US$ 25 365 900 • Strengthening secondary health care, obstetric care and referral services: US$ 60 372 500 • Sustaining delivery of primary health care: US$ 34 307 500 • Reinforcing immunization and polio eradication activities: US$ 22 156 000. • Enhancing and expanding disease early warning alert and response systems/networks: US$ 5 549 750. • Integrating mental health and psychosocial support services in primary, secondary and tertiary health care services and at community level: US$ 4 785 000. • Reinforcing inter- and intra- hub health sector coordination: US$ 3 086 250 . • Reinforce Health Information Systems for Emergency Response and Resilience - US$ 1 527 700. • Enhancing the prevention and early detection of malnutrition in children under five and referral services for patients with severe acute malnutrition with complications: US$ 1 666 250; • Establishing sustainable quality water supply and integrated medical waste management systems in health care facilities; supporting WASH services in under -served and vulnerable populations and IDPs: US$ 4 931 250. USAID 11.3% China 0.6% Funding Gap 71.9% Spain 0.2% Japan 0.1% Norway 5.5% Kuwait 1.3% ECHO 4.3% 33 6. WHO OFFICES AND HUBS Inside Syria In Damascus, WHO leads the health sector response and coordinates more than 80 health sector partners. WHO’s country office in Damascus comprises around 80 public health and support staff, and focuses on the following areas: 1. Leadership: Whole of Syria joint strategic planning, implementation, monitoring and reporting. 2. Advocacy: advocate with the highest levels of government for sustained access to all parts of the country to deliver humanitarian aid. 3. Health diplomacy: support the work of the International Syria Support Group and the Office of the Special Envoy for Syria. 4. Information: coordinate the collection, analysis and dissemination of information on health risks, needs and gaps across Syria. Gaziantep, Turkey WHO’s hub in Gaziantep coordinates around 58 health cluster partners working in opposition-controlled areas in northern Syria. The office comprises around 20 staff. It collects and analyses health information on health needs and gaps to support the emergency response, and documents attacks on health care to support WHO’s advocacy efforts. Public health officers in Gaziantep provide material support and guidance to NGO partners providing health care services in northern Syria. The office trains health care workers to fill gaps in the provision of health care services, and provides technical support for mass vaccination campaigns for children in besieged and hard-to-reach areas. A total of 506 health care facilities report to the disease early warning and response network (EWARN) managed by Gaziantep. Amman, Jordan Two WHO staff in the Amman hub are responsible for leading and coordinating health partners working in opposition-controlled areas in southern Syria. WHO Amman leads the health sector working group comprising 21 UN agencies, national and international NGOs, and local health authorities. It provides direct support to 76 primary health care centres and field hospitals in southern Syria (64 in Daraa and Quneitra governorates and 12 in Rural Damascus). Regional and headquarters offices WHO’s regional office in Cairo and its headquarters office in Geneva provide strategic guidance, technical expertise, surge, communications and resource mobilization support. 5. Resource mobilization: raise funds to support WHO’s work in Syria. 6. Strategic communications: disseminate quarterly Whole of Syria donor updates; present WHO’s work in Syria in international fora. 7. Technical expertise: provide technical advice to partners; ensure that critical gaps in the emergency response are filled. WHO’s four sub-offices in Aleppo, Hassakeh, Homs and Lattakia work closely with WHO’s network of focal points throughout the country to monitor the health response and report back to Damascus on emerging needs. 32 Damascus Dar'a Quneitra As-Sweida Lattakia Tartous Al-Hasakeh Deir-ez-Zor Ar-Raqqa Idleb Rural Damascus Homs Hama Aleppo Gaziantep Amman Damascus WHO office WHO sub office Hard to reach areas Beisiged areas Quamishli sub office Aleppo sub office Lattakia sub office Homs sub office WHO OFFICES AND SUB OFFICES Annex 1 Activities by area of intervention Coordination Primary health care Trauma care Secondary health care Mental health Outputs Medicines and supplies donated Training Vaccination campaigns Other activities Medicines and supplies donated Medicines and supplies donated Medicines and supplies donated Training Training Other outputs Other outputs Training Other outputs Coordinated: • Health partners’ participation in inter-agency convoys and the health supplies to be included in each one. • The health sector response to displaced people in the governorates of Al-Hasakeh, Tartous and Rural Damascus. • The emergency health response to the refugee influx from Mosul, Iraq. • The development of a six-month plan to revitalize disrupted health services in Tadmor and Al-Qaryatien in Homs. • The continuity of health care services in the aftermath of attacks on health care facilities. • The evacuation of residents of east Aleppo in December 2016. • The development of a contingency plan to continuing supplying priority health care centres in northern Syria. • The assessment of health care facilities in besieged and hard-to-reach locations covered by inter-agency humanitarian convoys. Advocated: • For the use of SARC mobile clinics in hard-to-reach and besieged locations. • For greater access to besieged and hard-to-reach areas to assess health needs, identify gaps and deliver humanitarian aid. Monitored: • Attacks on health care facilities and personnel. • The overall health response. Informed: • The Special Advisor to the United Nations Special Envoy by means of regular updates addressing the evolving health situation in Syria and access to besieged and hard- to-reach areas. These updates were forwarded to ISSG members. • Over 4 million treatments delivered to more than 800 health care facilities across the country. • 26 406 primary health care providers trained on basic routine immunization services, vaccine management, cold chain and logistics, AFP surveillance, management of noncommunicable diseases, reproductive health, childhood illnesses. • Three polio vaccination campaigns conducted (approximately 2.3 million children vaccinated in each campaign). • Three multi-antigen vaccination campaigns conducted in hard-to-reach and besieged areas. Over 800 000 children were vaccinated. • Two health care centres rehabilitated in Quneitra and Rural Damascus governorates. • Over 2 million treatments including life-saving medicines, surgical supplies and kits. • 228 blood safety kits to screen donated blood for HIV, hepatitis B and C. Each kit contains enough supplies to test 2000 blood samples. • Anaesthesia machines, operating theatre equipment, beds for intensive care units, ultrasound machines, ventilators, incubators. • Over 800 artificial limbs and assistive devices. • 20 fully equipped ambulances (of which six were deployed to Aleppo). • Approximately 1.2 million treatments, including over 800 000 insulin injections. • Supplies to support 23 700 dialysis sessions. • Medical equipment for emergency and diagnostic services in Damascus, As-Sweida and Aleppo. • Medical and other supplies to cover the basic needs of patients in mental hospitals in Duma and Aleppo. • Over 29 600 psychotropic treatments distributed to 12 governorates. • 2409 health care workers trained on rational use of medicines, infection control, leadership, warehouse management and quality control. • 2958 health care workers and mental health professionals trained on mhGAP, psychological first aid, self-help strategies, psychotherapeutic interventions, supporting survivors of gender-based violence, treating substance abuse, and psychiatric nursing. • A study analysing the capacity of the secondary health care system to provide health care during the current crisis and in the longer term, based on an assessment of 14 hospitals in Syria. • Assessment of cancer care services in Syria. • Two psychiatric wards rehabilitated in hospitals in Hama and Lattakia. • Over 100 patients including the elderly and those with mental health problems relocated from east Aleppo to Ibn Khaldoun Hospital in December 2016. • Mental health and psychosocial support services supported in community centres in Aleppo. • 3786 health care workers trained on trauma care, first aid, basic life support. • Contingency plan to prepare for the possible use of chemical weapons in Aleppo governorate. • Updated WHO training course for clinicians and responders on dealing with exposure to chemical and hazardous materials. • Plan of action to address the growing needs for physical rehabilitation services. 34 35 Nutrition Disease surveillance Health information system Water, Sanitation and Hygiene Working with NGOs Medicines and supplies donated Medicines and supplies donated Supplies and equipment donated Supplies and equipment donated Other outputs Other outputs Training Disease outbreaks Other outputs Medicines and supplies donated Training courses Other outputs Other outputs • Therapeutic nutrition medicines and supplies, anthropometric equipment and WHO guidelines on the management of severe acute malnutrition distributed to hard-to- reach and besieged areas via inter-agency convoys. • 200 000 vials of meglumine antimoniate (to treat leishmaniasis). • Medicines to treat 6500 cases of brucellosis. • 527 laboratory kits and supplies for reference laboratories in Damascus and Aleppo. • 14 diarrhoeal disease kits, 70 000 capsules of influenza medicines, 250 000 vials of influenza vaccines. • 5426 blankets for areas with high rates of severe acute respiratory infection. • Cholera rapid diagnostic tests (distributed to most governorates). • Computers, laptops, tablets and mobile phones distributed to HeRAMS focal points across the country. • Two water treatment units for dialysis machines donated to dialysis centres in Aleppo and Homs. • 29 hand-operated water filtration units and 14 000 jerry cans donated to medical checkpoints and mobile clinics in hard-to-reach and besieged locations. • 38 mobile water quality testing instruments, reagents and consumables delivered to hard-to-reach and besieged locations. • Five unexploited groundwater wells in Aleppo rehabilitated. The wells supply safe water to five public hospitals in Aleppo. • Improved completeness of reporting. All 111 public hospitals and 99% of 1787 health centres report fully to HeRAMS. • Template launched to monitor attacks against health care facilities and staff. • Software applications and automated systems developed for WHO Syria and health partners. • Health care facilities assessed during 34 field visits. • Information on the status on functionality and accessibility of health care facilities regularly published. • HeRAMS launched in northern Syria. • Health care facilities in southern Syria that are accessible from Jordan assessed for the first time since March 2015. • 2534 health workers trained on disease surveillance, using EWARS, laboratory safety procedures, managing communicable diseases. • 199 cases of Guillain-Barré syndrome reported from Damascus, Lattakia and Rural Damascus governorates. WHO coordinated the collection of samples for testing and procured apheresis devices and immunoglobulin. • 16 suspected cases of meningitis reported from the besieged town of Madaya. WHO supported the evacuation of 11 patients, nine of whom were admitted to a Damascus hospital for investigation and treatment and two of whom were referred to facilities in Idleb. • Outbreaks of acute diarrhoea reported in four locations in Rural Damascus governorate. WHO donated diarrhoeal disease kits and worked with the Water, Sanitation and Hygiene sector to distribute water chlorination tablets. • 33% increase in severe acute respiratory infections compared to the same period in 2015. WHO distributed medicines, vaccines, antibiotics and blankets, printed awareness- raising materials and donated diagnostic tests to the public health laboratory. • Completeness and timeliness of reporting to the disease surveillance system/ network improved to over 85%. • Cholera preparedness plan. • Deworming campaign to reduce the prevalence of soil-transmitted worms among schoolchildren. Over 2 million children were treated. • Survey to assess the sero-prevalence of hepatitis B and C among selected groups. • 1.6 million treatments (including for trauma care, mental health, nutrition, primary and secondary health care) distributed to NGOs across the country. • More than 226 500 medical consultations provided by NGOs supported by WHO. • More than 25 000 patients in collective shelters in Aleppo received treatment through mobile clinics donated by WHO. • More than 30 000 people in NGO-managed community centres in Aleppo supported by WHO received mental health care and psychosocial support. • 1412 health care workers trained on nutrition surveillance, breastfeeding promotion, malnutrition care and management. • 70 grant agreements and over 270 in-kind donation agreements signed with 68 NGO partners managed by WHO’s office in Damascus. • 15 grant agreements signed with five NGO partners managed by WHO’s office in Gaziantep. • Breastfeeding counselling programme launched in 317 health care centres. Approximately 144 000 consultations provided thus far. • Early childhood development programmes integrated into nutrition programmes. • Baby-Friendly Hospital Initiative reactivated in 21 hospitals. • 18 stabilization centres launched in hospitals across the country. 788 patients with severe acute malnutrition with complications received life-saving treatment. • More than 614 000 children screened for malnutrition. 3736 Developed Countries Price: USD 30.00 Developing Countries Price: USD 20.00 ANNUAL REPORT 2016 World Health Organization Syrian Arab Republic WHO Country Office (Damascus, Syrian Arab Republic) Elizabeth Hoff, WHO Representative hoffe@who.int WHO Country Office (Damascus, Syrian Arab Republic) Noha Alarabi, Donor and Reporting Officer alarabin@who.int WHO Headquarters (Geneva, Switzerland) Cintia Diaz-Herrera, Team Leader, Resource Mobilization for Appeals WHO Health Emergencies Programme diazherrerac@who.int Photo credits for cover photo: Aleksander Nordahl 32 Photo Credits: WHO CONTENTS Foreword 1. Situation in 2016 2. Highlights 3. WHO’s response in 2016 • Leading the health response • Bridging the political divide - Working with the International Syria Support Group • Accessing people in need • Working with partners • Attacks on health care • The tragedy of Aleppo • Public health areas of focus 4. Funds received in 2016 5. Funding requirements for 2017 6. WHO offices and hubs • Inside Syria • Gaziantep • Amman Annex 1: activities and outputs by public health area of intervention 6 8 9 12 12 13 13 14 16 16 18 20 28 29 30 31 31 31 32 54 “As the conflict continues, more lives are lost every day, not just due to the violence, but as people become victims of a failing health care system that can no longer provide them with the health services they need to stay alive.” Dr Ala Alwan, former WHO Regional Director for the Eastern Mediterranean Photo Credits: WHO 76 Syria is entering its sixth year of conflict, and there is no end in sight. Access to health care remains severely compromised. More than half of hospitals and health care facilities in Syria are either closed or functioning only partially, and there are severe shortages of staff, equipment and supplies. Over half the country’s health care personnel have left the country since the crisis began. In 2016, there were confirmed reports of 338 attacks on health care facilities across Syria. Many hospitals and health care facilities have been damaged beyond repair, depriving people of health care just when they need it most. In addition, around 30 000 people each month are injured in the conflict. Without timely and appropriate treatment, many of them will suffer lifelong disabilities. The long-term economic and health consequences to the country are incalculable. A quarter of the population in Syria lives in besieged and hard-to-reach locations. Throughout 2016, WHO continued to advocate for regular access to people in these areas. To some extent, its efforts have paid off. WHO and its humanitarian partners were able to deliver humanitarian assistance to all besieged areas in Syria for the first time since the conflict began. However, access remained sporadic, and government forces continued to confiscate essential medicines and surgical supplies from inter-agency convoys. Moreover, the government continues to withhold approvals to evacuate critically ill patients from besieged areas. Only two of WHO’s 18 requests to evacuate critically ill patients from the besieged areas of Madaya, east Aleppo and Foah were authorized. Diplomatic efforts to end the conflict continue. WHO has strongly supported the work of the International Syria Support Group (ISSG) , whose mandate is to negotiate a political solution to end the crisis. The ISSG led the efforts to negotiate increased access to besieged and hard-to-reach areas. Moreover, it was instrumental in gaining all parties’ acceptance of the detailed medical evacuation plan for east Aleppo that was prepared by WHO on behalf of its UN partners. A WHO team remained in Aleppo throughout December 2016 to oversee its implementation. WHO and staff from the Syrian Arab Red Crescent monitored the departure of the remaining residents of east Aleppo to make sure that all parties complied with the terms and conditions of the evacuation plan. Thanks to this meticulous planning and monitoring, around 35 000 people were safely evacuated in just over one week. WHO’s painstaking work in Aleppo will serve as a blueprint for similar operations in the future. In 2017, WHO will continue to advocate for unimpeded access to all parts of Syria to assess health care needs and ensure that people receive appropriate health care and follow up. Seriously ill patients in besieged areas must be promptly evacuated for proper medical care, and their safe return to their homes and families must be guaranteed. WHO extends its heartfelt thanks to all staff and partners for their commitment, collaboration and trust. I wish to pay particular tribute to the Syrian Arab Red Crescent for its dedication and support. In a year full of tragedy, it suffered its own devastating losses in the bombing at Orem Al-Kubra in November 2016. Elizabeth Hoff FOREWORD Photo Credits: Aleksander Nordahl 98 Intense hostilities continued across many parts of Syria in 2016. The situation remained characterized by widespread violence, indiscriminate attacks on civilian populations, serious human rights violations and mass population displacements. As a result, an already catastrophic humanitarian situation deteriorated yet further. By the end of 2016, more than 300 000 people had been killed and over 1.5 million had been injured since the crisis began. A total of 13.5 million people were in need of humanitarian assistance, 6.5 million people had been forced from their homes, and around 4.8 million had sought refuge in other countries. Almost one million people remained trapped in besieged areas, and almost four million were living in hard-to-reach areas, including one million who were militarily encircled. More than 80% of the population is living below the poverty line. Many children have known nothing but conflict. In February 2016, the situation offered a glimmer of hope with the International Syria Support Group’s adoption of the Munich Declaration setting out the terms of a cessation of hostilities. UN Security Council resolution 2268, adopted later that month, endorsed the Munich Declaration and also demanded a cessation of hostilities. These initiatives resulted in a short-lived reprieve, but the violence soon resumed, with devastating impacts on civilian populations. In the absence of a political solution, the conflict looks set to continue in 2017. • Over 11 million treatments delivered across Syria, of which over 1.7 million were delivered through cross-border operations. • Essential medical equipment and ambulances distributed to hospitals and health care facilities. • Children in besieged and hard-to-reach areas vaccinated against childhood diseases. • All 18 besieged areas reached with humanitarian health assistance. • 34 cross-border missions conducted to besieged and hard-to-reach locations. Thanks to sustained diplomatic pressure, access to besieged and hard-to-reach areas improved significantly in 2016 compared to the previous year. By the end of the year, WHO and its UN partners were able to reach all besieged locations with desperately needed humanitarian assistance. However, government forces continued to systematically remove life-saving medical and surgical supplies from cross-line inter-agency convoys, and medical evacuations continued to be obstructed by the parties to the conflict. Impact of crisis on health care delivery The destruction of hospitals and health care facilities has deprived millions of people of access to even basic health care. Around half of Syria’s public hospitals and health care centres are either closed or only partially functional. Those that remain operational have suffered daily power cuts, and only 12% of them have back-up generators. In some areas, the prevailing insecurity remains a major obstacle to accessing health care. As a result of lack of access to timely trauma care, up to one third of those injured in the conflict will suffer life-changing disabilities and will require long-term care. Many pregnant women have no access to life-saving obstetric care or essential reproductive health care. Patients with untreated chronic diseases face the prospect of death or disabilities. The mass exodus of health care professionals and the collapse of the national health information system have compounded the dire health situation. • 1618 sentinel sites across the country reporting to the disease early warning and response system/network. • Nutritional surveillance services for children under five expanded to 445 health care centres. • Health care facilities across the country continually assessed. • More than 41 000 health care staff trained on a wide range of topics including trauma care, first aid, primary health care, reproductive health, and the management of noncommunicable diseases. • Over US$ 43 million mobilized in funding support. 1. SITUATION IN 2016 2. HIGHLIGHTS Photo Credits: WHO 1110 Thirteen year old Bakry is from east Aleppo. He has congenital deformations in both feet, and cannot walk without assistance. Miraculously though, he can ride a bicycle. Bakry’s father and his two brothers left home four months ago to buy food. That was the last time he ever saw them. He wants to know what happened. He dreams of them all the time. Along with thousands of others, Bakry and his mother were forced to leave their home during the evacuation of east Aleppo in December 2016. Due to poor health, Bakry’s mother couldn’t carry her son. Bakry had to ride his bike. Bakry and his mother trudged and cycled for ten hours through the snow to reach the checkpoint. They were greeted by chaos, as hundreds of families waited to leave the city. Bakry and his A BOY AND HIS BIKE Photo Credits: WHO mother endured a night of sub-zero temperatures before they were allowed to get on one of the buses. They finally reached Jibreen collective shelter 22 hours later. Sadly, the journey through east Aleppo had taken a toll on both Bakry and his bike. His feet were swollen and injured, and his bike was damaged beyond repair. A team of volunteers in the shelter inspected Bakry’s feet and referred him to a local hospital for observation. He was discharged two days later, happy to be reunited with his mother but downcast at the loss of his bike. However, thanks to a private donation from an Italian donor, and to Bakry’s immense joy, WHO replaced his bike. It is impossible not to admire the bravery of children like Bakry who survive the horrors of war. His story is a lesson in courage. 1312 3. WHO’S RESPONSE IN 2016 LEADING THE HEALTH RESPONSE WHO leads and coordinates more than 80 health partners including UN agencies, international NGOs, the International Committee of the Red Cross, the International Federation of Red Cross and Red Crescent Societies, and the Syrian Arab Red Crescent (SARC). Its main office in Damascus and its hubs in Gaziantep and Amman regularly convene meetings of health partners to plan, implement and monitor the overall health response. WHO coordinates strategic planning and operational reviews, leads the process of assessing humanitarian health needs and oversees the preparation of the health component of the annual humanitarian response plan for Syria. BRIDGING THE POLITICAL DIVIDE On behalf of all health partners, WHO has consistently advocated at the highest diplomatic levels for unhindered access to all areas in the country. The Organization maintains close links with the International Syria Support Group, the Office of the Special Envoy for Syria, the Syrian Arab Red Crescent (SARC), the International Committee of the Red Cross, and community and religious leaders across the country.It continually advocates with senior government representatives for unhindered access to all parts of Syria. Although its advocacy efforts are highly visible and politically sensitive, it has remained firmly neutral in presenting arguments driven by humanitarian needs and the obligation to treat all people equally regardless of their political affiliations. The UN Security Council (UNSC) has played a key role in facilitating WHO’s interventions in Syria. Several UNSC resolutions have called on the Syrian Working with the International Syria Support Group WCO/Syria has strongly supported the work of the International Syria Support Group (ISSG), whose mandate is to find a diplomatic solution to the Syria crisis. The ISSG is co-chaired by the US and Russia and includes senior representatives of over 20 governments. WHO has used several health initiatives to support the ISSG’s efforts to rebuild trust among the different communities in Syria. For In 2016, health partners focused on four core functions: coordination, health information, health systems, and filling gaps in health care delivery. WHO and its partners prepared joint contingency plans, improved information sharing, and strengthened cross-line and cross-border operations. WHO worked closely with the UN country team led by the Humanitarian Coordinator and with the Water, Sanitation and Hygiene, Nutrition and Logistics clusters to plan operations and pool resources. government to permit all parts of the country to access humanitarian aid. Resolutions 2165 and 2191 authorizing cross-border operations have been instrumental in allowing aid to be delivered to people who cannot be reached by WHO’s office in Damascus. WHO has also drawn on international health agreements, treaties and legal instruments and declarations such as the International Health Regulations, international humanitarian law, the Geneva Conventions and the UN Declaration on Noncommunicable Diseases. In November 2016, the head of the WHO country office in Syria briefed the UN Security Council on the health situation in Syria, via video link, during the Council’s meeting on the situation in the Middle East. She outlined the dire health situation inside Syria and the challenges it presented for WHO’s work on the ground, and appealed to the Council to use every last ounce of its influence to bring an immediate end to attacks on health care facilities and the suffering in Syria. example, the Organization has prepared detailed plans for mass vaccination, and has suggested that these campaigns be used to help bring different communities together. The ISSG was instrumental in helping negotiate the government’s acceptance of the detailed medical evacuation plan for east Aleppo that was prepared by WHO on behalf of its UN partners. WHO Representative giving a speech to the Security Council on attacks of health facilities. Photo Credits: WHO ACCESSING PEOPLE IN NEED Distribution of NGOs More than a quarter of Syrians live in areas that are classified as besieged or hard to reach. Many of these areas are off limits to UN agencies, and they are often those where the acute needs are greatest. WHO relies heavily on national NGOs to deliver essential health care services in these locations. In 2016, thanks to inter-agency convoys, WHO was able to deliver life-saving supplies to Darayya (Rural Damascus) for the first time in almost four years. Other long-besieged towns also received life-saving assistance. For example, on 10 June Government security forces continued to remove medical supplies, particularly trauma kits, surgical supplies, anaesthetics and antibiotics, from inter- agency convoys. Medical supplies were confiscated from more than three quarters of these convoys. By the end of the year, the national authorities had confiscated 75 tons of medicines and medical supplies. Moreover, attempts to deliver aid to besieged areas were deliberately obstructed or delayed. Between January and December 2016, WHO submitted 41 Q4 Q3 Q2 Q1 Number of treatments rejected Number of treatments approved 176,140 328,177 49,188 618,125 71,713 820,015 25,345 979,217 Medicines and supplies delivered via inter-agency convoys in 2016 2016, an inter-agency convoy of 38 trucks laden with humanitarian supplies entered the besieged town of Duma for the first time in more than two years. By the end of 2016, inter-agency convoys had delivered aid to all besieged locations in Syria. WHO participated in 69 inter-agency convoys and undertook 34 cross-border missions to hard-to- reach and besieged locations. On behalf of its health partners, it consolidated lists of medical supplies and equipment to be included in convoys and monitored their safe delivery. requests to national authorities to deliver medicines and supplies to 117 locations in 11 governorates. Fewer than half of these requests were approved; the remainder went unanswered. WHO reports all incidents of rejected and confiscated items and government withholding of approvals for the delivery of humanitarian aid to the UN Security Council and to donors. WHO has steadfastly advocated for the safe delivery of all medical supplies to all area in Syria. Damascus Dar'a Quneitra As-Sweida Lattakia Tartous Al-Hasakeh Deir-ez-Zor Ar-Raqqa Idleb Rural Damascus Homs Hama Aleppo 1514 Hard to reach areas Headquarter 68 Health center (dispensary) 125 Dialysis center 7 Mobile clinic 13 Hospital 10 Beisiged areas Pharmacy 9 Psychiatric clinic 1 H H H H H H H H 1716 WORKING WITH PARTNERS WHO leads and coordinates health sector agencies working on the emergency response. WHO’s network of national and local partners includes academia, professional associations, NGOs and students. The WHO country office in Damascus draws on approximately 70 NGO partners who deliver essential health care in hard-to-reach and besieged areas. These NGOs have undergone stringent vetting by the WCO and by the United Nations Office of the Special Envoy for Syria. As much as 30% of WHO’s humanitarian budget is dedicated to supporting its NGO partners. The Organization has established rigorous mechanisms to assess potential NGO partners, train them, and monitor their performance. WHO’s network of focal points throughout Syria assesses needs, monitors ongoing activities, and reviews health facility and NGO records to ensure that WHO’s supplies are reaching end beneficiaries. This has allowed WHO to operate effectively, delivering humanitarian supplies based on real- time needs assessments conducted by those who are able to witness the situation on the ground at first hand. WHO staff talk to children at Al-Mabara NGO in Aleppo. MEDICAL EVACUATIONS FROM BESIEGED AND HARD-TO-REACH LOCATIONS The blockage of urgent medical evacuations results in unnecessary civilian deaths and suffering. WHO has consistently advocated for the regular medical evacuation of critically ill people (and accompanying family members) for life-saving medical care, together with guarantees for their safe return following treatment. In early 2016, as a result of WHO’s sustained advocacy, the national authorities agreed to authorize medical evacuations from besieged and hard-to-reach areas. As an immediate consequence hundreds of people were evacuated for urgent medical treatment. Since then, however, medical evacuations have been approved only sporadically. Moreover, the SARC’s plan to deploy mobile clinics to besieged and hard- to-reach locations on a permanent basis, submitted to the national authorities several months ago, has yet to be approved. In 2016, the government approved only two of WHO’s 18 requests to evacuate critically ill patients from the besieged areas of Madaya, east Aleppo and Foah. Even when patients are evacuated, they do not always receive treatment in time. Moaz and Nawras Hashash, conjoined twins from Eastern Ghouta, were just two of the children requiring urgent medical care in 2016. They were evacuated, but later died. Photo Credits: WHO 1918 ATTACKS ON HEALTH CARE The number of attacks on hospitals and health care facilities in Syria continued to rise despite intense international attention and media reports. Syria is now the most dangerous country in the world for health care workers. Hundreds have been killed. Thousands more have courageously chosen to stay behind and fulfil their oath to save lives. Some have literally gone underground to keep providing care. In 2016, there were confirmed reports of 338 attacks on health care facilities across Syria. Over 30 health care workers were killed and almost 100 were wounded. WHO has repeatedly condemned these attacks in the strongest possible terms . Nonetheless, they continue unabated. More than half the country’s hospitals and health care facilities have either closed or are only partially functional. Hospitals and other health care facilities in east Aleppo have been almost obliterated. The dangers faced by health care workers were starkly illustrated in November 2016, when a SARC convoy with UN supplies headed for Orem Al- Kubra in Aleppo was destroyed while offloading 31 UN-contracted commercial trucks carrying flour, medicines and supplies, winter clothes and blankets for 78 000 people. The SARC warehouse and most of the trucks were destroyed. At least 18 people including the head of the SARC in Orem Al-Kubra were killed. WHO alone lost nine tons of emergency http://www.emro.who.int/media/news/whocondemns-multiple-attacks-on-health-facilitiesin- the-syrian-arab-republic.html The remains of a burnt-out truck containing WHO medicines and supplies destined for Orem Al-Kubra. medicines and supplies destined for hospitals and health care centres in Aleppo and Orem Al-Kubra. Attacks on health care facilities and workers have enormous impacts on the communities that they serve. For example, before three hospitals in rural Western Aleppo were attacked, they provided more than 10 000 consultations and 1500 surgeries per month. Every attack on the health care system has a domino effect. Its immediate consequence is to deprive people of urgently needed care when they need it most. The long-term consequences include the need to rebuild and re-equip hospitals and train new doctors and other health care professionals. The associated costs can run to hundreds of millions of dollars. Moreover, the health of the population can be severely affected. People with chronic diseases go without treatment, children are not vaccinated, and those who suffer traumatic injuries often die or are left with life-changing disabilities. The overall costs to the country are incalculable. WHO is working to document attacks on health care facilities in Syria and around the world, and recommend concrete actions including national legislation and policies to reduce the risk of attacks during conflicts and other emergencies. 2120 In 2016, Aleppo, a city of 1.8 million people, became the most visible face of Syria’s suffering. Throughout the year, there was severe, sustained fighting between government and opposition forces, with control of several parts of east Aleppo passing back and forth between them. Tens of thousands of people in east Aleppo were trapped and living in dire conditions, without electricity and with severely limited access to food, water and health care. Hundreds of people were killed and thousands more were injured as the heavy ground fighting and bombardments continued. West Aleppo came under sustained mortar and rocket attacks. Its hospitals were overwhelmed and working round the clock to handle the huge numbers of wounded patients, many of whom were severely injured and required emergency surgery and follow up care. WHO deployed additional staff to west Aleppo and donated more than 700 tons of medical supplies. THE TRAGEDY OF ALEPPO In early December 2016, government forces escalated their military operations in east Aleppo. Around 90 000 residents fled the area and sought refuge in other locations, including government- designated collective shelters in the western part of the city. WHO deployed six mobile clinics to west Aleppo, and distributed around 300 tons of medicines and supplies to the hospitals, health care facilities and NGO partners responding to this new wave of displacements. Senior staff from WHO including the head of the office in Damascus spent several weeks in west Aleppo to monitor the unfolding situation and prepare for a mass evacuation of the remaining residents of east Aleppo. Humanitarian access to east Aleppo remained severely restricted. WHO repeatedly called for the immediate and safe evacuation of the sick and wounded out of east Aleppo, and the safe passage of medicines and medical supplies into the area. The Organization worked closely with UN partners to prepare detailed medical evacuation plans based on different scenarios. It continued to work with the International Syria Support Group to negotiate a ceasefire that would be honoured by all parties and allow it to implement its plans. In the absence of a sustainable ceasefire, and despite brief reprieves, the situation in east Aleppo continued to deteriorate. By the end of September 2016, the situation was increasingly desperate. Most of east Aleppo’s hospitals and health care facilities had been destroyed, and supplies of food, water, medicine and fuel were dwindling rapidly. WHO staff inspect the rubble of a PHC centre in east Aleppo destroyed by bombardments. WHO had been supporting this centre since 2014. People newly displaced from east Aleppo wait to be seen at a mobile clinic in west Aleppo donated by WHO. In December 2016, more than 20 000 people were treated at the six mobile clinics donated by WHO. Almost 1400 people were referred to hospitals for advanced care. Photo Credits: WHO Photo Credits: WHO 23 By 13 December 2016, just 35 000 people were left in a handful of neighbourhoods in east Aleppo. The government announced that it would begin evacuating them according to the UN’s painstakingly negotiated humanitarian medical evacuation plan. Between 15 and 22 December, the remaining residents of east Aleppo were evacuated in a meticulously orchestrated operation. Families were loaded into waiting buses at an agreed checkpoint and taken across the city to a second checkpoint, from where they departed for the opposition- controlled areas of Idleb and rural western Aleppo. Several hundred seriously ill patients were WHO staff meet with the vaccination team at Hanano collective shelter in west Aleppo. The team is responsible for making sure that all children under five years of age evacuated from east Aleppo are vaccinated against polio. evacuated by ambulance. WHO, the ICRC and the SARC monitored the evacuation, and ensured that the seriously ill and wounded were referred to hospitals in Idleb and rural western Aleppo on arrival. The health cluster in Gaziantep deployed more than 150 ambulances to transport the ill and injured. WHO pre-positioned emergency medicines and supplies in referral hospitals in western rural Aleppo and Idleb, and set up medical checkpoints to assess and treat patients. More than 20 mobile clinics along the route to Idleb were on standby to provide health care. By 22 December 2016, around 35 000 people had been successfully evacuated. WHO also supported three multi-antigen vaccination campaigns that reached over 800 000 children in besieged and hard-to-reach locations. PUBLIC HEALTH AREAS OF FOCUS Trauma care Trauma is a leading cause of mortality and morbidity in Syria, with 30% of trauma cases resulting in permanent disabilities requiring long-term rehabilitative care. WHO has donated trauma care medicines, surgical supplies and kits, equipment for operating theatres and intensive care units, and prosthetic devices. The Organization has trained health care workers on basic trauma care, and supported the strengthening of physical rehabilitation services across the country. Childhood vaccination Vaccination rates have dropped sharply since the conflict began (see chart below). The polio outbreak in Deir ez-Zor at the end of 2013 served as a dramatic reminder of the importance of vaccination. In 2016, WHO, UNICEF and other partners implemented five mass vaccination polio campaigns, each of which reached an average of 2.3 million children under five years of age. Thanks to these interventions, Syria has remained polio-free for the last three years. Primary health care Primary health care (PHC) services are generally the point of entry for patients seeking health care. When PHC services are disrupted, patients cannot obtain ongoing health care or be assessed and if necessary referred to hospitals or specialized health care centres. In 2016, WHO trained over 20 000 health care workers to provide basic PHC, donated medicines and supplies to support PHC centres, and purchased ambulances to strengthen referral services. Given the heavy burden of noncommunicable diseases (NCDs) including diabetes and kidney diseases, much of WHO’s efforts focused on procuring medicines to treat NCDs and supplies for haemodialysis centres. Vaccination coverage rates in Syria: 2009-2016 100 90 80 70 60 %50 40 30 20 10 0 Polio 3 Measles2 DTP3 2009 99 99 91 97 78 75 67 60 62 66 68 66 64 60 51 57 63 68 64 2010 2011 2012 2013 2014 2015 2016 Photo Credits: WHO 22 2524 Secondary health care Because of the widespread destruction of health care facilities, many people who need specialist medical care can no longer access it. They face long- term health consequences that have significant costs for the health care system. In 2016, WHO donated emergency equipment and supplies to support hospital operating theatres and intensive care units, and other specialist supplies to support haemodialysis sessions. Mental health Despite, or perhaps because of, the challenges, mental health services in Syria are becoming more widely available. WHO has trained health care staff in primary health care facilities on its Mental Health Gap Action Programme (mhGAP), which aims to scale up services for mental, neurological and substance use disorders in countries with scarce resources. Mental health care is now being offered in primary and secondary health care facilities in some of the most affected governorates in Syria. In contrast, before the conflict began, mental health care was provided in hospitals in just two cities Nutrition Malnutrition rates are rising across the country, especially in besieged and hard-to-reach locations where people face acute shortages of basic life necessities. WHO has worked with UNICEF to support the establishment of nutrition stabilization centres and the revitalization of the national nutrition surveillance system. WHO continues to promote breastfeeding promotion and appropriate infant and young child feeding practices in line with WHO and UNICEF guidelines. Disease surveillance and response The maintenance of epidemiologic surveillance and response to communicable disease outbreaks is of utmost public health importance. WHO’s disease early warning and response system/network (EWARS/N) serves as the primary mechanism for monitoring and responding to disease outbreaks in Syria. WHO has trained health care staff on EWARS/N, and donated laptops, mobile phones and other equipment to strengthen timely reporting. In 2016, the number of health care facilities reporting to EWARS/N rose from 1512 to 1618. No major disease outbreaks were reported in Syria in 2016. Health information Throughout 2016, WHO published regular information on the status of health care facilities in Syria. These data are crucial to inform decision making and help ensure that scarce resources are directed to where they are needed most. According to WHO’s Health Resources Availability Mapping System (HeRAMS), the number of medical doctors working in public hospitals dropped by almost 3% between May and November 2016 alone. Water, Sanitation and Hygiene (WASH) Sufficient quantities of clean water are essential to the safe and efficient functioning of hospitals. Clean water is necessary for simple things like hand washing, bathing patients and preparing food. It is needed for sterilizing surgical instruments. It must be rigorously purified for use in haemodialysis. In 2016, WHO’s specialist water engineers installed equipment to provide safe and reliable water supplies for five hospitals in Aleppo. This included drilling and equipping five groundwater wells, and installing water filtration and purification equipment, solar generators and water storage tanks. This ensured that each hospital would have at least a three-day supply of clean water to support its essential functions. Nine-year old Wafaa was at home with her father when their house in east Aleppo was rocked by a huge explosion. Wafaa screamed in pain as her body was set alight by the flames that ripped through the house. Her father covered her with blankets in a desperate attempt to staunch the flames, and took her to the nearest hospital. She was immediately transferred to a hospital in western Aleppo, and later referred to a specialist hospital in Turkey, where she remained for almost two months. Wafaa’s life has been saved, and her vision and hearing are unimpaired, but this once joyous little girl has been deeply scarred, both inside and outside. WAFAA’S STORY When the family recounts what they have been through, their grief and despair are evident. Wafaa’s mother Duaa had lost her own mother and all of her siblings during the conflict in Aleppo. She recalls how she broke down when she saw her daughter lying in a hospital bed, covered in bandages. Wafaa’s father had feared for his wife’s sanity when she followed her daughter to Turkey. Duaa has spent hours praying for her little girl to be restored to health. “Her burned face is the trigger for traumatic flashbacks. Wafaa suffers tremendously from other children’s taunts. They call her ‘deformed’, ‘ugly’, a ‘monster’.” Duaa would do anything to have her beautiful girl restored to a normal existence. Wafaa has four wishes. She would like to get medical treatment to restore her face and body. She would like to become a teacher so that she can help other children. She wants her mother to get well and not cry any more. And she wants God to forgive her friends and the people who hurt her and her family. Wafaa’s wishes are slowly coming true. Surgeons in Damascus will soon begin the long and painful process of cosmetic reconstruction. Her father has noticed a change in his daughter. “She grew up very quickly after her accident. She has gone back to school, and is determined to learn. And, for the first time in a very long time, my wife has begun to smile again.” Photo Credits: WHO Photo Credits: WHO Photo Credits: WHO 2726 2928 4. FUNDS RECEIVED IN 2016 5. FUNDS REQUIRED FOR 2017 WHO would like to thank the following donors for their generous support in 2016: Donor USAID Norway ECHO Pooled Fund -OCHA Kuwait DFID China Spain Japan Amount contributed (in US$) 17 500 000 8 550 015 6 726 457 5 861 180 2 000 000 1 578 947 1 000 000 335 196 100 000 43 651 795 WHO has requested a total of US$ 163 748 100 to implement the following interventions under the Humanitarian Response Plan for Syria for 2017: • Enhancing trauma care, mass casualty management and physical rehabilitation: US$ 25 365 900 • Strengthening secondary health care, obstetric care and referral services: US$ 60 372 500 • Sustaining delivery of primary health care: US$ 34 307 500 • Reinforcing immunization and polio eradication activities: US$ 22 156 000. • Enhancing and expanding disease early warning alert and response systems/networks: US$ 5 549 750. • Integrating mental health and psychosocial support services in primary, secondary and tertiary health care services and at community level: US$ 4 785 000. • Reinforcing inter- and intra- hub health sector coordination: US$ 3 086 250 . • Reinforce Health Information Systems for Emergency Response and Resilience - US$ 1 527 700. • Enhancing the prevention and early detection of malnutrition in children under five and referral services for patients with severe acute malnutrition with complications: US$ 1 666 250; • Establishing sustainable quality water supply and integrated medical waste management systems in health care facilities; supporting WASH services in under -served and vulnerable populations and IDPs: US$ 4 931 250. USAID 11.3% China 0.6% Funding Gap 71.9% Spain 0.2% Japan 0.1% Norway 5.5% Kuwait 1.3% ECHO 4.3% 31 6. WHO OFFICES AND HUBS Inside Syria In Damascus, WHO leads the health sector response and coordinates more than 80 health sector partners. WHO’s country office in Damascus comprises around 80 public health and support staff, and focuses on the following areas: 1. Leadership: Whole of Syria joint strategic planning, implementation, monitoring and reporting. 2. Advocacy: advocate with the highest levels of government for sustained access to all parts of the country to deliver humanitarian aid. 3. Health diplomacy: support the work of the International Syria Support Group and the Office of the Special Envoy for Syria. 4. Information: coordinate the collection, analysis and dissemination of information on health risks, needs and gaps across Syria. Gaziantep, Turkey WHO’s hub in Gaziantep coordinates around 58 health cluster partners working in opposition- controlled areas in northern Syria. The office comprises around 20 staff. It collects and analyses health information on health needs and gaps to support the emergency response, and documents attacks on health care to support WHO’s advocacy efforts. Public health officers in Gaziantep provide material support and guidance to NGO partners providing health care services in northern Syria. The office trains health care workers to fill gaps in the provision of health care services, and provides technical support for mass vaccination campaigns for children in besieged and hard-to-reach areas. A total of 506 health care facilities report to the disease early warning and response network (EWARN) managed by Gaziantep. Amman, Jordan Two WHO staff in the Amman hub are responsible for leading and coordinating health partners working in opposition-controlled areas in southern Syria. WHO Amman leads the health sector working group comprising 21 UN agencies, national and international NGOs, and local health authorities. It provides direct support to 76 primary health care centres and field hospitals in southern Syria (64 in Daraa and Quneitra governorates and 12 in Rural Damascus). Regional and headquarters offices WHO’s regional office in Cairo and its headquarters office in Geneva provide strategic guidance, technical expertise, surge, communications and resource mobilization support. 5. Resource mobilization: raise funds to support WHO’s work in Syria. 6. Strategic communications: disseminate quarterly Whole of Syria donor updates; present WHO’s work in Syria in international fora. 7. Technical expertise: provide technical advice to partners; ensure that critical gaps in the emergency response are filled. WHO’s four sub-offices in Aleppo, Hassakeh, Homs and Lattakia work closely with WHO’s network of focal points throughout the country to monitor the health response and report back to Damascus on emerging needs. 30 Damascus Dar'a Quneitra As-Sweida Lattakia Tartous Al-Hasakeh Deir-ez-Zor Ar-Raqqa Idleb Rural Damascus Homs Hama Aleppo Gaziantep Amman Damascus WHO office WHO sub office Hard to reach areas Beisiged areas Quamishli sub office Aleppo sub office Lattakia sub office Homs sub office WHO OFFICES AND SUB OFFICES Annex 1 Activities by area of intervention Coordination Primary health care Trauma care Secondary health care Mental health Outputs Medicines and supplies donated Training Vaccination campaigns Other activities Medicines and supplies donated Medicines and supplies donated Medicines and supplies donated Training Training Other outputs Other outputs Training Other outputs Coordinated: • Health partners’ participation in inter-agency convoys and the health supplies to be included in each one. • The health sector response to displaced people in the governorates of Al-Hasakeh, Tartous and Rural Damascus. • The emergency health response to the refugee influx from Mosul, Iraq. • The development of a six-month plan to revitalize disrupted health services in Tadmor and Al-Qaryatien in Homs. • The continuity of health care services in the aftermath of attacks on health care facilities. • The evacuation of residents of east Aleppo in December 2016. • The development of a contingency plan to continuing supplying priority health care centres in northern Syria. • The assessment of health care facilities in besieged and hard-to-reach locations covered by inter-agency humanitarian convoys. Advocated: • For the use of SARC mobile clinics in hard-to-reach and besieged locations. • For greater access to besieged and hard-to-reach areas to assess health needs, identify gaps and deliver humanitarian aid. Monitored: • Attacks on health care facilities and personnel. • The overall health response. Informed: • The Special Advisor to the United Nations Special Envoy by means of regular updates addressing the evolving health situation in Syria and access to besieged and hard- to-reach areas. These updates were forwarded to ISSG members. • Over 4 million treatments delivered to more than 800 health care facilities across the country. • 26 406 primary health care providers trained on basic routine immunization services, vaccine management, cold chain and logistics, AFP surveillance, management of noncommunicable diseases, reproductive health, childhood illnesses. • Three polio vaccination campaigns conducted (approximately 2.3 million children vaccinated in each campaign). • Three multi-antigen vaccination campaigns conducted in hard-to-reach and besieged areas. Over 800 000 children were vaccinated. • Two health care centres rehabilitated in Quneitra and Rural Damascus governorates. • Over 2 million treatments including life-saving medicines, surgical supplies and kits. • 228 blood safety kits to screen donated blood for HIV, hepatitis B and C. Each kit contains enough supplies to test 2000 blood samples. • Anaesthesia machines, operating theatre equipment, beds for intensive care units, ultrasound machines, ventilators, incubators. • Over 800 artificial limbs and assistive devices. • 20 fully equipped ambulances (of which six were deployed to Aleppo). • Approximately 1.2 million treatments, including over 800 000 insulin injections. • Supplies to support 23 700 dialysis sessions. • Medical equipment for emergency and diagnostic services in Damascus, As-Sweida and Aleppo. • Medical and other supplies to cover the basic needs of patients in mental hospitals in Duma and Aleppo. • Over 29 600 psychotropic treatments distributed to 12 governorates. • 2409 health care workers trained on rational use of medicines, infection control, leadership, warehouse management and quality control. • 2958 health care workers and mental health professionals trained on mhGAP, psychological first aid, self-help strategies, psychotherapeutic interventions, supporting survivors of gender-based violence, treating substance abuse, and psychiatric nursing. • A study analysing the capacity of the secondary health care system to provide health care during the current crisis and in the longer term, based on an assessment of 14 hospitals in Syria. • Assessment of cancer care services in Syria. • Two psychiatric wards rehabilitated in hospitals in Hama and Lattakia. • Over 100 patients including the elderly and those with mental health problems relocated from east Aleppo to Ibn Khaldoun Hospital in December 2016. • Mental health and psychosocial support services supported in community centres in Aleppo. • 3786 health care workers trained on trauma care, first aid, basic life support. • Contingency plan to prepare for the possible use of chemical weapons in Aleppo governorate. • Updated WHO training course for clinicians and responders on dealing with exposure to chemical and hazardous materials. • Plan of action to address the growing needs for physical rehabilitation services. 32 33 Nutrition Disease surveillance Health information system Water, Sanitation and Hygiene Working with NGOs Medicines and supplies donated Medicines and supplies donated Supplies and equipment donated Supplies and equipment donated Other outputs Other outputs Training Disease outbreaks Other outputs Medicines and supplies donated Training courses Other outputs Other outputs • Therapeutic nutrition medicines and supplies, anthropometric equipment and WHO guidelines on the management of severe acute malnutrition distributed to hard-to- reach and besieged areas via inter-agency convoys. • 200 000 vials of meglumine antimoniate (to treat leishmaniasis). • Medicines to treat 6500 cases of brucellosis. • 527 laboratory kits and supplies for reference laboratories in Damascus and Aleppo. • 14 diarrhoeal disease kits, 70 000 capsules of influenza medicines, 250 000 vials of influenza vaccines. • 5426 blankets for areas with high rates of severe acute respiratory infection. • Cholera rapid diagnostic tests (distributed to most governorates). • Computers, laptops, tablets and mobile phones distributed to HeRAMS focal points across the country. • Two water treatment units for dialysis machines donated to dialysis centres in Aleppo and Homs. • 29 hand-operated water filtration units and 14 000 jerry cans donated to medical checkpoints and mobile clinics in hard-to-reach and besieged locations. • 38 mobile water quality testing instruments, reagents and consumables delivered to hard-to-reach and besieged locations. • Five unexploited groundwater wells in Aleppo rehabilitated. The wells supply safe water to five public hospitals in Aleppo. • Improved completeness of reporting. All 111 public hospitals and 99% of 1787 health centres report fully to HeRAMS. • Template launched to monitor attacks against health care facilities and staff. • Software applications and automated systems developed for WHO Syria and health partners. • Health care facilities assessed during 34 field visits. • Information on the status on functionality and accessibility of health care facilities regularly published. • HeRAMS launched in northern Syria. • Health care facilities in southern Syria that are accessible from Jordan assessed for the first time since March 2015. • 2534 health workers trained on disease surveillance, using EWARS, laboratory safety procedures, managing communicable diseases. • 199 cases of Guillain-Barré syndrome reported from Damascus, Lattakia and Rural Damascus governorates. WHO coordinated the collection of samples for testing and procured apheresis devices and immunoglobulin. • 16 suspected cases of meningitis reported from the besieged town of Madaya. WHO supported the evacuation of 11 patients, nine of whom were admitted to a Damascus hospital for investigation and treatment and two of whom were referred to facilities in Idleb. • Outbreaks of acute diarrhoea reported in four locations in Rural Damascus governorate. WHO donated diarrhoeal disease kits and worked with the Water, Sanitation and Hygiene sector to distribute water chlorination tablets. • 33% increase in severe acute respiratory infections compared to the same period in 2015. WHO distributed medicines, vaccines, antibiotics and blankets, printed awareness- raising materials and donated diagnostic tests to the public health laboratory. • Completeness and timeliness of reporting to the disease surveillance system/ network improved to over 85%. • Cholera preparedness plan. • Deworming campaign to reduce the prevalence of soil-transmitted worms among schoolchildren. Over 2 million children were treated. • Survey to assess the sero-prevalence of hepatitis B and C among selected groups. • 1.6 million treatments (including for trauma care, mental health, nutrition, primary and secondary health care) distributed to NGOs across the country. • More than 226 500 medical consultations provided by NGOs supported by WHO. • More than 25 000 patients in collective shelters in Aleppo received treatment through mobile clinics donated by WHO. • More than 30 000 people in NGO-managed community centres in Aleppo supported by WHO received mental health care and psychosocial support. • 1412 health care workers trained on nutrition surveillance, breastfeeding promotion, malnutrition care and management. • 70 grant agreements and over 270 in-kind donation agreements signed with 68 NGO partners managed by WHO’s office in Damascus. • 15 grant agreements signed with five NGO partners managed by WHO’s office in Gaziantep. • Breastfeeding counselling programme launched in 317 health care centres. Approximately 144 000 consultations provided thus far. • Early childhood development programmes integrated into nutrition programmes. • Baby-Friendly Hospital Initiative reactivated in 21 hospitals. • 18 stabilization centres launched in hospitals across the country. 788 patients with severe acute malnutrition with complications received life-saving treatment. • More than 614 000 children screened for malnutrition. 3534 Developed Countries Price: USD 30.00 Developing Countries Price: USD 20.00 ANNUAL REPORT 2016 World Health Organization Syrian Arab Republic WHO Country Office (Damascus, Syrian Arab Republic) Elizabeth Hoff, WHO Representative hoffe@who.int WHO Country Office (Damascus, Syrian Arab Republic) Noha Alarabi, Donor and Reporting Officer alarabin@who.int WHO Headquarters (Geneva, Switzerland) Cintia Diaz-Herrera, Team Leader, Resource Mobilization for Appeals WHO Health Emergencies Programme diazherrerac@who.int Photo credits for cover photo: Aleksander Nordahl