herams annual reportapplications.emro.who.int/docs/copub_syr_jan_dec_2015_en_166… · herams|...

This is to acknowledge that the data provided in this report is a product of joint collaboration between the

World Health Organization, Ministry of Health, and Ministry of Higher Education in the Syrian Arab Republic.

The report covers the months of January to December 2015.

HeRAMS Annual Report

January - December 2015

Public Hospitals in the Syrian Arab Republic

HeRAMS| Public Hospitals’ Annual Report for 2015, Health Information Management Unit, WHO, Syrian Arab Republic Page 1 of 37

Contents

Executive summary ............................................................................................................................................ 5

1. Completeness of Hospitals Reporting ........................................................................................................ 7

2. Functionality and accessibility of the Public Hospitals ............................................................................... 7

2.1 Functionality Status of the Public Hospitals ........................................................................................ 7

2.2 Accessibility to public hospitals ........................................................................................................... 9

3. Infrastructure Patterns of the Public Hospitals ........................................................................................ 11

3.1 Level of Damage of the hospitals’ buildings ...................................................................................... 11

3.2 Analysis of the inpatient capacity ...................................................................................................... 14

3.3 Water sources and functionality status ............................................................................................. 15

3.4 Availability of electricity generators .................................................................................................. 16

4. Availability of Health Human Resources .................................................................................................. 17

4.1 Availability of medical staff by category and affiliation .................................................................... 18

4.2 Availability of medical doctors by affiliation (MoH vs. MoHE hospitals) .......................................... 19

4.3 Availability of medical doctors by gender (MoH vs. MoHE hospitals) .............................................. 20

5. Availability and Utilization of the Health Services .................................................................................... 21

5.1 General Clinical services .................................................................................................................... 22

5.2 Surgical and Trauma care .................................................................................................................. 23

5.3 Maternal health services ................................................................................................................... 26

5.4 Child Health ....................................................................................................................................... 28

5.5 Nutrition ............................................................................................................................................ 28

5.6 NCDs (non-communicable diseases) ................................................................................................. 29

5.7 Mental Health .................................................................................................................................... 31

6. Availability of Medical Equipment ............................................................................................................ 32

7. Availability of Medicines & Medical supplies ........................................................................................... 34

8. Conclusions and Recommendations ........................................................................................................ 36

Cover photo credit: WHO/Syria


List of Figures

Figure 1: Distribution of public hospitals by affiliation, per governorate 7

Figure 2: Functionality Status- December 2015 7

Figure 3: Number and percentage of the public hospitals by functionality status, per governorate, December 2015 8

Figure 4: Trend analysis of functionality status of public hospitals, January to December 2015 9

Figure 5: Accessibility status- December 2015 9

Figure 6: Accessibility status of the public hospitals per governorate, December 2015 9

Figure 7: Trend analysis of accessibility to public hospitals, January to December 2015 10

Figure 8: Level of Damage - December 2015 11

Figure 9: Number and percentage of the public hospitals by level of damage, per governorate, December 2015 12

Figure 10: Trend analysis of public hospitals’ level of damage, January to December 2015 12

Figure 11: The number of emergency beds vs. total number of beds in functional hospitals, per governorate, December 2015

14

Figure 12: Percentage of available number of beds in functional hospital versus the original inpatient capacity, December 2015

14

Figure 13: Main sources of water, December 2015 15

Figure 14: Distribution of water sources/ types at functional public hospitals, per governorate, December 2015 15

Figure 15: Functionality status of the water sources at functional public hospitals, December 2015 15

Figure 16: Percent of hospitals in need for generators out of total functional hospitals, December 2015 16

Figure 17: Proportion of health staff in hospitals, December 2015 17

Figure 18: Trend analysis of number of doctors (a sum of Specialists, Emergency Physicians, Resident Doctors, Dentists) in public hospitals during 2015

18

Figure 19: Trend analysis of number of Nurses in public hospitals during 2015 18

Figure 20: Trend analysis of number of midwives in public hospitals during 2015 19

Figure 21: Proportions and numbers of key staff work in MoH vs. MoHE hospitals, December 2015 19

Figure 22: Comparison of the medical staff of MoH vs. MoHE hospitals, December 2015 20

Figure 23: Proportions of doctors (a total of Specialists, Emergency Physicians, Resident Doctors, Dentists), by gender, per governorate, December 2015

20

Figure 24: Availability of health services in the functional public hospitals, December 2015 21

Figure 25: Estimated caseload of functional public hospitals (outpatient consultations and emergency cases), January to December 2015

21

Figure 26: Proportions of workload from January to December 2015, per governorate 22

Figure 27: The number of outpatient and inpatient in public hospitals, December 2015 22

Figure 28: Trend analysis of outpatient and inpatient in public hospitals, January to December 2015 22

Figure 29: The number of patients received services in laboratories, blood bank, and imaging services in public hospitals, December 2015

23

Figure 30: Trend analysis of number of patients received services in blood banks and imaging service in public hospitals, January to December 2015

23

Figure 31: The number of reported cases in emergency department in public hospitals, December 2015 23

Figure 32: The number of reported cases of mass casualties in public hospitals, December 2015 24

Figure 33: The number of emergency surgeries vs. elective surgeries in public hospitals, December 2015 24

Figure 34: Percentage of total emergency surgeries to elective surgeries in public hospitals per governorate, December 2015

25

Figure 35: Trend analysis of number of patients received services in blood banks and imaging services in public hospitals, January to December 2015

25


Figure 36: The No. of normal deliveries and caesarean sections (CSs) performed at public hospitals, December 2015

26

Figure 37: Percentage of caesarean sections to normal deliveries in public hospitals, December 2015 27

Figure 38: Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections in public hospitals,

December 2015

27

Figure 39: Comparison of MoH & MoHE hospitals workload of normal deliveries vs. CSs, December 2015 27

Figure 40: Number of children with severe diseases in public hospitals, December 2015 28

Figure 41: Trend analysis of reported cases of severe children diseases in public hospitals, January to December

2015

28

Figure 42: The number of children with severe acute malnutrition with complications in public hospitals,

December 2015

28

Figure 43: Trend analysis of number of children with severe acute malnutrition with complications in public

hospitals, January to December 2015

29

Figure 44: The number of NCDs’ consultations in public hospitals, December 2015 29

Figure 45: Trend analysis of total monthly number of patients with NCDs reported in public hospitals, January to

December 2015

30

Figure 46: The number of outpatient psychiatric cases vs. the number of inpatients in public hospitals, December

2015

31

Figure 47: Trend analysis of number of outpatient psychiatric cases vs. the number of inpatients in public


31

Figure 48: Percentage of functional essential equipment/ total available equipment in functional public hospitals,

December 2015

32

Figure 49: Percentage of functional specialized equipment/ total available equipment in the functional public

hospitals, December 2015

32

Figure 50: Availability of and medical supplies for one month in the functional public hospitals, December 2015 34

List of Tables

Table 1: The list of hospitals with reported fully damaged buildings 13

Table 2: Special cases of hospitals with reported fully damaged buildings, and operating partially from other

locations

13

Table 3: Special cases of hospitals with reported partially damaged buildings, and operating partially (limited

provided health services) from other locations

13

List of Maps

Map 1: Distribution and functionality status of public hospitals [MoH & MoHE], December 2015 8

Map 2: Accessibility to public hospitals [MoH & MoHE], December 2015 10

Map 3: Level of damage of the hospitals’ buildings, by governorate [MoH & MoHE], December 2015 12

Map 4: Availability of medical doctors in functional public hospitals, by end of December 2015, per governorate 17

Map 5: Percent of functional specialized equipment/ total available equipment in functional public hospitals,

December 2015

33

Map 6: Percentage of available medicines in functional public hospitals, December 2015 35


Abbreviations

CEmOC Comprehensive Emergency Obstetric Care

CS Caesarean Sections

DoH Directorate of Health

ESKD End Stage Kidney Disease

HeRAMS Health Resources & Services Availability Mapping System

HIS Health Information System

ICT Information and Communication Technology

ICU/ CCU Intensive Care Unit / Critical Care Unit

IDPs Internally Displaced People

MoH Ministry of Health

MoHE Ministry of Higher Education

NCDs Non-communicable Diseases

WHO World Health Organization


Executive summary

Regular assessment to monitor the impact of the crisis on the health facilities functionality, accessibility,

condition status, availability of resources and services, has been conducted using HeRAMS (Health

Resources & services Availability Mapping System) tool. The report provides descriptive and trend analysis

for the situation of public hospitals in all 14 governorates of Syria [including Ministry of Health (MoH) and

Ministry of Higher Education (MoHE) hospitals (a total of 113 hospitals)].

Despite the challenging security situation and protracted crisis, in addition to the wide disruption of the

Health System, implementation of HeRAMS has been successfully institutionalized and strengthened in

public health facilities during 2014 and 2015.

Completeness of Hospitals’ reporting remained 100%, where all 99 (MoH) hospitals and 14 (MoHE) hospitals

reported to HeRAMS by end of December 2015.

Functionality status of the public hospitals

By the end of December 2015, and out of the 113 assessed public hospitals [MoH & MoHE], 43% (49) were

reported fully functioning, 31% (35) hospitals were reported partially functioning, while 26% (29) were

reported non-functioning.

Accessibility status of the public hospitals

By the end of December 2015, 60% (68) hospitals were reported accessible, 18% (20) hard-to-access, and

22% (25) were inaccessible.

Infrastructure of the public hospitals

By the end of December 2015, 42% (48) hospitals were reported damaged [13% fully damaged and 29%

partially damaged], while 55% (62) of public hospitals were reported intact while the infrastructure of three

public hospitals were unknown.

Analysis on inpatient capacity in functional hospitals has shown shortage of beds at varying degrees, across

all governorates.

Assessing the availability of water sources at functional public hospitals indicated that 40% (34) are using

main pipelines, 7% (6) are mainly using wells, 49% (41) are using both (main pipeline and well), while 4% (3)

are using other sources of water.

Electricity power is widely disrupted nationwide and majority of public hospitals are dependent on

generators' power. According to HeRAMS assessment 40% (34) of functional public hospitals across Syria are

in need for electrical generators, mainly reported from 11 governorates: Quneitra, Aleppo, Deir-ez-Zor,

Dar’a, Rural Damascus, Al-Hasakeh, Hama, Damascus, Homs, Lattakia and Tartous.

Human Resources for Health

The emergency physicians remain the lowest proportion of health staff in public hospitals (0.3%), followed

by dentists (1%), pharmacists (1%), Midwives (5%), Laboratory personnel (7%), specialists (15%), resident

doctors (17%), and nurses (54%).

Trend analysis of available number of medical doctors and nurses during 2015 has shown consistent decline. In functional public hospitals the number of medical doctors [specialists, emergency doctors, resident doctors, dentists] has decreased by 11% in December 2015 compared to January 2015, similarly the number of nurses and number of midwives has decreased by 9% and 13%, respectively .


Analysis of proportions of medical doctors [specialists, emergency doctors, resident doctors, dentists]

working at MoHE hospitals versus MoH hospitals has shown that 31% of medical doctors work in MoHE,

while 69% are in MoH hospitals.

Analysis of availability of medical doctors by gender has shown that lowest proportions of Female to Male

medical doctors are in Al-Hasakeh, Deir-ez-Zor and Ar-Raqqa governorates.

Availability and Utilization of Health Services

As a result of disrupted healthcare delivery and non-functionality of the hospitals, limited provision of health

services was observed across governorates, even within functional hospitals. Detailed analysis on services’

availability and utilization throughout 2015 by category (i.e., general clinical services, surgical & trauma care,

maternal healthcare, child healthcare, nutrition, NCDs, and mental health) is provided at governorate level.

Availability of Medical Equipment

Analysis of availability of essential and specialized equipment was measured across all functional public

hospitals [MoH & MoHE], in terms of functional equipment out of the total available equipment in the

hospital. The produced analysis provides good indication of the current readiness of the hospitals to provide

the health services, and also to guide focused planning for procurement and distribution of equipment and

machines, to fill-in identified gaps that were observe even within the functional public hospitals.

Availability of Medicines and Medical Supplies

Availability of medicines and medical supplies at hospitals’ level was evaluated based on a standard list of

identified priority medicines and medical supplies for duration of one month.

The key identified gaps of medicines and consumables at functional hospitals include the hepatitis vaccine

(87%), tetanus shots (85%), medicines affecting the blood, such as heparin (58%), antidotes for poisoning

(57%), specific antibiotics for multi-resistant bacteria (57%), dermatological preparation (57%), delivery

related medicines (51%), dialysis consumables (49%), Albumin (35%), etc.


1. Completeness of Hospitals Reporting

The completeness of reporting from public hospitals across Syria remained at 100%, where all the 99

Ministry of Health (MoH) Hospitals and the 14 Ministry of Higher Education (MoHE) hospitals continued to

report to HeRAMS in December 2015.

The distribution of public hospitals by affiliation [MoH & MoHE], per governorate is shown in Figure 1.

Figure 1: Distribution of public hospitals by affiliation, per governorate

The following sections provide descriptive and trend analysis on the functionality status, accessibility, and

infrastructure of the public hospitals, availability of resources & services, and available equipment and

medicines by the end of December 2015.

The provided analysis supports informed decision making, better planning and allocation of resources, and

contributes to significant and focused humanitarian response by WHO and health sector partners.

2. Functionality and accessibility of the Public Hospitals

The following sub-sections provide analysis on the functionality and accessibility status of the public

hospitals at governorate level.

2.1 Functionality Status of the Public Hospitals

Functionality of the public hospitals was defined and

assessed at three levels;

Fully Functioning: a hospital is open, accessible, and

provides healthcare services with full capacity (i.e.,

staffing, equipment, and infrastructure).

Partially functioning: a hospital is open and provides

healthcare services, but with partial capacity (i.e.,

either shortage of staffing, equipment, or damage in

infrastructure).

Not functioning: a hospital is out of service, because it

is either fully damaged, inaccessible, no available staff,

or no equipment.

15 15 14 14

9 8

7 6 6

5 4 4

3

1

11

8

13 14

9

6 7

6 6 5

4 4 3

1

4

7

1 0 0

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0 0 0 0 0 0 0 0 0

2

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12

14

16

Aleppo Damascus RuralDamascus

Homs Dar'a Lattakia Deir-ez-Zor Tartous Hama Al-Hasakeh Idleb Ar-Raqqa As-Sweida Quneitra

Total Public Hospitals Total MoH Hospitals Total MoHE Hospitals

Figure 2: Functionality Status- Dec 2015

Non-Functioning

29

Partially Functioning

35

Fully Functioning

49 26%

31%

43%


By the end of December 2015, and out of the 113 assessed public hospitals [MoH & MoHE], 43% (49)

were reported fully functioning, 31% (35) hospitals were reported partially functioning, while 26% (29)

were reported non-functioning [Figure 2].

The hospitals reported partially functioning or non-functioning are in 12 out of a total 14 govrnorates (86%

of governorates). Detailed analysis on the functionality status of the MoH and MoHE hospitals at

governorate level is presented in [Figure 3] and [Map 1]. All public hospitals in Idleb were reported out of

service.

Figure 3: Number and percentage of the public hospitals by functionality status, per governorate, December 2015

Map 1: Distribution and Functionality status of public Hospitals, December 2015

0

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Idleb

Ar-Raqqa

Dar'a

Deir-ez-Zor

Homs

Rural Damascus

Al-Hasakeh

Aleppo

Hama

Damascus

As-Sweida

Lattakia

Tartous

Quneitra

Fully Functioning Partially Functioning Non-functioning


Constant deterioration of functionality status of public hospitals has been observed during 2015; 29

hospitals were reported out-of-service in December 2015 compared to 19 in January 2015, while June

marked a record high of 31 non-functional hospitals [Figure 4].

Figure 4: Trend analysis of functionality status of public hospitals, January to December 2015

2.2 Accessibility to public hospitals

Accessibility to public hospitals is defined at three levels:

Accessible: a hospital is easily accessible for patients and

health staff.

Hard-to-reach: a hospital is hardly reached, due to security

situation or long distance.

Inaccessible: a hospital is not accessible because of the

security situation, or a hospital is accessible only to a small

fraction of the population, or military people (inaccessible

to civilians).

By the end of December 2015, 60% (68) hospitals were reported accessible, 18% (20) hard-to-access,

and 22% (25) were inaccessible [Figure 5]. Distribution of public hospitals by accessibility status is

presented in Map 2.

Figure 6: Accessibilty status of the public hospitals per governorate, December 2015

53 53 50 50 49

46 46 46 47 48 49 49

41 40 40 37 36 36 37 37 36 36 35 35

19 20 23

26 28

31 30 30 30 29 29 29

0

10

20

30

40

50

60

Jan 2015 Feb 2015 Mar 2015 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015

Fully Functioning Partially Functioning Non-functioning

0

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Idleb

Homs

Aleppo

Rural Damascus

Dar'a

Deir-ez-Zor

As-Sweida

Damascus

Hama

Lattakia

Tartous

Al-Hasakeh

Ar-Raqqa

Quneitra

Yes Hard to access No

Figure 5: Accessibility status- Dec 2015

Hard to access

20

22%

Yes 68

No 25

18%

60%


Map 2: Accessibility to public hospitals [MoH & MoHE], December 2015

Trend analysis on accessibility to public hospitals [MoH & MoHE] from January to December 2015, is

presented in Figure 7.

Figure 7: Trend analysis of accessibility to public hospitals, January to December 2015

78 77 74 73

70 67 68 69 68 68 68 68

18 19 20 18 19 19 19 19 20 20 20 20

17 17 19

22 24

27 26 25 25 25 25 25

0

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20

30

40

50

60

70

80

90


Yes Hard to access No


3. Infrastructure Patterns of the Public Hospitals

The following sub-sections provide analysis on the infrastructure patterns of the public hospitals, in terms of

building condition, inpatient capacity, water sources, availability of ambulances, and electricity generators,

all summarized at governorate level.

3.1 Level of Damage of the hospitals’ buildings

The level of damage to hospital buildings was measured at

three levels:

Fully damaged: either, all the building is destroyed, about

75% or more of the building is destroyed, or damage of

the essential services’ buildings.

Partially damaged: where part of the building is damaged.

Intact: where there is no damage in the building.

Analysis of the level of damage provides good indication on the

potential costs for reconstruction.

By the end of December 2015, 42% (48) hospitals were reported damaged [13% fully damaged and 29%

partially damaged], while 55% (62) of public hospitals were reported intact. The level of damage of three

hospitals was unconfirmed due to escalating security situation: Al-Bassel Tadmor, Al-Bassel Al-Qaryatein and

Al-Bassel Sokhneh hospitals in Homs governorate [Figure 8]. Distribution of public hospitals by level of

damage is presented in Map 3, while more details are provided at governorate’s level in Figure 9.

Map 3: Level of Damage of the Hospitals’ buildings, by governorate [MoH & MoHE], December 2015

It is essential to cross-analyze the infrastructural damage of the public hospitals in relation to the

functionality status (i.e. provision of services). Some hospitals have resiliently continued to provide services

Figure 8: Level of Damage - Dec 2015

Not damaged

62

55%

Partially damaged

33

Fully damaged

15

No Report 3

29%

13% 3%


regardless of the level of damage of the building and by optimizing intact parts of the building or in a few

cases operating from other neighboring facilities. The national figures translate as follows:

Out of the 33 partially damaged hospitals, 17 hospitals were reported partially functioning and 14 out of

service (non-functioning), while two hospitals (Yabroud in Rural Damascus, and Ebn Khaldoun Psychiatric

hospital in Aleppo) were reported to be fully functioning providing all services through salvaging medical

equipment from the damaged section of the hospital with full staffing capacity.

Out of the 15 fully damaged hospitals, 10 were reported non-functioning while 5 hospitals have opted

for innovative ways to continue providing health services to populations in need through partially

functioning from other nearby temporary locations and provide health services with limited staff

capacity and resources. More details of the 5 hospitals are available in the HeRAMS database.

Then again, hospitals with intact buildings (62 hospitals) does not directly reflect full functionality, only

47 of the 62 intact hospitals are fully functioning, while 13 are partially functioning and 2 hospitals are

not functioning all together, due to limited access of patients and health staff to the facilities resulting

from the dire security situation as well as critical shortage of supplies.

Figure 9: Number and percentage of the public hospitals by level of damage, per governorate, December 2015

Trend analysis on condition of the public hospitals (level of damage of the building) from January to

December 2015 is presented in Figure 10.

Figure 10: Trend analysis of public hospitals’ level of damage, January to December 2015

0

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14

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Idleb

Dar'a

Ar-Raqqa

Rural Damascus

Deir-ez-Zor

Homs

Aleppo

Al-Hasakeh

Hama

Lattakia

Damascus

Tartous

As-Sweida

Quneitra

Fully damaged Partially damaged Not damaged No Report

14 13 14 14 14 14 15 15 15 15 15 15

32 32 34 33 33 34 33 34 34 34 34 33

67 68 65 66 64 62 62 62 61 61 61 62

0 0 0 0 2 3 3 2 3 3 3 3 0

10

20

30

40

50

60

70

80


Fully damaged Partially damaged Not damaged No Report


The tables below list the hospitals, which reported fully damaged (buildings), in addition to the list of

hospitals that are operating from different location (s) given that the original building is fully damaged or

partially damaged.

Table 1: The list of hospitals with reported fully damaged buildings:

# Hospital Name Province District Affiliation

1 Rural Damascus specialized hospital – Duma Rural Damascus Duma MoH 2 Harasta general hospital Rural Damascus Harasta MoH 3 Al-Mleha hospital Rural Damascus Harasta MoH 4 An-Nashabeyeh hospital Rural Damascus An-Nashabeyeh MoH 5 Darayya general hospital Rural Damascus Darayya MoH 6 Zahi Azraq general hospital Aleppo The fourth MoH 7 E'zaz national hospital Aleppo E'zaz MoH 8 Children hospital Aleppo Third MoH 9 Al-Qusayr general hospital Homs Al-Qusayr MoH 10 Helfaya hospital Hama Muhardeh MoH 11 Children hospital Al-Hasakeh Al-Hasakeh MoH 12 Maternity and Paediatric specialized hospital Deir-ez-Zor Deir-ez-Zor MoH 13 Alfurat general hospital Deir-ez-Zor Deir-ez-Zor MoH 14 Jassem general hospital Dar'a Nawa MoH 15 Al-Kindi university hospital Aleppo The fourth MoHE

Table 2: Special cases of hospitals which reported fully damaged (buildings), and operating partially from

other locations:

# Hospital name Province District Type Condition Affili-

ation

New location

1 Zahi Azraq general hospital Aleppo The fourth General Fully damaged

MoH Ar-Razi hospital

2 Children hospital Aleppo Third Specialized Fully damaged

MoH Ar-Razi hospital + Maternity hospital

3 Children hospital Al-Hasakeh Al-Hasakeh Specialized Fully damaged

MoH Al-Hasakeh National hospital

4 Maternity and Paediatric specialized hospital

Deir-ez-Zor Deir-ez-Zor Specialized Fully damaged

MoH Al-Assad hospital

5 Alfurat general hospital Deir-ez-Zor Deir-ez-Zor Specialized Fully damaged

MoH Al-Assad hospital

Table 3: Special cases of hospitals which reported partially damaged (buildings), and operating partially

(limited provided health services) from other locations: # Hospital name Province District Type Condition Affili-

ation New location

1 Martyr Basil al-Assad in Deir Atia/Qalamoun Autonomous hospital

Rural Damascus

Al-Nabak General Partially

damaged

MoH Deir- Atia Health Centre

2 Qaara/ Qalamoun Autonomous hospital

Rural Damascus

Al-Nabak General Partially

damaged

MoH One floor in Qara Municipal (they moved

the functional medical equipment to the

new location)

3 Ophthalmology hospital

Aleppo Third Specialized Partially

damaged

MoH Part of the hospital operating from Al-

Razi hospital, while the other from the

Obs. & Gyn. Hospital in Aleppo

The information above could guide focused rehabilitation activities for hospitals’ infrastructure, which could

improve functionality status of hospitals to reach fully functional level, especially for partially functional

hospitals that need small scale of rehabilitation.


3.2 Analysis of the inpatient capacity

The inpatient capacity has been analyzed in terms of the total number of beds available in functional

hospitals by end of 2015 compared to the original number of beds in these hospitals pre-crisis or the

maximum inpatient capacity) [Figure 11].

Figure 11: Comparison of inpatient capacity (available vs. maximum) in functional hospitals per governorate,

December 2015

Reduced inpatient capacity (shortage of beds) was observed in all governorates at varying degrees. This may

be correlated to the upsurge in usage of beds in functional hospitals, as direct implication of the crisis on the

overstretched public health sector. Figure 12 illustrates the proportion of available beds in functional

hospitals versus the original inpatient capacity at governorate levels.

Figure 12: Percentage of available number of beds in functional hospital versus the original inpatient capacity,

December 2015

The lowest percentage (25%) of available beds in functional hospital versus original inpatient capacity is

observed in Dar’a governorate, mainly reported from the national hospital [the current number of beds are

14, while the original hospital capacity is 60 beds].

3,500

2,455 2,429

1,917

1,160 1,107

675 670 660 630 618 610

200

3,146

1,532 1,772

1,352

917 1,062

311 485 507

155 239 413

133

Damascus Aleppo Lattakia RuralDamascus

Hama Tartous Homs Al-Hasakeh As-Sweida Dar'a Deir-ez-Zor Ar-Raqqa Quneitra

Original/Max. No. of Beds Available No. of Beds

96% 90%

79% 77% 73% 72% 71% 68% 67%

62%

46% 39%

25%

72%

Tartous Damascus Hama As-Sweida Lattakia Al-Hasakeh RuralDamascus

Ar-Raqqa Quneitra Aleppo Homs Deir-ez-Zor Dar'a Overall

% of available beds /total original beds


3.3 Water sources and functionality status

Availability of water sources at public hospitals was assessed

using a standard checklist of main types of water sources (i.e.,

main pipeline, well, or both (main pipeline and well)).

By the end of December 2015 and out of 84 functional public

hospitals, 40% (34) are using main pipelines, 7% (6) are mainly

using wells, 49% (41) are using both (main pipeline and well),

while 4% (3) are using other sources of water [Figure 13].

Detailed analysis on distribution of water sources at functional

public hospitals is presented at governorate level on [Figure

14].

Figure 14: Distribution of water sources/ types at functional public hospitals, per governorate, December 2015

Functionality status of the water sources was measured at three levels; fully functional, partially functional,

and not functional. Figure 15, provides details on functionality status of water sources at functional

hospitals, (84/113) per governorate.

Figure 15: Functionality status of the water sources at functional public hospitals, December 2015

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Aleppo

Hama

Quneitra

Al-Hasakeh

Deir-ez-Zor

Dar'a

Rural Damascus

As-Sweida

Homs

Ar-Raqqa

Damascus

Tartous

Lattakia

Main Pipeline Main Pipeline and Well Well Other

13

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0

0

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Damascus

Aleppo

Lattakia

Rural Damascus

Tartous

Hama

Homs

Ar-Raqqa

Al-Hasakeh

As-Sweida

Dar'a

Quneitra

Deir-ez-Zor

Fully Functioning Partially Functioning No Report

Main Pipeline, 34, 40%

Main Pipeline

and Well, 41, 49%

Well, 6, 7%

Other, 3, 4%

Figure 13: Main Sources of Water, Dec 2015


3.4 Availability of electricity generators

Availability of electricity generators continued to be highly demanded with the current situation, where

electricity power is widely disrupted and majority of public hospitals are dependent on generators' power.

Availability of electrical generators at functional hospitals was measured by assessing the functional out of

the total existing generators in the hospital. The percent of hospitals in need for electricity generators out of

the total functional hospital is summarized at governorate level [Figure 16].

40% (34) of functional public hospitals across Syria are in need for electrical generators, mainly reported

from 11 governorates: Quneitra, Aleppo, Deir-ez-Zor, Dar’a, Rural Damascus, Al-Hasakeh, Hama, Damascus,

Homs, Tartous and Lattakia [Figure 16].

Figure 16: Percent of hospitals in need for generators out of total functional hospitals, December 2015

100%

77% 75% 75%

56%

50%

40%

27% 25%

17% 13%

0% 0%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Quneitra Aleppo Deir-ez-Zor Dar'a RuralDamascus

Al-Hasakeh Hama Damascus Homs Tartous Lattakia Ar-Raqqa As-Sweida Total


4. Availability of Health Human Resources

Availability and trend of health human

resources were analyzed across all public

hospitals [MoH & MoHE] considering the

following scopes:

Comparative and trend analysis of medical

staff by category (i.e., doctors, nurses,

midwives)

Trend analysis of availability of medical

doctors by affiliation; MoH vs. MoHE

hospitals

Trend analysis of availability of medical

doctors by gender, per governorate

The proportion between different categories of health staff, among the total functional (fully and partially)

MoH and MoHE hospitals (84/113), by the end of December 2015, is as follows: the emergency physicians

remain the lowest proportion of health staff in public hospitals (0.3%), followed by dentists (1%),

pharmacists (1%), Midwives (5%), Laboratory personnel (7%), specialists (15%), resident doctors (17%), and

nurses (54%); [Figure 17].

The availability and level of medical staffing (by category and gender) in public hospitals a, as is summarized

at governorate’s level in Map 4. The categories of staff included in the map are: specialists, emergency

physicians, resident doctors, and dentists.

Map 4: Availability of medical doctors in functional public hospitals, by end of December 2015, per governorate

Specialist 15%

Emergency Physician

0%

Resident Doctor 17%

Dentist 1%

Nurses 54%

Laboratory 7%

Midwives 5%

Pharmacists 1%

Figure 17: Proportion of Health Staff in Hospitals, December 2015


4.1 Availability of medical staff by category and affiliation

The availability medical staff in functional public hospitals is analyzed by category [i.e., medical doctors1,

nurses, and midwives] and affiliation [MoH vs. MoHE hospitals], as follow:

i. Trend analysis of medical doctors [a total of specialists, Emergency doctors, resident doctors,

dentists]:

The number of medical doctors in public hospital has slightly decreased by 11% in December 2015 (9,455

compared to January 2015 (10,586).

Figure [18] shows the trend analysis of reported medical doctors from January to December 2015, in

functional public hospitals.

Figure 18: Trend analysis of number of doctors (a total of Specialists, Emergency Physicians, Resident Doctors, and

Dentists) in public hospitals during 2015

ii. Trend analysis of Nurses:

The number of nurses in public hospital has slightly decreased by 9% in December 2015 (14,892), compared

to January 2015 (16,450).

Figure [19] shows trend analysis for the reported number of nurses from January to December 2015.

Figure 19: Trend analysis of number of Nurses in public hospitals during 2015

1 A total of specialists, Emergency doctors, resident doctors, and dentists

10,586

10,801 10,819 10,742

10,519

10,296 10,280 10,266 10,154 10,160

9,909

9,455

8500

9000

9500

10000

10500

11000

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

16,450 16,696

16,293

15,972 15,753

15,498 15,614 15,548

15,324 15,339

14,933 14,892

13500

14000

14500

15000

15500

16000

16500

17000

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015


iii. Trend analysis of Midwives:

The number of midwives in public hospital has slightly decreased by 13% in December 2015 (1,319),

compared to January 2015 (1,516). The drop is mainly observed in Deir-ez-Zor governorate.

Figure [20] shows trend analysis for the reported number of midwives from January to December 2015.

Figure 20: Trend analysis of number of midwives in public hospitals during 2015

4.2 Availability of medical doctors by affiliation (MoH vs. MoHE hospitals)

Analysis of proportions of medical doctors [specialists, emergency doctors, resident doctors, dentists]

working at MoHE hospitals versus MoH hospitals in December 2015 has shown that 31% (2,952) of medical

doctors (specialists and resident doctors) work in MoHE, while 69% (6,503) are in MoH hospitals.

20% out of total Specialists (4,228) work in public hospitals are in MoHE hospitals; 43% out of total resident

doctors (4,798) are in MoHE hospitals; and 25% out of total the nurses & midwives (16,211) are in MoHE

hospitals. Details on proportions and numbers of key staff work in MoH vs. MoHE hospitals, by end of

December 2015, are presented in [Figure 21].

Figure 21: Proportions and numbers of key staff work in MoH vs. MoHE hospitals, December 2015

1,516

1,490

1,464 1,445 1,441

1,352 1,376

1,362 1,346 1,348

1,302 1,319

1150

1200

1250

1300

1350

1400

1450

1500

1550

Jan2015

Feb2015

Mar2015

Apr2015

May2015

Jun2015

Jul2015

Aug2015

Sep2015

Oct2015

Nov2015

Dec2015

3,382

90

2,713

318

10,994 1,410 1,142

846

2,085

21

3,898 379 177

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Specialist EmergencyPhysician

Resident Doctor Dentist Nurses Laboratory Midwives

MoHE

MoH


However, MoHE hospitals are located in four governorates (Damascus, Rural Damascus, Aleppo, and

Lattakia), they serve the whole country. A comparison between the total available medical-related staff in

MoH vs. MoHE hospitals is shown in [Figure 22].

Figure 22: Comparison of the medical staff of MoH vs. MoHE hospitals, December 2015

A comparative analysis for the number of medical doctors [specialists, emergency doctors, resident doctors,

dentists] working in MoH hospitals between June and December 2015, has shown a drop of 386 (3,338 in

June compared to 2,952 in December 2015); similarly, a drop of 455 (6,958 to 6,503) in MoHE hospitals.

This could be interpreted as fleeing of specialized medical staff out of the country in some cases, and

relocation / reassignment of medical staff to DoHs/ health centres on other cases, based on functionality

status of the hospitals, and security situation in the area.

4.3 Availability of medical doctors by gender (MoH vs. MoHE hospitals)

By analyzing the proportion of male to female doctors (a total of: Specialists, Emergency Physicians, Resident

Doctors, Dentists), lowest proportions are seen in Al-Hasakeh, Deir-ez-Zor and Ar-Raqqa governorates

[Figure 23].

Figure 23: Proportion of Doctors (a total of Specialists, Emergency Physicians, Resident Doctors, Dentists), by gender,

per governorate, December 2015

55

5

14

8 26

2

53

5

43

4

58

22

5

12

9

10 3 7 14 0 0 0 0

96

1

18

0

26

0

26

4

91

4

15

70

2

45

4

47

13 42 81

12

1 0 8

1,4

38

62

8

61

1

1,4

19

2,2

17

31

7

37

9

98

5

30

8

89

68 13

8

13

1

20 1

11

11

7

32

68 99 1

95

96

0 29 52

0

500

1,000

1,500

2,000

2,500

Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia

MoH MoHE

Specialist Emergency Physician Resident Doctor Dentist Nurses Midwives Pharmacists

1907 288 963 908 817 297 503

152 23 140 40 186 84

1026 130 535 577 344 145 212

31 6 36 17 62 26

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Damascus RuralDamascus

Aleppo Lattakia Tartous Homs Hama Al-Hasakeh Deir-ez-Zor Ar-Raqqa Dar'a As-Sweida Quneitra

Male Female


5. Availability and Utilization of the Health Services

The availability of core healthcare services is monitored through HeRAMS at hospital’s level, considering a

standard list of health services (including: General Clinical Services, Surgical and Trauma care, Child Health,

Nutrition, Maternal & Newborn Health, Non-communicable Diseases, and Mental Health).

Analysis of availability of health services has been conducted across all functional public hospitals [MoH &

MoHE]: (84/113). As a result of disrupted healthcare delivery and non-functionality of hospitals, limited

provision of health services was observed across governorates, even within functional hospitals [Figure 24].

Figure 24: Availability of Health Services in the functional Public Hospitals, December 2015

**Detailed information on availability of services per governorate is available in the HeRAMS Database.

The workload and utilization of the health services were analyzed in terms of the total estimated serviced

people in all functional public hospitals during January and December 2015 per governorate [Figure 25]. In

2015, the total estimated caseload in functional public hospitals is 6,334,010.

Figure 25: Estimated caseload of functional public hospitals (outpatient consultations and emergency cases), January

to December 2015

11%

31%

35%

41%

55%

65%

71%

73%

74%

76%

79%

80%

83%

85%

87%

91%

Acute psychiatric inpatient unit

Outpatient psychiatric care

Cancer treatment services

Management of severe acute malnutrition with complications

Management of children diseases

(CEmOC) Comprehensive emergency obstetric care

Emergency surgery

Mass casualty management

ICU services

Cardiovascular services

End Stage Kidney Disease (ESKD) treatment

Blood bank service

Elective surgery

Imaging service

Solid waste management

Emergency department services

1,321,953

981,599

747,374

647,939 636,004

505,247 442,229

353,249

228,053 147,274 117,196 106,870

53,400 45,623

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

Damascus Lattakia Aleppo Homs Tartous Hama Al-Hasakeh RuralDamascus

As-Sweida Ar-Raqqa Deir-ez-Zor Dar'a Quneitra Idleb


The proportion of workload of functional hospitals

per governorate is provided on Figure 26.

Detailed analysis on utilization of the core health

services is provided on the following sub-sections,

including:

1. General Clinical Services (Outpatient,

Inpatient, Laboratory, Blood bank services,

Imaging services)

2. Surgical and Trauma care

3. Maternal health services [normal deliveries,

caesarean sections, and CEmOC]

4. Nutrition

5. Child Health

6. Non-communicable diseases

7. Mental Health

5.1 General Clinical services

The following sections provide analysis on the utilization of health services in functional public hospitals at

governorate level.

i. Outpatient and inpatient:

The number of outpatients to inpatients was assessed at a hospital level, and the total numbers reported in

December 2015 were summarized and analyzed at governorate level [Figure 27].

Figure 27: The number of Outpatient and Inpatient in public hospitals, December 2015

Trend analysis of total reported numbers of Outpatient and Inpatient from functional public hospitals [MoH

& MoHE], for twelve months (January to December 2015), is presented in [Figure 28]. In 2015, the total

reported outpatients are 3,005,756 while the inpatients are 804,649.

Figure 28: Trend analysis of Outpatient and Inpatient in public hospitals, January to December 2015

54,319

41,288

32,596

24,038 21,356

15,724 12,625

6,280 6,105 4,299 4,281 1,600 1,389

17,808

6,215 4,626 7,555

2,472 5,166 5,331

2,620 5,180 41

4,485 413 731

0

10,000

20,000

30,000

40,000

50,000

60,000

Damascus Lattakia Aleppo Tartous Homs Hama RuralDamascus

Al-Hasakeh Ar-Raqqa Deir-ez-Zor As-Sweida Quneitra Dar'a

Outpatient services Inpatients services

202,427

255,271

304,016 277,312

259,927 261,619 235,079

280,021

240,309 226,524 237,351 225,900

59,459 62,492 70,066 66,221 65,928 65,932 66,669 77,664 71,806 70,769 65,000 62,643

0

50000

100000

150000

200000

250000

300000

350000


Outpatient services Inpatients services

Damascus 21%

Lattakia 15%

Aleppo 12% Homs

10%

Tartous 10%

Hama 8%

Al-Hasakeh 7%

Rural Damascus 5%

As-Sweida 4%

Ar-Raqqa 2%

Deir-ez-Zor 2%

Dar'a 2%

Quneitra 1%

Idleb 1%

Figure 26: Proportions of workload during 2015, per governorate


ii. Laboratories, blood bank, and imaging services

The number of patients received services in hospitals’ laboratories, blood bank, and imaging departments

was assessed at a hospital level, and the total number of cases from January to December 2015 analyzed at

governorate level [Figure 29].

Figure 29: The number of patients received services in laboratories, blood bank, and imaging services in public


Trend analysis of number of patients received services in hospitals’ blood banks and imaging departments,

from January to December 2015, is presented in [Figure 30]. In 2015, the total reported patients received

services in blood banks are 275,016 while patients received imaging services are 2,145,212 [of note: the

total performed service (X-Ray, MRI, and CT Scan pictures) in 2015 are 3,005,823].

Figure 30: Trend analysis of number of patients received services in blood banks and imaging services in public


5.2 Surgical and Trauma care

The surgical and trauma care services is assessed at hospitals’ level. Descriptive analysis is conducted at

governorate’s level for the number of reported emergency cases, mass causalities, and surgeries (elective

and emergency).

iii. Emergency cases reported in emergency departments

Figure 31 presents the total number of cases in emergency departments, reported during December 2015

from functional public hospitals at governorate level.

Figure 31: The number of reported cases in emergency department in public hospitals, December 2015

45

7,0

59

68

,65

1

17

0,0

67

15

8,1

37

16

8,7

61 8

1,5

79

19

7,6

36

10

5,9

69 1

3,1

66

2,4

61

10

,63

3

48

,75

7

19

,91

9

6,8

52

36

2

4,9

30

2,6

98

1,9

76

61

1

1,6

65

87

8

20

26

1 91

37

0

11

0

40

,97

1

8,0

43

22

,80

9

22

,62

3

21

,97

3

10

,13

0

19

,44

8

8,3

99

1,3

60

83

2

1,7

05

9,1

89

1,2

50

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

500000



Laboratory services Blood bank service Imaging service

23,289 23,395 26,857 24,598 23,848 22,292 20,934 23,079 23,026 22,221 20,653 20,824

156,912 171,621

194,439 184,184 186,069 184,464 174,944 191,674

177,433 178,225 176,515 168,732

0

50000

100000

150000

200000

250000


Blood bank service Imaging service

48,272

37,355

30,155 29,550 29,402 25,140

22,667

15,188 13,007

5,867 3,577 3,109 1,269

0

10,000

20,000

30,000

40,000

50,000

60,000

Damascus Lattakia Al-Hasakeh Homs Aleppo Tartous Hama RuralDamascus

As-Sweida Ar-Raqqa Dar'a Quneitra Deir-ez-Zor


iv. Mass causalities

Figure 32 presents the total number of mass causality cases, reported during December 2015 from

functional public hospitals at governorate level.

Figure 32: The number of reported cases of mass casualties in public hospitals, December 2015

v. Emergency and Elective surgeries:

The number of emergency surgeries to elective surgeries was assessed at a hospital level, and total numbers

were summarized and analyzed at governorate level [Figure 33].

During December 2015, the highest workload of elective surgeries is reported from Damascus MoH Hospital

(Al-Mojtahid: 983 surgeries), followed by Al-Assad university hospital in Damascus (817 surgeries), Al-Assad

university hospital/ Lattakia (817 surgeries), Aleppo university hospital (794 surgeries), Hama national

hospital (789 surgeries), Ar-Razi MoH hospital in Aleppo (732), Al-Bassel Heart Institute in Damascus (663),

and Al-Mouwasat university hospital (625).

While the highest workload of emergency surgeries is reported from Al-Bassel hospital in Tartous (2,004),

followed by National hospital in Lattakia (574), then Al-Mouwasat MoHE hospital (494), and Ar-Razi MoH

hospital in Aleppo (351), As-Salameyeh national hospital (307), Hama national hospital (295), and Zaid Ash-

Shariti hospital in As-Sweida (259).

*Of note, the highest number of functional public hospitals is in Damascus, of which 14 out of 15 hospitals

provide elective surgeries, except Ibn-Roshd hospital for Mental Health.

Figure 33: The number of emergency surgeries vs. elective surgeries in public hospitals, December 2015

2,237

922

641 531 496

187 185 128 82 77 30 29 11

0

500

1,000

1,500

2,000

2,500

Hama Dar'a Aleppo Quneitra Damascus RuralDamascus

Homs Al-Hasakeh Tartous Ar-Raqqa Deir-ez-Zor Lattakia As-Sweida

5,064

2,327 1,973

1,473 1,093

732 652 579 430 165 88 44 6

907 1,153

645 984

2,326

284 55 67 204 222 132 32 2

0

1000

2000

3000

4000

5000

6000

Damascus Lattakia Aleppo Hama Tartous As-Sweida RuralDamascus

Homs Al-Hasakeh Ar-Raqqa Quneitra Dar'a Deir-ez-Zor

Elective surgery Emergency surgery


By analyzing the percent of total emergency surgeries to elective surgeries during December 2015, the

highest percent of emergency surgeries across different governorates is reported in Tartous, Quneitra , Ar-

Raqqa , Dar'a, and Hama governorates. Across all reported functional public hospitals, 32% of surgeries are

emergency while 68% are elective [Figure 34].

In Tartous, the highest figures are reported from Al-Basil surgical hospital, which is the biggest hospital in

Tartous, located in the south eastern part of the governorate and adjacent to Hama and Homs. The location

of this hospital is also very close to the highway, and majority of the road incidents are received there.

In Ar-Raqqa, the number of emergency surgeries is relatively high because of emergency cases received

from surrounding in-secure areas.

In Hama, the number of emergency surgeries is relatively high because of emergency cases received from

surrounding in-secure areas (Rural Hama, Idleb, and Rural Lattakia).

In Dar’a and Quneitra, the high percent of emergency surgeries is due to the escalating security situation;

emergency surgeries are given higher priority than cold surgeries.

Figure 34: Percentage of total emergency surgeries to elective surgeries in public hospitals per governorate,

December 2015

Trend analysis of total number of elective and emergency surgeries reported in functional public hospitals

[MoH & MoHE], from January to December 2015 is presented in Figure 35. In 2015, the total reported

emergency surgeries are 96,766 while the elective surgeries are 196,401.

Figure 35: Trend analysis of number of patients received emergency surgeries and elective surgeries in public


8% 10% 15% 25% 25% 28% 32% 33%

40% 42%

57% 60% 68%

32%

92% 90% 85% 75% 75% 72% 68% 67%

60% 58%

43% 40% 32%

68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

RuralDamascus

Homs Damascus Aleppo Deir-ez-Zor As-Sweida Al-Hasakeh Lattakia Hama Dar'a Ar-Raqqa Quneitra Tartous Total

% Emergency surgery % Elective surgery

7,213 6,596 8,020 7,899 8,601 8,319 8,219

9,395 8,152

9,646

7,693 7,013

13,161

15,176

17,290 16,260 16,589

18,881

15,796

19,400

16,927 15,957 16,338

14,626

0

5000

10000

15000

20000

25000


Emergency surgery Elective surgery


5.3 Maternal health services

Analysis of availability and utilization of maternal health services was conducted considering three scopes:

Utilization of service (caesarean sections (CS) vs. normal deliveries); December 2015 summary

figures by governorate

Percentage of CSs to normal deliveries, of December 2015

Trend analysis of the monthly normal deliveries vs. caesarean sections, January to December 2015

i. Utilization of service (caesarean sections vs. normal deliveries)

The numbers of caesarean sections performed at public hospitals (in December 2015) versus the normal

deliveries have been analyzed at governorates’ level [Figure 36].

The highest numbers are reported from Maternity hospital in Ar-Raqqa [normal deliveries are 1,500 while

CSs are 355]. Of note, the maternity hospital in Ar-Raqqa is the only reported provider for delivery services in

the governorate, after closure of the maternity specialized centre in the city in addition to the high cost of

delivery in private centres, which is unbearable cost for the residing population

The high figures reported in Damascus hospitals are from the Obs. and Gyn. MoHE Hospital [normal

deliveries are 567 while CSs are 468] followed by Al-Zahrawi MoH Hospital [normal deliveries 391 while the

CSs are 103 case.

Figure 36: The No. of normal deliveries and caesarean sections (CSs) performed at public hospitals, December 2015

ii. Percentage of CS to normal deliveries

The global norm for the percentage of CS to normal deliveries is 5% to 15%. Based on [Figure 34], 12

governorates are above the threshold.

The highest figures of caesarian sections in December 2015 are reported in Lattakia (478 CSs compared to

272 normal deliveries) and Tartous (442 CSs compared to 311 normal deliveries), which are due to cultural

preferences, where the pregnant women opt for cesarean sections for several reasons, such as:

Reducing the pain associated with childbirth

Choosing a fixed date for delivery, in relation to other social occasions

In Homs, Rural Damascus, and Aleppo the high numbers of CSs are due to the fact that majority of the

pregnant women prefer to do caesarean sections, because of the security situation and hassles they could go

through if they opted for normal delivery.

Across all reported functional hospitals in December 2015, 37% (3,524) of deliveries are CSs while 63%

(5,880) are normal deliveries. Details on percent of CSs to normal deliveries per governorate in December

2015, is provided in [Figure 37].

1702

958

717 659

325 311 280 272 240 226

85 70 35

386

571

115

611

291

442

165

478

217 180

28 40 0

0

200

400

600

800

1000

1200

1400

1600

1800

Ar-Raqqa Damascus Al-Hasakeh Hama RuralDamascus

Tartous As-Sweida Lattakia Homs Aleppo Dar'a Quneitra Deir-ez-Zor

Normal_deliveries CSs


Figure 37: percentage of caesarean sections to normal deliveries in public hospitals, December 2015

iii. Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections

Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections reported from the MoH &

MoHE hospitals, from January to December 2015 is shown in Figure 38. In 2015, the total reported normal

deliveries are 63,185 while the caesarean sections are 39,635.

Figure 38: Trend analysis of the monthly numbers of normal deliveries vs. caesarean sections in public hospitals,

January to December 2015

iv. Comparison of MoH and MoHE hospitals workload of Normal Deliveries vs. CSs:

Comparison analysis between MoH and MoHE hospitals that provide Obstetrics & Gynecology services

across four governorates, has shown higher workload for the MoHE Hospitals mainly in Damascus

governorate (Al-Tawleed [Obstetrics and Gynecology] hospital for MoHE); [Figure 39].

Figure 39: Comparison of MoH & MoHE hospitals workload of normal deliveries vs, CSs, December 2015

36% 41% 52% 53% 53% 56%

63% 63% 64% 75% 82% 86%

100%

64% 59% 48% 47% 47% 44%

37% 37% 36% 25% 18% 14%

0%

0%10%20%30%40%50%60%70%80%90%

100%

Lattakia Tartous Hama Homs RuralDamascus

Aleppo Damascus As-Sweida Quneitra Dar'a Ar-Raqqa Al-Hasakeh Deir-ez-Zor

CSs % Normal deliveries %

5,633

4,871 5,364

4,887

4,161 4,381

5,290

5,941 5,742 5,837

5,198

5,880

3,469 2,982

3,577 3,314 3,111 3,065

3,314 3,621

3,169 3,321 3,168 3,524

0

1000

2000

3000

4000

5000

6000

7000



391

325

77

226

567

149

46 103

291

54

429 468

126

49

0

100

200

300

400

500

600

Damascus Rural Damascus Aleppo Lattakia Damascus Rural Damascus Aleppo Lattakia

MoH Hospitals MoHE Hospitals



5.4 Child Health

Management of severe children diseases (such as acute respiratory diseases, Meningitis, blood diseases

cancer, etc…) are assessed at hospitals level. Figure 40 shows the distribution of total reported cases of

children with severe diseases by governorate.

Figure 40: Number of children with severe diseases in public hospitals, December 2015

The high reported figures in Tartous, Quneitra, Damascus, Hama, and As-Sweida are due to the high

numbers of IDPs, and also availability of MoHE referral hospitals for children in some of these areas. While in

Quneitra it was due to bad weather condition.

Trend analysis of reported cases of severe children diseases from January to December 2015, is presented in

[Figure 41]. In 2015, the total reported cases of severe children diseases are 40,232.

Figure 41: Trend analysis of reported cases of severe children diseases in public hospitals, January to December 2015

5.5 Nutrition

Monitoring of cases of severe acute malnutrition with complications is systematically conducted at public

hospitals level; Figure 42 demonstrates the number of cases reported in December 2015, at governorate

level.

Figure 42: The number of children with severe acute malnutrition with complications in public hospitals, December

2015

681

540 478

422 374

265

122 92 80 77

47 0 0

0

100

200

300

400

500

600

700

800

Tartous Quneitra Damascus Hama As-Sweida Aleppo Homs Lattakia Dar'a RuralDamascus

Al-Hasakeh Deir-ez-Zor Ar-Raqqa

2,901 3,119

3,758 3,751 3,633 3,359

3,545 3,777

3,210 2,929 3,072 3,178

0

500

1000

1500

2000

2500

3000

3500

4000


Management of children diseases

12 11

8 7

3 3

0 0 0 0 0 0 0 0

2

4

6

8

10

12

14

Lattakia Hama Al-Hasakeh Damascus RuralDamascus

Aleppo Tartous Homs Deir-ez-Zor Ar-Raqqa Dar'a As-Sweida Quneitra


The high reported figures in Lattakia, Hama, Al-Hasakeh, and Damascus are due to the high numbers of IDPs.

Trend analysis of reported cases of severe acute malnutrition from January to December 2015, is presented

in [Figure 43]. In 2015, the total reported children with severe acute malnutrition are 807.

Figure 43: Trend analysis of number of children with severe acute malnutrition with complications in public


5.6 NCDs (non-communicable diseases)

NCDs were assessed through HeRAMS by checking the availability and utilization of services at hospitals

level. The majority of high reported figures of NCDs (Diabetes, Hypertension, Cardiovascular, Kidney and

Cancer diseases) are from Damascus hospitals.

Among all NCDs, Cancer patients’ consultations are the highest reported figures, mainly in Damascus, Rural

Damascus (has one cancer specialized hospital), and Lattakia (has one cancer specialized hospital) public

hospitals, where cancer referral hospitals are located. It worth mentioning that cancer is treated at

secondary and tertiary levels only, while other NCDs (diabetes and hypertension, etc…) usually managed at

primary and secondary care levels, unless patients develop complications.

Cardiovascular consultations were high in Damascus (has two cardiovascular specialized hospitals), Lattakia

(has one cardiovascular specialized hospital), Aleppo (has two cardiovascular specialized hospitals), Tartous,

and Homs in December 2015 [Figure 44].

Figure 44: The number of NCDs’ consultations in public hospitals, December 2015

*ESKD: End Stage Kidney Disease

44

65

56

41

80

57

80 85 83 83

89

44

0

10

20

30

40

50

60

70

80

90

100


Management of severe acute malnutrition with complications

727

214 128

391

74

739

55 24 57

0

24 76 74

1212

325 520

70 195

318

72

993

28 58 46 38 85

3399

200

1272

2663

822 630

391

135 21

320

16

427

92

843

113 289

399 346 110

344 190

16 53 40 119 25

2606

4470

919

2688

32 174

512

0 2 0 0 132

0

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000



Diabetes Hypertension Cardiovascular ESKD Cancer


The monthly trend of reported NCDs’ consultations at functional public hospitals from January to December

2015 is shown in [Figure 45].

In 2015, the total reported NCDs’ consultations are as follow:

Diabetes: 36,481

Hypertension: 52,648

Cardiovascular: 127,659

ESKD: 36,719 [of note: the total performed ESKD Sessions in 2015: 279,283]

Cancer: 167,933

Figure 45: Trend analysis of total monthly number of NCDs’ consultations reported in public hospitals, January to

December 2015

The high numbers were reported mainly from Al-Bairouni MoHE hospital in Rural Damascus (4,468), which is

the biggest cancer specialized hospital.

3,247 3,425

3,778 3,583

3,266 2,920 2,604

2,861 2,937 2,778 2,499 2,583

4,805 5,468 5,567 4,931 4,980

3,739 4,343

3,564 3,568 3,784 3,939 3,960

9,774 10,600

11,883

10,940 10,486 10,170 9,953

11,264 10,370

10,871 10,960 10,388

3,593 3,613

3,319 3,032 3,074

2,838 2,932 2,821

2,850 2,927 2,833 2,887

12,538

14,101 13,966 14,514

15,303 15,889

13,957

15,713

12,865

14,138 13,414

11,535

0

2000

4000

6000

8000

10000

12000

14000

16000

18000


Diabetes Hypertension Cardiovascular ESKD Cancer


5.7 Mental Health

Availability and utilization of mental health services were assessed through HeRAMS by checking the

outpatient and inpatient services at hospitals level and the number of patients. Summary of the total

reported consultations (outpatient) and inpatients at public hospitals, per governorate level is shown in

[Figure 46].

The high figures of outpatients in Aleppo are reported from Ibn-Khaldoun mental health specialized

hospital/ MoH (4,334 cases) and Zahi Azraq MoH hospital (52 cases), while in Damascus high reporting is

received from Ibn-Roshod mental health specialized hospital/ MoH (407 cases), followed by Al-Mojtahid

[Damascus MoH Hospital] (222 cases), Al-Mouwasat MoHE hospital (173 cases), and Children MoHE hospital

(36 cases).

The key figures of inpatients are reported from Damascus (Ibn-Roshod hospital (407 cases), followed by Al-

Mouwasat MoHE hospital (14 cases); Rural Damascus (Ibn-Sina Psychiatric MoH hospital (400 cases); and

Aleppo (Ibn-Khaldoun MoH hospital (130 cases)).

Figure 46: The number of outpatient psychiatric cases vs. the number of inpatients in public hospitals, December

2015

Trend analysis of monthly reported number of outpatient psychiatric cases vs. the number of inpatients in

public hospitals [MoH & MoHE] from January to December 2015 is shown in [Figure 47]. In 2015, the total

reported outpatient psychiatric cases are 61,788 while the psychiatric inpatient cases are 11,673.

Figure 47: Trend analysis of number of outpatient psychiatric cases vs. the number of psychiatric inpatient cases in

public hospitals, January to December 2015

4,386

838

150 129 74 26 0 0 0 0 0 0 0 130 421

8 0 400

0 0 0 0 2 0 0 0 0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Aleppo Damascus Lattakia Homs RuralDamascus

Dar'a Tartous Hama Al-Hasakeh Deir-ez-Zor Ar-Raqqa As-Sweida Quneitra

Outpatient psychiatric care Psychiatric inpatient

3,025

3,647

4,347

4,896 5,235

5,615

5,071

6,460

5,866 5,989 6,034 5,603

849 881 866 967 1,017 1,060 1,051 1,069 979 999 974 961

0

1000

2000

3000

4000

5000

6000

7000


Outpatient psychiatric care Psychiatric inpatient


6. Availability of Medical Equipment

The availability of different types of essential and specialized equipment and supplies was assessed at

hospital level, based on a standard checklist2.

In its fifth year of crisis, Syria’s hospitals are still suffering from shortages and/or malfunction of medical

devices/ equipment to provide secondary care services. In insecure governorates, medical devices are either

destroyed, burned, or malfunctioned, while in safe areas the medical devices are overburdened by increased

numbers of people (actual numbers of people in the area, in addition to IDPs and patients /injured people

from surrounding areas).

Maintenance of malfunctioned devices remains a concern, due to non-availability of spare parts, accredited

agent to provide maintenance support, or difficulty of accessibility in many cases.

Analysis of availability of essential and specialized equipment was measured across all functional public

hospitals [MoH & MoHE] (84/113), in terms of functional equipment out of the total available equipment in

the hospital. The produced analysis provides good indication of the current readiness of the hospitals to

provide the health services, and also to guide focused planning for procurement of equipment and

machines, to fill-in identified gaps.

Gaps on essential and specialized equipment and machines were observed, even within the functional public

hospitals. Further details are provided on [Figure 48] and [Figure 49].

Figure 48: Percentage of functional essential equipment/ total available equipment in functional public hospitals,

December 2015

Figure 49: Percentage of functional specialized equipment/ total available equipment in the functional public


2 A more detailed list of essential equipment is available upon request.

73%

86%

86%

87%

89%

90%

90%

91%

91%

92%

93%

93%

94%

95%

96%

98%

Ambu bag (Paediatric and Adult)

Sterilizer/ Autoclave

Suction machine

Delivery_table

Pulse Oximeter

Weighing Scale for adults

Operating_tables

Minor Surgical sets

Weighing Scale for infants

Light source (flashlight acceptable)

Height Measurement Device

Fetoscope

Oxygen cylinders

Length Measurement Device

Nebulizer

Vaginal examination set

53% 69% 70%

73% 74% 74%

79% 80% 82% 83%

85% 85%

87% 88%

95%

MRI machine CT Scan

X-Ray Renal Dialysis machine

Ventilators – Adult Cardiotocography (Monitoring of fetalheart frequency)

Portable X-Ray Ultrasound

ECG Incubator for new born

DC Shock machine/ Defibrillator Anaesthesia machines

Ventilators – Paediatric ICU/CCU Monitors Major surgical sets


Analysis of availability of specialized equipment [Figure 49] has highlighted many gaps and urgent needs for

equipment and machines at different governorates; such as:

MRI machines: main gaps are in Damascus, Aleppo, Lattakia, Tartous, Homs, Hama, Al-Hasakeh, Deir-

ez-Zor, Ar-Raqqa, Dar'a, Quneitra hospitals.

Cardio-topography (Monitoring of fetal-heart frequency); main gaps are in Damascus, Rural

Damascus, Al-Hasakeh, Dar'a, Quneitra hospitals.

CT scanners: main gaps are in Rural Damascus, Deir-ez-Zor, Ar-Raqqa, Dar'a hospitals.

Ventilators for adults: main gaps are Rural Damascus, Deir-ez-Zor, Ar-Raqqa, Dar'a hospitals.

X-Ray machines: main gaps are in Deir-ez-Zor and As-Sweida hospitals.

Portable X-Ray: main gaps are in Aleppo, Al-Hasakeh, Ar-Raqqa hospitals.

Renal dialysis machines: main gaps are in Rural Damascus, Dar’a, Al-Hasakeh hospitals.

Incubator for new born: main gaps are Homs, Dar'a, Quneitra hospitals.

Map 5: Percent of functional specialized equipment/ total available equipment in functional public hospitals,

December 2015


7. Availability of Medicines & Medical supplies

Availability of medicines and medical supplies at hospitals’ level was evaluated based on a standard list of

identified priority medicines (driven from the national Essential Medicine List), and medical supplies for

duration of one month [Figure 47].

The key identified gaps of medicines and consumable at functional hospitals include the hepatitis vaccine

(87%), tetanus shots (85%), affecting blood (58%), antidotes for poisoning (57%), antibiotics for multi-

resistant bacteria (57%), dermatological preparation (57%), delivery related medicines (51%), dialysis

consumables (49%), Albumin (35%), etc.

Figure 50: Availability of medicines and medical supplies for one month in the functional public hospitals, December

2015

Based on the priority medicines list agreed by MoH and WHO, WHO has managed to address the gaps of

medicines identified at all levels of healthcare.

Percentages of available medicines in functional public hospitals, by governorates, are visualized in Map 6.

More details on availability of medicines and medical supplies at governorate level are available in HeRAMS

Database.

13%

15%

42%

43%

43%

43%

49%

51%

65%

65%

67%

68%

71%

74%

77%

79%

79%

81%

82%

85%

85%

87%

88%

89%

Hepatitis vaccine

Tetanus shot

Medicines affecting the blood (anti-anemia medicines, heparin, warfarin, etc.,)

Antidots for Poisoning

Specific antibiotics for multi –resistant bacteria / infectious diseases

Dermatological preparations/ topical (Burns, and anti-infective, etc...)

Delivery related medicines (i.e., Oxytocin , … )

Dialysis consumables

Albumin

Medicines acting on respiratory system (e.g., medicines of Asthma, H1N1 ARI… like salbutamol …)

Anti-diabetic preparations (especially Insulin)

Antibiotics for Children

Gastrointestinal medicines

Anaphylactic shock

Cardiac and /or Vascular Drugs (Anti-hypertensive Drugs, Diuretics, …)

Preoperative medication

IV Fluid

Antibiotics for Adults

General Anesthetics

Local Anesthetics

Antiseptics

Analgesics, antipyretics, non-steroidal anti-inflammatory Medicines

Serums

Anti-allergic including Steroids


Map 6: Percentage of available medicines in functional public hospitals, December 2015


8. Conclusions and Recommendations

Constant deterioration of functionality status of public hospitals was observed throughout 2015. For

example, 29 hospitals were reportedly out-of-service in December 2015 compared to 19 in January of

the same year, while June marked a record high of 31 non-functional hospitals. Similarly, access to the

public hospitals deteriorated throughout 2015 with 25 hospitals reportedly non-accessible at the close

of the year compared to 17 at the beginning of the year in January 2015. Functionality status of

hospitals was highly affected by the dire security situation and limited access by health staff and

patients as well as critical shortages of supplies.

Levels of damages of the hospitals’ buildings directly affected the functionality status and provision of

health services; however some hospitals have resiliently continued to provide services regardless of

levels of damage to the building and by utilizing intact parts of the building or operating from other

neighboring facilities in a few cases. Rehabilitation of the damaged hospitals’ infrastructure, in addition

to provision of supplies and medical equipment will significantly improve functionality of hospitals,

readiness and provision of essential health services at secondary care level.

Consistent decline of the available number of medical staff (doctors, nurses and midwives) throughout

2015 was observed, and interpreted as fleeing of specialized medical staff out of the country in some

cases, and relocation / reassignment of medical staff to DoHs/ health centres in other cases, based on

functionality status of the hospitals, and security situation in the area. Increased capacity building

activities and training courses of the national health staff will help in improving technical capacity of

healthcare providers and filling gaps in certain areas.

Limited functionality and accessibility to public hospitals in addition to large displacement of people

have greatly overburdened the few functional public hospitals’ resources. Increasing provision of

specialized medical machines, as well as medicines and supplies especially for NCDs (such as cancer

treatment, as observed the highest consultations among other NCDs) provides an affordable alternative

compared to the high cost of healthcare in the private sector.

Conducting a qualitative survey on provision of health services from the populations’ point of view, using

HeRAMS data as a baseline, will help in concretely measuring the impact of the crisis on public health

sector in terms of responsiveness of hospitals and quality of provided services.


January - December 2015

© World Health Organization 2015. All rights reserved. The designations employed and the presentation of the material in this publication do not

imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,

city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border

lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that

they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and

omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the

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warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event

shall the World Health Organization be liable for damages arising from its use.

WHO-EM/SYR/026/E

HeRAMS Annual Report

January - December 2015 Public Hospitals in the Syrian Arab Republic

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