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World Health Organization Syrian Arab Republic

Donor Update 2014 (Q2)

World Health Organization

Syrian Arab Republic

Donor Update 2014 (Q2)

Contact Details

WHO Country Office (, Syrian Arab Republic) Ms Elizabeth Hoff, WHO Representative [email protected]

WHO Emergency Support Team (Amman, Jordan) Ms Louise Kleberg, External Relations [email protected]

WHO Headquarters (Geneva, Switzerland) Ms Cintia Diaz-Herrera, Coordinator External Relations, Emergency Risk Management and Humanitarian Response [email protected]

Cover photo credit: WHO/B.Khabbieh

Content 6 The Situation in in Q2 of 2014

8 WHO in Syria: Responding to Needs

17 Challenges and Mitigation Measures 20 Financial Overview for Q2 of 2014

22 WHO Strategic Interventions Under SHARP 2014

23 Glossary

Photo credit: WHO/O.Sanadiki credit: Photo

The Situation in Syria in Q2 of 2014 1. People in need of humanitarian assistance

The violence in the Syrian Arab Republic has continued to escalate during Q2. The past three months have been marked by continuing conflict, with pockets of sustained high-intensity fighting. There have been no major changes in the balance of power in the central and southern regions, in spite of government gains in these areas. Opposition groups continued to fight the Syrian Armed Forces (SAF) along the main highway linking Syria‟s major urban centres, from to Dar‟a, while combat between armed opposition groups including The Islamic State of Iraq and Levant and Kurdish forces continued in the east and north. Clashes in frontline areas (including Dar‟a, Deir ez-Zor, Rural Damascus, and Aleppo) have led to new large-scale displacements and a worsening humanitarian situation. The number of people in need has therefore increased significantly due to barriers accessing humanitarian assistance, reduced agricultural production, scarce employment opportunities, decreased purchasing power, and exhausted coping mechanisms.1

. People in Need (PiN): 10.8 M (compared to 6.8 M in Q2 2013 and 9.3 M in Q1 of 2014); . Internally Displaced People (IDPs) 6.5 M (compared to 4.25 M in Q2 2013; the UN has not yet released updated

figures for the number of IDPs for Q2); . People killed: 160,000 (compared to 93,000 in Q2 2013 and 150,000 in Q1) . People injured: 750,000 (compared to 465,000 in Q2 2013 (same figure as in Q1 of 2014)).

Al_Qunaytirah Graph 1. Updated figures of estimated population in governorates, PiN and IDPs (OCHA, May 2014) As_Suweida PiN SHARP Revision IDPs SHARP Revision Pop_Est_2011 Lattakia Tartous Dara Hassakeh Dayr_Az_Zor Homs City_Damascus Idleb Rural Damascus Aleppo

Rural City_Da Dayr_Az As_Suwe Al_Quna Aleppo Damascu Idleb Homs Hassakeh Hama Dara Raqqa Tartous Lattakia mascus _Zor ida ytirah s PiN SHARP Revision 2,575,00 1,654,00 1,117,00 820,000 748,000 711,000 582,000 533,000 517,000 490,000 472,500 363,500 133,500 87,000 IDPs SHARP Revision 1,787,00 770,000 708,000 410,000 560,000 441,000 197,500 245,500 266,000 177,000 452,000 300,000 69,000 72,000 Pop_Est_2011 4,868,00 2,836,00 1,501,00 1,754,00 1,803,00 1,239,00 1,512,00 1,628,00 1,027,00 944,000 797,000 1,008,00 370,000 90,000

1 Source: Syria Needs Analysis Project (SNAP), ACAPS, May 2014

6 2. Disintegration of the public health system The crisis has disrupted health care services and led to dire shortages of essential medicines, supplies and health care workers, especially those trained in emergency care. Despite the challenges faced in reaching contested/remote areas, WHO managed to reach 2,519,270 people in Q2 (making a cumulative total of 5,071,776 people reached between January and June 2014). For the first time in three years, WHO was able to deliver noncommunicable disease medicines to Douma in the besieged area of East Ghouta in Rural Damascus.

Even when people in need were able to access health services, positive health outcomes were undermined by the effects of protracted stress, suffering and increased vulnerability.

Graph 2. Overview of functionality of As of June 2014, hospitals and health care facilities have been hospitals (June 2014) damaged in 11 of Syria‟s 14 governorates. The most heavily affected governorates are Aleppo, Rural Damascus, Homs, Dar‟a and Deir ez- 23% Zor.

47% Hospitals fully . Functionality of hospitals2 (see Graph 2): Just under half functioning of the 97 MH hospitals are fully functioning. The remainder are Hospitals partially either only partially functioning, or have ceased to function functioning altogether. Hospitals not functioning . Access of patients to hospitals (see Graph 3): 69 of the 30% 97 MoH hospitals are accessible, and 20 are not accessible. The status of accessibility of the remaining 8 hospitals is unknown. Almost two thirds of ambulances have been damaged. Graph 3. Overview of access of patients to hospitals (June 2014) Mortar and attacks, including barrel bombing and airstrikes, car bombs, hijackings and kidnappings are some of the daily 8% challenges faced by health care workers. Many health professionals have left the country3, creating severe shortages in many areas 21% Hospitals fully including trauma care, anaesthesiology and laboratory diagnosis. accessible Hospitals not Graph 5. Percentage of health staff estimated to be accessible present in the country by category (March 2014)

Access status not Emergency available 71% Physicians Specialists 0.20% Others 11% 22%

Graph 4. Number of people per medical doctor by governorate Resident doctor (March 2014) Pharmacists 10% 0.50% 441 Tartous 718 1,077 Lattakia 1,111 1,336 Hama 2,103 5,040 Aleppo 6,040 7,984 Rural Damascus 9,298 Nurses and 10,480 midwives Homs 21,464 36% Technicians 21%

2 Percentages have changed compared to previous quarterly reports, as the Ministry of Health previously reported all hospitals located in opposition-controlled areas as 'not functioning'. Thanks to the expansion of the HeRAMs and the increased number of health workers trained in reporting on functionality and accessibility, WHO is now able to provide a more comprehensive picture of the situation on the ground. 3 Unfortunately no updated data is available from the MoH

7

3

WHO in Syria: Responding to Needs

Photo credit: WHO/O.Sanadiki credit: Photo Achievements in Q2

2,519,270 people (for a total of 5,071,776 1.2 million aquatab tablets were distributed in between January and June 2014) directly Aleppo city. Each tablet is sufficient to disinfect benefited from the distribution of medicines and the daily drinking water supply of a single family. equipment as well as from health care. 137,975 people (for a total of 447,875 between 6 river water purification units were distributed January and June 2014) to Al-Boukamal Town in the Governorate of Deir benefited from the delivery and distribution of ez-Zor, where the local water filtration plant was health kits. damaged in the fighting.

2,913,640 children under 5 years of age were 35 HIS sentinel sites were established across vaccinated against polio in all governorates. Syria and 90% of health care facilities were assessed for damage and functionality across the Over 3,660 health care workers were trained on country. first aid, infection control, HeRAMs reporting, chemical hazards and water testing, early detection The lives of over 45 children under 5 years of of malnutrition, etc. age were saved in Hama, Deir ez-Zor, Homs, Aleppo, Lattakia and Damascus, thanks to the 62 new EWARS sentinel sites WHO-supported programme to establish were established throughout Syria in Q2, including therapeutic feeding centres in hospitals. over 21 sites in opposition-controlled areas (reaching a total of 528) after WHO successfully A plan to establish an in-patient psychiatric advocated with the Government for the expansion unit for 20 people was prepared in collaboration of EWARS and the distribution of essential with Al-Mouwasat hospital. medicines and medical supplies in opposition- controlled areas.

Despite serious obstacles in delivering humanitarian aid to contested areas, the medicines, medical supplies and equipment delivered to opposition areas by WHO accounted for over 28% of all items delivered in Q2 of 2014. A total of 705,396 people benefited from these efforts.

B.Khabbieh

Photo credit: WHO/ credit: Photo 9

Graph 6. Overview of beneficiaries reached by end of Q2 of 2014 by distribution hub (including week 26)

Graph 7. Comparison of beneficiaries reached throughout 2013 and

beneficiaries reached by Q2 of 2014 (including week 26)

4,742,103 4.6 mio

2,913,640 Overall Beneficiaries 2013 2.2 mio

1.5 mio Beneficiaries Jan - May 2014

447,875

Treatments IEHK and other kits Polio campaign

10 Overall goal: to reduce morbidity and Inter-agency needs mapping – In Q2, WHO mortality in the Syrian population provided consolidated health information each month to OCHA‟s „Dashboard‟ – a multi-sector WHO‟s regional strategy for the Syria crisis, falling monitoring tool that displays the number of within the WHO Emergency Response beneficiaries reached by each sector. WHO also Framework, focuses on five priorities: provided consolidated health sector information to OCHA‟s bi-weekly Humanitarian Bulletin. 1. Leading and coordinating the health Working with local NGOs and focal persons - sector; WHO has increased the number of local NGO 2. Providing health information to partners from 36 (in December 2013) to 454. provide evidence for the emergency These NGOs - located in all 14 governorates of response; Syria - provide primary and secondary level 3. Enhancing access to quality and medical care, including trauma care5, through fixed priority preventive and curative health and mobile clinics. Via these networks, vulnerable services; and hard-to-reach populations are able to access 4. Strengthening disease surveillance health care services. In addition, WHO‟s national 6 and response; network of 22 focal persons continues to monitor 5. Providing technical guidance on activities and assess the health situation in Aleppo, Al-Hassakeh, Ar-Raqqah, Deir ez-Zor, Dar'a, priority public health issues. Idleb, Lattakia, Quneitra, Hama As-Suwayda, , Rural Damascus and Damascus. Their Q2 of 2014 was characterized by the increased reports are used to underpin decisions on the momentum in the delivery of essential life-saving distribution of medicines and medical supplies and medicines, medical supplies and equipment to training needs across the country. hard-to-reach areas, of which 28% went to opposition-controlled areas, thanks to successful 2. WHO’s health information system (HIS) negotiations with the government with regard to WHO‟s Health information system (HIS) maps bureaucratic procedures. health care needs and service availability, and provides the basis for comprehensive and effective 1. Health sector leadership and coordination health sector planning and coordination and the As the lead UN agency for the health sector, more efficient coordination and use of resources. WHO works with central and local health authorities, other UN agencies, local and During Q2 of 2014, the Health Resources & international nongovernmental organizations Services Availability Mapping System (HeRAMs) (NGOs) and community-based organizations was further strengthened through: (CBOs) in both government- and opposition- . Enhanced capacity of health staff – WHO controlled areas. WHO and partners jointly map strengthened the capacity of 625 health resources, review the evolving health response, professionals and statisticians on HeRAMs and identify and fill gaps, thus making the best reporting by conducting nine training possible use of limited resources. workshops in Damascus, Rural Damascus, Quneitra, Lattakia, Dar‟a, Aleppo, As- The Health Working Group (HWG) - Suwayda and Tartous. Some workshops that Emerging health needs were discussed, as in could not be conducted at governorate level previous quarters, at the HWG‟s bi-weekly for security reasons (Quneitra and Dar‟a) were meetings bringing together UN agencies and conducted in Damascus instead. NGO representatives. Health authorities . Recruitment of additional focal persons to participated once a month. HWG members address gaps in reporting and data verification reviewed requests for assistance from national especially in heavily affected and inaccessible health authorities and NGO partners, and jointly areas (e.g. Ar-Raqqah, Deir ez-Zor and Dar‟a). planned inter-agency convoys to distribute life- saving medicines, health kits and supplies throughout the country. The EWARS weekly bulletins provided essential information to underpin HWG decisions on the pre-positioning 4 25% increase compared to previous quarter 5 of medicines and supplies. Currently, 122 NGOs are approved by the Ministry of Foreign Affairs, and less than 30% out of these have a health mandate. 6 Including 5 new focal persons appointed in Q1.

11 Key achievements in Q2: distributed to accessible governorates. Additional quantities of rapid blood tests (enough for 20,000 Strengthened management for emergency blood bags) were provided for hard-to-reach areas. response –90%7 of the public hospitals were assessed (compared to 83% in Q1). The results of Effective distribution of medicines – The these assessments will be used to make strategic WHO Distribution Plan for 2014, based on decisions on the distribution of medicines and information collected from assessments across the medical supplies, as well as the priority hospitals to country, continued to guide WHO‟s interventions be rehabilitated. The data collected from the 35 in Q2 of 2014. The plan specifies the number of HIS sentinel sites will also feed into the response people in need of assistance by governorate/ strategy of WHO. disease and pinpoints which percentage of medicines should go to which hospital, health WHO mapped all hard-to-reach and inaccessible facility or partner NGO. areas for polio vaccinators and closely monitored changes in access to those areas. Supporting emergency services and operating theatres in health facilities –WHO provided Continued information flow between different gases to operate anaesthesia machines for an MoH reporting levels – WHO used data collection central hospital in Damascus. mechanisms such as tele-assessments to obtain timely information at different reporting levels - Strengthening the capacity of first-responders from individual health facilities up to the level of To alleviate the steady loss of health professionals the health directorate. across the country, WHO trained a total of 45 health professionals in first aid and another 131 in

trauma care and management during Q2. 3. Enhancing access to preventive and curative health services Primary health care (PHC) Increasing the availability of essential life- saving medicines - In Q2, WHO continued to Responding to the decrease in vaccination procure and distribute essential medical supplies coverage – and life-saving medicines for trauma and emergency obstetric care. This included: Polio . 110 cases of Acute Flaccid Paralysis were . Medical kits, including burn-dressing kits, reported, out of which one was confirmed as Emergency kit type A and B, basic and a polio case (in 2014). supplementary health kits covering the needs . 3 polio vaccination campaigns were of approximately 350,000 people in heavily conducted in Q2 [April (2,913,640 children < affected governorates (i.e. Deir ez-Zor, Homs, 5 years of age), May (2.83 million children < 5 Aleppo, Dar‟a, Idleb and Ar Raqqa); years of age) and June (2.7 million8 children . Essential life-saving medicines and medical <5 years of age)] utilizing bivalent oral polio supplies for more than 200,000 trauma care vaccine (bOPV). treatments. The medicines were distributed to . Two workshops were conducted after each most governorates across Syria, including in campaign polio vaccination campaign for opposition-controlled areas such as Al- evaluation purposes. Boukamal, Ar-Raqqah and East Aleppo. . The national polio laboratory was provided with technical support. Almost one third (28%) of these items were distributed to opposition-controlled areas. Other vaccine-preventable diseases: During Global Vaccination Week (24 – 30 April Maintaining blood safety – 2014), the MoH with the support of WHO In Q2, WHO procured safety blood kits for both vaccinated 300,000 drop-out children <5 years of the central blood bank and hard-to-reach areas, age in all governorates against diphtheria, pertussis including equipment for ELIZA testing for the and typhoid (DPT), measles, mumps and rubella Hepatitis C Virus (HCV). Blood safety kits (MMR), tuberculosis (TB) and hepatitis B. (enough to screen 150,000 blood bags) were Special efforts were made to reach children in provided to the central blood bank to be

8 This is an estimate as reporting forms from the field are still 7 10% increase since previous quarter being collected.

12 inaccessible areas. The high turnover of field of different Syrian line ministries as well as vaccinators means that constant efforts are UN agencies and national and international required to identify and train new staff. WHO also NGOs. supported the training of new MoH staff in most . Recruited three mental health focal persons in governorates, with the help of local NGOs. Lattakia, Homs and Aleppo. These focal persons will: a) coordinate between WHO and Mental health the MoH at field level and b) strengthen the WHO implemented the following mental health case management skills of the newly trained activities in Q2: general practitioners and psychotherapists. . Introduced a community-based multi- . Supported nation-wide, inter-agency disciplinary care model to fill urgent gaps in assessments of: a) mental health and service provision according to WHO phsychosocial needs, b) child protection status standards. A total of 34 psychologists and and c) availability of services to treat the four clinical psychotherapy supervisors will victims of gender-based violence. The results undergo an intensive five-month training will be published in September 2014. course on the use of the model. WHO has . Assessed the status of mental health care in hired four international experts to lead the Ibn Sina hospital (Rural Damascus), Ibn Rush course. As a result of the above intervention, hospital (Damascus), and various facilities in over 43,000 persons from the most vulnerable Homs and Hama. Immediate needs were population groups across Syria will have reported to the MoH and followed up, i.e. access to professional supervision. through the distribution of psychotropic . Conducted 15 training courses in seven medicines. governorates (Damascus, Rural Damascus, . Initiated the development of a toolkit in As-Suwayda, Homs, Hama, Tartous and (audio and print) to guide families and Lattakia) for a total of 70 practitioners from communities on coping with stress, including selected centres. Topics addressed included self-help techniques. depression, psychosis, stress-related . Began developing Arabic materials for the conditions, self-harm/suicide and other integration of mental health and psychosocial significant emotional or medically unexplained support services into health care services for complaints. Participants will continue children with severe acute malnutrition. (This receiving on-the-job training at their material will be finalized in Q4 of 2014.) respective centres and will be able to diagnose, treat and follow up on patients Malnutrition suffering from moderate to severe mental WHO implemented the following activities in Q2: illness (approximately 15% of the Syrian population). . Convened a workshop in April to launch the . Prepared a plan to 1) rehabilitate and expand pilot phase of a project to re-evaluate and the in-patient psychiatric unit for 20 beds at revive the country's nutritional surveillance Al-Mouwasat hospital in Damascus 2) system. The project will be piloted in seven rehabilitate parts of the out-of-service Ibn centres in Damascus, Rural Damascus, Homs, Khaldoun for Mental Disorder Hospital in Aleppo, Dar‟a, Tartous and Deir ez-Zor. A Aleppo, including the out-patient clinics, and total of 56 health workers from these centres 3) restore Ibn Ruchd psychiatric hospital in were trained on modified anthropometric and Damascus. The establishment of the first in- reporting modalities and on the nutritional patient unit at a general hospital in Syria is in screening of children under five. line with WHO recommendations to . Convened a second workshop in early June to mainstream mental health care into general evaluate the pilot phase and plan for the health care to enhance access and reduce expansion of the surveillance system across stigma. the country. . Provided psychotropic medicines to various . Trained 33 doctors from Damascus, Rural health care facilities levels across the country Damascus, Deir ez-Zor, Dara‟a, Hama, (e.g. the psychiatric hospital in Douma). Lattakia, As-Suwayda and Idleb on the . Revised its plan to scale up the mental health management of severe acute malnutrition. response in Syria to meet emerging needs in 2014 and 2015. The plan was developed Since the official inauguration in April 2014 of the during a joint MoH – WHO workshop in May WHO-supported programme for the 2014. Participants included the representatives establishment of Therapeutic Feeding Centres in

13 10

hospitals, the lives of more than 45 children under Hospital supplies and equipment – WHO five have been saved in Hama, Deir ez-Zor, delivered 10 haemodialysis machines to health Homs, Aleppo, Lattakia and Damascus. So far, 10 facilities and local NGOs (Al-Afyiah and Al-Ihsan) centres have been established and more are being in Rural Damascus (Qalamoun), Ar-Raqqah, set up to cover a catchment population of over 1.5 Homs, Hama, Quneitra, As-Suwayda, Deir ez-Zor million children under five across Syria. and Aleppo, along with medical supplies to support haemodialysis sessions. In addition, at the request of the MoH, a three-day workshop was conducted in May for 45 doctors and other health staff to improve the level of care provided to

kidney transplant patients.

Strengthening Syria’s overall readiness and capacity to respond to acute public health events involving chemicals 12 Since late 2012, WHO has increased preparedness for the possible use of toxic chemicals against the

Syrian population. This has included continuous Photocredit: WHO/O.Sanadiki public health threat assessments, increased WHO is a member of the Nutrition Sector response capacity at WHO, and the deployment of Working Group chaired by the MoH. The group chemical expertise to the field. In 2013, WHO was has recently revised the nutrition sector‟s targets, involved in both the Secretary indicators and activities under the Syrian General‟s mechanism, and in responding directly Humanitarian Assistance Response Plan (SHARP) to acute public health risks in the field through for 2014. training, issuing guidelines for clinicians, and distributing medical supplies. In 2014, WHO has Essential medical care at the secondary and realigned its programme to the new context of tertiary levels chemical disarmament and the destruction process currently under way. Nevertheless, continued More than 2 million people remain in acute need vigilance, preparedness and support for a potential of secondary and tertiary health care services. response have been maintained. WHO implemented the following activities in Q2: Clinical training in pre-hospital and hospital settings Gaps in medicines for NCDs and WHO has established a roster of trainers to build emergency/trauma care –WHO procured and capacity across the country, each of whom has distributed critically needed medicines, based on been given advanced training by international the 2014 Syrian Essential Medicines List. These experts outside the country. WHO has trained included: approximately 200 Syrian clinicians and public health officials from NGOs (including the Syrian . 2,190 Factor VIII vials of different strengths Arab Red Crescent) in six priority governorates (distributed to MoH hospitals, the Children‟s (Aleppo, Damascus, Rural Damascus, Homs, Hospital in Damascus and Lattakia Hospital); Lattakia and Tartous). . Four trucks filled with IV fluids (for MoH/MoHE warehouses in As-Suwayda, WHO has developed a four-day course that Lattakia, Tartous and Aleppo); covered: . 10,000 ampules of ceftriaxone antibiotic to . Command and control and incident treat severe bacterial infections (distributed to management systems. the Children‟s Hospital in Damascus); . The use and maintenance of Level C personal . 30,000 doses of Tacrolimus for kidney protective equipment (PPE) for chemical transplant patients (distributed to MoH and hazards. MoHE hospitals). . The initial clinical management of chemical exposures from nerve agents, vesicants, and toxic industrial chemicals. Infection control – A week-long theoretical and . Basic life support and airway management. practical workshop on infection control was . Emergency decontamination. conducted for 40 health professionals (to be followed by a second training in August). Procurement and distribution of personal protective

14 equipment to priority hospitals across Syria – In procuring additional medicines and diarrhoea kits cooperation with the Organization for the to support a rapid response to outbreaks Prohibition of Chemical Weapons-United Nations (especially in view of the upcoming summer Joint Mission, WHO procured 500 sets of level C months). chemical PPE for Syrian healthcare facilities. A total of 300 sets have been distributed (based on Main achievements under the EWARS programme training carried out) to 20 locations across six in Q2: governorates. Another 100 have been supplied to SARC, and 50 have been reserved for training . The quality of EWARS reporting was activities. WHO is holding the remaining 50 in monitored by MoH and WHO focal persons reserve for emergencies. by means of bi-weekly supervisory visits and

quality control checklists in all 14 Strengthening planning capacity - An incident planning governorates. tool has been developed and will be rolled out to . WHO responded to a typhoid fever outbreak Syrian hospitals in the next quarter. in Deir ez-Zor governorate by distributing medicines and WASH items. Training and protection of UN/WHO staff – In Q1 . and Q2, WHO trained over 140 UN staff on Regular shipment of stool samples of chemical weapon awareness and self-protection. suspected polio cases continued throughout Since February, WHO has maintained a stockpile Q2. of 1,500 nerve agent auto-injectors. . Capacity-building activities were conducted targeting a total of 1,624 people. Distribution of medicines to treat chemical exposures Since early 2013, WHO has distributed atropine Water, sanitation and hygiene (WASH) supplies to health care facilities in Syria. Since the removal of chemical weapons from the country, In Q2, WHO distributed water disinfecting the risk of large-scale nerve agent exposures has chemicals, purification units, and water quality decreased; WHO has adjusted its distribution testing kits to heavily affected areas including: strategy accordingly. In the first half of 2014, WHO distributed atropine for approximately Aleppo City - 1.2 million aquatab tablets were 100,000 beneficiaries in formulations used in procured for Aleppo City, where over half the standard medical interventions as well as population was deprived of water following the organophosphate therapy. destruction of the main pipelines for the Suleiman Al-Halabi pumping station. Government-operated 4. Disease surveillance and response health care centres distributed the aquatabs and information leaflets to the local population. Each Another 62 new sentinel sites were added to the aquatab is sufficient to disinfect the daily drinking Early Warning and Response System (EWARS) water supply for a single family. system in Q2, making a total of 528 sites reporting WHO also distributed 108 residual chlorine testing on epidemic-prone diseases throughout the kits and eight mobile kits for testing water quality country. Just over one third of these new sites are for bacteriological contamination. Currently, in opposition-controlled areas. SARC and GOPA are cooperating with WHO in the field of water quality testing. During Q2, data were collated into weekly epidemiological bulletins that were used to support informed decisions on contingency planning and the strategic pre-positioning of supplies in key areas.

A tool to assist planning for pre-positioning medicines and kits, called the „medicines calculator‟ was developed in Q2. The tool captures the attack rate and epidemiological profile of specific diseases, and calculates the quantities of medicines required based on these factors and the estimated population likely to need treatment. Based on the findings of the medicines calculator, WHO is

15

O.Sanadiki Photo credit: WHO/ credit: Photo Deir ez-Zor (Al-Boukamal Town) - Six river . A total of 114 people including WHO focal water purification units were provided to Al- points, NGO representatives and water utility Boukamal where the local water filtration plant technicians were trained on the use of residual was damaged due to the persistent fighting and chlorine test kits. Those trained will go on to shelling. Prior to WHO‟s delivery of these units, train other individuals in their respective locals were relying on untreated water from local organizations. groundwater wells containing sewage water mixed . Twelve laboratory chemists from water quality with river water. The six purification units have laboratories, GOPA and SARC were trained enough capacity to provide clean drinking water on the use of mobile bacteriological test kits. for 200,000 people (treatment capacity of 1,440 Additional bacteriological kits were provided m3 of water per day). In addition, WHO delivered to the trainees to distribute to other chemists 400,000 aquatab tablets, 20 residual chlorine in the water quality laboratories. testing kits and four bacteriological test kits, better equipping Al-Boukamal town to mitigate the risk 5. Technical guidance on priority public of water contamination and spread of waterborne health issues diseases. Building national capacity Damascus (Al-Mouwassat Hospital and In Q2 of 2014, WHO supported training initiatives Paediatric Hospital) - Sterilizers and disinfectant for 3,664 health care providers on: units for medical waste were distributed to Al- . HIS reporting (625); Mouwassat and Paediatric Hospitals of Damascus. . Polio (375); The two additional units, which supplement an . Trauma care (131); earlier delivery from WHO, will allow both . EWARS (1,624); hospitals to disinfect additional amounts of . Nutrition (252); medical waste, and provide a back-up unit if . Mental health (139); required. WHO plans to train the staff of both . First aid (40); hospitals on the safe management of medical . NCD management (181); waste. . Hepatitis management (52); . PHC centres assessment (85); Capacity-building . Secondary health care (49); . Management of chemical injuries (78); . MoH logistics (33).

16

Challenges and Mitigation Measures

Rural Damascus Rural

Photo credit: WHO/ credit: Photo

The main challenge to the delivery of trauma regularly denied inclusion in inter-agency convoys care in Syria continues to be the interdiction of and some WHO-specific shipments. the government of Syria with regard to the distribution of essential life-saving surgical and all In each of the four reports submitted by the UN related medicines and supplies (including sedatives, Secretary General to the Security Council on antibiotics and all injectable items) to the contested Resolution 2139 (2014), WHO has provided areas. information on difficulties faced with the delivery of medicines and medical supplies to “hard-to- Thanks to its intensive advocacy efforts, WHO has reach” areas across Syria. During the first half of managed to reach both government- and 2014, WHO has reported a decrease in the opposition-controlled areas during Q2. Medical proportion of beneficiaries denied assistance. supplies were delivered via international convoys and distributed to local NGOs providing health care services, as well as through air-lifts to i.e. Al Hassakeh governorate.

The recent (5 May 2014) introduction by the Government of the new MoFA- and MoSA- developed “transport facilitation mechanism” has led to a reduction of overall aid access. After recent discussions with the MoH and the Office of the President, WHO has now been exempted from some of its provisions. WHO‟s distribution of aid will continue through the MoH on a case-by-case basis. However, WHO will implement the required sealing of trucks carrying humanitarian supplies under the auspice of designated security officials.

In the distribution of its supplies, WHO is However, access of medical supplies and currently requested to submit the following equipment has been severely constrained by the information: i) description of materials; ii) continued deterioration of the overall security warehouses; iii) routes; iv) quantities; v) transport situation and continued denial of some medical vehicles used; vi) recipients vii) area of assistance and most surgical supplies into distribution, and viii) start and end date of the opposition-controlled areas. Key challenges delivery. This information is required even for include: deliveries within the boundaries of Damascus. . Lack of access to all areas (including during The prevention of delivery of certain medical polio vaccination campaigns) due to supplies and equipment, particularly to opposition- insecurity. controlled areas, continues to lead to civilian loss . The continuing prevention of delivery of of life and lack of access to life-saving medical essential medical supplies and equipment, assistance. particularly to opposition-held areas, with injectable medicines, antiseptics, psychotropic Only polio vaccine and medicines for medicines, surgical supplies and vaccines noncommunicable diseases, painkiller tablets, and (except polio) routinely denied inclusion in some antibiotics are routinely allowed into convoys. opposition-controlled areas. Shipments containing . Removal of medicines and medical equipment injectable medicines, antiseptics, serums, from government-approved WHO convoys. psychotropic medicines and surgical equipment, or . Increasingly complex government any item that may be used for surgical requirements for the movement of interventions, are often denied access. In addition humanitarian supplies diarrhoeal disease kits (diarrhoea is the most common cause of death in children), syringes for In order to enhance clarity of needs and thereby routine vaccine and measles vaccines (over 2800 improve efficiency in providing essential cases of suspected measles have been reported secondary and tertiary care, WHO increased in during the first and second quarters of 2014), are Q2 the number of coordination meetings and

18 strengthened the presence of MoH staff at the . Complications in delivery of materials and Health Sector Working Group meetings. implementation of activities in heavily affected areas –With the most recent With regard to the Health Information System government-enforced regulations, many (HIS), data collection and reporting were difficulties were faced in the timely delivery of disrupted for reasons of both access and frequent supplies to the opposition-controlled area of power cuts. WHO has continued to both procure Al-Boukamal. Problems were resolved and distribute communications equipment (faxes, through the constant follow-up of the computers and mobile phones) and to train health growing WHO logistics team. care staff. (A total of 625 health professionals and statisticians were trained in Q2, as outlined in When installing water purification units; sections above.) distributing aquatabs to people in need; and testing water quality in water tankers, coordination with The implementation of the two WASH other UN agencies and NGOs operating on the programme components was negatively affected ground has proven crucial in reaching the most by a number of challenges: heavily affected areas. More efforts should be put into coordination at central and local level with MoH.

Photo credit: WHO/Aleppo

19 Financial Overview for Q2 of 2014

Graphic representation of the increase in funding between Q1 and Q2 and funding gap to be met in Q3 and Q4

Funding required US$ 185,966,152

Current funding gap US$ 141,276,774 Funding received

US$ US$

41,000,133 44,689,378 Photo credit: WHO

Q1 Q2 Q3 Q4

Percentage of funding received versus funding required (Q2)

Received by Q2 24%

Still required under SHARP 2014 76%

US$ 175,807,652

Fundring required

US$ Funding 44,689,378 received by Q2 US$ US$ 8,500,000 1,658,500

Health Nutrition WASH Fundring required 175,807,652 1,658,500 8,500,000 Funding received by Q2 44,689,378 0 0

20 Overview of Funding Received By Donor in Q2 Of 2014

Canada 10% USAID 29%

ECHO 26% UNOCHA 1%

United Kingdom 0%

United Arab Emirates 2% Russia 2% Finland 2% Rotary Norway Kuwait International 15% 12% 1%

Overview of human resources present in the WHO Syria country office

3 International staff 5

Male

Female 39 National staff 22

21 WHO Strategic Interventions Under SHARP 2014

The United Nations estimates that 9.3 million 6. Rehabilitation of health facilities: To support people will be affected by the crisis in 2014, public and private health infrastructure and including 6.4 million IDPs, and 2.8 million who services affected by the crisis and enhance have lost their jobs. The Health Sector will revitalization of health services and restoration of require US$ 233,376,172, with WHO requiring health facilities in affected areas. 24 US$ 178,309,652, in order to continue providing . Funds needed: US$ 4,000,000 essential health care services to increasingly . Implementing agencies: WHO and UNDP vulnerable people in need across the Syrian Arab Republic. The Essential Medicines List for 2014 is 7. Health information system (HIS): To further budgeted at US$ 450 million. strengthen the HIS for emergency using Health Resources and Services Availability Mapping Building on lessons learned from the approaches System (HeRAMs) for regular, timely and accurate adopted in 2013 and interventions undertaken, collection and dissemination of data. WHO is pursuing the following strategic areas for . Funds needed: US$ 921,270 2014: . Implementing agency: WHO

1. Revitalization of primary health care 8. Coordination: (i) To strengthen health sector services: To improve access to comprehensive coordination to address the needs of people in primary health care (PHC) services, including need and (ii) to provide improved access of reproductive health and vaccinations. vulnerable populations to a quality basic health . Funds needed: US$ 101,898,970 care package of services and allow for adequate . Implementing agencies: WHO, UNFPA, preparation and response capacities for ongoing UNICEF, UNHCR, IOM, PU and IMC and new emergencies. . Funds needed: US$ 462,796 2. Essential medical care at secondary and . Implementing agency: WHO tertiary level: To improve access (including to Palestinian refugees) to secondary health care 9. Tuberculosis and HIV/AIDS: To strengthen services and limited tertiary health care services i.e. the national Tuberculosis and HIV/AIDS for burn victims. programme. . Funds needed: US$ 55,514,126 . Funds needed: US$ 390,550 . Implementing agencies: WHO and UNRWA . Implementing agency: UNDP.

3. Trauma care: To strengthen the level of Health Sector partners will also continue preparedness for and management of trauma, implementing life-saving WASH and Nutrition including referral mechanisms, for an increasing interventions in 2014: number of injuries across the country. . Funds needed: US$ 45,495,000 10. Water, sanitation and hygiene (WASH): . Implementing agency: WHO Ensure water, sanitation and hygiene services to the agreed standard with primary purpose of 4. Early warning, alert and response system satisfying vital needs, dignity and reduction of (EWARS): To prevent, early detect and respond public health related risk for population in need in to epidemic prone diseases and contain the current all governorates. polio epidemic and its spread to other countries/ Funds needed: US$ 115,780,725 regions. . Implementing agencies: UNICEF, UNFPA, . Funds needed: US$ 16,486,560 UNDP, WHO, IOM and PU. . Implementing agency: WHO 11. Nutrition: Emergency Life Saving Nutrition 5. Mental health: To strengthen mental health Services for crisis affected Internally Displaced service delivery across Syria. population in all governorates inside Syria. . Funds needed: US$ 8,206,900 . Funds needed: US$ 16,858,500 . Implementing agency: WHO . Implementing agencies: UNICEF and WHO.

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List of Abbreviations

CBO Community-based Organization

EMST Emergency Support Team

EML Essential Medicines List EWARS Early Warning, Alert and Response System GOPA Greek Orthodox Patriarchate of Antioch and All the East HeRAMs Health Resources Availability Mapping System

HIS Health Information System ICRC International Committee of the Red Cross

IDP Internally Displaced Person IEHK Inter-agency Emergency Health Kit

MoH Ministry of Health MoHE Ministry of Higher Education MoFA Ministry of Foreign Affairs

MoSA Ministry of Social Affairs NCDs Noncommunicable Diseases

(I)NGO (International) Nongovernmental Organization OCHA Office for the Coordination of Humanitarian Affairs

PFA Psychological First Aid PHC Primary Health Care PSS Psychosocial Support

SAM Severe Acute Malnutrition SARC Syrian Arab Red Crescent SHARP Syria Humanitarian Assistance and Response Plan UNFPA United Nations Population Fund

WCO WHO Country Office WHO World Health Organization

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