HeRAMS annual report January – December 2019 public hospitals in the Syrian Arab Republic

HeRAMS Annual Report January - December 2019 Public Hospitals in the Syrian Arab Republic WHO-EM/SYR/039/E World Health Organization Health Resources and Services Availability Monitoring System Syrian Arab Republic HeRAMS Annual Report January - December 2019 Public Hospitals in the Syrian Arab Republic WHO-EM/SYR/039/E This is to acknowledge that the data provided in this report is a product of joint collaboration between the World Health Organization, Ministry of Health, and Ministry of Higher Education in the Syrian Arab Republic. The report covers the months of January to December 2019. © World Health Organization 2020 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. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. [Title]. Cairo: WHO Regional Office for the Eastern Mediterranean; 2019. Licence: CC BYNC-SA 3.0 IGO. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-partyowned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. 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. Contents Introduction Executive summary 1. Completeness of hospitals reporting 2. Functionality and accessibility of the public hospitals 2.1 Functionality status of the public hospitals 2.2 Density of the public hospitals 2.3 Accessibility to public hospitals 3. Accessibility to public hospitals 4. Infrastructure patterns of the public hospitals 4.1 Level of damage of the hospitals’ buildings 4.2 Analysis of the inpatient capacity 4.3 Water sources and functionality status 4.4 Availability of electricity generators 5. Availability of health human resources 5.1 Availability of medical staff by category and affiliation 5.2 Availability of medical doctors by affiliation (MoH vs. MoHE hospitals) 5.3 Availability of medical doctors by gender (MoH vs. MoHE hospitals) 6. Availability and utilization of the health services 6.1 General clinical services 6.2 Surgical and trauma care 6.3 Maternal health services 6.4 Child health 6.5 Nutrition 6.6 Communicable diseases services 6.7 NCDs (non-communicable diseases) 6.8 Rehabilitation services 6.9 Mental health 6. Availability of medical equipment 7. Availability of medicines & medical supplies 8. Conclusions and recommendations 1 1 3 4 4 7 8 8 10 10 14 15 17 18 21 23 25 27 29 31 38 41 42 43 44 47 48 49 51 52 Abbreviations CEmOC Comprehensive Emergency Obstetric Care CS Caesarean Sections DoH Directorate of Health ESKD End Stage Kidney Disease HeRAMS Health Resources & Services Availability Monitoring System HIS Health Information System HRP Humanitarian Response Plan ICT Information and Communication Technology ICU/ CCU Intensive Care Unit / Critical Care Unit IDPs Internally Displaced People MoH Ministry of Health MoHE Ministry of Higher Education NCDs Non-communicable Diseases OCHA United Nations Office for the Coordination of Humanitarian Affairs WHO World Health Organization HeRAMS | Annual Report 2019 Public Hospitals1 HeRAMS is a global health information management tool (for mapping, collection, collation and analysis of information on health resources and services) that aims to provide timely, relevant and reliable information for decision-making. It is used to guide interventions at the primary and secondary care levels, measure gaps and improve resource planning, ensure that actions are evidence-based, and enhance the coordination and accountability of WHO and other health sector partners. HeRAMS in Syria is a World Health Organization (WHO) project that aims at strengthening the collection and analysis of information on the availability of health resources and services in Syria at health facility level. A team of national health staff from all governorates was formulated for HeRAMS reporting, and different data collection mechanisms were introduced to address the shortage of timely and relevant information. The main HeRAMS tool for collecting data is a questionnaire that assesses the functionality status, accessibility, health infrastructure, human resources, availability of health services, equipment and medicines at primary and secondary care level. Regular assessment to monitor the impact of the crisis on the health facilities functionality, accessibility, condition status, availability of resources and services, has been conducted using HeRAMS (Health Resources & services Availability Monitoring System) tool. The report provides descriptive and trend analysis for the situation of public hospitals in all 14 governorates of Syria [including Ministry of Health (MoH) and Ministry of Higher Education (MoHE) hospitals (a total of 113 hospitals)]. Despite the challenging security situation and protracted crisis, in addition to the wide disruption of the Health System, implementation of HeRAMS has been successfully institutionalized and strengthened in public health facilities since 2014. Completeness of hospitals’ reporting remained 100%, where all 113 public hospitals: 100 (MoH) hospitals and 13 (MoHE) hospitals reported to HeRAMS by end of December 2019. Functionality status of the public hospitals By the end of December 2019, and out of the 113 assessed public hospitals [MoH & MoHE], 50% (57) were reported fully functioning, 25% (28) hospitals were reported partially functioning (i.e., shortage of staff, equipment, medicines or damage of the building in some cases), while 25% (28) were reported non-functioning. Accessibility status of the public hospitals By the end of December 2019, 81% (91) hospitals were reported accessible, 8% (9) hard-to-access, and 11% (13) were inaccessible. Introduction Executive summary HeRAMS | Annual Report 2019 Public Hospitals2 Infrastructure of the public hospitals By the end of December 2019, 43% (49) hospitals were reported damaged [10% fully damaged and 33% partially damaged], while 57% (64) of public hospitals were reported intact. Analysis on inpatient capacity in functional hospitals has shown shortage of beds at varying degrees, across all governorates. Assessing the availability of water sources at functional public hospitals indicated that 37.6% (32) are using main pipelines, 9.4% (8) are mainly using wells, 49.4% (42) are using both (main pipeline and well), while 3.5% (3) are using other sources of water. Electricity power is widely disrupted nationwide and majority of public hospitals are dependent on generators’ power. According to HeRAMS assessment 26% (22) of functional public hospitals across Syria are in need for electrical generators, mainly reported from 9 governorates: Damascus, Rural Damascus, Aleppo, Tartous, Hama, Al-Hasakeh, Dar’a, As-Sweida, and Quneitra. Human resources for health The general practitioner (0.2%) and emergency physician (0.3%) were the lowest proportion of health staff in public hospitals, followed by dentists (0.8%), pharmacists (0.7%), midwives (4.9%), laboratory (5.1%), specialists (12.5%), resident doctors (20.7%), and nurses (52.8%). Trend analysis of available number of medical doctors, nurses, and midwives during 2019 has shown slight increase. In functional public hospitals the number of medical doctors [general practitioner, specialists, emergency doctors, resident doctors, dentists] has increased by 11% in December 2019 compared to January 2019, similarly the number of nurses and number of midwives has increased by 3% and 4%, respectively. Analysis of proportions of medical doctors [general practitioner, specialists, emergency doctors, resident doctors, dentists] working at MoHE hospitals versus MoH hospitals has shown that 26% of medical doctors work in MoHE, while 74% are in MoH hospitals. Analysis of availability of medical doctors by gender has shown that lowest proportion of female to male medical doctors is in Ar-Raqqa governorate (24%). Availability and utilization of health services As a result of disrupted healthcare delivery and non-functionality of the hospitals, limited provision of health services was observed across governorates, even within functional hospitals. Detailed analysis on services’ availability and utilization throughout 2019 by category (i.e., General Clinical Services, Surgical and Trauma care, Child Health, Nutrition, Maternal & Newborn Health, Communicable Diseases, Non- communicable Diseases, and Mental Health) is provided at governorate level. Availability of medical equipment Analysis of availability of essential and specialized equipment was measured across all functional public hospitals [MoH & MoHE], in terms of functional equipment out of the total available equipment in the hospital. The produced analysis provides good indication of the current readiness of the hospitals to provide the health services, and also to guide focused planning for procurement and distribution of equipment and machines, to fill-in identified gaps that were observe even within the functional public hospitals. HeRAMS | Annual Report 2019 Public Hospitals3 The completeness of reporting from public hospitals across Syria remained at 100%, where all the 113 public hospitals: 100 Ministry of Health (MoH) Hospitals and the 13 Ministry of Higher Education (MoHE) hospitals continued to report to HeRAMS in December 2019. Noting that two new MoH established hospitals and started to functioning since October 2019; Children hospital in Tartous and Shaba hospital in As-Sweida. The distribution of public hospitals by affiliation [MoH & MoHE], per governorate is shown in Figure 1. The following sections provide descriptive and trend analysis on the functionality status, accessibility, and infrastructure of the public hospitals, availability of resources & services, and available equipment and medicines by the end of December 2019. The provided analysis supports informed decision making, better planning and allocation of resources, and contributes to significant and focused humanitarian response by WHO and health sector partners. Figure 1: Distribution of public hospitals by affiliation, per governorate 1. Completeness of hospitals reporting 8 14 11 4 6 7 16 6 5 7 4 7 4 1 7 1 4 0 1 0 0 0 0 0 0 0 0 0 15 15 15 4 7 7 16 6 5 7 4 7 4 1 0 2 4 6 8 10 12 14 16 18 Damascus Rural Damascus Aleppo Idleb Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Total MoH Hospitals Total MoHE Hospitals Total Public Hospitals Availability of medicines and medical supplies Availability of medicines and medical supplies at hospitals’ level was evaluated based on a standard list of identified priority medicines and medical supplies for duration of one month. The key identified gaps of medicines and consumables at functional hospitals include the: Tetanus shot (89%), Cancer related medicines (84%), Hepatitis vaccine (73%), Psychotropic medinas (70%), etc. HeRAMS | Annual Report 2019 Public Hospitals4 The following sub-sections provide analysis on the functionality and accessibility status of the public hospitals at governorate level. 2.1 Functionality status of the public hospitals Functionality of the public hospitals was defined and assessed at three levels; • Fully functioning: a hospital is open, accessible, and provides healthcare services with full capacity (i.e., staffing, equipment, and infrastructure). • Partially functioning: a hospital is open and provides healthcare services, but with partial capacity (i.e., either shortage of staffing, equipment, or damage in infrastructure). • Non-functioning: a hospital is out of service, because it is either fully damaged, inaccessible, no available staff, or no equipment. Figure 2: Functionality status - December 2019 2. Functionality and accessibility of the public hospitals Fully Functioning Partially Functioning Non-Functioning 57 28 28 50% 25% 25% By the end of December 2019, and out of the 113 assessed public hospitals [MoH & MoHE], 50% (57) were reported fully functioning, 25% (28) hospitals were reported partially functioning, while 25% (28) were reported non-functioning [Figure 2]. The hospitals reported partially functioning or non-functioning are in 12 out of a total 14 governorates (86% of governorates). Detailed analysis on the functionality status of the MoH and MoHE hospitals at governorate level is presented in [Figure 3] and [Map 1]. All public hospitals in Idleb were reported out of service. HeRAMS | Annual Report 2019 Public Hospitals5 Figure 3: Number and percentage of the public hospitals by functionality status, per governorate, December 2019 0 0 0 1 1 5 7 8 3 5 6 13 7 1 3 2 5 3 5 4 2 1 0 1 2 0 0 4 4 2 1 1 6 4 5 0 1 0 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Idleb Deir -ez-Zor Ar -Raqqa Dar'a Al -Hasakeh Homs Aleppo Rural Damascus As -Sweida Hama Lattakia Damascus Tartous Quneitra Fully Functioning Partially Functioning Non-functioning Map 1: Distribution and functionality status of public hospitals, December 2019 HeRAMS | Annual Report 2019 Public Hospitals6 58 57 57 56 56 57 57 57 57 57 57 57 27 28 28 29 29 28 28 28 28 28 28 28 26 26 26 26 26 26 26 26 26 28 28 28 0 20 40 60 80 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Fully Functioning Partially Functioning Non-functioning Figure 4: Trend analysis of functionality status of public hospitals, January to December 2019 Slight variation of functionality status of public hospitals has been observed during 2019 [Figure 4]. Map 2: Trend analysis of functionality status of public hospitals, January to December 2019 HeRAMS | Annual Report 2019 Public Hospitals7 2.2 Density of the public hospitals Hospitals density reflects the total number of hospitals relative to population size (based on OCHA HRP 2019), which helps measure physical access to outpatient health care services. Comparing with Sphere standards for hospitals (250,000), five governorates (Aleppo, Ar-Raqqa, Rural Damascus, Hama, and Al- Hasakeh) are over the standard density reference; due to high number of population against the available functioning public hospitals [Figure 5] and Map 3. Map 3: Density of the public hospitals per governorate, December 2019 Figure 5: Density of the public hospitals per governorate, December 2019 357,561 345,401 316,045 268,437 265,085 247,083 169,499 169,213 145,106 129,480 122,359 103,269 94,793 240,542 - 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 Aleppo Ar-Raqqa Rural Damascus Hama Al -Hasakeh Deir-ez-Zor Lattakia Dar'a Homs Tartous Damascus Quneitra As -Sweida Syria Sphere standards for hospitals (250,000) HeRAMS | Annual Report 2019 Public Hospitals8 Figure 6: Accessibility status - December 2019 Yes Hard to access No 91 9 13 81% 8% 11% 2.3 Special cases The following public hospitals have been considered as non-functioning, but are providing health services by non-MoH staff with no information available, where data is being collected by cross-border partners: 1. “Idleb National Hospital” in Idleb: partially damaged, providing health services by non-MoH staff since 2015. 2. “Ibn Seina Hospital” in Idleb: partially damaged, providing health services by non-MoH staff since 2015. 3. “Ma’arrat An-Nu’man Hospital” in Idleb: partially damaged, providing health services by non-MoH staff since 2016. Accessibility to public hospitals is defined at three levels: • Accessible: a hospital is easily accessible for patients and health staff. • Hard-to-reach: a hospital is hardly reached, due to security situation or long distance. • Inaccessible: a hospital is not accessible because of the security situation, or a hospital is accessible only to a small fraction of the population, or military people (inaccessible to civilians). By the end of December 2019, 81% (91) hospitals were reported accessible, 8% (9) hard-to-access, and 11% (13) were inaccessible [Figure 6]. Distribution of public hospitals by accessibility status is presented in Map 4 , while more details are provided at governorate’s level in Figure 7. 3. Accessibility to public hospitals HeRAMS | Annual Report 2019 Public Hospitals9 Figure 7: Accessibilty status of the public hospitals per governorate, December 2019 0 9 4 3 3 12 4 6 6 13 7 7 16 1 2 1 0 1 3 1 0 0 1 0 0 0 0 4 4 1 1 0 0 0 1 1 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Idleb Aleppo Hama Ar -Raqqa As -Sweida Damascus Al -Hasakeh Deir -ez-Zor Dar'a Rural Damascus Lattakia Tartous Homs Quneitra Yes Hard to access No Map 4: Accessibility to public hospitals [MoH & MoHE], December 2019 Trend analysis on accessibility to public hospitals [MoH & MoHE] from January to December 2019, is presented in Figure 8. HeRAMS | Annual Report 2019 Public Hospitals10 Figure 8: Trend analysis of accessibility to public hospitals, January to December 2019 85 91 91 91 91 91 92 91 91 91 91 91 8 8 8 8 8 8 8 8 8 9 9 9 18 12 12 12 12 12 11 12 12 13 13 13 0 20 40 60 80 100 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Yes Hard to access No Figure 9: level of damage - December 2019 4. Infrastructure patterns of the public hospitals Fully damaged Partially damaged Not damaged 11 38 64 57% 33% 10% The following sub-sections provide analysis on the infrastructure patterns of the public hospitals, in terms of building condition, inpatient capacity, water sources, availability of ambulances, and electricity generators, all summarized at governorate level. 4.1 Level of damage of the hospitals’ buildings The level of damage to hospital buildings was measured at three levels: • Fully damaged: either, all the building is destroyed, about 75% or more of the building is destroyed, or damage of the essential services’ buildings. • Partially damaged: where part of the building is damaged. • Intact: where there is no damage in the building. Analysis of the level of damage provides good indication on the potential costs for reconstruction. By the end of December 2019, 43% (50) hospitals were reported damaged [10% fully damaged and 33% partially damaged], while 57% (64) of public hospitals were reported intact [Figure 9]. Distribution of public hospitals by level of damage is presented in Map 5, while more details are provided at governorate’s level in Figure 10. HeRAMS | Annual Report 2019 Public Hospitals11 Map 5: Level of Damage of the Hospitals’ buildings, by governorate [MoH & MoHE], December 2019 It is essential to cross-analyze the infrastructural damage of the public hospitals in relation to the functionality status (i.e. provision of services). Some hospitals have resiliently continued to provide services regardless of the level of damage of the building and by optimizing intact parts of the building or in a few cases operating from other neighboring facilities. The national figures translate as follows: Out of the 38 partially damaged hospitals, 14 hospitals were reported partially functioning and 19 out of service (non-functioning), while 5 hospitals (Ebn Khaldoun Psychiatric hospital in Aleppo, As-Salameyeh National hospital in Hama, As-Suqailbeyeh National hospital in Hama, Al-Bairouni hospital in Rural Damascus, and Dermatology and Venereology hospital in Damascus) were reported to be fully functioning providing all services with full staffing capacity. Out of the 11 fully damaged hospitals, 7 were reported non-functioning while 4 hospitals have opted for innovative ways to continue providing health services to populations in need through partially functioning from other nearby temporary locations and provide health services with limited staff capacity and resources. More details of the 4 hospitals are available in the HeRAMS database. Then again, hospitals with intact buildings (64 hospitals) does not directly reflect full functionality, only 52 of the 64 intact hospitals are fully functioning, while 10 are partially functioning, and two hospitals are not functioning, due to limited access of patients and health staff to the facilities resulting from the dire security situation as well as critical shortage of supplies. HeRAMS | Annual Report 2019 Public Hospitals12 13 13 12 11 11 11 11 11 11 11 11 11 37 36 37 38 38 38 38 38 38 38 38 38 61 62 62 62 62 62 62 62 62 64 64 64 0 20 40 60 80 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Fully damaged Partially damaged Not damaged 0 1 0 5 1 1 2 1 0 0 0 0 0 0 4 5 6 3 7 2 6 1 1 1 2 0 1 1 7 7 3 8 3 3 6 13 7 4 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Idleb Deir -ez-Zor Dar'a Aleppo Rural Damascus Hama Homs Al -Hasakeh Ar -Raqqa Lattakia Damascus Tartous As -Sweida Quneitra Fully damaged Partially damaged Not damaged Figure 10: Number and percentage of the public hospitals by level of damage, per governorate, December 2019 Figure 11: Trend analysis of public hospitals’ level of damage, January to December 2019 Trend analysis on condition of the public hospitals (level of damage of the building) from January to December 2019 is presented in Figure 11. The tables below list the hospitals, which reported fully damaged (buildings), in addition to the list of hospitals that are operating from different location (s) given that the original building is fully damaged or partially damaged. HeRAMS | Annual Report 2019 Public Hospitals13 Table 1: The list of hospitals with reported fully damaged buildings Table 2: Special cases of hospitals which reported fully damaged (buildings), and operating partially from other locations Table 3: Special cases of hospitals which reported partially damaged (buildings), and operating partially (limited provided health services) from other locations AffiliationDistrictProvinceHospital Name# MoHDuma Rural DamascusRural Damascus specialized hospital – Duma 1 MoHThe fourthAleppoZahi Azraq general hospital2 MoHE'zazAleppoE'zaz national hospital3 MoHThirdAleppoOphthalmology hospital4 MoHThirdAleppoChildren hospital5 MoHAl-QusayrHomsAl-Qusayr general hospital6 MoHAl-QuabuHomsTaldaw hospital7 MoHMuhardehHamaHelfaya hospital8 MoHAl-HasakehAl-HasakehChildren hospital9 MoHAl-MayadinDeir-ez-ZorModern Medicine hospital10 MoHEThe fourthAleppoAl-Kindi university hospital11 New locationAffiliationConditionTypeDistrictProvinceHospital name# Ar-Razi hospitalMoHFully damagedGeneralThe fourthAleppoZahi Azraq general hospital1 Ar-Razi hospital + Al-Bassel Heart Institute MoHFully damagedSpecializedThirdAleppoOphthalmology hospital2 Ar-Razi hospital + Maternity hospital MoHFully damagedSpecializedThirdAleppoChildren hospital3 New medical center in Al-hasakah MoHFully damagedSpecializedAl-HasakehAl-HasakehChildren hospital4 New locationAffiliationConditionTypeDistrictProvinceHospital name# Qara Municipal MoH Partially damaged GeneralAl-Nabak Rural Damascus Al-Bassel-Qara hospital1 Al-Assad hospitalMoH Partially damaged SpecializedDeir-ez-ZorDeir-ez-ZorChildren and Obstetrics hospital2 Al-Assad hospitalMoH Partially damaged SpecializedDeir-ez-ZorDeir-ez-ZorAl-Furat hospital3 The information above could guide focused rehabilitation activities for hospitals’ infrastructure, which could improve functionality status of hospitals to reach fully functional level, especially for partially functional hospitals that need small scale of rehabilitation. HeRAMS | Annual Report 2019 Public Hospitals14 Figure 12: Comparison of inpatient capacity (original vs. available) in functional hospitals per governorate, December 2019 Figure 13: Percentage of available number of beds in functional hospital versus the original inpatient capacity, December 2019 2,840 2,203 2,096 1,958 1,186 1,160 810 792 720 670 558 260 200 3,245 1,677 1,549 1,629 1,152 952 311 494 583 451 232 188 133 Damascus Lattakia Aleppo Rural Damascus Tartous Hama Dar'a Homs As -Sweida Al -Hasakeh Deir -ez-Zor Ar -Raqqa Quneitra Original No. of Beds Available No. of Beds 114% 97% 83% 82% 81% 76% 74% 72% 67% 67% 62% 42% 38% 82% Damascus Tartous Rural Damascus Hama As -Sweida Lattakia Aleppo Ar-Raqqa Al -Hasakeh Quneitra Homs Deir-ez-Zor Dar'a Overall % of available beds /Total original beds 4.2 Analysis of the inpatient capacity The inpatient capacity has been analyzed in terms of the total number of beds available in functional hospitals by end of 2019 compared to the original number of beds in these hospitals pre-crisis or the maximum inpatient capacity) [Figure 12]. Reduced inpatient capacity (shortage of beds) was observed in all governorates at varying degrees. This may be correlated to the upsurge in usage of beds in functional hospitals, as direct implication of the crisis on the overstretched public health sector. The number 114% in Damascus illustrates that some hospitals have expanded their operational capacity to meet the increase needs of provision health services. Figure 13 illustrates the proportion of available beds in functional hospitals versus the original inpatient capacity at governorate levels. HeRAMS | Annual Report 2019 Public Hospitals15 Figure 15: Main sources of water, December 2019 Figure 14: number of hospital beds (including ICU)/10,000 Population in public hospitals, December 2019 Main Pipeline, 32, 38% Main Pipeline and Well, 42, 49% Well, 8, 9% Other, 3, 4% 4.3 Water sources and functionality status Availability of water sources at public hospitals was assessed using a standard checklist of main types of water sources (i.e., main pipeline, well, or both (main pipeline and well)). By the end of December 2019 and out of 85 functional public hospitals, 38% (32) are using main pipelines, 9% (8) are mainly using wells, 49% (42) are using both (main pipeline and well), while 4% (3) are using other sources of water [Figure 15]. The lowest percentage (38%) of available beds in functional hospital versus original inpatient capacity is observed in Dar’a governorate, mainly reported from Jassem hospital, Nawa hospital, and the national hospital. The follow figure shows the number of hospital beds (including ICU)/10,000 Population, given that the benchmark is greater than 10 health staff per 10,000 population (Inter-Agency Standing Committee (IASC) Standards). The national levels in addition to eight governorates (Hama, Rural Damascus, Al-Hasakeh, Aleppo, Homs, Deir-ez-Zor, Dar’a, and Ar-Raqqa) are below benchmark in [Figure 14]. 18 15 14 13 13 7 5 4 4 3 3 3 3 6 0 2 4 6 8 10 12 14 16 18 20 Damascus As -Sweida Lattakia Quneitra Tartous Hama Rural Damascus Al -Hasakeh Aleppo Homs Deir-ez-Zor Dar'a Ar-Raqqa Grand Total Number of hospital beds (including ICU)/10,000 Population Inter-Agency Standing Committee (IASC) Standards: 10 hospital beds HeRAMS | Annual Report 2019 Public Hospitals16 Figure 17: Functionality status of the water sources at functional public hospitals, December 2019 14 11 8 7 7 7 5 5 3 2 1 1 1 0 2 3 0 0 0 1 0 2 3 1 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Damascus Aleppo Homs Rural Damascus Lattakia Tartous Hama Dar'a Deir -ez-Zor As -Sweida Al -Hasakeh Ar -Raqqa Quneitra Fully Functioning Partially Functioning Functionality status of the water sources was measured at three levels; fully functional, partially functional, and not functional. Figure 17, provides details on functionality status of water sources at functional hospitals, (85/113) per governorate. Figure 16: Distribution of water sources/ types at functional public hospitals, per governorate, December 2019 0 0 0 0 1 1 2 3 4 4 5 5 7 9 5 4 1 1 1 1 11 5 2 2 0 0 0 0 1 0 3 0 0 0 1 0 3 2 0 1 0 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aleppo Hama Al -Hasakeh Quneitra Ar -Raqqa Dar'a Deir -ez-Zor As -Sweida Damascus Rural Damascus Tartous Homs Lattakia Main Pipeline Main Pipeline and Well Well Other Detailed analysis on distribution of water sources at functional public hospitals is presented at governorate level on [Figure 16]. HeRAMS | Annual Report 2019 Public Hospitals17 4.4 Availability of electricity generators Availability of electricity generators continued to be highly demanded with the current situation, where electricity power is widely disrupted and majority of public hospitals are dependent on generators’ power. Availability of electrical generators at functional hospitals was measured by assessing the functional out of the total existing generators in the hospital. Figure 18: Hours of availability of electricity (from all sources) on average during the day in functional hospitals, December 2019 24.0 21.7 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 22.3 24.0 24.0 23.6 20.5 21.0 21.5 22.0 22.5 23.0 23.5 24.0 24.5 Damascus Rural Damascus Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir -ez-Zor Ar -Raqqa Dar'a As -Sweida Quneitra Syria Figure 19: Percent of hospitals in need for generators out of total functional hospitals, December 2019 100% 55% 50% 40% 40% 27% 25% 17% 14% 0% 0% 0% 0% 26% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Quneitra Aleppo Al -Hasakeh Rural Damascus Hama Damascus As-Sweida Dar'a Tartous Lattakia Homs Deir -ez-Zor Ar-Raqqa Total The percent of hospitals in need for electricity generators out of the total functional hospital is summarized at governorate level [Figure 19]. 26% (22) of functional public hospitals across Syria are in need for electrical generators, mainly reported from 9 governorates: Damascus, Rural Damascus, Aleppo, Tartous, Hama, Al-Hasakeh, Dar’a, As-Sweida, and Quneitra. HeRAMS | Annual Report 2019 Public Hospitals18 5. Availability of health human resources Availability and trend of health human resources were analyzed across all public hospitals [MoH & MoHE] considering the following scopes: • Comparative and trend analysis of medical staff by category (i.e., doctors, nurses, midwives) • Trend analysis of availability of medical doctors by affiliation; MoH vs. MoHE hospitals • Trend analysis of availability of medical doctors by gender, per governorate The proportion between different categories of health staff, among the total functional (fully and partially) MoH and MoHE hospitals (85/113), by the end of December 2019, is as follows: The general practitioner (0.2%) and emergency physician (0.3%) were the lowest proportion of health staff in public hospitals, followed by dentists (0.8%), pharmacists (0.7%), midwives (4.9%), laboratory (5.1%), specialists (12.5%), resident doctors (22.7%), and nurses (52.3%); [Figure 20]. Figure 20: Proportion of health staff in hospitals, December 2019 General Practitioner 0.2% Specialist 12.5% Emergency Physician 0.3% Resident Doctor 22.7% Dentist 0.8% Nurses 52.8% Laboratory 5.1% Midwives 4.9% Pharmacists 0.7% HeRAMS | Annual Report 2019 Public Hospitals19 Table 4: Availability of human resources of functioning public hospitals, per governorate, December 2019 O th er s T ec hn ic ia ns U ni ve rs ity * P ha rm ac is ts M id w iv es La bo ra to ry N ur se s D en tis t R es id en t Do ct or E m er ge nc y Ph ys ic ia n O th er Sp ec ia lis ts N eu ro lo gi ca l su rg er y G en er al su rg er y O rt ho pe di c su rg er y G en er al Pr ac tit io ne r Go ve rn or at e 2,9541,315550801583883,760382,726188301758470Damascus 88243012517871321,282755842264312212Rural Damascus 1,0733222051690165930571,0137357636306Aleppo Idleb 1,151491245302471492,552601,12321512851404Lattakia 1,637820253271202322,3373756421437859375Tartous 42472468172331651,6179195152385423113Homs 749896139112321571,6174657611346844294Hama 13614427544372942670552532Al-Hasakeh 345289170135745743290320121Deir-ez-Zor 8127743710124000220636Ar-Raqqa 23215227548384120590431452Dar'a 58729877495531,0031120111321473As-Sweida 2277011415911631084372320Quneitra 10,4785,9781,7512201,5411,60916,6182637,1381023,2486335425858Grand Total * Health workers in the health centres who hold university degrees (engineer, law, trade and economics .......) HeRAMS | Annual Report 2019 Public Hospitals20 The availability and level of medical staffing (by category and gender) in public hospitals a, as is summarized at governorate’s level in Map 6. The categories of staff included in the map are: general practitioner, specialists, emergency doctors, resident doctors, dentists. Map 6: Availability of medical doctors in functional public hospitals, by end of December 2019, per governorate HeRAMS | Annual Report 2019 Public Hospitals21 5.1 Availability of medical staff by category and affiliation The availability medical staff in functional public hospitals is analyzed by category [i.e., medical doctors1, nurses, and midwives] and affiliation [MoH vs. MoHE hospitals], as follow: i. Trend analysis of medical doctors [a total of general practitioner, specialists, emergency doctors, resident doctors, dentists]: The number of medical doctors in public hospital has slightly increased by 11% in December 2019 (11,484 compared to January 2019 (10,371). Figure [21] shows the trend analysis of reported medical doctors during 2018 and 2019, in functional public hospitals. 9,999 9,919 9,888 9,902 9,936 10,305 10,432 10,299 10,217 10,190 10,234 10,551 10,371 10,185 10,319 10,327 10,317 10,799 11,196 11,319 11,286 11,090 11,194 11,484 9,000 9,500 10,000 10,500 11,000 11,500 12,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2018 2019 Figure 21: Trend analysis of number of doctors (a total of general practitioner, specialists, emergency physicians, resident doctors, and dentists) in public hospitals during 2018 and 2019 ii. Trend analysis of nurses: The number of nurses in public hospital has slightly increased by 3% in December 2019 (16,618), compared to January 2019 (16,160). Figure [22] shows trend analysis for the reported number of nurses during 2018 and 2019. HeRAMS | Annual Report 2019 Public Hospitals22 Figure 22: Trend analysis of number of nurses in public hospitals during 2018 and 2019 15,645 15,752 15,810 16,016 15,962 16,056 16,090 16,115 16,191 16,222 16,214 16,198 16,160 16,389 16,323 16,243 16,509 16,767 16,880 16,726 16,643 16,899 16,769 16,618 15,000 15,200 15,400 15,600 15,800 16,000 16,200 16,400 16,600 16,800 17,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2018 2019 Figure 23: Trend analysis of number of midwives in public hospitals during 2018 and 2019 1,449 1,493 1,509 1,512 1,495 1,493 1,492 1,487 1,484 1,486 1,468 1,479 1,478 1,508 1,515 1,490 1,537 1,545 1,542 1,544 1,510 1,519 1,540 1,541 1,430 1,450 1,470 1,490 1,510 1,530 1,550 1,570 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2018 2019 iii. Trend analysis of midwives: The number of midwives in public hospital has slightly increased by 4% in December 2019 (1,541), compared to January 2019 (1,478). Figure [23] shows trend analysis for the reported number of midwives during 2018 and 2019. HeRAMS | Annual Report 2019 Public Hospitals23 Figure 24: Proportions and numbers of key staff work in MoH vs. MoHE hospitals, December 2019 57 3,108 98 4,974 234 12,637 1,286 1,333 1 4 2,164 29 3,981 323 208 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% General Practitioner Specialist Emergency Physician Resident Doctor Dentist Nurses Laboratory Midwives MoHE MoH However, MoHE hospitals are located in four governorates (Damascus, Rural Damascus, Aleppo, and Lattakia), they serve the whole country. A comparison between the total available medical-related staff in MoH vs. MoHE hospitals is shown in [Figure 25]. 5.2 Availability of medical doctors by affiliation (MoH vs. MoHE hospitals) Analysis of proportions of medical doctors [general practitioner, specialists, emergency physician, resident doctors, dentists] working at MoHE hospitals versus MoH hospitals in December 2019 has shown that 26% (3,013) of medical doctors (general practitioner, specialists, emergency physician, resident doctors, dentists) work in MoHE, while 74% (8,471) are in MoH hospitals. 2% out of total general practitioner (58) work in public hospitals are in MoHE hospitals; 21% out of total specialists (3,923) work in public hospitals are in MoHE hospitals; 4% out of total emergency physician (102) work in public hospitals are in MoHE hospitals; 30% out of total resident doctors (7,138) are in MoHE hospitals; 11% out of total dentist (236) work in public hospitals are in MoHE hospitals and 24% out of total the nurses & midwives (16,618) are in MoHE hospitals. Details on proportions and numbers of key staff work in MoH vs. MoHE hospitals, by end of December 2019, are presented in [Figure 24]. HeRAMS | Annual Report 2019 Public Hospitals24 Figure 26: Number of nurses and midwives per doctor in public hospitals, December 2019 10.4 4.4 4.2 4.0 3.4 2.5 2.1 1.7 1.6 1.5 1.0 0.8 0.7 1.6 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Deir-ez-Zor Ar-Raqqa As -Sweida Dar'a Homs Al -Hasakeh Tartous Hama Rural Damascus Lattakia Damascus Quneitra Aleppo Grand Total Number of nurses and midwives per doctor MoH benchmark (2) The follow figure shows the number of nurses and midwives per doctor, given that the benchmark is at least 2 nurses and midwives for each doctor (MoH, 2011). The national levels in addition to six governorates (Hama, Rural Damascus, Lattakia, Damascus, Quneitra, and Aleppo) are below or equal benchmark in [Figure 26]. The follow figure shows the number of health staff (doctors, nurses and midwives) per 10,000 population, given that the benchmark is greater than 22 health staff per 10,000 population (Inter-Agency Standing Committee (IASC) Standards). The national levels in addition to eight governorates (Homs, Deir-ez-Zor, Rural Damascus, Aleppo, Dar’a, Al-Hasakeh, and Ar-Raqqa) are below or equal benchmark in [Figure 27]. Figure 25: Comparison of the medical staff of MoH vs. MoHE hospitals, December 2019 0 11 6 4 0 1 0 0 52 5 22 4 20 8 5 03 42 7 59 22 1 10 8 18 4 7 17 0 0 0 4 1, 76 3 47 8 43 6 57 9 96 3 80 57 7 54 4 19 5 5 7 52 19 2 0 8 1, 48 7 95 8 60 6 1, 49 2 2, 27 3 32 4 32 4 1, 06 0 55 8 7 65 1 67 10 3 0 2 5 80 0 500 1,000 1,500 2,000 2,500 Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia MoH MoHE General Practitioner Specialist Emergency Physician Resident Doctor Dentist Nurses Midwives Pharmacists HeRAMS | Annual Report 2019 Public Hospitals25 Figure 27: number of health staff (doctors, nurses and midwives) per 10,000 population in public hospitals, December 2019 Figure 28: Proportion of Doctors (a total of Specialists, Emergency Physicians, Resident Doctors, Dentists), by gender, per governorate, December 2019 2295 522 892 1068 721 317 656 86 45 28 72 169 101 1439 342 620 751 447 231 408 50 23 9 42 92 58 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Damascus Rural Damascus Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Male Female 20.3 12.9 15.3 6.9 15.4 7.9 3.8 0.9 2.7 3.8 1.1 1.3 0.5 5.6 20.5 25.8 21.5 26.5 11.2 12.0 11.1 7.7 4.1 2.4 4.1 2.8 1.8 8.1 0.9 1.3 2.1 2.5 1.5 1.7 1.6 1.8 0.3 0.2 0.5 0.4 0.5 0.8 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 Damascus Tartous Lattakia As -Sweida Quneitra Hama Homs Deir-ez-Zor Rural Damascus Aleppo Dar'a Al -Hasakeh Ar-Raqqa Grand Total Health Staff /10,000 Population Doctors Nurses Midwives Inter-Agency Standing Committee (IASC) Standards: health staff > 22 5.3 Availability of medical doctors by gender (MoH vs. MoHE hospitals) By analyzing the proportion of male to female doctors (a total of: general practitioner, specialists, emergency physician, resident doctors, dentists), lowest proportions are seen in Ar-Raqqa governorate (24%). [Figure 28]. HeRAMS | Annual Report 2019 Public Hospitals26 Figure 29: Percentage of functioning public hospitals without medical staff (gaps), December 2019 0.0 1.2 15.3 27.1 62.4 63.5 64.7 0 10 20 30 40 50 60 70 80 90 100 Nurses Specialist Doctor Resident Doctor Midwives Dentist Practitioner Emergency Physician HeRAMS | Annual Report 2019 Public Hospitals27 Figure 30: Availability of health services in the functional public hospitals, December 2019 30% 35% 57% 59% 62% 67% 68% 68% 74% 74% 74% 77% 78% 78% 78% 82% 83% 88% 88% 89% 90% 91% Cancer treatment services Management of severe acute malnutrition with complications Rehabilitation services Medical evacuation Waste management Comprehensive abortion care Management of children diseases Treatment of diabetic complications Burn patient management Communicable diseases services (CEmOC) Comprehensive emergency obstetric care End Stage Kidney Disease (ESKD) treatment Acute psychiatric inpatient unit Trauma services Emergency surgery Cardiovascular services ICU services Management of diabetes Hypertension services Safe water availability Blood bank service Sanitation availability **Detailed information on availability of services per governorate is available in the HeRAMS database. The workload and utilization of the health services were analyzed in terms of the total estimated serviced people in all functional public hospitals during January and December 2019 per governorate [Figure 31]. In 2019, the total estimated caseload in functional public hospitals is 7,566,249. 6. Availability and utilization of the health services The availability of core healthcare services is monitored through HeRAMS at hospital’s level, considering a standard list of health services (including: General Clinical Services, Surgical and Trauma care, Child Health, Nutrition, Maternal & Newborn Health, Communicable Diseases, Non-communicable Diseases, and Mental Health). Analysis of availability of health services has been conducted across all functional public hospitals [MoH & MoHE]: (85/113). As a result of disrupted healthcare delivery and non-functionality of hospitals, limited provision of health services was observed across governorates, even within functional hospitals [Figure 30]. HeRAMS | Annual Report 2019 Public Hospitals28 Figure 31: Estimated caseload of functional public hospitals (outpatient consultations and emergency cases), January to December 2019 1,528,148 994,044 869,682 842,931 722,986 603,959 560,994 345,081 326,682 309,040 259,101 126,783 76,818 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 1,600,000 1,800,000 Damascus Lattakia Aleppo Homs Tartous Hama Rural Damascus Ar-Raqqa Al -Hasakeh Dar'a As -Sweida Deir-ez-Zor Quneitra 621,035 639,985 666,941 623,091 571,808 615,054 718,432 616,927 651,993 656,810 592,783 591,390 500000 550000 600000 650000 700000 750000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Estimated caseload Figure 32: Trend analysis of estimated caseload in public hospitals, January to December 2019 Most of healthcare services had a remarkable drop in June; due to the limited medical visits in Ramadan (fasting month). The proportion of workload of functional hospitals per governorate is provided on Figure 31. Detailed analysis on utilization of the core health services is provided on the following sub-sections, including: 1. General Clinical Services (Outpatient, Inpatient, Laboratory, Blood bank services, Imaging services) 2. Surgical and Trauma care 3. Maternal health services [normal deliveries, caesarean sections, and CEmOC] 4. Nutrition 5. Child Health 6. Communicable diseases 7. Non-communicable diseases 8. Mental Health HeRAMS | Annual Report 2019 Public Hospitals29 Damascus 20% Lattakia 13% Aleppo 12% Homs 11% Tartous 10% Hama 8% Rural Damascus 7% Ar-Raqqa 5% Al -Hasakeh 4% Dar'a 4% As-Sweida 3% Deir -ez-Zor 2% Quneitra 1% Figure 33: Proportions of workload during 2019, per governorate Figure 34: The number of Outpatient and Inpatient in public hospitals, December 2019 71,869 37,186 36,495 33,941 26,264 25,704 21,426 16,887 7,407 6,375 5,048 4,705 2,627 13565 5999 5982 4908 10751 8135 8904 1316 1173 3105 4855 1615 320 0 10000 20000 30000 40000 50000 60000 70000 80000 Damascus Lattakia Aleppo Homs Rural Damascus Tartous Hama Ar-Raqqa Deir-ez-Zor Dar'a As -Sweida Al -Hasakeh Quneitra Outpatient services Inpatients services 6.1 General clinical services The following sections provide analysis on the utilization of health services in functional public hospitals at governorate level. i. Outpatient and inpatient The number of outpatients to inpatients was assessed at a hospital level, and the total numbers reported in December 2019 were summarized and analyzed at governorate level [Figure 34]. HeRAMS | Annual Report 2019 Public Hospitals30 Figure 35: Trend analysis of outpatient and Inpatient in public hospitals, January to December 2019 299,928 332,437 339,352 319,570 269,881 302,713 385,016 283,295 335,992 337,732 297,979 295,934 75,695 74,028 76,116 75,215 71,857 77,734 88,560 77,537 80,129 76,002 67,685 70,628 0 50000 100000 150000 200000 250000 300000 350000 400000 450000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Outpatient services Inpatients services Trend analysis of total reported numbers of outpatient and Inpatient from functional public hospitals [MoH & MoHE], for twelve months (January to December 2019), is presented in [Figure 35]. In 2019, the total reported outpatients are 3,799,829 while the inpatients are 911,186. Figure 36: The number of patients received services in laboratories, blood bank, and imaging services in public hospitals, December 2019 589,585 113,739 169,154 307,503 231,051 140,898 220,711 10,498 23,393 7,036 30,888 77,252 16,257 5,058 830 1,337 1,832 1,459 1,351 3,035 425 223 61 262 560 116 52,258 16,924 36,851 23,790 21,261 18,783 108,384 6,731 2,583 1,203 6,018 7,514 1,605 0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 Damascus Rural Damascus Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Laboratory services Blood bank service Imaging service ii. Laboratories, blood bank, and imaging services The number of patients received services in hospitals’ laboratories, blood bank, and imaging departments was assessed at a hospital level, and the total number of cases from January to December 2019 analyzed at governorate level [Figure 36]. Trend analysis of number of patients received services in hospitals’ blood banks and imaging departments, from January to December 2019, is presented in [Figure 37]. In 2019, the total reported patients received services in blood banks are 208,884 [of note: the total number of blood bags and products in 2019 are 385,847], while patients received imaging services are 2,950,359 [of note: the total performed service (X-Ray, MRI, and CT Scan pictures) in 2019 are 3,726,687]. HeRAMS | Annual Report 2019 Public Hospitals31 Figure 37: Trend analysis of number of patients received services in blood banks and imaging services in public hospitals, January to December 2019 17,603 17,076 17,614 17,669 17,467 18,970 18,023 18,896 17,128 15,954 15,935 16,549 31,154 32,386 32,412 33,898 34,467 33,163 34,606 31,828 31,363 30,902 28,550 31,118 238,820 238,596 252,011 233,370 218,780 221,219 257,383 233,577 254,295 262,962 235,441 303,905 0 50000 100000 150000 200000 250000 300000 350000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Blood bank service Blood bags and products Imaging service 1,846,321 1,872,740 1,976,187 1,924,265 1,714,390 1,878,963 2,112,496 1,869,067 1,990,516 1,931,187 1,837,213 1,937,965 1400000 1500000 1600000 1700000 1800000 1900000 2000000 2100000 2200000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Laboratory services 6.2 Surgical and trauma care The surgical and trauma care services is assessed at hospitals’ level. Descriptive analysis is conducted at governorate’s level for the number of reported emergency cases, and surgeries (elective and emergency). iii. Emergency cases reported in emergency departments Figure 38 presents the total number of cases in emergency departments, reported during December 2019 from functional public hospitals at governorate level. Figure 38: The number of reported cases in emergency department in public hospitals, December 2019 48,515 41,298 32,522 30,988 29,129 24,309 21,992 20,325 19,884 17,952 3,208 2,400 2,156 0 10000 20000 30000 40000 50000 60000 Damascus Lattakia Aleppo Tartous Homs Hama Rural Damascus Al -Hasakeh Dar'a As -Sweida Quneitra Ar-Raqqa Deir-ez-Zor HeRAMS | Annual Report 2019 Public Hospitals32 Figure 39: Trend analysis of number of reported cases in emergency department in public hospitals, January to December 2019 320,368 306,689 326,739 302,873 301,476 312,053 332,815 333,126 315,282 318,284 294,167 294,678 280000 290000 300000 310000 320000 330000 340000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Emergency services Trend analysis of total number of cases in emergency departments in functional public hospitals [MoH & MoHE], for twelve months (January to December 2019), is presented in [Figure 39]. In 2019, the total number of cases in emergency departments are 3,758,550. iv. Emergency and elective surgeries The number of emergency surgeries to elective surgeries was assessed at a hospital level, and total numbers were summarized and analyzed at governorate level [Figure 40]. During December 2019, the highest workload of elective surgeries is reported from Al-Assad university hospital in Damascus (914), followed by Damascus MoH Hospital (Al-Mojtahid: 909), Tishreen university hospital in Lattakia (739), Al-Mouwasat university hospital (694), Hama national hospital (682), Al- Bassel Heart Institute in Damascus (652), Aleppo university hospital (611), Dermatology and Venereology university hospital (602), and Ar-Razi MoH hospital in Aleppo (600). While the highest workload of emergency surgeries is reported from Al-Bassel hospital in Tartous (2,453), followed by National hospital in Lattakia (592), Hama national hospital (543), Zaid Ash-Shariti hospital in As-Sweida (461), Al-Mouwasat MoHE hospital (353), Aleppo university hospital (309), Tishreen university hospital in Lattakia (274), Obstetrics and Gynecology Hospital in Aleppo (231), and Hama national hospital (206). *Of note, the highest number of functional public hospitals is in Damascus, of which 14 out of 15 hospitals provide elective surgeries, except Ibn-Roshd hospital for mental health. HeRAMS | Annual Report 2019 Public Hospitals33 Figure 40: The number of emergency surgeries vs. elective surgeries in public hospitals, December 2019 5,844 1,895 1,495 1,339 1,210 1,138 1,091 697 676 224 152 123 57 931 616 986 1,170 92 106 2,755 108 486 89 167 5 35 0 1000 2000 3000 4000 5000 6000 7000 Damascus Aleppo Lattakia Hama Rural Damascus Homs Tartous Dar'a As -Sweida Al -Hasakeh Quneitra Deir-ez-Zor Ar-Raqqa Elective surgery Emergency surgery By analyzing the percent of total emergency surgeries to elective surgeries during December 2019, the highest percent across different governorates is reported in Tartous, Quneitra, Hama, As-Sweida, and Lattakia governorates. Across all reported functional public hospitals, 32% of surgeries are emergency while 68% are elective [Figure 41]. Trend analysis of total number of elective and emergency surgeries reported in functional public hospitals [MoH & MoHE], from January to December 2019 is presented in Figure 42. In 2019, the total reported emergency surgeries are 89,860 while the elective surgeries are 198,740. 4% 7% 9% 13% 14% 25% 28% 38% 40% 42% 47% 52% 72% 32% 96% 93% 91% 87% 86% 75% 72% 62% 60% 58% 53% 48% 28% 68% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Deir-ez-Zor Rural Damascus Homs Dar'a Damascus Aleppo Al -Hasakeh Ar-Raqqa Lattakia As -Sweida Hama Quneitra Tartous Total % Emergency surgery % Elective surgery Figure 41: Percentage of total emergency surgeries to elective surgeries in public hospitals per governorate, December 2019 HeRAMS | Annual Report 2019 Public Hospitals34 6,546 6,601 7,243 7,016 7,958 7,870 7,911 8,124 8,048 7,690 7,307 7,546 15,094 15,461 16,791 16,609 14,483 14,574 20,535 15,554 19,216 18,830 15,652 15,941 0 5000 10000 15000 20000 25000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Emergency surgery Elective surgery Figure 42: Trend analysis of number of patients received emergency surgeries and elective surgeries in public hospitals, January to December 2019 With note that increasing of the number if elective surgeries during July was due to desire of people to perform elective surgeries after the month of fasting in Ramadan (May and June). HeRAMS | Annual Report 2019 Public Hospitals35 Figure 43: The number of patients received ICU services in public hospitals, December 2019 Figure 44: Trend analysis of number of patients received ICU services in public hospitals, January to December 2019 1,361 902 802 777 715 405 303 289 134 107 88 58 29 0 200 400 600 800 1000 1200 1400 1600 Damascus Hama Aleppo Lattakia Homs As -Sweida Rural Damascus Tartous Dar'a Deir-ez-Zor Al -Hasakeh Quneitra Ar-Raqqa 6,569 5,900 6,253 5,839 5,875 5,980 6,372 5,773 5,981 6,224 5,908 5,970 5200 5400 5600 5800 6000 6200 6400 6600 6800 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 ICU services v. ICU services Figure 43 presents the total number of patients received ICU services reported during December 2019 from functional public hospitals at governorate level. Trend analysis of total number of patients received ICU services reported in functional public hospitals [MoH & MoHE], from January to December 2019 is presented in Figure 44. In 2019, the total reported total number of patients received ICU services are 72,644. HeRAMS | Annual Report 2019 Public Hospitals36 Figure 45: The number of patients received trauma services in public hospitals, December 2019 2,343 1,806 549 542 440 162 85 83 43 28 26 15 0 0 500 1000 1500 2000 2500 Damascus Hama Aleppo Dar'a Homs Lattakia Rural Damascus Tartous As -Sweida Deir-ez-Zor Al -Hasakeh Quneitra Ar-Raqqa vi. Trauma services Figure 45 presents the total number of patients received Orthopaedic/trauma ward for advanced orthopaedic care reported during December 2019 from functional public hospitals at governorate level. Trend analysis of total number of patients received trauma services reported in functional public hospitals [MoH & MoHE], from January to December 2019 is presented in Figure 46. In 2019, the total reported total number of patients received trauma services are 87,478. Figure 46: Trend analysis of number of patients received trauma services in public hospitals, January to December 2019 6,031 6,098 7,322 7,139 6,776 7,115 8,452 7,521 8,969 8,187 7,746 6,122 5000 5500 6000 6500 7000 7500 8000 8500 9000 9500 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Trauma services HeRAMS | Annual Report 2019 Public Hospitals37 Figure 48: Trend analysis of number of patients received burn patient management in public hospitals, January to December 2019 1,314 1,403 1,240 1,076 1,131 1,380 1,144 1,223 1,201 1,248 851 1,060 500 600 700 800 900 1000 1100 1200 1300 1400 1500 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Burn patient management Figure 47: The number of patients received burn patient management in public hospitals, December 2019 394 153 128 94 63 61 53 38 35 33 8 0 0 0 50 100 150 200 250 300 350 400 450 Tartous Homs Damascus Dar'a Rural Damascus Lattakia Al -Hasakeh Aleppo Hama Deir-ez-Zor As -Sweida Ar-Raqqa Quneitra vii. Burn patient management Figure 47 presents the total number of patients received burn patient management reported during December 2019 from functional public hospitals at governorate level. Trend analysis of total number of patients received burn patient management reported in functional public hospitals [MoH & MoHE], from January to December 2019 is presented in Figure 48. In 2019, the total reported total number of patients received burn patient management are 14,271. HeRAMS | Annual Report 2019 Public Hospitals38 Figure 49: Number of functioning hospitals providing CEmONC services/ 500,000 Population, December 2019 4.8 4.0 3.0 2.8 2.8 2.1 1.5 1.4 1.4 1.1 0.7 0.5 0.3 1.2 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Quneitra As -Sweida Dar'a Tartous Homs Lattakia Hama Ar-Raqqa Al -Hasakeh Rural Damascus Deir-ez-Zor Damascus Aleppo Grand Total Number of functioing hospitals providing CEmONC Services/ 500,000 Population Inter-Agency Standing Committee (IASC) Standards: 10 hospital beds 6.3 Maternal health services Analysis of availability and utilization of maternal health services was conducted considering three scopes: • Utilization of service (caesarean sections (CS) vs. normal deliveries); December 2019 summary figures by governorate • Percentage of CSs to normal deliveries, of December 2019 • Trend analysis of the monthly normal deliveries vs. caesarean sections, January to December 2019 i. Number of functioning hospitals providing CEmONC services/ 500,000 Population The follow figure shows the number of functioning hospitals providing (CEmOC) Comprehensive Emergency Obstetric Care (i.e., BEOC + caesarean section + safe blood transfusion) services/ 500,000 Population, given that the benchmark is at least 1 hospital providing CEmONC services (Inter-Agency Standing Committee (IASC) Standards). Three governorates (Deir-ez-Zor, Damascus, and Aleppo) are below benchmark in [Figure 49]. ii. Utilization of service (caesarean sections vs. normal deliveries) The numbers of caesarean sections performed at public hospitals (in December 2019) versus the normal deliveries have been analysed at governorates’ level [Figure 50]. The highest numbers are reported from Obstetrics and Gynecology MoHE hospital in Damascus [normal deliveries are 466 while CSs are 557], followed by Children and Obstetrics hospital in Deir-ez-Zor [normal deliveries are 167 while CSs are 257], Gynecology Hospital in Aleppo [normal deliveries are 341 while CSs are 257], Maternity hospital in Ar-Raqaa [normal deliveries are 380 while CSs are 230], and Az-Zahrawy hospital in Damascus [normal deliveries are 589 while CSs are 195]. HeRAMS | Annual Report 2019 Public Hospitals39 Figure 51: Percentage of caesarean sections to normal deliveries in public hospitals, December 2019 34% 39% 39% 47% 50% 57% 58% 58% 58% 62% 65% 66% 85% 56% 66% 61% 61% 53% 50% 43% 42% 42% 42% 38% 35% 34% 15% 44% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Lattakia Tartous Deir -ez-Zor Homs Hama As-Sweida Rural Damascus Aleppo Damascus Quneitra Ar-Raqqa Dar'a Al -Hasakeh Total CSs % Normal deliveries % 1,055 655 593 521 498 467 304 288 227 200 185 167 143 752 351 426 527 363 245 53 323 358 153 353 257 86 0 200 400 600 800 1000 1200 Damascus Ar-Raqqa Aleppo Hama Rural Damascus Dar'a Al -Hasakeh Homs Tartous As-Sweida Lattakia Deir -ez-Zor Quneitra Normal_deliveries CSs Figure 50: The No. of normal deliveries and caesarean sections (CSs) performed at public hospitals, December 2019 iii. Percentage of CS to normal deliveries The highest figures of caesarian sections in December 2019 are reported in Deir-ez-Zor (288 CSs compared to 80 normal deliveries), Lattakia (470 CSs compared to 331 normal deliveries), and Tartous (347 CSs compared to 274 normal deliveries). Across all reported functional hospitals in December 2019, 44% (4,247) of deliveries are CSs while 56% (5,303) are normal deliveries. Details on percent of CSs to normal deliveries per governorate in December 2019, is provided in [Figure 51]. HeRAMS | Annual Report 2019 Public Hospitals40 589 498 252 101 466 341 84 195 363 169 267 557 257 86 0 100 200 300 400 500 600 700 Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia MoH Hospitals MoHE Hospitals Normal_deliveries CSs 7,027 6,372 6,552 6,227 5,824 5,819 6,011 6,429 5,891 5,368 4,881 5,3035,187 4,661 4,995 4,608 4,483 4,471 4,742 4,458 4,430 4,329 3,981 4,247 3000 3500 4000 4500 5000 5500 6000 6500 7000 7500 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Normal deliveries CSs Figure 52: Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections in public hospitals, January to December 2019 Figure 53: Comparison of MoH & MoHE hospitals workload of normal deliveries vs, CSs, December 2019 iv. Comparison of MoH and MoHE hospitals workload of normal deliveries vs. CSs: Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections reported from the MoH & MoHE hospitals, from January to December 2019 is shown in Figure 52. In 2019, the total reported normal deliveries are 71,704 while the caesarean sections are 54,592. v. Comparison of MoH and MoHE hospitals workload of normal deliveries vs. CSs: Comparison analysis between MoH and MoHE hospitals that provide Obstetrics & Gynecology services across four governorates is shown in [Figure 53]. HeRAMS | Annual Report 2019 Public Hospitals41 920 744 525 387 295 95 77 76 62 52 16 8 0 0 200 400 600 800 1000 Hama Rural Damascus As -Sweida Tartous Damascus Homs Lattakia Dar'a Aleppo Ar-Raqqa Al -Hasakeh Quneitra Deir-ez-Zor 3,808 3,536 3,521 3,206 3,149 3,595 3,514 3,176 3,246 2,813 2,652 3,257 2000 2200 2400 2600 2800 3000 3200 3400 3600 3800 4000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Management of children diseases Figure 54: Number of children with severe diseases in public hospitals, December 2019 Figure 55: Trend analysis of reported cases of severe children diseases in public hospitals, January to December 2019 6.4 Child health Management of severe children diseases (such as acute respiratory diseases, Meningitis, blood diseases cancer, etc…) are assessed at hospitals level. Figure 54 shows the distribution of total reported cases of management of children classified with severe or very severe diseases (parenteral fluids and drugs, oxygen) by governorate. The high reported figures in Hama, Rural Damascus, As-Sweida, Tartous, and Damascus are due to the high numbers of IDPs, and also availability of MoHE referral hospitals for children in some of these areas. Trend analysis of reported cases of severe children diseases from January to December 2019, is presented in [Figure 55]. In 2019, the total reported cases of severe children diseases are 39,473. HeRAMS | Annual Report 2019 Public Hospitals42 26 11 11 11 11 8 3 2 2 2 1 0 0 0 5 10 15 20 25 30 Lattakia Damascus Aleppo Hama Dar'a Deir-ez-Zor Tartous Rural Damascus Homs As -Sweida Quneitra Al -Hasakeh Ar-Raqqa 73 83 69 93 96 123 135 86 92 95 87 88 0 20 40 60 80 100 120 140 160 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Management of severe acute malnutrition with complications Figure 56: The number of children with severe acute malnutrition with complications in public hospitals, December 2019 Figure 57: Trend analysis of number of children with severe acute malnutrition with complications in public hospitals, January to December 2019 6.5 Nutrition Monitoring of cases in stabilization centre for the management of severe acute malnutrition with medical complications, with availability of ready-to-use therapeutic foods and dedicated trained team of doctors, nurses, and nurse aids, 24/7 is systematically conducted at public hospitals level; Figure 56 demonstrates the number of cases reported in December 2019, at governorate level. The high reported figures in Lattakia, Damascus, Aleppo, Hama, Dar’a and Deir-ez-Zor, due to the high numbers of IDPs. Trend analysis of reported cases of severe acute malnutrition from January to December 2019, is presented in [Figure 57]. In 2019, the total reported children with severe acute malnutrition are 1,120. HeRAMS | Annual Report 2019 Public Hospitals43 1,160 507 476 156 74 45 41 25 17 12 10 0 0 0 200 400 600 800 1000 1200 1400 Hama Tartous Deir -ez-Zor Damascus As -Sweida Rural Damascus Aleppo Lattakia Dar'a Al -Hasakeh Homs Ar -Raqqa Quneitra 2,506 2,692 2,832 2,484 2,233 2,113 2,547 2,365 2,203 2,281 2,070 2,523 1500 1700 1900 2100 2300 2500 2700 2900 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Communicable diseases services Figure 59: Trend analysis of number of patients received communicable diseases in public hospitals, January to December 2019 Figure 58: The number of patients received communicable diseases in public hospitals, January to December 2018 6.6 Communicable diseases services Management of severe and/or complicated communicable diseases (such as meningitis, measles, SARI, others) are assessed at hospitals level. Figure 58 shows the distribution of total reported cases of communicable diseases services by governorate. Trend analysis of reported patients received communicable diseases from January to December 2019, is presented in [Figure 59]. In 2019, the total reported patients are 28,849. HeRAMS | Annual Report 2019 Public Hospitals44 47 8 41 5 40 2 93 0 20 9 96 6 99 21 2 59 19 0 23 2 73 721 ,0 86 96 2 61 12 5 13 6 33 62 2 0 0 7 5 304 99 60 0 99 6 2, 79 8 45 7 1, 08 8 98 5 80 82 10 2 48 4 86 97 2, 37 0 38 4 1, 91 8 3, 73 6 43 9 82 5 74 6 56 19 0 10 4 50 9 10 81, 18 8 19 0 64 2 48 6 38 9 19 1 40 6 20 4 85 10 2 12 6 84 4 30 2, 78 4 15 ,8 26 71 2 26 7 24 6 39 8 57 6 0 0 0 0 2 24 0 1, 81 6 17 6 66 6 1, 57 4 52 5 15 1, 56 6 2 75 0 11 8 26 6 0 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 Damascus Rural Damascus Aleppo Lattakia Tartous Homs Hama Al-Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As-Sweida Quneitra Management of diabetes Treatment of diabetic complications Hypertension Cardiovascular services End Stage Kidney Disease (ESKD) treatment Cancer Rehabilitation services Figure 60: The number of NCDs’ consultations in public hospitals, December 2019 6.7 NCDs (non-communicable diseases) NCDs were assessed through HeRAMS by checking the availability and utilization of services at hospitals level. The majority of high reported figures of NCDs (Diabetes, Treatment of diabetic complications, Hypertension, Cardiovascular, Kidney, and Cancer diseases) are from Damascus hospitals. Among all NCDs during 2019, Cancer patients’ consultations are the highest reported figures, mainly in Damascus, Rural Damascus (has one cancer specialized hospital). It worth mentioning that cancer is treated at secondary and tertiary levels only, while other NCDs (diabetes and hypertension, etc…) usually managed at primary and secondary care levels, unless patients develop complications. Cardiovascular consultations are the second highest reported figures during 2019, mainly in Lattakia (has one cardiovascular specialized hospital), Damascus (has two cardiovascular specialized hospitals), and Aleppo (has two cardiovascular specialized hospitals, Homa, Hama, and Tartous [Figure 60]. HeRAMS | Annual Report 2019 Public Hospitals45 5,295 5,623 5,685 5,643 5,733 5,641 6,356 5,091 5,413 4,888 4,692 4,346 2,035 2,137 2,153 2,125 1,735 1,807 1,789 1,637 1,804 2,025 1,811 1,843 1000 2000 3000 4000 5000 6000 7000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Management of diabetes Treatment of diabetic complications 7,591 8,543 8,496 8,232 7,777 7,516 9,146 8,132 8,499 7,983 7,652 7,967 7000 7500 8000 8500 9000 9500 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Hypertension Figure 61: Trend analysis of total monthly number of NCDs’ consultations reported in public hospitals, January to December 2019 The monthly trend of reported NCDs’ consultations at functional public hospitals from January to December 2019 is shown in [Figure 61]. In 2019, the total reported NCDs’ consultations are as follow: • Diabetes: 46,406 • Diabetic complications: 22,901 • Hypertension: 97,534 • Cardiovascular: 132,270 • ESKD: 50,895 [of note: the total performed ESKD Sessions in 2019: 373,311] • Cancer: 231,523 HeRAMS | Annual Report 2019 Public Hospitals46 4,190 3,963 4,049 4,089 4,177 4,041 4,094 4,182 4,252 4,120 4,855 4,883 3500 3700 3900 4100 4300 4500 4700 4900 5100 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 End Stage Kidney Disease (ESKD) treatment 18,072 17,487 18,472 19,132 15,022 17,356 21,242 17,227 22,625 23,695 20,160 21,033 14000 16000 18000 20000 22000 24000 26000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Cancer 11,667 12,211 12,178 11,304 9,822 9,288 11,436 9,052 11,551 12,032 10,515 11,214 8000 8500 9000 9500 10000 10500 11000 11500 12000 12500 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Cardiovascular services HeRAMS | Annual Report 2019 Public Hospitals47 Figure 62: The number of rehabilitation services in public hospitals, December 2019 1,816 1,574 1,566 666 525 266 176 118 75 15 2 0 0 0 200 400 600 800 1000 1200 1400 1600 1800 2000 Damascus Lattakia Hama Aleppo Tartous As -Sweida Rural Damascus Dar'a Deir-ez-Zor Homs Al -Hasakeh Ar-Raqqa Quneitra 6.8 Rehabilitation services Rehabilitation services and assistive device provision, including post-operative rehabilitation for trauma- related injuries are assessed at hospitals level. Figure 62 shows the distribution of total reported cases of rehabilitation services by governorate. Trend analysis of reported patients received rehabilitation services from January to December 2019, is presented in [Figure 63]. In 2019, the total reported patients are 94,046. 7,645 8,620 7,980 7,076 6,864 7,192 9,226 6,336 9,777 9,166 7,365 6,799 5000 6000 7000 8000 9000 10000 11000 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Rehabilitation services Figure 63: Trend analysis of number of rehabilitation services in public hospitals, January to December 2019 HeRAMS | Annual Report 2019 Public Hospitals48 Figure 64: The number of psychiatric inpatients in public hospitals, December 2019 Figure 65: Trend analysis of number of psychiatric inpatient cases in public hospitals, January to December 2019 398 235 41 1 0 0 0 0 0 0 0 0 0 0 100 200 300 400 500 Rural Damascus Aleppo Damascus Lattakia Tartous Homs Hama Al -Hasakeh Deir -ez-Zor Ar -Raqqa Dar'a As -Sweida Quneitra Psychiatric inpatient Psychiatric inpatient 782 803 816 780 735 756 761 750 710 697 675 675 600 650 700 750 800 850 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Psychiatric inpatient 6.9 Mental health Inpatient care for management of mental disorders by specialized health-care providers are assessed at hospitals level. Figure 64 shows the distribution of total reported cases of Psychiatric inpatient by governorate. The key figures of Psychiatric inpatient during December 2019 are reported from Rural Damascus (Ibn-Sina Psychiatric MoH hospital (388 cases), followed by Aleppo (Ibn-Khaldoun MoH hospital (235 cases). Trend analysis of monthly reported number of psychiatric inpatients in public hospitals [MoH & MoHE] from January to December 2018 is shown in [Figure 65]. In 2019, the total reported psychiatric inpatients cases are 8,940. HeRAMS | Annual Report 2019 Public Hospitals49 The availability of different types of essential and specialized equipment and supplies was assessed at hospital level, based on a standard checklist2. In its ninth year of crisis, Syria’s hospitals (have a remarkable improvements) are still suffering from shortages and/or malfunction of medical devices/ equipment to provide secondary care services. In insecure governorates, medical devices are either destroyed, burned, or malfunctioned, while in safe areas the medical devices are overburdened by increased numbers of people (actual numbers of people in the area, in addition to IDPs and patients /injured people from surrounding areas). Maintenance of malfunctioned devices remains a concern, due to non-availability of spare parts, accredited agent to provide maintenance support, or difficulty of accessibility in many cases. Analysis of availability of essential and specialized equipment was measured across all functional public hospitals [MoH & MoHE] (85/113), in terms of functional equipment out of the total available equipment in the hospital. The produced analysis provides good indication of the current readiness of the hospitals to provide the health services, and also to guide focused planning for procurement of equipment and machines, to fill-in identified gaps. Gaps on essential and specialized equipment and machines were observed, even within the functional public hospitals. Further details are provided on [Figure 66] and [Figure 67]. 7. Availability of medical equipment 71% 81% 83% 84% 86% 86% 89% 89% 90% 92% 92% 93% 93% 94% 95% 97% 98% 98% Autoclave Pulse Oximeter Dry_Sterilizer Oxygen Station Weighing Scale for infants Ambu bag (Paediatric and Adult) Delivery_table Weighing Scale for adults Operating_tables Suction machine Oxygen cylinders Fetoscope Vaginal examination set Weighing Scale for children Length Measurement Device Nebulizer Minor Surgical sets Height Measurement Device Figure 66: Percentage of functional essential equipment/ total available equipment in functional public hospitals, December 2019 2 A more detailed list of essential equipment is available upon request. HeRAMS | Annual Report 2019 Public Hospitals50 Figure 67: Percentage of functional specialized equipment/ total available equipment in the functional public hospitals, December 2019 71% 73% 74% 76% 77% 80% 80% 80% 81% 82% 82% 84% 86% 88% 97% CT Scan MRI machine Cardiotocography (Monitoring of fetalheart frequency) Ventilators – Adult Portable X-Ray X -Ray ECG Incubator for new born Anaesthesia machines Renal Dialysis machine Ultrasound DC Shock machine/ Defibrillator Ventilators – Paediatric ICU/CCU Monitors Major surgical sets HeRAMS | Annual Report 2019 Public Hospitals51 Based on the priority medicines list agreed by MoH and WHO, WHO has managed to address the gaps of medicines identified at all levels of health care. More details on availability of medicines and medical supplies at governorate level are available in HeRAMS database. 11% 16% 27% 30% 37% 37% 39% 55% 56% 57% 61% 63% 64% 64% 67% 73% 79% 79% 80% 81% 81% 82% 85% 86% 87% 93% Tetanus shot Cancer related medicines Hepatitis vaccine Psychotropic medinas (i.e., antipsychotics, antidepressants, antiepileptic and anxiolytics) Medicines affecting the blood (anti- anemia medicines, heparin, warfarin, etc.,) Dermatological preparations/topical (Burns, and anti-infective, etc...) Antidotes for Poisoning Medicines acting on respiratory system (e.g., medicines of Asthma, H1N1 ARI… like salbutamol …) Delivery related medicines (i.e., Oxytocin , … ) Specific antibiotics for multi – resistant bacteria/infectious diseases Dialysis consumables Anti -diabetic preparations (especially Insulin) Anaphylactic shock Antibiotics for Children Gastrointestinal Cardiac and /or Vascular Drugs (Anti -hypertensive Drugs, Diuretics, …) Local Anaesthetics General Anaesthetics Preoperative medication Albumin IV Fluid Anti -allergic including Steroids Analgesics, antipyretics, non-steroidal anti-inflammatory Medicines Antibiotics for Adults Serums Antiseptics Figure 68: Availability of medicines and medical supplies for one month in the functional public hospitals, December 2019 Availability of medicines and medical supplies at hospitals’ level was evaluated based on a standard list of identified priority medicines (driven from the national Essential Medicine List), and medical supplies for duration of one month [Figure 68]. 8. Availability of medicines & medical supplies HeRAMS | Annual Report 2019 Public Hospitals52 Slight variation of functionality status of public hospitals was observed throughout 2019. For example, 28 hospitals were reportedly out-of-service in December 2018 compared to 26 in January of the same year. Similarly, access to the public hospitals has minor changes throughout 2019 with 13 hospitals reportedly non-accessible in December 2019 compared to 18 in January of the same year. Functionality status of hospitals was highly affected by the dire security situation and limited access by health staff and patients as well as critical shortages of supplies. Levels of damages of the hospitals’ buildings directly affected the functionality status and provision of health services; however, some hospitals have resiliently continued to provide services regardless of levels of damage to the building and by utilizing intact parts of the building or operating from other neighboring facilities in a few cases. Rehabilitation of the damaged hospitals’ infrastructure, in addition to provision of supplies and medical equipment will significantly improve functionality of hospitals, readiness and provision of essential health services at secondary care level. Slight improvement of the available number of medical staff (doctors, nurses and midwives) throughout 2019 was observed. However, increased capacity building activities and training courses of the national health staff will help in improving technical capacity of healthcare providers and filling gaps in certain areas. Limited functionality and accessibility to public hospitals in addition to large displacement of people have greatly overburdened the few functional public hospitals’ resources. Increasing provision of specialized medical machines, as well as medicines and supplies especially for NCDs (such as cancer treatment, as observed the highest consultations among other NCDs) provides an affordable alternative compared to the high cost of healthcare in the private sector. Furthermore, the crisis aggravated the inequalities among regions, leaving many people deprived of the minimum level of health services. HeRAMS can help in directing the interventions of different players to the most vulnerable groups and those with the greatest needs, and in assessing the efficiency of interventions. Conducting a qualitative survey on provision of health services from the populations’ point of view, using HeRAMS data as a baseline, will help in concretely measuring the impact of the crisis on public health sector in terms of responsiveness of hospitals and quality of provided services. 9. Conclusions and recommendations