HeRAMS Summary Report 2nd Quarter 2018 (April – June)
Public Hospitals in the Syrian Arab Republic HeRAMS Summary Report 2nd Quarter 2018 (April – June)
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 April to June 2018. HeRAMS published reports are available at: http://www.emro.who.int/syr/information-resources/herams-reports.html
© World Health Organization 2018
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HeRAMS background 1
1. Completeness of hospitals’ reporting 1
2. Functionality status 2
3. Density of public hospitals 4
4. Accessibility to public hospitals 5
5. Level of damage to hospitals’ buildings 7
6. Infrastructure patterns of the functional public hospitals 9 6.1 Inpatient capacity 9 6.2 Water 10 6.3 Electricity 11
7. Availability of human resources for health 12
8. Availability of health services 17
9. Utilization of health services 18 9.1 General clinical services 19 9.1.1 Outpatient and inpatient 19 9.1.2 Laboratories, blood bank, and imaging services 20 9.2 Surgical and trauma care 21 9.2. 1 Emergency cases reported in emergency departments 21 9.2.2. Emergency and elective surgeries 22 9.2.3. ICU services (Intensive Care Unit) 23 9.2.4. Trauma services 23 9.2.5. Burn patient management 24 9.3. Maternal health services 25 9.3.1. Caesarean sections and normal deliveries 25 9.4. Child health 26 9.5. Nutrition 27 9.6. Communicable diseases services 28 9.7. Noncommunicable diseases (NCDs) 28 9.8. Rehabilitation services 30 9.9. Mental health 31
10. Availability of medical equipment 32
11. Availability of medicines & medical supplies 33 Key indicators
111 100% # of public hospitals Completeness rate
51% 23% 26% Fully functioning Partially functioning Non-functioning
15% 30% 55% Fully damaged Partially damaged Intact
11,855 10,305 17,549 # of available beds # of medical # of nurses & doctors midwives 547,695 Estimated caseload (June 2018) HeRAMS Summary Report | 2nd Quarter 2018 1 Public Hospitals
HeRAMS background
HeRAMS (Health Resources and Services Availability HeRAMS in Syria is a World Health Organization Monitoring System)1 is a global health information (WHO) project that aims at strengthening the management tool (for monitoring, collection, collection and analysis of information on the collation and analysis of information on health availability of health resources and services in resources and services) that aims to provide timely, Syria at health facility level. A team of national relevant and reliable information for decision- health staff from all governorates was formulated making. It is used to guide interventions at the for HeRAMS reporting, and different data collection primary and secondary care levels, measure gaps mechanisms were introduced to address the and improve resource planning, ensure that actions shortage of timely and relevant information. are evidence-based, and enhance the coordination The main HeRAMS tool for collecting data is a and accountability of WHO and other health sector questionnaire that assesses the functionality partners. status, accessibility, health infrastructure, human resources, availability of health services, equipment and medicines at primary and secondary care level.
1. Completeness of hospitals’ reporting
1. Completeness rate: 100% 2. Ministry of Health (MoH) hospitals: 98 3. Ministry of Higher Education (MoHE) hospitals: 13 4. Total hospitals: 111
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 8 6 6 6 6 6 5 5 6 4 4 4 4 4 3 3 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
1 The HeRAMS name has been updated globally to be “Health Resources and Services Availability Monitoring System” instead of Health Resources and Services Availability Mapping System” HeRAMS Summary Report | 2nd Quarter 2018 2 Public Hospitals
2. Functionality status
• Fully functioning: a hospital is open, • Non-functioning: a hospital is out of accessible, and provides healthcare services service, because it is either fully damaged, with full capacity (i.e., staffing, equipment, inaccessible, no available staff, or no and infrastructure). equipment.
• 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).
Figure 2: Functionality status - June 2018
Fully Functioning 56 26% Partially Functioning 26 51% Non-Functioning 29 23%
Figure 3: Functionality status, per governorate, June 2018
Fully Functioning Partially Functioning Non-functioning
Quneitra 1 0 As-Sweida 3 0 Tartous 6 0 Damascus 14 1 0 Lattakia 6 1 0 Hama 5 0 1 Aleppo 7 4 4 Rural Damascus 7 3 5 Homs 4 6 6 Ar -Raqqa 1 1 2 Al-Hasakeh 1 4 0 Dar'a 1 2 4 Deir-ez-Zor 0 4 3 Idleb 0 4
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HeRAMS Summary Report | 2nd Quarter 2018 3 Public Hospitals
Map 1: Functionality status, per governorate, June 2018
Figure 4: Trend analysis of functionality status, January 2017 to June 2018
60 55 56 54 55 54 54 54 54 54 56 57 56 56 55 56 52 51 49 50
40 31 31 31 31 31 33 30 30 30 30 29 29 29 29 29 29 29 29 30 29 30 29 28 28 27 20 26 25 26 25 26 26 26 26 25 26 26 26
10
0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Fully Functioning Partially Functioning Non-functioning HeRAMS Summary Report | 2nd Quarter 2018 4 Public Hospitals
3. Density of public hospitals
Hospitals density reflects the total number of hospitals relative to population size (based on OCHA HRP 2018), which helps measure physical access to outpatient health care services.
Figure 5: Density of the public hospitals per governorate, June 2018
500,000 434,904 population per functioning MoH + MOHE public hospitals 450,000 400,000 346,225 318,974 318,242 350,000 287,966 300,000 233,835 Sphere standards for hospitals (250,000) 250,000 178,406 162,651 200,000 144,987 134,957 129,567 122,575 121,662 150,000 100,000 50,000 - Ar-Raqqa Aleppo Rural Dar'a Hama Al -Hasakeh Deir-ez-Zor Lattakia Homs As -Sweida Tartous Quneitra Damascus Damascus
Map 2: Density of the public hospitals per governorate, June 2018 HeRAMS Summary Report | 2nd Quarter 2018 5 Public Hospitals
4. Accessibility to public hospitals
• Accessible: a hospital is easily accessible for • Inaccessible: a hospital is not accessible patients and health staff. because of the security situation, or a hospital is accessible only to a small fraction of the • Hard-to-reach: a hospital is hardly reached, population, or military people (inaccessible to due to security situation or long distance. civilians).
Figure 6: Accessibility status - June 2018
22% Yes 76 Hard to access 11 68% No 24 10%
Figure 7: Accessibilty status per governorate, June 2018
Yes Hard to access No
Quneitra 1 0 Ar-Raqqa 4 0 Deir-ez-Zor 7 0 Al-Hasakeh 5 0 Tartous 6 0 Lattakia 7 0 Damascus 11 4 0 As-Sweida 2 1 0 Hama 4 1 1 Homs 10 0 6 Rural Damascus 9 1 5 Aleppo 8 3 4 Dar'a 2 1 4 Idleb 0 4
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HeRAMS Summary Report | 2nd Quarter 2018 6 Public Hospitals
Map 3: Accessibilty status per governorate, June 2018
Figure 8: Trend analysis of accessibility to public hospitals, January 2017 to June 2018
90
80
77 70 75 76 76 76 73 73 73 71 71 72 72 72 72 71 70 70 69 60
50
40 29 28 26 26 26 26 26 27 26 26 27 30 25 25 25 24 24 24 24
20
10 16 16 14 14 14 13 13 13 13 13 12 10 10 11 11 11 10 11 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Yes Hard to access No HeRAMS Summary Report | 2nd Quarter 2018 7 Public Hospitals
5. Level of damage to hospitals’ buildings
• Fully damaged: either, all the building is • Partially damaged: where part of the building destroyed, about 75% or more of the building is damaged. is destroyed, or damage of the essential services’ buildings. • Intact: where there is no damage in the building.
Figure 9: level of damage - June 2018
15% Fully damaged 17 Partially damaged 33 55% Not damaged 61 30%
Map 4: Level of damage of the hospitals’ buildings by governorate, June 2018 HeRAMS Summary Report | 2nd Quarter 2018 8 Public Hospitals
Figure 10: Level of damage of the hospitals’ buildings per governorate, June 2018
Fully damaged Partially damaged Not damaged
Quneitra 0 1 As-Sweida 0 3 Tartous 0 6 Damascus 0 1 14 Lattakia 0 1 6 Ar -Raqqa 0 1 3 Al-Hasakeh 1 1 3 Hama 1 2 3 Rural Damascus 4 4 7 Aleppo 5 3 7 Homs 1 9 6 Dar'a 1 5 1 Deir-ez-Zor 4 2 1 Idleb 0 4 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Figure 11: Trend analysis of public hospitals’ level of damage, January 2017 to June 2018
70 60 60 59 59 60 59 60 60 61 60 61 61 60 60 60 61 61 61 60
50 36 36 40 35 35 35 35 35 35 34 34 33 33 34 34 34 33 33 33
30 16 16 16 16 16 16 16 16 16 17 17 17 17 17 17 17 17 17 20
10 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 Jan Feb Mar Apr May Jun Jul 2017 Aug Sep Oct Nov Dec Jan Feb Mar Apr May June 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Fully damaged Partially damaged Not damaged No Report HeRAMS Summary Report | 2nd Quarter 2018 9 Public Hospitals
6. Infrastructure patterns of the functional public hospitals
6.1. Inpatient capacity
Figure 12: Comparison of inpatient capacity (original vs. available) in functional hospitals per governorate, June 2018
3,270 Original No. of Beds Available No. of Beds Total: 15,375 Total: 11,855 2,863
2,203 2,105 1,977 1,673 1,370 1,446 1,160 1,107 987 1,008 870 812 660 618 570 500 377 505 247 198 230 141 200 133
Damascus Lattakia Aleppo Rural Damascus Hama Tartous Al-Hasakeh Homs As-Sweida Deir-ez-Zor Dar'a Ar -Raqqa Quneitra
Figure 13: Percentage of available number of beds in functional hospital versus the original inpatient capacity, June 2018
114%
91% 85% 77% 77% 76% 73% 67% 65% 61% 57% 46% 40% 35%
Damascus Tartous Hama As -Sweida Lattakia Rural Quneitra Aleppo Ar-Raqqa Al -Hasakeh Homs Deir-ez-Zor Dar'a Overall Damascus HeRAMS Summary Report | 2nd Quarter 2018 10 Public Hospitals
6.2. Water Figure 14: Main sources of water, June 2018
Other, 2, 3% Well, 6, 7% Main Pipeline, 32, 39%
Main Pipeline and Well, 42, 51%
Figure 15: Distribution of water sources/ types at functional public hospitals, per governorate, June 2018
Lattakia 7 0 Ho ms 5 2 3 0 Damascus 5 10 0 Tartous 4 2 0 Rural Damascus 4 5 1 0 As -Sweida 2 1 0 Ar -Raqqa 2 0 Dar'a 1 1 1 0 Deir -ez-Zor 1 3 0 Al -Ha sa keh 1 4 0 Quneitra 0 1 0 Ha ma 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
Figure 16: Functionality status of the water sources at functional public hospitals, June 2018
Deir -ez-Zor 4 Quneitra 1 0 Ar -Raqqa 1 1 As -Sweida 2 1 Al -Ha sa keh 2 3 Dar'a 3 0 Ha ma 5 0 Tartous 6 0 Lattakia 7 0 Rural Damascus 7 3 Ho ms 8 2 Aleppo 11 0 Damascus 14 1
%0 %10 %20 %30 %40 %50 %60 %70 %80 %90 %100
Fully Functioning Partially Functioning HeRAMS Summary Report | 2nd Quarter 2018 11 Public Hospitals
6.3. Electricity
Figure 17: Hours of availability of electricity (from all sources) on average during the day in functional hospitals, June 2018
24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 23.3 22.9 22.7 23.2 21.0 18.0
Damascus Rural Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Syria Damascus
Figure 18: Percent of hospitals in need for generators out of total functional hospitals, June 2018
100% 100%
90%
80%
70% 60% 60% 55%
50% 40% 40% 33% 33% 30% 29% 27% 30% 20% 17% 20%
10% 0% 0% 0% 0% Quneitra Al -Hasakeh Aleppo Hama Dar'a As-Sweida Rural Damascus Homs Tartous Lattakia Deir -ez-Zor Ar -Raqqa Total Damascus HeRAMS Summary Report | 2nd Quarter 2018 12 Public Hospitals
7. Availability of human resources for health
Figure 19: Proportion of health staff in hospitals, June 2017
General Pharmacists Practitioner Midwives 1% 0.3% Specialist 5% 14% Laboratory 6% Emergency Physician 0.4%
Resident Doctor 19%
Dentist 1% Nurses 54%
Table 1: Availability of human resources of functioning public hospitals, per governorate, June 2018
Pharmacists General University Technicians Others Governorate General Practitioner Orthopedic surgery surgery Neurological surgery Other Specialists Emergency physician Resident Doctor Dentist Nurses Laboratory Midwives
Damascus 0 45 65 20 843 17 2466 36 3701 422 148 83 536 1245 3003 Rural Damascus 10 21 29 4 229 5 276 9 1217 126 93 24 122 415 934 Aleppo 6 26 37 4 383 7 940 51 971 208 112 14 178 314 1032 Idleb Lattakia 14 40 50 9 522 23 883 48 2485 153 232 28 212 503 1109 Tartous 15 43 68 4 467 18 523 38 2388 246 117 28 239 1088 1484 Homs 15 32 42 5 232 14 123 21 1291 145 184 17 71 646 436 Hama 4 27 44 8 348 14 352 38 1448 162 237 15 131 660 842 Al-Hasakeh 2 6 6 1 79 2 55 2 361 58 53 5 31 161 169 Deir-ez-Zor 2 2 1 0 39 0 10 4 593 91 152 1 59 250 374 Ar-Raqqa 12 5 6 0 19 3 0 0 214 9 26 3 11 18 4 Dar'a 3 2 3 1 39 0 13 0 276 22 41 4 19 119 183 As-Sweida 1 8 16 3 108 4 100 1 999 61 85 4 70 316 475 Quneitra 0 3 3 3 47 3 71 4 112 8 13 3 12 79 225 Grand Total 84 260 370 62 3355 110 5812 252 16056 1711 1493 229 1691 5814 10270 HeRAMS Summary Report | 2nd Quarter 2018 13 Public Hospitals
Map 5: Availability of medical doctors in functional public hospitals, by end of June 2018, per governorate
Figure 20: trend analysis of number of doctors (a total of general practitioner, specialists, emergency physicians, resident doctors, and dentists) in public hospitals during 2017 and 2018
10400 10,305
10200 9,999 9,960 9,915 9,919 9,936 10000 9,873 9,888 9,902 9,830 9,769 9,781 9,788 9,800 9800
9,536 9,525 9600 9,386 9400 9,184 9200
9000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 HeRAMS Summary Report | 2nd Quarter 2018 14 Public Hospitals
Figure 21: Trend analysis of number of nurses in public hospitals during 2017 and 2018
16300 16,056 16,016 16100 15,962 15,810 15900 15,752 15,645 15700 15,531
15500 15,391 15,277 15,221 15300 15,203 15,168 15,100 15,023 15,054 15,029 15100 14,972 14,867 14900
14700 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Figure 22: Trend analysis of number of midwives in public hospitals during 2017 and 2018
1550 1,509 1,512 1,493 1,495 1,493 1500
1,449 1450
1400 1,375
1,331 1,329 1,332 1350 1,322 1,324 1,324 1,312 1,311 1,310 1,303 1,307 1300
1250 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 HeRAMS Summary Report | 2nd Quarter 2018 15 Public Hospitals
Figure 23: Proportions and numbers of key staff work in MoH vs. MoHE hospitals, June 2018
%100 3 10 28 204 %90 778 3,956 364 %80 2,173 %70 %60 %50 107 MoHE 74 224 1,289 %40 3,269 12,100 1,347 %30 3,639 MoH %20 %10 %0 General Specialist Emergency Resident Dentist Nurses Laboratory Midwives Practitioner Physician Doctor
Figure 24: Comparison of the medical staff of MoH vs. MoHE hospitals, June 2018
General Practitioner Specialist Emergency Physician Resident Doctor Dentist Nurses Midwives Pharmacists
2,500 2,241
2,000 1,465 1,460 1,435 1,500 1,050 1,001 908 1,000 622 615 562 544 514 411 356 339 318 309 270 241
500 232 209 152 107 99 93 87 80 51 51 49 46 40 37 26 25 20 18 18 18 17 9 9 8 8 7 7 6 6 6 6 5 5 3 2 2 1 0 0 0 0 0 0 0 0 0 Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia MoH MoHE
Figure 25: Number of nurses and midwives per doctor in public hospitals, June 2018
14.0 12.8
12.0
10.0
8.0
6.0 5.3 5.2 4.5
4.0 3.0 2.7 2.2 2.1 2.0 1.7 MoH benchmark (2) 2.0 1.1 0.9 0.7 1.7 0.0 Deir-ez-Zor Ar-Raqqa Dar'a As-Sweida Homs Al-Hasakeh Rural Tartous Hama Lattakia Damascus Quneitra Aleppo Total Damascus HeRAMS Summary Report | 2nd Quarter 2018 16 Public Hospitals
Figure 26: Proportion of doctors (a total of specialists, emergency physicians, resident doctors, dentists), by gender, per governorate, June 2018
Male Female
%100 9 6 %90 37 357 39 170 283 20 77 3,442 %80 1,290 229 541 601
%70
%60
%50 49 39 %40 116 819 95 314 552 41 164 6,446 %30 2,202 354 913 988
%20
%10
%0 Damascus Rural Aleppo Lattakia Tartous Homs Hama Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As -Sweida Quneitra Total Damascus
Figure 27: Percentage of functioning public hospitals without medical staff (gaps), June 2018
Emergency Physician 62.2
Dentist 58.5
Practitioner 56.1
Midwives 28.0
Resident Doctor 13.4
Specialist Doctor 2.4
Nurses 0.0
0 10 20 30 40 50 60 70 80 90 100 HeRAMS Summary Report | 2nd Quarter 2018 17 Public Hospitals
8. Availability of health services
The availability of core healthcare services is 2. Surgical and Trauma care monitored through HeRAMS at hospital’s level, 3. Maternal health services [normal deliveries, considering a standard list of health services caesarean sections, and CEmOC] including: 4. Nutrition 5. Child Health 1. General Clinical Services (Outpatient, Inpatient, 6. Communicable diseases Laboratory, Blood bank services, Imaging 7. Non-communicable diseases services) 8. Mental Health
Figure 28: Availability of health services in the functional public hospitals, June 2018
Emergency services 93% Sanitation availability 91% Imaging service 91% Safe water availability 90% Management of diabetes 90% Elective surgery 88% Hypertension services 87% Blood bank service 86% Cardiovascular services 82% ICU services 80% Emergency surgery 77% End Stage Kidney Disease (ESKD) treatment 76% Trauma services 73% Treatment of diabetic complications 72% Burn patient management 72% (CEmOC) Comprehensive emergency obstetric care 70% Communicable diseases services 70% Waste management 67% Acute psychiatric inpatient unit 67% Comprehensive abortion care 65% Management of children diseases 60% Medical evacuation 59% Rehabilitation services 58% Management of severe acute malnutrition with complications 33% Cancer treatment services 31% HeRAMS Summary Report | 2nd Quarter 2018 18 Public Hospitals
9. Utilization of health services
Figure 29: Estimated caseload of functional public hospitals (outpatient consultations and emergency cases), June 2018
120,000 112,632
100,000
74,797 80,000 70,166 59,721 55,164 60,000 50,915 37,522 40,000 28,157 21,397 20,000 12,334 11,693 8,237 4,960
0 Damascus Lattakia Aleppo Homs Tartous Hama Rural Al -Hasakeh As -Sweida Deir-ez-Zor Ar-Raqqa Dar'a Quneitra Damascus
Figure 30: Trend analysis of estimated caseload in public hospitals, January 2017 to June 2018
617,370 604,206 602,618 650000 584,354 586,164 574,566 576,063 568,532 600000 537,833 538,321 543,710 538,372 547,184 547,695 523,749 511,726 550000 490,088 463,022 500000 450000 400000 350000 300000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Estimated caseload
Figure 31: Proportions of workload during June 2018, per governorate
Dar'a Deir -ez-Zor 1% Ar-Raqqa 2% 2% Quneitra 1% As-Sweida 4% Al-Hasakeh 5% Damascus 21%
Rural Damascus 7%
Hama 9% Lattakia 14%
Tartous 10%
Aleppo Homs 13% 11% HeRAMS Summary Report | 2nd Quarter 2018 19 Public Hospitals
9.1. General clinical services 9.1.1. Outpatient and inpatient:
• Outpatient department (OPD) with at least one doctor
• Inpatients services: At least 20 inpatient bed capacity with availability of medical doctors (MD), nurses and midwifes, and 4–5 beds for short observation before admission, or 24/48 hour hospitalization
Figure 32: The number of outpatient and inpatient in public hospitals, June 2018
Outpatient services Inpatients services 70000 57,509 60000
50000 41,085 36,892 40000 30,999 26,489 30000 22,351 16893 16,649 20000 9476 9,851 9,163 6583 7867 7485 10000 5937 4115 5,313 4,668 2184 5263 2862 2,266 1,636 851 666 297 0 Damascus Aleppo Lattakia Homs Tartous Hama Rural Ar-Raqqa Deir-ez-Zor As -Sweida Al -Hasakeh Dar'a Quneitra Damascus
Figure 33: Trend analysis of outpatient and Inpatient in public hospitals, January 2017 to June 2018
313,367 350000 306,756 301,643 302,091 292,024 284,900 292,604 290,300 287,901 274,983 270,107 269,230 264,871 300000 255,591 243,009 248,855 248,037
250000 204,272
200000
150000 76,033 74,387 75,468 74,168 75,453 64,499 69,530 67,751 70,398 67,800 66,937 71,955 71,283 70,479 100000 59,042 61,961 62,502 54,233
50000
0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
Outpatient services Inpatients services HeRAMS Summary Report | 2nd Quarter 2018 20 Public Hospitals
9.1.2. Laboratories, blood bank, and imaging services
• Laboratory services including public health laboratory • Blood bank service • Imaging service (X-Ray, ultrasound, CT Scanner, MRI, Mammography…etc.)
Figure 34: The number of patients received services in laboratories, blood bank, and imaging services in public hospitals, June 2018 490,729 600000
500000 279,365 212,261 209,091
400000 191,888 135,748 300000 87,902 69,153 41,673 35,849 34,950 27,873 25,613 24,249 20,755 17,770 15,681 13,629 12,821 200000 10,680 7,710 5,465 4,500 4,455 3,608 2,556 2,549 2,414 2,106 2,068 1,371 930 653 458 317 248 83 43 100000 72
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
Figure 35: Trend analysis of number of patients received services in blood banks and imaging services in public hospitals, January 2017 to June 2018
300000 240,698 237,641 231,274 229,706 230,155 235,453 240,103 217,730 221,593 212,270 221,492 215,873 250000 200,288 205,646 207,912 186,606 176,122 183,568 200000
150000
100000 28,746 26,510 29,994 28,662 31,775 25,198 31,098 30,471 28,287 32,077 31,082 30,841 34,203 32,558 32,250 33,307 33,889 31,415 50000 15,511 13,552 16,434 16,455 18,214 14,341 18,311 18,137 16,339 17,958 18,437 18,097 18,155 17,925 17,588 18,841 18,23416,862 0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
Blood bank service Blood bags and products Imaging service
2000000 1,875,460 1,803,205 1900000 1,795,3281,776,723 1,771,469 1,766,551 1,720,211 1,720,729 1800000 1,701,149 1,698,935 1,692,730 1,673,245 1,628,541 1700000 1,593,073 1,567,572 1,505,029 1600000 1,447,311 1,461,732 1500000 1400000 1300000 1200000 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
Laboratory services HeRAMS Summary Report | 2nd Quarter 2018 21 Public Hospitals
9.2. Surgical and Trauma care 9.2.1. Emergency cases reported in emergency departments
Medical and surgical triage, advanced life support (defibrillator) and airway management, acceptance of referral, advance stabilization and referral, availability of second-line emergency and pain management drugs
Figure 36: The number of reported cases in emergency department in public hospitals, June 2018
60000 54,481
50000 37,905 40000 29,081 28,722 28,675 28,564 30000 23,489 20,873 20000 16,084
10000 5,971 3,324 3,171 1,842 0 Damascus Lattakia Aleppo Homs Tartous Hama Al -Hasakeh Rural As -Sweida Dar'a Quneitra Deir-ez-Zor Ar-Raqqa Damascus
Figure 37: Trend analysis of number of reported cases in emergency department in public hospitals, January 2017 to June 2018
350000 303,044 301,550 311,534 288,792 281,358 272,665 277,598 281,391 282,676 283,259 279,720 282,182 262,414 258,198 263,048 261,581 300000 246,188 253,639 250000
200000
150000
100000
50000
0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
Emergency services HeRAMS Summary Report | 2nd Quarter 2018 22 Public Hospitals
9.2.2. Emergency and elective surgeries:
• Emergency surgery (including advanced fracture • Elective surgery (including but not limited to management through at least one operating full surgical wound care) theatre with basic general anaesthesia)
Figure 38: The number of emergency surgeries vs. elective surgeries in public hospitals, June 2018
Elective surgery Emergency surgery
5000 4,436 4500 4000 3500 3000 2,469 2500 1,973 2000 1,725 1,301 1500 1,073 1,124 1,064 804 948 815 806 1000 505 657 549 500 99 164 131 163 84 100 60 75 132 35 58 0 Damascus Aleppo Lattakia Hama Tartous Rural As -Sweida Homs Al -Hasakeh Deir-ez-Zor Dar'a Quneitra Ar-Raqqa Damascus
Figure 39: Percentage of total emergency surgeries to elective surgeries in public hospitals per governorate, June 2018
% Emergency surgery % Elective surgery 100% 90% 31% 80% 38% 36% 70% 58% 55% 68% 66% 63% 66% 60% 83% 81% 81% 80% 91% 50% 40% 69% 30% 62% 64% 20% 42% 45% 32% 34% 38% 34% 10% 17% 19% 19% 20% 9% 0% Rural Homs Al -Hasakeh Damascus Aleppo Lattakia Deir-ez-Zor Dar'a Hama As -Sweida Ar-Raqqa Quneitra Tartous Total Damascus
Figure 40: Trend analysis of number of patients received emergency surgeries and elective surgeries in public hospitals, January 2017 to June 2018
18,001 20000 17,830 17,426 17,319 16,357 16,797 16,440 16,929 18000 15,784 15,811 14,645 14,579 15,149 13,752 14,166 16000 13,595 13,073 14000 11,477 12000 9,045 10000 7,696 7,411 7,531 7,679 6,701 6,700 6,984 7,209 7,151 7,211 6,647 7,207 7,093 7,184 8000 6,072 5,807 5,835 6000 4000 2000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Emergency surgery Elective surgery HeRAMS Summary Report | 2nd Quarter 2018 23 Public Hospitals
9.2.3. ICU services (Intensive Care Unit):
Figure 41: The number of patients received ICU services in public hospitals, June 2018
1200 1142 921 1000 909 800 800 513 600 436 311 400 236 139 102 200 54 48 36 0 Damascus Hama Lattakia Aleppo Homs As -Sweida Tartous Rural Al -Hasakeh Dar'a Quneitra Ar-Raqqa Deir-ez-Zor Damascus
Figure 42: Trend analysis of number of patients received ICU services in public hospitals, January 2017 to June 2018
8000 6735 6204 6240 6054 5900 5944 5909 5932 7000 5590 5820 5803 5864 5597 5661 5806 5587 5647 5275 6000 5000 4000 3000 2000 1000 0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
ICU services
9.2.4. Trauma services:
• Orthopedic/trauma ward for advanced orthopedic
Figure 43: The number of patients received trauma services in public hospitals, June 2018
3000 2648 2500 2163
2000 1574 1500 1000 679 306 500 113 79 71 62 40 30 25 7 0 Hama Damascus Lattakia Aleppo Homs Rural Ar-Raqqa Tartous As-Sweida Dar'a Deir-ez-Zor Al-Hasakeh Quneitra Damascus HeRAMS Summary Report | 2nd Quarter 2018 24 Public Hospitals
Figure 44: Trend analysis of number of patients received trauma services in public hospitals, January 2017 to June 2018
12000 10,469 9,512 9,715 9,873 8,949 8,903 10000 7,801 8,023 8,107 7,797 6,696 6,825 8000 6,060 5,590 5,795 5,257 6000 4,468 4,235 4000 2000 0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Trauma services
9.2.5. Burn patient management:
Figure 45: The number of patients received burn patient management in public hospitals, June 2018
450 393 400 350 300 250 200 119 150 81 76 100 47 43 38 33 29 50 16 9 7 0 0 Tartous Homs Damascus Lattakia Al -Hasakeh Deir-ez-Zor Ar-Raqqa Hama Aleppo Rural As -Sweida Dar'a Quneitra Damascus
Figure 46: Trend analysis of number of patients received burn patient management in public hospitals, January 2017 to June 2018
1,823 2000 1,602 1,572 1800 1,539 1,385 1600 1,272 1,285 1,288 1,276 1,165 1,192 1,148 1,131 1400 1,094 1,036 1,076 1,108 1200 891 1000 800 600 400 200 0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
Burn patient management HeRAMS Summary Report | 2nd Quarter 2018 25 Public Hospitals
9.3. Maternal health services 9.3.1. Caesarean sections and normal deliveries
Figure 47: The No. of normal deliveries and caesarean sections (CSs) performed at public hospitals, June 2018
Normal_deliveries CSs 1200 1051 1000 745 800 699 593 562 511 600 445 478 393 330 352 343 400 271 292 260 302 236 236 192 167 172 136 200 46 75 45 58 0 Damascus Ar -Raqqa Rural Hama Aleppo Al-Hasakeh As-Sweida Lattakia Homs Dar'a Tartous Quneitra Deir-ez-Zor Damascus
Figure 48: Percentage of caesarean sections to normal deliveries in public hospitals, June 2018
100% 90% 19% 28% 38% 38% 36% 80% 43% 41% 41% 44% 52% 70% 58% 56% 70% 67% 60% 50% 40% 81% 72% 62% 63% 64% 30% 57% 59% 59% 56% 48% 20% 42% 44% 30% 33% 10% 0% Deir-ez-Zo r Tartous Lattakia Homs Hama Rural Damascus Aleppo Al-Hasakeh Quneitra As-Sweida Ar -Raqqa Dar'a Syria Damascus CSs % Normal deliveries %
Figure 49: Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections in public hospitals, January 2017 to June 2018
6000 5,047 5,152 5,010 4,866 4,781 4,703 4,798 4,382 4,453 5000 4,196 4,073 4,027 4,110 4,114 3,730 3,917 3,400 3,523 4000 4,143 4,135 3000 3,862 4,127 3,974 3,980 3,500 3,593 3,578 3,703 3,749 3,662 3,278 3,227 3,225 3,422 2000 2,932 2,849 1000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Normal deliveries CSs HeRAMS Summary Report | 2nd Quarter 2018 26 Public Hospitals
Figure 50: Comparison of MoH & MoHE hospitals workload of normal deliveries vs, CSs, June 2018
700 593 579 600 535 516 500 445 400 281 272 300 206 209 166 200 121 120 140 71 100 0 Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia MoH Hospitals MoHE Hospitals
Normal_deliveries CSs
9.4. Child health
• Management of children classified with severe or very severe diseases (parenteral fluids and drugs, oxygen)
Figure 51: Number of children with severe diseases in public hospitals, June 2018
700 651 645 600 500 413 400 337 300 243 223 182 200 73 49 100 3 0 0 0 0 Tartous Hama As -Sweida Aleppo Damascus Rural Homs Lattakia Al -Hasakeh Quneitra Deir-ez-Zor Ar-Raqqa Dar'a Damascus
Figure 52: Trend analysis of reported cases of severe children diseases in public hospitals, January 2017 to June 2018
4000 3,522 3,533 3,196 3,185 3,151 3,091 3,039 2,998 3,124 3,029 3500 2,926 2,806 2,827 2,819 2,582 2,735 2,572 3000 2,401 2500 2000 1500 1000 500 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Management of children diseases HeRAMS Summary Report | 2nd Quarter 2018 27 Public Hospitals
9.5. Nutrition
• Stabilization centre for the management of severe acute malnutrition with medical complications, with availability of F75, F100, ready-to-use therapeutic foods and dedicated trained team of doctors, nurses, and nurse aids, 24/7
Figure 53: The number of children with severe acute malnutrition with complications in public hospitals, June 2018
16 15 15 15 14 12 10 8 7 8 6 3 4 1 2 0 0 0 0 0 0 0 Damascus Aleppo Lattakia As -Sweida Hama Rural Homs Tartous Al -Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a Quneitra Damascus
Figure 54: Trend analysis of number of children with severe acute malnutrition with complications in public hospitals, January 2017 to June 2018
140 122 120 113 100 110 90 80 73 68 71 61 61 60 52 66 56 64 56 51 49 40 41 45 20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Management of severe acute malnutrition with complications HeRAMS Summary Report | 2nd Quarter 2018 28 Public Hospitals
9.6. Communicable diseases services
• Management of severe and/or complicated communicable diseases (such as meningitis, measles, SARI, others)
Figure 55: The number of patients received communicable diseases services in public hospitals, June 2018
1500 1,159
1000
500 218 187 77 76 67 53 43 20 5 3 0 0 0 Ha ma Tartous Damascus Ho ms Deir -ez-Zor Aleppo Al -Ha sa keh As -Sweida Rural Dar'a Lattakia Ar -Raqqa Quneitra Damascus
Figure 56: Trend analysis of number of patients received communicable diseases services in public hospitals, January 2017 to June 2018
4,693 5000 4500 3,862 4000 3,386 2,931 3500 3000 2,256 2,192 2,221 2,042 2,021 2,093 2,014 1,908 2500 1,755 1,771 1,747 1,722 1,525 1,703 2000 1500 1000 500 0 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018
Communicable diseases services
9.7. Noncommunicable diseases (NCDs)
• Management of diabetes • Management of hypertension • Treatment of diabetic complications (Kidney • Management of cardiovascular diseases failure, Diabetic retinopathy, Neuropathy • Haemodialysis unit Diabetes, Ft Diabetes … etc.) • Management of cancer diseases HeRAMS Summary Report | 2nd Quarter 2018 29 Public Hospitals
Figure 57: The number of NCDs’ consultations in public hospitals, June 2018
18000 16,433 16000 14000 12000 10000 8000 6000 2,849 2,403 2,166
4000 1,858 1,479 1,451 1,407 1,098 982 831 776 737 703 700 682 561 553 526 526 479 464 452 443 427 403 400 383 357 336 314 301 249 237 226 180 173 164 161 163 157 97 92 80 132 77 71 120 120 117 9 61 61 4 4 0 0 0 0 0 110 0 0 49 48 45 44 38 26 24 24 24 20 21 20 18 2000 11 213 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
Figure 58: Trend analysis of total monthly number of NCDs’ consultations reported in public hospitals, January 2017 to June 2018
4,112 4,270 4,116 4500 3,933 4,061 3,966 3,990 3,664 3,676 3,751 4000 3,471 3,390 3,501 3,399 3,273 3,192 3,320 3500 3,047 3000 2500 2000 2,185 2,190 1500 1,977 2,003 1,977 1,969 2,035 1,801 1,844 1,882 1,887 1,939 1,938 1,912 1000 1,757 1,444 1,375 1,365 500 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Management of diabetes Treatment of diabetic complications
8000 7500 7,440 6,867 6,970 7000 7,069 6,690 6,967 6,815 6500 6,455 6,512 6,061 6,604 6,148 6,324 6000 6,314 5,538 5,625 5500 5,458 5000 4,821 4500 4000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Hypertension
13000 12500 12,417 12,313 12000 12,055 11,762 11,299 11,635 11500 11,167 11,146 10,891 11000 11,167 10,763 10,740 10500 10,515 9,823 10,170 10000 9,801 9,713 9500 9000 8,864 8500 8000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Cardiovascular services HeRAMS Summary Report | 2nd Quarter 2018 30 Public Hospitals
3700 3,638 3600 3,573 3,482 3,544 3500 3,482 3,415 3,386 3400 3,435 3,460 3,393 3300 3,310 3,297 3,369 3,296 3,264 3,283 3200 3,217 3,168 3100 3000 2900 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 End Stage Kidney Disease (ESKD) treatment
25000 22,306 23,638 23000 21,474 22,102 21000 19,568 20,802 21,107 20,081 19,583 19000 18,558 18,840 16,731 18,600 17000 17,075 16,082 17,064 15000 13000 12,645 11000 9000 7000 6,789 5000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Cancer
9.8. Rehabilitation services
• Rehabilitation services and assistive device provision, including post-operative rehabilitation for trauma-related injuries
Figure 59: The number of rehabilitation services in public hospitals, June 2018
2500 1,906 2000 1,362 1500 787 1000 644 334 331 500 228 88 51 45 6 0 0 0 Damascus Ha ma Aleppo Tartous Lattakia Ar -Raqqa As -Sweida Rural Dar'a Deir -ez-Zor Al -Ha sa keh Ho ms Quneitra Damascus HeRAMS Summary Report | 2nd Quarter 2018 31 Public Hospitals
Figure 60: Trend analysis of number of rehabilitation services in public hospitals, January 2017 to June 2018
6,791 7000 6,565 6,346 6500 5,887 5,779 5,782 5,690 5,628 5,622 5,750 6000 5,571 5,591 5,573 5,521 5,479 5500 4,814 4,867 5000 4500 4,069 4000 3500 3000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 Rehabilitation services
9.9. Mental health
• Inpatient care for management of mental disorders by specialized health-care providers
Figure 61: The number of psychiatric inpatients in public hospitals, June 2018
2500 1,906 2000 1,362 1500 787 1000 644 334 331 500 228 88 51 45 6 0 0 0 Damascus Ha ma Aleppo Tartous Lattakia Ar -Raqqa As -Sweida Rural Dar'a Deir -ez-Zor Al -Ha sa keh Ho ms Quneitra Damascus
Figure 62: Trend analysis of psychiatric inpatient cases in public hospitals, January 2017 to June 2018
1400 1,271 1,242 1,234 1300 1,233 1,221 1,179 1,168 1,164 1,119 1,139 1200 1,088 1,108 1100 938 962 1000 896 878 849 900
800
700 622
600
500 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018
Psychiatric inpatient HeRAMS Summary Report | 2nd Quarter 2018 32 Public Hospitals
10. Availability of medical equipment
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.
Figure 63: Percentage of functional essential equipment/ total available equipment in functional public hospitals, June 2018
Nebulizer 98% Minor Surgical sets 97% Height Measurement Device 95% Length Measurement Device 95% Oxygen Station 94% Oxygen cylinders 93% Vaginal examination set 92% Weighing Scale for adults 91% Weighing Scale for children 90% Operating_tables 89% Fetoscope 88% Suction machine 88% Dry_Sterilizer 84% Delivery_table 84% Ambu bag (Paediatric and Adult) 83% Weighing Scale for infants 82% Pulse Oximeter 82% Autoclave 73%
Figure 64: Percentage of functional specialized equipment/ total available equipment in the functional public hospitals, June 2018
Major surgical sets 96% ICU/CCU Monitors 87% Ventilators – Paediatric 87% Ultrasound 84% CT Scan 81% Renal Dialysis machine 81% DC Shock machine/ Defibrillator 81% Anaesthesia machines 80% X -Ray 79% Incubator for new born 76% ECG 76% Portable X- Ray 75% Cardiotocography (Monitoring of fetalheart frequency) 74% Ventilators – Adult 73% MRI machine 62% HeRAMS Summary Report | 2nd Quarter 2018 33 Public Hospitals
11. Availability of medicines & medical supplies
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 65: Availability of medicines and medical supplies for one month in the functional public hospitals, June 2018
Antiseptics 94% Serums 93% Analgesics, antipyretics, nonsteroidal anti- inflammatory 90% Anti- allergic including Steroids 88% Local Anaesthetics 84% Albumin 81% IV Fluid 81% Antibiotics for Adults 80% Anaphylactic shock 78% General Anaesthetics 77% Preoperative medication 75% Cardiac and /or Vascular Drugs (Anti - hypertensive Drugs, 73% Anti- diabetic preparations (especially Insulin) 73% Gastrointestinal 69% Medicines acting on respiratory system (e.g., medicines of 69% Antibiotics for Children 68% Dialysis consumables 61% Delivery related medicines (i.e., Oxytocin , … ) 55% Specific antibiotics for multi – resistant bacteria/infectious 53% Antidotes for Poisoning 44% Medicines affecting the blood (anti - anemia medicines, 44% Dermatological preparations/topical (Burns, and anti 41% Hepatitis vaccine 28% Psychotropic medinas (i.e., antipsychotics, antidepressants, 24% Tetanus shot 19% Cancer related medicines 18%