August 2020 Fig.: Al Resala Foundation- Triage Point in Al Resala PHC Afrin

HEALTH CLUSTER BULLETIN August 2020 Fig.: Al Resala Foundation- Triage point in Al Resala PHC Afrin.

Turkey Cross Border Emergency type: complex emergency Reporting period: 01.09.2020 to 30.09.2020 12 MILLION* 2.8 MILLION 3.7 MILLION 25**ATTACKS PEOPLE IN NEED OF HEALTH PIN IN SYRIAN REFUGGES AGAINST HEALTH CARE HEALTH ASSISTANCE NWS HNO 2020 IN TURKEY (**JAN - SEPT 2020) (A* figures are for the Whole of Syria HNO 2020 (All figures are for the Whole of Syria) HIGHLIGHTS 137 HEALTH CLUSTER MEMBERS • By the end of the month, over 1,000 SARS-COV-2 41 IMPLEMENTING PARTNERS REPORTING were confirmed from NWS. Of all cases, 16% are MEDICINES DELIVERED1 health care workers (physicians, dentists, nurses, TREATMENT COURSES FOR COMMON 1,024,800 pharmacists and medical/clinical technicians), DISEASES plus an additional 8.7% are ancillary staff working FUNCTIONAL HEALTH FACILITIES HERAMS in healthcare facilities. 150 FUNCTIONING FIXED PRIMARY HEALTH • Two aid workers from the Turkish Red Crescent CARE FACILITIES Society (TRCS) were attacked, one was reported 63 FUNCTIONING HOSPITALS dead the other injured. In addition, several staff 63 MOBILE CLINICS members of Syria Relief and Development (SRD) HEALTH SERVICES2 were injured in separated violent events. 776,716 CONSULTATIONS • New mental health consultations and follow-ups DELIVERIES ASSISTED BY A SKILLED 9,208 by the end of September totalled 69,732, which is ATTENDANT 112% of the all such services provided in the year 14,711 REFERRALS 2019 i.e. 62,099. 865,840 MEDICAL PROCEDURES • The COVID-19 pandemic has unveiled the huge 35,305 TRAUMA CASES SUPPORTED 1,511 NEW CONFLICT RELATED TRAUMA CASES challenges and risks health workers are facing VACCINATION globally such as working in stressful environments which makes health workers more prone to errors 9,785 CHILDREN AGED ˂1 VACCINATED3 which can lead to patient harm. Therefore, the MENTAL HEALTH SERVICES World Patient Safety Day 17 Sept 2020 theme was ‘Health Worker Safety: A Priority for Patient Safety’ 9,835 MENTAL HEALTH CONSULTATIONS with a slogan “Safe health workers, Safe patients”. DISEASE SURVEILLANCE • The Syrian Pound depreciation and the Turkish Lira SENTINEL SITES REPORTING OUT OF A 463 spread in the NWS markets creates serious TOTAL OF 471 operational challenges for the humanitarian actors WOS HEALTH HRP & COVID-19 2020 FUNDING $US4 working in the NWS. HRP RECEIVED $96.7 M (21.8% funded) • 25,387 cases of cutaneous leishmaniasis were COVID19 IN 2020 $66.1 M (41.9% funded) diagnosed so far in 2020.

1 Supplies were cross border delivered by the WHO Gaziantep Hub and distributed to implementing health cluster partners in northwest Syria. 2 Figures reported and updates are from 1 – 30 September 2020. 3 Routine immunization with pentavalent vaccine (5 in 1 vaccine) 4 Source: OCHA Financial Tracking System, Syrian Arab Republic Humanitarian Response Plan (HRP 2020) as of 30 September 2020. https://fts.unocha.org/ 1

Situation Update:

Even though two violent attacks involved the humanitarian community during the month of September, in many aspects, since the cease fire of the 6 March, the Syria armed conflict is slowing down. Large-scale military operations are not happening with the exception of the Southern tip of Idleb and northern Hama governorates. As well, with the exception of the northwest, virtually no frontlines remain actively contested, and since mid-2018, the Government of Syria has presided over all of ‘useful Syria’, the Aleppo-Damascus- Homs axis, without serious challenges.5 In 2020, the armed conflict has taken a second role, and so far this year the worsening of the economic crises with the devaluation of the Syrian Pound and the ongoing coronavirus (SARS-COV-2) pandemic outbreak are the leading scenarios at the main stage.

In regard to the economy, the devaluation of the Syrian Pound (SYP) has been unprecedented as seen in the SYP/USD conversion rates in 2020 when compared to 2018 (-insert table on right), affecting the salaries of government employees, the public sector which includes healthcare workers. By contrast, is been reported specially in the NWS that armed group salaries have grown, creating a pool for mercenaries as seen by the reported increase number of Syrian military recruitments been used in Libya and other armed conflict countries. Furthermore, the Turkish Lira (TL) found a way to circulate in NWS via circulars issued in both Idleb and Northern Aleppo mandating the use of Turkish Lira and or banning the use of SYP. Both, SYP depreciation and TL spread in the NWS markets creates serious operational challenges for the humanitarian actors working in the NWS. As Syria’s economic deterioration persists, the been established economic, military/political, and geographical boundaries within the Syrian Arab Republic are likely to be further defined in the months to come.

As the economic situation worseness in the NWS and the state defragmentation , as well is the COVID-19 outbreak. By the end of the month of September, 1,072 cases have been confirmed positive for SARS-COV-2 causative agent of COVID-19, with 526 cases recovered and 6 associated deaths. Besides the obvious risk of virus transmission in the communities and into the IDP camps, a worrisome seen behavior are the refusal of suspected contacts and/or asymptomatic/mild cases to be quarantined and isolated for the required 14 day. Furthermore, the number of cases within the healthcare workforce and among the humanitarian workers is staggering. Of all cases, 172 (16%) are 100 90 health care workers; 80 70 such as physicians, 60 50 dentists, nurses, 40 30 pharmacists and 20 10 various medical / 0 clinical technicians. In 9 20 301 10 20 301 10 20 30 addition to, another 8.7% are ancillary July August September staff working in healthcare facilities. Fig. Epi-curve – Laboratory-confirmed COVID-19 Cases in Northwest Syria (9 Jul - Sept 30, 2020) @WHO

Some of the local de-facto authorities, such as the ‘Syrian Salvation Government’ (SSG) in Idleb issued a circular closing all wedding halls, public swimming pools, gyms, amusement parks, private educational institutions and restaurants for a week as precautionary measures from COVID-19. As well, the Local Council in Jarablus town in northern Aleppo governorate issued a circular to close cafes, restaurants and barber shops and all residents are asked to wear masks and implement physical distancing rules while vising public markets. Both these actions/recommendations were welcome but did not lasted. The Health Cluster NWS COVID-19 Taskforce continues to advocate for preventive measures at both community and health facility level in attempt to mitigate the further spread of the outbreak and aim to decrease avoidable morbidity and mortality.

5 https://coar-global.org/2020/09/30/the-economy-of-war-in-syria-armed-group-mobilization-as-livelihood-and-protection-strategy/ 2

Public health risks, priorities, needs and gaps

• The significant and increasing number of SARS-COV-2 infected healthcare workers is a public health risk for both the community and the patients’ safety. In addition, there is a potential of a foreseen collapse of the health service delivery if the contagion is not control. • Due to the community transmission of the virus, there is risk of disruption to routine immunization activities due to both COVID-19 related burden on the health system and decreased demand for vaccination because of physical distancing requirements or community reluctance. The high potential for vaccine preventable diseases (VPD) outbreaks makes it imperative for the NWS to maintain continuity of immunization services wherever services can be conducted under safe conditions. • Seen the spread of the virus within the health staff, scaling-up of testing for health care workers (HCWs) is needed with a special focus on those who are working in COVID-19’s designated health facilities (e.g. hospitals, CCTCs) and those caring for the vulnerable groups such as in TB clinics, dialysis centres, etc.. • There are increasing demands on testing in the next period as cases increases there is the need of strengthening the contact tracing and expanding the screening to the affected population. • Sigma and possible discrimination against the positive cases inside the communities are playing an important role in creating high resistance from the “contact cases” to be place on isolation and/or quarantine facilities. • Infection and Prevention Control measures need to be rigorously implemented not only at health facilities but at communities and camp settings, therefore, camp managers need to be aware on preventive activities and to emphasize on the public use of fabric face masks, physical distancing, avoiding mass gatherings and other measures as recommended by WHO guidelines. • Due to shortage of masks in the market, there is a need to enhance the local procurement and production of fabric masks in the field. This should be done in line with the COVID-19’s taskforce recommendations and WHO’s global guidelines for fabric mask production and usage. • Multi-Drug Resistance (MDR) Tuberculosis and as well visceral leishmaniasis cases are raising in NWS.

Health Cluster Coordination and Service Delivery

As for the Cluster coordination regular activities, two virtual bi-weekly and one ad-hoc Health Cluster meetings were held in the month of September and attended by more than 80 health cluster partners and stakeholders. In addition, the NWS Health Cluster COVID-19’ Taskforce continue to meet biweekly and ad-hoc as required by the ongoing outbreak needs.

A Health Cluster benchmark for the month of September, was to resume the process for the Health Cluster Co-Coordination position, a post vacant for almost 2 years after a couple of unsuccessful attempts for a transparent election process and insufficient participation/quota of active Health Cluster partners. The nomination was opened with an expectation to have a Co-Coordinator from an active cluster partners in early October.

In regard to the Health Cluster Information Management products, in addition to the monthly 4Ws, the quarterly HeRAMS analysis, the monitoring and reporting on attacks against health care, and the regular and ad-hoc infographics, the IMO team supported the thematic Technical Working Groups and the COVID-19 taskforce. Representing the COVID-19 TF, the Health Cluster team continues to monitor and share daily situation updates and the established NWS COVID-19 Dashboard is kept up-to date and accessible for the general Health Cluster membership and is publicly open to the whole humanitarian community.

Furthermore, the Health Cluster team is continuously communicating with members/partners, donors and acting health authorities to assure the continuation of Essential Health Care Services, based on agreed needs and gaps. In regard to funding gaps, the HRP 2020 shows a dramatic below 22% funding received, and the funding donations (health and non-health) for the COVID-19 response although did doubled in September (from 22.8% to 41.9%), the overall gap is almost 60% of the estimated USD 158M requirements for an effective response. Decreasing this gap by year’s end is crucial in order to sustain testing, case management of COVID- 19 suspected and confirmed cases, and to avoid a potential detrimental outcome.

On Service Delivery, 41 Health Cluster implementing partners shared their 4Ws reports for the month of September and it’s worth to be noted that several end of year targets were achieved during the end of Q3 2020. Otherwise, the monthly trends for most indicators did not show pronounced fluctuations and have remained essentially the same compared to previous month. However, there were some exceptions; such as in the number of treatment courses provided, which registered a whopping 166% increase, as more deliveries of supplies took place.

Of the targets achieved, in Mental Health the number of new patients receiving consultations and the number of new consultations and follow-ups, which registered a 47% increase from the previous month. Compared to last year, new mental health consultations and follow-ups by the end of September totalled 69,732, which is 112% of the all such services provided in the year 2019 i.e. 62,099.

These ‘early” achievements can be attributable to increase expansion and accessibility to MHPSS programs, and as well COVID-19 related counselling services been rolled out in communities. It’s also worth to note that mental health needs are critical, and heave been prioritised during the year. A welcoming slight decline is seen in the number of hostility-related trauma consultations by 16.5%. The graphs to the right and above illustrate the ongoing trends for the year as end of September.

The second set of indicators which surpassed the year targets were linked to the NWS Referral Networks. As Turkey had limited had the Cross-Border movements prior and as part of the COVID-19 pandemic restrictions, the established referral networks had expanded and strengthen services and coordination. This have a direct effect on both the increase number of referrals inside Syria and as result the increase number of total referrals.

The following page/table summarizes and illustrates the monthly progression of the indicators as from January to September 2020. The average number of OPD consultations were 774,356, and the average of medical procedures was 865,840; both closely approximate with the number of such services provided in September. While the number of emergency major surgeries was 1,094, registered an increase of 15.2% from the previous month. Number of ICU and ward admissions were also below the monthly averages for the year, with 794 ICU admissions and 24,531 ward admissions; registering an 8.4% decrease in ICU admissions and a 3.6 decrease in ward admissions, compared to last month, this may correlate with the COVID-19 temp suspension of activities.

Regarding vaccine preventable diseases in children, the number of under one year old who received DPT3 as well as children 1 to 2-year-old, who received MMR2 was well above the average of 8,132 and 8,755, respectively. 4

During the month of September and so far during this year, the Health Cluster service delivery is summarised in the cumulative monthly 4Ws indicators as per below table:

Table 1: Health Cluster NWS monthly & cumulative indicators for January to September 2020- Disclaimer: figures may change due to late inputs by partners and data cleaning 5

Health Cluster Technical Working Groups Advocacy and Communication TWG: Health and Partners Updates - voluntary contributions partners, with WHO, commemorate the World Patient Safety day on September 17. Some partners shared Hand In Hand For Aid and Development related posts on social medial such as the one below (HIHFAD): below a success story shared by HIHFAD from Independent Doctors Association (IDA): for a patient with amputation who becomes an expert and inspiration for people with amputation. Video at: https://m.facebook.com/watch/?v=735351687016660&_rdr

“Abdul Mawla, a 24 y/o man, experienced the bitterness of the Syrian war and was one of its victims, but through his determination he became one of the inspirations for those affected by the war. He was injured during his displacement journey to Jabal al- Zawiya in 2012. He was not able to receive appropriate treatment in NWS after he walked 100 km to reach Jabal Al Zawiya. At That time, the obstacle was the lack of equipment and experienced professional staff. In Turkey, Abdul Mawla got his leg amputated due to the complexity of his case.

Following a state of saddens due to this precious loss, but with the big support from his family and friends, he decided to get a prosthetic limb and the journey of success began. Seeing the big number of injured waiting for the same service in NWS, he decided to be a volunteer to work in the same center as well he was granted a university scholarship from a German university in the same field and graduated in 2016. Fig: IDA- Social media post for the world Patient Safety day

Abdul Mawla was one of the staffs in the very first MENTOR Initiative supported in September 64 prosthetic limbs center in 2016. And he is continuing health facilities in NWS, 1 more than the previous serve the people affected by the war. month. The leishmaniasis mobile treatment clinics are still same, 8, divided as 4 in Idleb governorate, 1 in Afrin, 2 in Azaz and 1 in west rural Aleppo serving the same 72 locations. In September, 4 Visceral Leishmaniasis (VL) were diagnosed in addition to 3,081 new cases of Cutaneous Leishmaniasis (CL) and provided 36,562 leishmaniasis treatment courses. In Total, 25,387 cases of CL were diagnosed in 2020 reflected in the figure below:

Fig: HIHFAD- True story: Abdel Mawla, from a survivor to a saviour

Abdel Mawla stated: “I become happy when I meet my peers and serve them. I do my best to help them by various means and try effect on them by my successful experience and teach them that disability is not the end of life, but it is the beginning. I become glad, when I find someone who has overcome his/her disability and I try to learn from him/her experience.” Fig: Number of new Cutaneous Leishmaniasis cases from Nov19-Sep20 6

Al-Resala Foundation (RF) conducted a virtual A HIV service mapping, in coordination with the training on Self-Care, Staff-Care and stress Health Cluster IMO, was prepared. The mapping management during COVID-19. The training was shows, 70 health facilities providing partially HIV attended by 82 participants (51 males and 31 females) services in Aleppo and Idleb Governorates including from 8 organizations. counselling, rapid test and Elisa test. HIV treatment is not available in the NWS. As well, the health service provision continues via Al Resala PHC and Shamarin PHC, both in Al Resala Camp Syria Relief and Development (SRD) started in Afrin, and 2 mobile clinics operating in Al-Manarah operating 5 PHCs in Tal Abyad, Bdama, Althahr, Albel camp in Al Dana, in Bulbul and Sharran. In September, and Al-Basuta; two hospitals, a Surgical Hospital (Al 8,739 beneficiaries received health care services out Rajaa Hospital) in Qah-Idleb- and a Maternity and of which 3,476 are IDPs with application of IPC Child Hospital (Nabe Al Salam Hospital) in Ras Al Ein- measures in line with the global recommendations. Al Hasakeh. The services provided included general medicine, internal medicine, reproductive health, health On capacity building, an IPC standards and triage promotion, referral services, MHPSS services, and protocols training was conducted in Afrin and community health services. attended by 41 trainees. In addition, 336 trainees from CCCTs, hospitals and dead body management Awareness campaign addressing COVID-19 mental teams from two NGOs and the Civil Defence were health and anti-stigma was conducted in Al-Resala trained on IPC measures and dead body management. camp (Afrin, Bulbul district) and Al-Manarah camp. The training was physical with strict application of IPC Furthermore, a Referral Network training was measures and attended by 42 females and 36 males conducted for the focal points on SOPs and processes. divided into eight different groups and their ages The training was held in A’zaz in Northern Aleppo and ranged between 18 - 59 years old. attended by 21 trainees. Lastly, a Psychological First Aid (PFA) - COVID-19 tailored curriculum - was Psychological First Aid (PFA) was provided in the same provided to 14 trainees. time by the Community Health workers (CHWs) with distribution of 1,194 dignity hygiene kits. Sustainability, Empowerment and Economic Development (SEED), during the month of September continued providing tele-medicine and served 279 patients (128 females and 151 males and 116 under 18 y/o). The most reported cases were neurology, dermatology, otolaryngology, ophthalmology, hematology, cardiology and internal medicine. As well, physical consultations were provided as needed or when procedures are requested.

Fig: Al Resala Foundation- Paediatric consultation

Sexual and Reproductive Health (SRH) TWG: Based on an SRH survey in 78 health centres (54 communities) in NWS, there are 93% of births that are taking place at the health facilities and 7% are home deliveries, these deliveries are performed by dayeh - traditional midwives. As for maternal mortality, in September, 21 partners (88 facilities) reported to the SRW WG and two maternal deaths were registered. Fig: SEED – EKG test for a patient

Monitoring of violence against health care in the context of COVID-19 As for the Whole of Syria, 56% of the total attacks Although not reported as an attack against health against health care over the past 12 months (1 Oct care, on September 14, the Turkish Red Crescent 2019 – 30 Sep 2020) were reported as violence with (Turk Kizilay) communicated to the Health Cluster heavy weapons. And as of the end of September 2020, that an aid worker was killed, and another was 13 people were killed and 41 were injured. wounded after masked assailants attacked the group's vehicle near the northern Syrian town of al-Bab. It said The Health Cluster raises the voice again to all parties the attack took place between al-Bab and the Turkish of the armed conflict to preserve the lives of civilians, border town of Cobanbey, despite the vehicle having humanitarian aid workers and health care workers. a Kizilay, or Red Crescent, logo on its roof. Such attacks represent both a violation of International Humanitarian Law (IHL) and a violation As shared by a TRC colleague: “This barbaric attack has of human rights. not only targeted the TRC but the entire humanitarian community. We are in mourning for the tragic loss of Plans for future response: events & dates a member of the TRC family.” ➢ October 10: World Mental Health Day (WMHD) Furthermore, as stated the TRC President Dr. Kerem A call upon organisations, leaders, influencers, Kinik: “I strongly condemn the outrageous attack on mental health advocates and practitioners who the Turkish Red Crescent staff, who were carrying a share the conviction of better mental health for distinct Red Crescent emblem during the incident. all, for a day of celebration, deliberation, solidarity They were under the protection of international and action. humanitarian law. I believe the perpetrators will be caught as soon as possible. I express my condolences As part of the activities ongoing, the MHPSS TWG to the Turkish Red Crescent family.” Source: https://www.kizilay.org.tr/Haber/KurumsalHaberDetay/5459 developed for the 10 September Suicide Prevention Day an Online Suicide Questionnaire In 2016, the United Nations’ Security Council for Health Workers, specific for PHC doctors, unanimously adopted Resolution 2286, which called Psychiatrists, Psychologists, PSWs, paramedics, for the protection of health care during conflict, GBV/CP workers, and key health staffs at the strongly condemned attacks and demanded that emergency rooms. Please see the at: parties to armed conflicts ensure “the respect and https://ee.kobotoolbox.org/x/o4sWgxCT protection of all medical and humanitarian personnel Furthermore, a flyer in Arabic addressing Suicide: exclusively engaged in medical duties, their means of Messages about Myths&Facts on Suicide.pdf transport and equipment, as well as hospitals and other medical facilities”. MHPSS Helpline Posters with one phone number The nature of attacks varies greatly across contexts that will link our Frontline Workers and their and can range from the use of heavy weapons against families, COVID-19 patients, and their families, health facilities to administrative obstructions. plus all members of the communities thru According to the WHO ‘any verbal or physical act of professional MHPSS Helpline helpers who are violence, obstruction or threat that interferes with the ready to receive their calls with confidentiality. availability, access and delivery of such services’ is + 90 546 878 5540 defined as attack on health care.