Health assessment for the Syrian population after the war. Overview of the current health status, health problems, and the future of the health system in Syria

Table of content

Introduction:

Aim of the research:
Objectives:
Research questions:

Methods:
Search strategy:

Results of the search:

Thematic analysis:
Syrian health system before the war:
Current health status for the population inside Syria:
1- Under opposition control:
2- Under governmental control:
Health status for the Syrian refugees:
1- Refugees in Turkey:
2- Refugees in Lebanon:
3- Refugees in Jordan:
4- Refugees in Europe:
5- Refugees in other countries:
Public health indicators of the Syrian population:
1- Mental health:
2- Maternal and children health:
3- Oral health:
4- Non-communicable diseases:
5- Infectious and communicable diseases:
6- Occupational health and healthcare providers situation:
7- Health system in Syria during COVID-19 pandemic:
The future of the health system in Syria:

Conclusion:

Acknowledgments:

References:

Abstract

10 years of the Syrian war had a devastating effect on all aspects of the Syrian lives, millions of refugees and displaces people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, over 50% of the health facilities have been destroyed and over 70% of the healthcare providers fled the country seeking safety, left the rest of the health system inside Syria under the great workload and mental pressure, with very limited resources and equipment's, and high need for the health services.

This literature review aims to review all the literature written on health in Syria during the ten years of war and to summarize - within one study -all aspects of health for the Syrian population. Five databases were searched and 207 articles were included according to the inclusion criteria, the articles were divided into 12 categories according to the topic of the article.

Through this review, the current health status of the Syrian population living inside Syria -whether under governmental or opposition control - was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information as this literature reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID -19 pandemic on the Syrian health system. The results of the review are irritating, as still after 10 years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs.

The review ended with the future of the health system in Syria, suggesting 5 major steps to rebuild the Syrian health system with the main focus on health informatics, repairing the health infrastructure, increasing the capacity, improving the human resources, and supporting medical research and research productivity.

This review focused on the direct and indirect consequences of the Syrian war over public health, reviewing, summarizing, and categorizing all the available articles and data, which makes it up- to-date research that can be of great importance for any plan to rebuild the health system in Syria.

Introduction:

The Syrian war is now without a doubt the worst humanitarian crisis of the 21st century, the war which has started in 2011 entries its 10th year by March 2021, with millions of displaced populations both inside and outside Syria, hundreds of thousands were killed, injured, become a handicap, or still until this moment lost without a trace 1. The movement which was part of the Arab spring in 2011, turned into the biggest refugee's crisis of the modern world, with millions of Syrian flee their houses and became refugees in other countries, and over 6 million internally displaced, and enormous destruction to the infrastructure, health system, social status of the population, economic crisis, and an increasing need for humanitarian support from the international community. 2

The international community's continued failure to solve the Syrian crisis has resulted in the destruction of infrastructure. This includes the collapse of Syria's health system, which has left millions of internally displaced people (IDPs) in desperate need of medical assistance.3

IDP populations are increasingly vulnerable to infectious and non-communicable diseases, poor maternal and child health outcomes, trauma, and mental health issues as the conflict worsen, while healthcare workers continue to flee the country, and those who remain in the healthcare field inside Syria are facing numerous challenges, including multiple attacks on medical facilities and working conditions that severely impede healthcare delivery and assistance.4 The IDPs are arguably the most vulnerable population within this conflict-driven public health crisis. Despite the fact that the fundamental 'right to health' is a recognized international legal principle, its implementation is inadequate according to the UN Security Council. Other vulnerable groups, such as refugees and ethnic minorities, have been negatively affected as a result of these factors.[3, 5]

Syria's healthcare facilities and workers have been directly affected by the conflict and violence. According to the non-governmental organization "Physicians for Human Rights (PHR)", 382 attacks on medical facilities occurred between March 2011 and June 2016, killing 757 medical personnel 3. These attacks have destroyed the public health system, resulting in serious population health consequences such as an increase in infectious and non-communicable disease risks, serious maternal and child health challenges, conflict-related trauma, and mental health issues, as well as the exodus of Syrian healthcare workers who are seeking to flee the conflict 6. Due to the conflict, aid workers and medical suppliers have found it difficult to reach civilians, particularly IDPs in informal camps scattered across the country or in besieged areas such as Aleppo 7. Moreover, there have been many attacks on the health facilities operating in Syria from different sides, which further complicated the healthcare access for the population inside Syria.8

Syria's health system provided high-quality care prior to the war 9, however, according to the OCHA, only 64% of hospitals and 52% of primary health-care centers in the country were operational by the end of 2019, at a very low functioning percentage comparing to there function before the war 10, and the drugs industry have collapsed 11. Moreover, the Syrian refugee crisis remains the world's largest refugee and displacement crisis of our time. About 5.6 million Syrians are refugees, and another 6.1 million people are displaced within Syria. Nearly 11.1 million people in Syria need humanitarian assistance. About half of the people affected by the Syrian refugee crisis are children. The majority of the refugees are hosted in Turkey, Lebanon, Egypt, Iraq, and Jordan [5, 12].

One of the most pressing concerns for Syrian refugees is access to health care. Primary health care and emergency lifesaving interventions are top priorities for UNHCR and its partners. The overall access to healthcare services is more difficult than any time before. Donors must increase funding, personnel, and medical supplies to support these health needs until a diplomatic solution for Syria allows refugees to return safely [4, 13], as access to healthcare is one of the refugees rights 12.

Therefore, and based on the information provided earlier, it is of great importance to document the health status of the Syrian population after 10 years of war, to have an overview of the current health situation, the remaining health facilities, and the challenges facing the healthcare system. This review might be important for the future of the Syrian health system, to start working on the gaps in the Syrian health system to reach equal access to healthcare for the Syrian population, and to be prepared for the return of the refugees and their health needs in the future Syria.

Aim of the research:

This research aims to review all the literature written on health in Syria during the ten years of war and to summarize - within one study - all aspects of health for the Syrian population both internal population (living inside Syria or IDPs), and external population (refugees and asylum seekers outside Syria) to provide an overview for the current health status, health problems, and the future of the health system in Syria.

Objectives:

The primary objectives of this literature review are the following:

1- Summarize the available literature on the current health status of the Syrian population.
2- Describe the public health consequences of the Syrian crisis.
3- Discuss the health gaps among the Syrian populations.
4- Suggest strategies to help rebuild the health system in Syria based on the current status.

The secondary objective of this study:

1- Build a unified database for all the research articles which have been published concerning health during the Syrian war.
2- Summaries all the available data in one article.

Research questions:

The main questions of this review were:

1- What is the current health status for the Syrian population living inside Syria, and for the Syrian refugees in the neighboring countries?
2- What is the level of access to health care services for the Syrian population?
3- What is the impact of the Syrian crisis on the public health indicators?
4- What are the challenges and future perspectives of the health system in Syria?

Methods:

This literature review covered all the articles published on the subject of Syrian health during the years of war and took place in January-march 2021. The modified Arksey and O'Malley framework was used as the conceptual approach for the review process 14.

Search strategy:

Basic keywords and MeSH terms were used to identify relevant articles and publications through the different databases. The search strategy included the following:

("Syria" or "Syrian") AND ("war" or "crisis" or "conflict") AND ("Health")

The databases included in the search are the following:

Medline Ovid, PubMed, Embase, Scopus, Google Scholar.

Articles were included in the literature review if they achieved the following inclusion criteria:

1- Article covering directly one of the health-related aspects of the Syrian crisis.
2- Articles related to the Syrian population (not covering the effect of the war on the hosting population).
3- Written in English.
4- Published in peer-reviewed journals (excluding gray literature).
5- Published after 2012.
6- Full text available.

Results of the search:

The following Figure (Figure N.1) represents the search strategy and the citations included and excluded through the process.

Five databases were screened following the search strategy described in the methods section, a total number of (10941) references appeared through the search, 393 in PubMed, 6530 in Google Scholar, 1264 in Medline Ovid, 175 in Embase, and 2579 in Scopus.

An initial check was made for all the search results, and 10604 were excluded for not being relatable for the topic of the research, and 337 were included.

The 337 references were imported into the Endnote citation manager library, and the first step was to identify if there are and duplicated references, there were 30 duplicated references.

The 307 references were scanned and only 207 were included in the research, one hundred references were excluded for the following reasons:

- no full text available: 79
- not linked to the Syrian population: 5
- not directly concerning health: 16

The final number of the references included in this literature review was 207.

The articles were divided according to the topic of the research into 12 categories as the following:

- Mental health of the Syrian population: 25
- Children and maternal health of the Syrian population: 19
- Non-communicable diseases of the Syrian population: 11
- Infectious diseases of the Syrian population: 13
- Oral health of the Syrian population: 11
- Health of the Syrian refugees in different countries: 52
- Health of the Syrian population inside Syria: 13
- Access to healthcare services: 11
- Occupational health of the Syrian healthcare workers: 20
- Health during COVID-19 pandemic: 7
- General health system: 16
- Other aspects of the health of the Syrian population: 9

Figure N.1 - flowchart for the references included in the literature review

Abbildung in dieser Leseprobe nicht enthalten

Thematic analysis:

Syrian health system before the war:

Just before the war, the health service in Syria consisted primarily of a public system run by the government that provided primary care, with the private sector located in the big cities providing the majority of developed health services and advanced care, and over the last three decades, improvement has been made for the health system capacity which rapidly improved the national health indicators such as a falling infant mortality rate and an increased child immunization rate. Furthermore, the drug industry grew gradually, and Syria was able to produce 90% of its medication needs locally. In 2008, Syrians spent 60% of their health budget on out-of-pocket payments to private providers and co-payments to public hospitals. In recent years, attempts to liberalize the health-care system and give the private sector more autonomy have resulted in a widening of access to care and increased the financial burden on those least able to pay [15, 16].

Nonetheless, the start of the civil war resulted in a complete breakdown of the health infrastructure, with widespread destruction of facilities, a shortage of health care personnel and medicines, and a lack of safe routes and transportation, which raises the question about the current status and capacity of the Syrian health system after years of war 16.

Current health status for the population inside Syria:

Syria's health-care system has been severely damaged, and a large number of physicians and health-care providers have fled the country during the conflict, which increased the pressure and the workload on the remaining healthcare facilities and healthcare providers.

The humanitarian crisis in Syria has prompted hundreds of international and national non­governmental organizations, as well as UN agencies, to respond. While much has been written about the challenges of meeting the health needs of Syrian refugees in neighboring countries like Jordan, Lebanon, and Turkey, little has been written about the humanitarian challenges within Syria, particularly between 2013 and 2014, when non-governmental organizations operated in Syria with little UN support or leadership, particularly around obtaining information to guide health responses in Syria 17.

1- Under opposition control:

Many attempts have been established to create a primary health-care system in the most vulnerable sides of Syria, which is mainly the opposition territories. Those attempts have made an enormous effort to provide access to a variety of basic health-care services, including primary care. Despite these efforts, the current system remains fragile and unsustainable 18.

On the other hand, there has been a focus on rebuilding the health system in the Governance under Opposition Control, and it is now already in progress. Local health authorities need support to overcome identified challenges, and those challenges were security, funding, and capacity building. Three main solutions were discussed in a previous research article which mainly focused on supporting health directorates, reducing health-workers losses, and coordination between different actors. And without political, technical, and financial support, the health directorates will not overcome the ongoing challenges 19.

Another research published by the Lancet-AUB commission on Syria documented cross-border assistance to deliver humanitarian health services starting from Turkey towards the north-west of Syria, efforts have been made to integrate Syrian NGOs in the international response through the formalization of coordination structures. Collaborations between local and international actors have evolved over time as a result of convergent and sometimes competing dynamics, as evidenced by the delivery of medical aid across the Turkish border into Syria. This case study emphasizes the importance of pre-conflict professional networks in organizing, channeling, and providing services in areas where international aid workers are unable to reach. It's worth noting that professional networks can include and exclude populations, and their ability to reach vulnerable communities during conflicts needs to be better understood across sectors 20.

Furthermore, several research articles covered the situation of the health-workers inside Syria, in the side under opposition control, when responding to massive mass casualty events, health workers were the hardest hit by severe resource constraints and safety concerns. As a response, besiegement planning could consider capabilities to 1) respond to conflict through in-person/online health-worker training, for example, in triage, low-tech equipment and resource conservation, emergency response, and task-shifting; 2) mitigate targeting through facility security, for example, protection and deterrence through fortification, working underground, and reducing visibility 3) cope mentally, by feeling supported and valued despite extremely difficult circumstances, by ensuring internet and electricity access; low-tech/reusable equipment; securely stockpiling fuel, medicines, and supplies; and establishing alternative supply routes.21

During the years of war, several outbreaks have been documented, MSF has responded to the measles outbreak in the north of Syria and recorded other viral outbreaks such as hepatitis, brucellosis, typhoid, leishmaniasis, and tuberculosis 22. Another study used the Omaha system to determine health problems of internally displaced Syrians. The Omaha System-Problem Classification List can be used as a tool by public health nurses to identify health problems encountered by immigrants, Personal care was the most frequently diagnosed problem, followed by sanitation, communication with community resources, mental health, and residence.23

2- Under governmental control:

Health facilities in the areas under government control slowly lost the ability to function and provide healthcare services for the Syrian population. The destruction of major health facilities and drug factories, the increased number of doctors leaving the country, and the movement of millions of internally displaced people toward the major city were the main reasons for the low function of the remaining health facilities 15.

Very limited articles have been found over the current situation of the health system in areas under governmental control, and most articles does not mention the health capacity of the Syrian health system, however, all reports available point the huge humanitarian and health needs for the Syrian population, which requires an international collaboration to provide the support needed.

Health status for the Syrian refugees:

Starting from 2012, the number of Syrian refugees has increased dramatically, people fled across land and sea to reach safety in the neighboring countries, by the end of 2020 statistics showed that the number of Syrian refugees outside Syria exceeded 6 million, the majority of them lives in Turkey which is the host of 3.6 million Syrians, Lebanon which host almost a million, and Jordan which hosts over 600 thousand, and more hundreds of thousands in Iraq and Egypt. According to the European migration counsel, 1.3 million Syrians requested asylum in Europe, and the peak of the migration was in 2015-2016, and it had declined significantly since then. Most of the refugees have limited access to basic services.

Difference between health status of Syrian refugees and that in the host countries is investigated in this chapter.

1- Refugees in Turkey:

Turkey has had an open-door policy for refugees since the beginning of the Syrian refugee crisis, with over 3 million refugees entering the country and about 220.000 people living in camps. This explosive and unexpected increase in the Syrian population in Turkey has had several negative impacts on health and social determinants. Turkey has 20 large refugee camps spread across ten cities. The Ministry of Health runs 21 field hospitals within the camps, with 120 doctors and 400 allied health personnel working there. Also, 25 Syrian doctors work in clinics run by nongovernmental organizations (NGOs) and in refugee camps, providing medical care to fellow refugees. 24

The rate of incidence of preventable diseases has increased in Turkish residents as a result of lower vaccination rates for polio and measles. Between 2006 and 2010, there were no confirmed cases of measles, but that number increased to 9.7 per 100,000 people (6731 cases) in 2013. Following the polio outbreak in Syria, Turkey has begun immunizing all Syrian children entering refugee camps in Turkey. In seven provinces near Syria, the Ministry of Health plans to vaccinate approximately 1 million children under the age of five. Furthermore, because the rate of tuberculosis has increased in Turkey in 2014, refugees, particularly those living outside of camps, pose a significant health risk. In large cities like Istanbul, Ankara, and Izmir, many refugees live in deplorable conditions and are homeless. In the areas surrounding refugee camps, socioeconomic levels have fallen, forcing some Syrian women to turn to prostitution and forcing children to beg. 24

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