WHO-EM/SYR/039/E
HeRAMS Annual Report
January - December 2019
Public Hospitals in the Syrian Arab Republic WHO-EM/SYR/039/E
HeRAMS Annual Report
January - December 2019
Public Hospitals in the Syrian Arab Republic
World Health Organization Health Resources and Services Availability Monitoring System Syrian Arab Republic 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.
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Introduction 1
Executive summary 1
1. Completeness of hospitals reporting 3
2. Functionality and accessibility of the public hospitals 4 2.1 Functionality status of the public hospitals 4 2.2 Density of the public hospitals 7 2.3 Accessibility to public hospitals 8
3. Accessibility to public hospitals 8
4. Infrastructure patterns of the public hospitals 10 4.1 Level of damage of the hospitals’ buildings 10 4.2 Analysis of the inpatient capacity 14 4.3 Water sources and functionality status 15 4.4 Availability of electricity generators 17
5. Availability of health human resources 18 5.1 Availability of medical staff by category and affiliation 21 5.2 Availability of medical doctors by affiliation (MoH vs. MoHE hospitals) 23 5.3 Availability of medical doctors by gender (MoH vs. MoHE hospitals) 25
6. Availability and utilization of the health services 27 6.1 General clinical services 29 6.2 Surgical and trauma care 31 6.3 Maternal health services 38 6.4 Child health 41 6.5 Nutrition 42 6.6 Communicable diseases services 43 6.7 NCDs (non-communicable diseases) 44 6.8 Rehabilitation services 47 6.9 Mental health 48
6. Availability of medical equipment 49
7. Availability of medicines & medical supplies 51
8. Conclusions and recommendations 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 1 Public Hospitals
Introduction
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.
Executive summary
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. HeRAMS | Annual Report 2019 2 Public Hospitals
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 3 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.
1. Completeness of hospitals reporting
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.
Figure 1: Distribution of public hospitals by affiliation, per governorate
Total MoH Hospitals Total MoHE Hospitals Total Public Hospitals 18 16 16 15 15 15 16 14 14 11 12
10 8 7 7 7 7 7 7 7 7 8 6 6 6 5 5 6 4 4 4 4 4 4 4 4 1 1 1 1 2 0 0 0 0 0 0 0 0 0 0 0 Damascus Rural Aleppo Idleb Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Damascus
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. HeRAMS | Annual Report 2019 4 Public Hospitals
2. Functionality and accessibility of the public hospitals
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
25% Fully Functioning 57 Partially Functioning 28 50% Non-Functioning 28
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 5 Public Hospitals
Figure 3: Number and percentage of the public hospitals by functionality status, per governorate, December 2019
Fully Functioning Partially Functioning Non-functioning
Quneitra 1 0
Tartous 7 0
Damascus 13 2 0
Lattakia 6 1 0
Hama 5 0 1
As -Sweida 3 1 0
Rural Damascus 8 2 5
Aleppo 7 4 4
Homs 5 5 6
Al -Hasakeh 1 3 1
Dar'a 1 5 1
Ar -Raqqa 0 2 2
Deir -ez-Zor 0 3 4
Idleb 0 4
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Map 1: Distribution and functionality status of public hospitals, December 2019 HeRAMS | Annual Report 2019 6 Public Hospitals
Slight variation of functionality status of public hospitals has been observed during 2019 [Figure 4].
Figure 4: Trend analysis of functionality status of public hospitals, January to December 2019
80
60 58 57 57 56 56 57 57 57 57 57 57 57
40 26 26 26 26 26 26 26 26 26 28 28 28
20 27 28 28 29 29 28 28 28 28 28 28 28 0 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
Map 2: Trend analysis of functionality status of public hospitals, January to December 2019 HeRAMS | Annual Report 2019 7 Public Hospitals
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.
Figure 5: Density of the public hospitals per governorate, December 2019
400,000 357,561 345,401 350,000 316,045 300,000 268,437 265,085 240,542 247,083 Sphere standards for hospitals (250,000) 250,000 200,000 169,499 169,213 145,106 129,480 150,000 122,359 103,269 94,793 100,000 50,000 - Aleppo Ar-Raqqa Rural Hama Al -Hasakeh Deir-ez-Zor Lattakia Dar'a Homs Tartous Damascus Quneitra As -Sweida Syria Damascus Map 3: Density of the public hospitals per governorate, December 2019 HeRAMS | Annual Report 2019 8 Public Hospitals
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.
3. Accessibility to public hospitals
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).
Figure 6: Accessibility status - December 2019
11% Yes 91 8% Hard to access 9 No 13
81%
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. HeRAMS | Annual Report 2019 9 Public Hospitals
Figure 7: Accessibilty status of the public hospitals per governorate, December 2019
Yes Hard to access No
Quneitra 1 0 Homs 16 0 Tartous 7 0 Lattakia 7 0 Rural Damascus 13 1 1 Dar'a 6 0 1 Deir -ez-Zor 6 0 1 Al -Hasakeh 4 1 0 Damascus 12 3 0 As -Sweida 3 1 0 Ar -Raqqa 3 0 1 Hama 4 1 1 Aleppo 9 2 4 Idleb 0 4 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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 10 Public Hospitals
Figure 8: Trend analysis of accessibility to public hospitals, January to December 2019
100 85 91 91 91 91 91 92 91 91 91 91 91
80
60
40 18 12 12 12 12 12 11 12 12 13 13 13 20 8 8 8 8 8 8 8 8 8 9 9 9 0 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
4. Infrastructure patterns of the public hospitals
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.
Figure 9: level of damage - December 2019
10% Fully damaged 11
Partially damaged 38 57% 33% Not damaged 64
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 11 Public Hospitals
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 12 Public Hospitals
Figure 10: Number and percentage of the public hospitals by level of damage, per governorate, December 2019
Fully damaged Partially damaged Not damaged
Quneitra 0 1 As -Sweida 0 4 Tartous 0 7 Damascus 0 2 13 Lattakia 0 1 6 Ar -Raqqa 0 1 3 Al -Hasakeh 1 1 3 Homs 2 6 8 Hama 1 2 3 Rural Damascus 1 7 7 Aleppo 5 3 7 Dar'a 0 6 1 Deir -ez-Zor 1 5 1 Idleb 0 4 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Trend analysis on condition of the public hospitals (level of damage of the building) from January to December 2019 is presented in Figure 11.
Figure 11: Trend analysis of public hospitals’ level of damage, January to December 2019
80 61 62 62 62 62 62 62 62 62 64 64 64 60 37 36 37 38 38 38 38 38 38 38 38 38 40 13 13 12 20 11 11 11 11 11 11 11 11 11
0 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
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 13 Public Hospitals
Table 1: The list of hospitals with reported fully damaged buildings
# Hospital Name Province District Affiliation 1 Rural Damascus specialized hospital – Duma Rural Damascus Duma MoH 2 Zahi Azraq general hospital Aleppo The fourth MoH 3 E'zaz national hospital Aleppo E'zaz MoH 4 Ophthalmology hospital Aleppo Third MoH 5 Children hospital Aleppo Third MoH 6 Al-Qusayr general hospital Homs Al-Qusayr MoH 7 Taldaw hospital Homs Al-Quabu MoH 8 Helfaya hospital Hama Muhardeh MoH 9 Children hospital Al-Hasakeh Al-Hasakeh MoH 10 Modern Medicine hospital Deir-ez-Zor Al-Mayadin MoH 11 Al-Kindi university hospital Aleppo The fourth MoHE
Table 2: Special cases of hospitals which reported fully damaged (buildings), and operating partially from other locations
# Hospital name Province District Type Condition Affiliation New location
1 Zahi Azraq general hospital Aleppo The fourth General Fully damaged MoH Ar-Razi hospital
Ar-Razi hospital 2 Ophthalmology hospital Aleppo Third Specialized Fully damaged MoH + Al-Bassel Heart Institute Ar-Razi hospital + 3 Children hospital Aleppo Third Specialized Fully damaged MoH Maternity hospital New medical center 4 Children hospital Al-Hasakeh Al-Hasakeh Specialized Fully damaged MoH in Al-hasakah
Table 3: Special cases of hospitals which reported partially damaged (buildings), and operating partially (limited provided health services) from other locations
# Hospital name Province District Type Condition Affiliation New location
Rural Partially 1 Al-Bassel-Qara hospital Al-Nabak General MoH Qara Municipal Damascus damaged
Partially 2 Children and Obstetrics hospital Deir-ez-Zor Deir-ez-Zor Specialized MoH Al-Assad hospital damaged
Partially 3 Al-Furat hospital Deir-ez-Zor Deir-ez-Zor Specialized MoH Al-Assad hospital damaged
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 14 Public Hospitals
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].
Figure 12: Comparison of inpatient capacity (original vs. available) in functional hospitals per governorate, December 2019
Original No. of Beds Available No. of Beds 3,245 2,840
2,203 2,096 1,958 1,677 1,549 1,629 1,1861,152 1,160 952 810 792 720 670 494 583 558 311 451 232 260 188 200 133
Damascus Lattakia Aleppo Rural Damascus Tartous Hama Dar'a Homs As -Sweida Al -Hasakeh Deir -ez-Zor Ar -Raqqa Quneitra
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.
Figure 13: Percentage of available number of beds in functional hospital versus the original inpatient capacity, December 2019
114% % of available beds /Total original beds 97%
83% 82% 81% 82% 76% 74% 72% 67% 67% 62%
42% 38%
Damascus Tartous Rural Hama As -Sweida Lattakia Aleppo Ar-Raqqa Al -Hasakeh Quneitra Homs Deir-ez-Zor Dar'a Overall Damascus HeRAMS | Annual Report 2019 15 Public Hospitals
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].
Figure 14: number of hospital beds (including ICU)/10,000 Population in public hospitals, December 2019
Number of hospital beds (including ICU)/10,000 Population
20 18 18 15 16 14 14 13 13
12 Inter-Agency Standing Committee (IASC) Standards: 10 hospital beds 10
8 7 6 6 5 4 4 3 3 4 3 3
2
0 Damascus As -Sweida Lattakia Quneitra Tartous Hama Rural Damascus Al -Hasakeh Aleppo Homs Deir-ez-Zor Dar'a Ar-Raqqa Grand Total
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].
Figure 15: Main sources of water, December 2019
Other, 3, 4% Well, 8, 9% Main Pipeline, 32, 38%
Main Pipeline and Well, 42, 49% HeRAMS | Annual Report 2019 16 Public Hospitals
Detailed analysis on distribution of water sources at functional public hospitals is presented at governorate level on [Figure 16].
Figure 16: Distribution of water sources/ types at functional public hospitals, per governorate, December 2019
Lattakia 7 0 Homs 5 2 3 0 Tartous 5 2 0 Rural Damascus 4 5 1 0 Damascus 4 11 0 As -Sweida 3 1 0 Deir -ez-Zor 2 1 0 Dar'a 1 1 3 1 Ar -Raqqa 1 1 0 Quneitra 0 1 0 Al -Hasakeh 0 4 0 Hama 0 5 0 Aleppo 0 9 0 2
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Main Pipeline Main Pipeline and Well Well Other
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 17: Functionality status of the water sources at functional public hospitals, December 2019
Quneitra 0 Ar -Raqqa 1 1 Al -Hasakeh 1 3 As -Sweida 2 2 Deir -ez-Zor 3 0 Dar'a 5 1 Hama 5 0 Tartous 7 0 Lattakia 7 0 Rural Damascus 7 3 Homs 8 2 Aleppo 11 0 Damascus 14 1
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Fully Functioning Partially Functioning HeRAMS | Annual Report 2019 17 Public Hospitals
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
24.5 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 23.6 23.5
23.0
22.5 22.3
22.0 21.7
21.5
21.0
20.5 Damascus Rural Damascus Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir -ez-Zor Ar -Raqqa Dar'a As -Sweida Quneitra Syria
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.
Figure 19: Percent of hospitals in need for generators out of total functional hospitals, December 2019
100% 100%
90%
80%
70%
60% 55% 50% 50% 40% 40% 40% 27% 26% 30% 25% 17% 20% 14%
10% 0% 0% 0% 0% 0% Quneitra Aleppo Al -Hasakeh Rural Hama Damascus As-Sweida Dar'a Tartous Lattakia Homs Deir -ez-Zor Ar-Raqqa Total Damascus HeRAMS | Annual Report 2019 18 Public Hospitals
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
Figure 20: Proportion of health staff in hospitals, December 2019
General Practitioner 0.2% Pharmacists Midwives Specialist 0.7% 4.9% 12.5% Laboratory Emergency 5.1% Physician 0.3%
Resident Doctor 22.7%
Nurses Dentist 52.8% 0.8%
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]. HeRAMS | Annual Report 2019 19 Public Hospitals
Table 4: Availability of human resources of functioning public hospitals, per governorate, December 2019 Governorate General Practitioner Orthopedic surgery General surgery Neurological surgery Other Specialists Emergency Physician Resident Doctor Dentist Nurses Laboratory Midwives Pharmacists University* Technicians Others
Damascus 0 47 58 17 830 18 2,726 38 3,760 388 158 80 550 1,315 2,954
Rural Damascus 12 22 31 4 226 4 558 7 1,282 132 87 17 125 430 882
Aleppo 6 30 36 6 357 7 1,013 57 930 165 90 16 205 322 1,073
Idleb
Lattakia 4 40 51 8 512 21 1,123 60 2,552 149 247 30 245 491 1,151
Tartous 5 37 59 8 437 21 564 37 2,337 232 120 27 253 820 1,637
Homs 13 31 42 5 238 15 195 9 1,617 165 233 17 68 724 424
Hama 4 29 44 8 346 11 576 46 1,617 157 232 11 139 896 749
Al-Hasakeh 2 3 5 2 55 0 67 2 294 37 44 5 27 144 136
Deir-ez-Zor 1 2 1 0 32 0 29 3 574 74 135 0 17 289 345
Ar-Raqqa 6 3 6 0 22 0 0 0 124 10 37 4 7 27 81
Dar'a 2 5 4 1 43 0 59 0 412 38 48 5 27 152 232
As-Sweida 3 7 14 2 113 1 120 1 1,003 53 95 4 77 298 587
Quneitra 0 2 3 2 37 4 108 3 116 9 15 4 11 70 227
Grand Total 58 258 354 63 3,248 102 7,138 263 16,618 1,609 1,541 220 1,751 5,978 10,478
* Health workers in the health centres who hold university degrees (engineer, law, trade and economics ...... ) HeRAMS | Annual Report 2019 20 Public Hospitals
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 21 Public Hospitals
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.
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
12,000 11,484 11,319 11,500 11,196 11,286 11,194 11,090 11,000 10,799
10,371 10,319 10,327 10,317 10,500 10,185 10,551 10,432 10,305 10,299 10,000 10,217 10,190 10,234 9,999 9,919 9,888 9,902 9,936 9,500
9,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2018 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 22 Public Hospitals
Figure 22: Trend analysis of number of nurses in public hospitals during 2018 and 2019
17,000 16,880 16,899 16,767 16,726 16,769 16,800 16,643 16,618 16,509 16,600 16,389 16,323 16,243 16,400 16,160 16,200 16,000 16,191 16,222 16,214 16,198 16,056 16,090 16,115 15,800 16,016 15,962 15,600 15,752 15,810 15,400 15,645 15,200 15,000 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.
Figure 23: Trend analysis of number of midwives in public hospitals during 2018 and 2019
1,570 1,545 1,542 1,544 1,550 1,537 1,540 1,541
1,530 1,515 1,519 1,508 1,512 1,510 1,510 1,509 1,490 1,478 1,493 1,490 1,495 1,493 1,492 1,487 1,484 1,486 1,470 1,479 1,468 1,450 1,449 1,430 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2018 2019 HeRAMS | Annual Report 2019 23 Public Hospitals
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].
Figure 24: Proportions and numbers of key staff work in MoH vs. MoHE hospitals, December 2019
100% 1 4 29 90% 323 208 2,164 3,981 80% 70% 60% 50% 57 98 234 MoHE 40% 3,108 1,286 1,333 4,974 12,637 30% MoH 20% 10% 0% General Specialist Emergency Resident Dentist Nurses Laboratory Midwives Practitioner Physician Doctor
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]. HeRAMS | Annual Report 2019 24 Public Hospitals
Figure 25: Comparison of the medical staff of MoH vs. MoHE hospitals, December 2019
General Practitioner Specialist Emergency Physician Resident Doctor Dentist Nurses Midwives Pharmacists
2,500 2,273
2,000 1,763 1,492 1,487 1,500 1,060 963 958 1,000 606 579 577 544 525 503 478 436 427 324 324 224 221 500 208 167 108 103 87 80 80 65 59 57 55 52 25 19 19 18 17 8 7 6 5 4 4 4 11 2 1 0 0 0 0 0 0 0 0 0 0 Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia MoH MoHE
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].
Figure 26: Number of nurses and midwives per doctor in public hospitals, December 2019
Number of nurses and midwives per doctor
12.0
10.4
10.0
8.0
6.0
4.4 4.2 4.0 4.0 3.4
2.5 2.1 MoH benchmark (2) 1.7 1.6 2.0 1.6 1.5 1.0 0.8 0.7
0.0 Deir-ez-Zor Ar-Raqqa As -Sweida Dar'a Homs Al -Hasakeh Tartous Hama Rural Damascus Lattakia Damascus Quneitra Aleppo Grand Total
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]. HeRAMS | Annual Report 2019 25 Public Hospitals
Figure 27: number of health staff (doctors, nurses and midwives) per 10,000 population in public hospitals, December 2019
Health Staff /10,000 Population
45.0 0.9 40.0 1.3 2.1 35.0 2.5
30.0 20.5 1.5 21.5 25.0 25.8 Inter-Agency Standing Committee (IASC) Standards: health staff > 22
20.0 26.5 11.2 1.7
15.0 1.6 12.0 0.8
10.0 20.3 11.1 1.8 8.1 15.3 15.4 12.9 0.3 0.2 5.0 2.4 0.5 7.9 7.7 4.1 0.4 6.9 4.1 2.8 0.5 5.6 3.8 2.7 3.8 1.8 0.0 0.9 1.1 1.3 0.5 Damascus Tartous Lattakia As -Sweida Quneitra Hama Homs Deir-ez-Zor Rural Aleppo Dar'a Al -Hasakeh Ar-Raqqa Grand Total Damascus
Doctors Nurses Midwives
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].
Figure 28: Proportion of Doctors (a total of Specialists, Emergency Physicians, Resident Doctors, Dentists), by gender, per governorate, December 2019
Male Female 100%
90% 9 50 23 42 92 58 80% 1439 342 620 751 447 231 408 70%
60%
50%
40% 28 86 45 72 169 101 30% 2295 522 892 1068 721 317 656 20%
10%
0% Damascus Rural Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Damascus HeRAMS | Annual Report 2019 26 Public Hospitals
Figure 29: Percentage of functioning public hospitals without medical staff (gaps), December 2019
Emergency Physician 64.7
Practitioner 63.5
Dentist 62.4
Midwives 27.1
Resident Doctor 15.3
Specialist Doctor 1.2
Nurses 0.0
0 10 20 30 40 50 60 70 80 90 100 HeRAMS | Annual Report 2019 27 Public Hospitals
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].
Figure 30: Availability of health services in the functional public hospitals, December 2019
Sanitation availability 91% Blood bank service 90% Safe water availability 89% Hypertension services 88% Management of diabetes 88% ICU services 83% Cardiovascular services 82% Emergency surgery 78% Trauma services 78% Acute psychiatric inpatient unit 78% End Stage Kidney Disease (ESKD) treatment 77% (CEmOC) Comprehensive emergency obstetric care 74% Communicable diseases services 74% Burn patient management 74% Treatment of diabetic complications 68% Management of children diseases 68% Comprehensive abortion care 67% Waste management 62% Medical evacuation 59% Rehabilitation services 57% Management of severe acute malnutrition with complications 35% Cancer treatment services 30%
**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. HeRAMS | Annual Report 2019 28 Public Hospitals
Figure 31: Estimated caseload of functional public hospitals (outpatient consultations and emergency cases), January to December 2019
1,800,000 1,528,148 1,600,000 1,400,000
1,200,000 994,044 1,000,000 869,682 842,931 722,986 800,000 603,959 560,994 600,000 345,081 326,682 309,040 400,000 259,101 126,783 200,000 76,818 0 Damascus Lattakia Aleppo Homs Tartous Hama Rural Ar-Raqqa Al -Hasakeh Dar'a As -Sweida Deir-ez-Zor Quneitra Damascus
Figure 32: Trend analysis of estimated caseload in public hospitals, January to December 2019
750000 718,432
666,941 700000 651,993 656,810 639,985 623,091 650000 621,035 615,054 616,927 592,783 591,390 600000 571,808
550000
500000 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
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 29 Public Hospitals
Figure 33: Proportions of workload during 2019, per governorate
Deir -ez-Zor 2% Quneitra As-Sweida 1% Dar'a 3% 4% Al -Hasakeh 4% Damascus 20% Ar-Raqqa 5%
Rural Damascus 7% Lattakia 13% Hama 8%
Tartous Aleppo 10% 12% Homs 11%
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].
Figure 34: The number of Outpatient and Inpatient in public hospitals, December 2019
Outpatient services Inpatients services 80000 71,869 70000 60000 50000 37,186 36,495 40000 33,941 26,264 25,704 30000 21,426 16,887 13565 20000 10751 8135 8904 7,407 5999 5982 4908 6,375 5,048 4855 4,705 10000 1316 2,627 1173 3105 1615 320 0 Damascus Lattakia Aleppo Homs Rural Tartous Hama Ar-Raqqa Deir-ez-Zor Dar'a As -Sweida Al -Hasakeh Quneitra Damascus HeRAMS | Annual Report 2019 30 Public Hospitals
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 35: Trend analysis of outpatient and Inpatient in public hospitals, January to December 2019
450000 385,016 400000 339,352 335,992 337,732 332,437 319,570 350000 299,928 302,713 297,979 295,934 269,881 283,295 300000 250000 200000 150000 88,560 75,695 74,028 76,116 75,215 71,857 77,734 77,537 80,129 76,002 67,685 70,628 100000 50000 0 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
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].
Figure 36: The number of patients received services in laboratories, blood bank, and imaging services in public hospitals, December 2019 589,585 700,000
600,000 307,503 500,000 231,051 220,711
400,000 169,154 140,898 113,739 108,384 300,000 77,252 52,258 36,851 30,888 23,790 23,393 21,261 18,783 16,924 16,257 10,498 7,514 7,036 6,731
200,000 6,018 5,058 3,035 2,583 1,832 1,605 1,459 1,337 1,351 1,203 830 560 425 262 223 116 100,000 61
0 Damascus Rural Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Damascus
Laboratory services Blood bank service Imaging service
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 31 Public Hospitals
Figure 37: Trend analysis of number of patients received services in blood banks and imaging services in public hospitals, January to December 2019
350000 303,905 252,011 257,383 254,295 262,962 300000 238,820 238,596 233,577 235,441 233,370 218,780 221,219 250000 200000 150000 100000 31,154 32,386 32,412 33,898 34,467 33,163 34,606 31,828 31,363 30,902 28,550 31,118 50000 0 17,603 17,076 17,614 17,669 17,467 18,970 18,023 18,896 17,128 15,954 15,935 16,549 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
2,112,496 2200000 2100000 1,976,187 1,990,516 1,924,265 1,931,187 1,937,965 2000000 1,872,740 1,878,963 1,846,321 1,869,067 1,837,213 1900000 1,714,390 1800000 1700000 1600000 1500000 1400000 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
60000 48,515 50000 41,298
40000 32,522 30,988 29,129 30000 24,309 21,992 20,325 19,884 17,952 20000
10000 3,208 2,400 2,156 0 Damascus Lattakia Aleppo Tartous Homs Hama Rural Al -Hasakeh Dar'a As -Sweida Quneitra Ar-Raqqa Deir-ez-Zor Damascus HeRAMS | Annual Report 2019 32 Public Hospitals
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.
Figure 39: Trend analysis of number of reported cases in emergency department in public hospitals, January to December 2019
333,126 340000 332,815 326,739 330000 320,368 318,284 315,282 320000 312,053 306,689 310000 302,873 301,476 294,167 294,678 300000 290000 280000 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
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 33 Public Hospitals
Figure 40: The number of emergency surgeries vs. elective surgeries in public hospitals, December 2019
Elective surgery Emergency surgery 7000 5,844 6000
5000
4000 2,755 3000 1,895 1,495 2000 1,339 1,210 931 986 1,170 1,138 1,091 616 697 676 1000 486 92 106 108 224 89 152 167 123 5 57 35 0 Damascus Aleppo Lattakia Hama Rural Homs Tartous Dar'a As -Sweida Al -Hasakeh Quneitra Deir-ez-Zor Ar-Raqqa Damascus
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].
Figure 41: Percentage of total emergency surgeries to elective surgeries in public hospitals per governorate, December 2019
% Emergency surgery % Elective surgery 100% 90% 28% 80% 53% 48% 70% 60% 58% 62% 68% 75% 72% 60% 86% 93% 91% 87% 50% 96% 40% 72% 30% 47% 52% 20% 40% 42% 38% 32% 25% 28% 10% 14% 7% 9% 13% 0% 4% Deir-ez-Zor Rural Homs Dar'a Damascus Aleppo Al -Hasakeh Ar-Raqqa Lattakia As -Sweida Hama Quneitra Tartous Total Damascus 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. HeRAMS | Annual Report 2019 34 Public Hospitals
Figure 42: Trend analysis of number of patients received emergency surgeries and elective surgeries in public hospitals, January to December 2019
25000 20,535 19,216 18,830 20000 16,791 16,609 15,461 15,554 15,652 15,941 15,094 14,483 14,574 15000
7,958 7,870 7,911 8,124 8,048 7,690 7,546 10000 6,546 6,601 7,243 7,016 7,307
5000
0 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
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 35 Public Hospitals
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.
Figure 43: The number of patients received ICU services in public hospitals, December 2019
1600 1,361 1400 1200 902 1000 802 777 715 800 600 405 303 289 400 134 107 88 200 58 29 0 Damascus Hama Aleppo Lattakia Homs As -Sweida Rural Tartous Dar'a Deir-ez-Zor Al -Hasakeh Quneitra Ar-Raqqa Damascus
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.
Figure 44: Trend analysis of number of patients received ICU services in public hospitals, January to December 2019
6800 6,569 6600 6,372 6,253 6,224 6400 5,980 5,981 6200 5,908 5,970 5,900 5,839 5,875 6000 5,773 5800 5600 5400 5200 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 HeRAMS | Annual Report 2019 36 Public Hospitals
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.
Figure 45: The number of patients received trauma services in public hospitals, December 2019
2500 2,343
2000 1,806
1500
1000 549 542 440 500 162 85 83 43 28 26 15 0 0 Damascus Hama Aleppo Dar'a Homs Lattakia Rural Tartous As -Sweida Deir-ez-Zor Al -Hasakeh Quneitra Ar-Raqqa Damascus
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
9500 8,969 8,452 9000 8,187 8500 7,746 7,521 7,322 8000 7,139 7,115 7500 6,776 7000 6,031 6,098 6,122 6500 6000 5500 5000 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 37 Public Hospitals
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.
Figure 47: The number of patients received burn patient management in public hospitals, December 2019
450 394 400 350 300 250 200 153 128 150 94 63 61 53 100 38 35 33 50 8 0 0 0 Tartous Homs Damascus Dar'a Rural Lattakia Al -Hasakeh Aleppo Hama Deir-ez-Zor As -Sweida Ar-Raqqa Quneitra Damascus
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.
Figure 48: Trend analysis of number of patients received burn patient management in public hospitals, January to December 2019
1,403 1,380 1500 1,314 1400 1,248 1,240 1,223 1,201 1300 1,131 1,144 1200 1,076 1,060 1100 1000 851 900 800 700 600 500 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 HeRAMS | Annual Report 2019 38 Public Hospitals
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].
Figure 49: Number of functioning hospitals providing CEmONC services/ 500,000 Population, December 2019
Number of functioing hospitals providing CEmONC Services/ 500,000 Population
6.0
4.8 5.0
4.0 4.0
3.0 3.0 2.8 2.8
2.1 Inter-Agency Standing Committee (IASC) Standards: 10 hospital beds 2.0 1.5 1.4 1.4 1.1 1.2 1.0 0.7 0.5 0.3
0.0 Quneitra As -Sweida Dar'a Tartous Homs Lattakia Hama Ar-Raqqa Al -Hasakeh Rural Damascus Deir-ez-Zor Damascus Aleppo Grand Total
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 39 Public Hospitals
Figure 50: The No. of normal deliveries and caesarean sections (CSs) performed at public hospitals, December 2019
Normal_deliveries CSs 1200 1,055
1000 752 800 655 593 521 527 600 498 467 426 351 363 358 353 400 304 288 323 245 227 257 200 185 153 167 143 200 53 86
0 Damascus Ar-Raqqa Aleppo Hama Rural Dar'a Al -Hasakeh Homs Tartous As-Sweida Lattakia Deir -ez-Zor Quneitra Damascus
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].
Figure 51: Percentage of caesarean sections to normal deliveries in public hospitals, December 2019
100% 15% 90% 38% 35% 34% 80% 43% 42% 42% 42% 44% 53% 50% 70% 66% 61% 61% 60% 50% 85% 40% 62% 65% 66% 30% 57% 58% 58% 58% 56% 47% 50% 20% 34% 39% 39% 10% 0% Lattakia Tartous Deir -ez-Zor Homs Hama As-Sweida Rural Aleppo Damascus Quneitra Ar-Raqqa Dar'a Al -Hasakeh Total Damascus
CSs % Normal deliveries % HeRAMS | Annual Report 2019 40 Public Hospitals
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.
Figure 52: Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections in public hospitals, January to December 2019
7,027 7500 6,552 6,429 7000 6,372 6,227 6,011 6500 5,824 5,819 5,891 5,368 6000 5,187 5,303 5500 4,995 4,881 4,661 4,608 4,742 4,483 4,471 4,458 4,430 5000 4,329 4,247 4500 3,981 4000 3500 3000 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
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].
Figure 53: Comparison of MoH & MoHE hospitals workload of normal deliveries vs, CSs, December 2019
700 589 557 600 498 466 500 363 400 341 267 257 300 252 195 169 200 101 84 86 100 0 Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia MoH Hospitals MoHE Hospitals
Normal_deliveries CSs HeRAMS | Annual Report 2019 41 Public Hospitals
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.
Figure 54: Number of children with severe diseases in public hospitals, December 2019
1000 920 744 800
600 525 387 400 295
95 200 77 76 62 52 16 8 0 0 Hama Rural As -Sweida Tartous Damascus Homs Lattakia Dar'a Aleppo Ar-Raqqa Al -Hasakeh Quneitra Deir-ez-Zor Damascus
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.
Figure 55: Trend analysis of reported cases of severe children diseases in public hospitals, January to December 2019
3,808 4000 3,595 3800 3,536 3,521 3,514 3600 3,206 3,176 3,246 3,257 3400 3,149 3200 2,813 3000 2,652 2800 2600 2400 2200 2000 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 HeRAMS | Annual Report 2019 42 Public Hospitals
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.
Figure 56: The number of children with severe acute malnutrition with complications in public hospitals, December 2019
30 26 25 20
15 11 11 11 11 8 10 3 5 2 2 2 1 0 0 0 Lattakia Damascus Aleppo Hama Dar'a Deir-ez-Zor Tartous Rural Homs As -Sweida Quneitra Al -Hasakeh Ar-Raqqa Damascus
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.
Figure 57: Trend analysis of number of children with severe acute malnutrition with complications in public hospitals, January to December 2019
160 135 140 123 120 93 96 95 86 92 87 88 100 83 73 69 80 60 40 20 0 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 HeRAMS | Annual Report 2019 43 Public Hospitals
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.
Figure 58: The number of patients received communicable diseases in public hospitals, January to December 2018
1400 1,160 1200 1000 800 507 600 476
400 156 74 200 45 41 25 17 12 10 0 0 0 Hama Tartous Deir -ez-Zor Damascus As -Sweida Rural Aleppo Lattakia Dar'a Al -Hasakeh Homs Ar -Raqqa Quneitra Damascus
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.
Figure 59: Trend analysis of number of patients received communicable diseases in public hospitals, January to December 2019
2,832 2900 2,692 2,547 2700 2,506 2,484 2,523 2,365 2500 2,281 2,233 2,203 2300 2,113 2,070 2100 1900 1700 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
Communicable diseases services HeRAMS | Annual Report 2019 44 Public Hospitals
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].
Figure 60: The number of NCDs’ consultations in public hospitals, December 2019
18,000 16,000 15,826 14,000 12,000 10,000 8,000
6,000 3,736 2,798 2,784 2,370 1,918 1,816 1,574 1,566
4,000 1,188 996 1,088 1,086 966 930 844 825 746 712 666 642 600 580 576 525 509 499 486 484 478 457 439 415 406 402 398 389 384 267 266 261 259 246 232 224 209 204 191 190 176 98 97 99 96 86 85 82 7 5 75 73 0 72 2 2 0 0 0 0 0 0 0 0 0 136 62 56 126 125 118 108 104 102 102 33 30 30 21 19 2,000 15 190 0 Damascus Rural Aleppo Lattakia Tartous Homs Hama Al-Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As-Sweida Quneitra Damascus Management of diabetes Treatment of diabetic complications Hypertension Cardiovascular services End Stage Kidney Disease (ESKD) treatment Cancer Rehabilitation services HeRAMS | Annual Report 2019 45 Public Hospitals
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
Figure 61: Trend analysis of total monthly number of NCDs’ consultations reported in public hospitals, January to December 2019
7000 6,356 5,623 5,685 5,643 5,733 5,641 5,295 5,413 6000 5,091 4,888 4,692 5000 4,346
4000
3000 2,137 2,153 2,125 2,035 2,025 1,843 1,735 1,807 1,789 1,637 1,804 1,811 2000
1000 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
9500 9,146
9000 8,543 8,496 8,499 8,232 8500 8,132 7,983 7,967 7,777 8000 7,652 7,591 7,516 7500
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 Hypertension HeRAMS | Annual Report 2019 46 Public Hospitals
12,211 12,178 12500 12,032 11,667 12000 11,436 11,551 11,304 11,214 11500 11000 10,515
10500 9,822 10000 9,288 9500 9,052 9000 8500 8000 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
5100 4,855 4,883 4900 4700
4500 4,252 4,190 4,177 4,182 4300 4,120 4,049 4,089 4,041 4,094 3,963 4100 3900 3700 3500 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
26000 23,695 24000 22,625 21,242 21,033 22000 20,160 19,132 20000 18,072 18,472 17,487 17,356 17,227 18000 15,022 16000
14000 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 HeRAMS | Annual Report 2019 47 Public Hospitals
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.
Figure 62: The number of rehabilitation services in public hospitals, December 2019
2000 1,816 1800 1,574 1,566 1600 1400 1200 1000 800 666 525 600 400 266 176 118 200 75 15 2 0 0 0 Damascus Lattakia Hama Aleppo Tartous As -Sweida Rural Dar'a Deir-ez-Zor Homs Al -Hasakeh Ar-Raqqa Quneitra Damascus
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.
Figure 63: Trend analysis of number of rehabilitation services in public hospitals, January to December 2019
11000 9,777 10000 9,226 9,166 8,620 9000 7,980 7,645 7,365 8000 7,076 7,192 6,864 6,799 7000 6,336
6000
5000 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 HeRAMS | Annual Report 2019 48 Public Hospitals
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).
Figure 64: The number of psychiatric inpatients in public hospitals, December 2019
500 398 Psychiatric inpatient 400
300 235
200
100 41 1 0 0 0 0 0 0 0 0 0 0 Rural Aleppo Damascus Lattakia Tartous Homs Hama Al -Hasakeh Deir -ez-Zor Ar -Raqqa Dar'a As -Sweida Quneitra Damascus Psychiatric inpatient
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.
Figure 65: Trend analysis of number of psychiatric inpatient cases in public hospitals, January to December 2019
816 850 803 782 780 800 761 756 750 735 750 710 697 675 675 700
650
600 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 HeRAMS | Annual Report 2019 49 Public Hospitals
7. Availability of medical equipment
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].
Figure 66: Percentage of functional essential equipment/ total available equipment in functional public hospitals, December 2019
Height Measurement Device 98% Minor Surgical sets 98% Nebulizer 97% Length Measurement Device 95% Weighing Scale for children 94% Vaginal examination set 93% Fetoscope 93% Oxygen cylinders 92% Suction machine 92% Operating_tables 90% Weighing Scale for adults 89% Delivery_table 89% Ambu bag (Paediatric and Adult) 86% Weighing Scale for infants 86% Oxygen Station 84% Dry_Sterilizer 83% Pulse Oximeter 81% Autoclave 71%
2 A more detailed list of essential equipment is available upon request. HeRAMS | Annual Report 2019 50 Public Hospitals
Figure 67: Percentage of functional specialized equipment/ total available equipment in the functional public hospitals, December 2019
Major surgical sets 97% ICU/CCU Monitors 88% Ventilators – Paediatric 86% DC Shock machine/ Defibrillator 84% Ultrasound 82% Renal Dialysis machine 82% Anaesthesia machines 81% Incubator for new born 80% ECG 80% X -Ray 80% Portable X-Ray 77% Ventilators – Adult 76% Cardiotocography (Monitoring of fetalheart frequency) 74% MRI machine 73% CT Scan 71% HeRAMS | Annual Report 2019 51 Public Hospitals
8. Availability of medicines & medical supplies
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].
Figure 68: Availability of medicines and medical supplies for one month in the functional public hospitals, December 2019
Antiseptics 93%
Serums 87%
Antibiotics for Adults 86%
Analgesics, antipyretics, non-steroidal anti-inflammatory Medicines 85%
Anti-allergic including Steroids 82%
IV Fluid 81%
Albumin 81%
Preoperative medication 80%
General Anaesthetics 79%
Local Anaesthetics 79%
Cardiac and /or Vascular Drugs (Anti-hypertensive Drugs, Diuretics, …) 73%
Gastrointestinal 67%
Antibiotics for Children 64%
Anaphylactic shock 64%
Anti -diabetic preparations (especially Insulin) 63%
Dialysis consumables 61%
Specific antibiotics for multi – resistant bacteria/infectious diseases 57%
Delivery related medicines (i.e., Oxytocin , … ) 56%
Medicines acting on respiratory system (e.g., medicines of Asthma, H1N1 ARI… like salbutamol …) 55%
Antidotes for Poisoning 39%
Dermatological preparations/topical (Burns, and anti-infective, etc...) 37%
Medicines affecting the blood (anti- anemia medicines, heparin, warfarin, etc.,) 37%
Psychotropic medinas (i.e., antipsychotics, antidepressants, antiepileptic and anxiolytics) 30%
Hepatitis vaccine 27%
Cancer related medicines 16%
Tetanus shot 11%
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. HeRAMS | Annual Report 2019 52 Public Hospitals
9. Conclusions and recommendations
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.