Hospital survey report october 2015 by UOSSM

SURVEY QUESTIONNAIRE REPORT OF HOSPITALS OPERATING IN SYRIAN-OPPOSITION CONTROLLED AREAS SECOND REPORT OCT. 2015

ANNEX 1. ACRONYMS AND ABBREVIATIONS ------------------------------------------------------------1EXECUTIVE SUMMARY ---------------------------------------------------------2INTRODUCTION --------------------------------------------------------------3SURVEY OBJECTIVES ----------------------------------------------------------4DEFINING THE DIFFERENT REGIONS IN SYRIA --------------------------------------5PROJECT STAFF---------------------------------------------------------------6METHODOLOGY ---------------------------------------------------------------

10 14 16 16 17 17 18

Phase I: Preparation of the Survey (One-month) -------------------------------------------- 18 PHASE II: Conducting the Survey (One-month duration) ----------------------------------- 20 Phase III: Data analysis and reporting (One-month duration) ------------------------------ 20 The difference between this survey and April 2015 survey:-------------------------------- 20 The difference between this survey and HeRAMS: ------------------------------------------ 21 7-RESULTS WHOLE OF SYRIA

22 22

Services available per hospital ----------------------------------------------------------------- 23 Hospital Beds ------------------------------------------------------------------------------------- 26 Devices: ------------------------------------------------------------------------------------------- 27 Blood Banks --------------------------------------------------------------------------------------- 37 Physiotherapy ------------------------------------------------------------------------------------ 39 Renal Dialysis Unit (RDU): ----------------------------------------------------------------------- 40 Workload: ----------------------------------------------------------------------------------------- 41 Hospitals Financial Support: -------------------------------------------------------------------- 46 Human Resources: ------------------------------------------------------------------------------- 47 ON THE GOVERNORATE LEVEL

------------------------------------------------------------------------ 55

1- Damascus -------------------------------------------------------------------------------------- 55 2- Aleppo ------------------------------------------------------------------------------------------ 70 3- Rural Damascus ------------------------------------------------------------------------------- 86 4- Homs ------------------------------------------------------------------------------------------ 100 5-Hama ------------------------------------------------------------------------------------------- 114 6- Latakia ----------------------------------------------------------------------------------------- 127 7-Idleb -------------------------------------------------------------------------------------------- 140 12- Daraa ----------------------------------------------------------------------------------------- 153 14- Qunaitra ------------------------------------------------------------------------------------- 166 CONCLUSION AND RECOMMENDATION FUTURE PLAN: 177

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Figures

Fig. 1 Number of Available Departments / Whole of Syria ............................................... 23 Fig. 2 Number of Surgical Outpatient Department / whole of Syria ................................... 24 Fig. 3 Number of Non-Surgical Outpatient Department / Whole of Syria ........................... 25 Fig. 4 Number of Beds / Whole of Syria ......................................................................... 26 Fig. 5 Number of X-Ray Equipment / Whole of Syria........................................................ 28 Fig. 6 Number of ICU Equipment / Whole of Syria........................................................... 30 Fig. 7 Number of Operating Room Equipment / Whole of Syria ........................................ 31 Fig. 8 Number of Laboratory Equipment / Whole of Syria ................................................ 32 Fig. 9 Number of Shared Equipment / Whole of Syria ...................................................... 34 Fig. 01 Electric Generator Capacity and Fuel Consumption .............................................. 37 Fig. 11 Number of Available Blood Banks / Whole of Syria ............................................... 38 Fig. 12 Number of Available Physiotherapy / Whole of Syria ............................................ 39 Fig. 01 Number of Available Renal Dialysis Units / Whole of Syria ..................................... 40 Fig. 01 Number of Emergency Visitors and admission / Whole of Syria .............................. 41 Fig. 15 Number of Outpatient Visitors and Admission / Whole of Syria ............................. 41 Fig. 16 Hospital Documentation Availably / Whole of Syria and governorates .................... 42 Fig. 17 Number of Surgeries without Details (depend on Hospital Record) / Whole of Syria. 43 Fig. 18 Number of Surgeries with Details (depend on Hospital Record) / Whole of Syria ..... 44 Fig. 19 Number of Hospital Deliveries / Whole of Syria .................................................... 45 Fig. 01 Financial Support Staff / Whole of Syria .............................................................. 46 Fig. 21 Financial Support Running Cost / Whole of Syria .................................................. 46 Fig. 00 Financial Support Consumables / Whole of Syria .................................................. 47 Fig. 23 Human Resources Full Details Hospitals .............................................................. 47 Fig. 24 Number of Human Resources who work in one or more than Hospital ................... 48 Fig. 02 Human Resources Surgical Doctors / Whole of Syria ............................................. 51 Fig. 26 Human Resources Non-Surgical Staff / Whole of Syria .......................................... 52 Fig. 27 Human Resources Nursing Staff / Whole of Syria.................................................. 53 Fig. 28 Human Resources Technicians / Whole of Syria ................................................... 54 Fig. 30.1 Number of Available Departments / Damascus ................................................. 56 Fig. 31.1 Number of Surgical Out Patient Department / Damascus ................................... 56 Fig. 32.1 Number of Non-Surgical Outpatient Department / Damascus ............................. 57 Fig. 33.1 Number of Beds / Damascus ........................................................................... 57 Fig. 34.1 Number of X-Ray Equipment / Damascus.......................................................... 58 Fig. 35.1 Number of ICU Equipment / Damascus............................................................. 58 Fig. 36.1 Number of Operating Room Equipment / Damascus .......................................... 59 Fig. 37.1 Number of Laboratory Equipment / Damascus .................................................. 60 Fig. 38.1 Number of Shared Equipment / Damascus ........................................................ 61 Fig. 39.1 Number of Available Blood Banks / Damascus ................................................... 62 Fig. 40.1Number of Available Physiotherapy / Damascus ................................................. 62 Fig. 41.1 Number of Emergency Visitors and admission / Damascus ................................. 63 Fig. 42.1 Number of Outpatient Visitors and Admission / Damascus ................................. 63 Fig. 43.1 Number of Surgeries without Details (depend on Hospital Record) / Damascus .... 64 Fig. 44.1 Number of Surgeries with Details (depend on Hospital Record) / Damascus ......... 65 Fig. 45.1 Number of Hospital Deliveries / Damascus ....................................................... 65 Fig. 46.1 Financial Support Staff / Damascus .................................................................. 66 Fig. 47.1 Financial Support Running Cost / Damascus ...................................................... 66 Fig. 48.1 Financial Support Consumables / Damascus...................................................... 66

Fig. 49.1 Human Resources Surgical Doctors / Damascus ................................................. 67 Fig. 50.1 Human Resources Non-Surgical Staff / Damascus .............................................. 68 Fig. 51.1 Human Resources Nursing Staff / Damascus ..................................................... 69 Fig. 52.1 Human Resources Technicians / Damascus ....................................................... 69 Fig. 53.2 Number of Available Departments / Aleppo ...................................................... 71 Fig. 54.2 Number of Available Departments / Aleppo ...................................................... 71 Fig. 55.2 Number of Non-Surgical Outpatient Department / Aleppo ................................. 72 Fig. 56.2 Number of Beds / Aleppo................................................................................ 72 Fig. 57.2 Number of X-Ray Equipment / Aleppo .............................................................. 73 Fig. 58.2 Number of X-Ray Equipment / Aleppo .............................................................. 73 Fig. 59.2 Number of X-Ray Equipment / Aleppo .............................................................. 74 Fig. 60.2 Number of Laboratory Equipment / Aleppo ...................................................... 75 Fig. 61.2 Number of Shared Equipment / Aleppo ............................................................ 76 Fig. 62.2 Number of Available Blood Banks / Aleppo ....................................................... 77 Fig. 63.2 Number of Available Physiotherapy / Aleppo .................................................... 77 Fig. 64.2 Number of Available Renal Dialysis Units / Aleppo ............................................. 78 Fig. 65.2 Number of Emergency Visitors and admission / Aleppo ...................................... 78 Fig. 66.2 Number of Outpatient Visitors and Admission / Aleppo...................................... 78 Fig. 67.2 Number of Surgeries without Details (depend on Hospital Record) / Aleppo ......... 79 Fig. 68.2 Number of Surgeries with Details (depend on Hospital Record) / Aleppo.............. 80 Fig. 69.2 Number of Hospital Deliveries / Aleppo ............................................................ 81 Fig. 70.2 Financial Support Staff / Aleppo ...................................................................... 81 Fig. 71.2 Financial Support Running Cost / Aleppo .......................................................... 82 Fig. 72.2 Financial Support Consumables / Aleppo .......................................................... 82 Fig. 73.2 Human Resources Surgical Doctors / Aleppo ..................................................... 83 Fig. 74.2 Human Resources Non-Surgical Staff / Aleppo .................................................. 84 Fig. 75.2 Human Resources Nursing Staff / Aleppo.......................................................... 85 Fig. 76.2 Human Resources Technicians / Aleppo ........................................................... 85 Fig. 77.3 Number of Available Departments / Rural Damascus ......................................... 87 Fig. 78.3 Number of Surgical Out Patient Department / Rural Damascus ........................... 87 Fig. 79.3 Number of Non-Surgical Outpatient Department / Rural Damascus ..................... 88 Fig. 80.3 Number of Beds / Rural Damascus ................................................................... 88 Fig. 81.3 Number of X-Ray Equipment / Rural Damascus ................................................. 89 Fig. 82.3 Number of ICU Equipment / Rural Damascus .................................................... 89 Fig. 83.3 Number of Operating Room Equipment / Rural Damascus .................................. 90 Fig. 84.3 Number of Laboratory Equipment / Rural Damascus .......................................... 91 Fig. 85.3 Number of Shared Equipment / Rural Damascus ............................................... 92 Fig. 86.3 Number of Available Blood Banks / Rural Damascus .......................................... 92 Fig. 87.3 Number of Available Physiotherapy / Rural Damascus ....................................... 93 Fig. 88.3 Number of Available Renal Dialysis Units / Rural Damascus ................................ 93 Fig. 89.3 Number of Emergency Visitors and admission / Rural Damascus ......................... 93 Fig. 90.3 Number of Outpatient Visitors and Admission / Rural Damascus ......................... 94 Fig. 91.3 Number of Surgeries without Details (depend on Hospital Record) / Rural Damascus ................................................................................................................................. 94 Fig. 92.3 Number of Surgeries with Details (depend on Hospital Record) / Rural Damascus . 95 Fig. 93.3 Number of Hospital Deliveries / Rural Damascus ............................................... 96 Fig. 94.3 Financial Support Staff / Rural Damascus .......................................................... 96 Fig. 95.3 Financial Support Running Cost / Rural Damascus.............................................. 96

Fig. 96.3 Financial Support Consumables / Rural Damascus ............................................. 97 Fig. 97.3 Human Resources Surgical Doctors / Rural Damascus ........................................ 97 Fig. 98.3 Human Resources Non-Surgical Staff / Rural Damascus ...................................... 98 Fig. 99.3 Human Resources Nursing Staff / Rural Damascus ............................................. 99 Fig. 100.3 Human Resources Technicians / Rural Damascus ............................................. 99 Fig. 101.4 Number of Available Departments / Homs .................................................... 101 Fig. 102.4 Number of Surgical Out Patient Department / Homs ...................................... 101 Fig. 103.4 Number of Surgical Out Patient Department / Homs ...................................... 102 Fig. 104.4 Number of Beds / Homs .............................................................................. 102 Fig. 105.4 Number of X-Ray Equipment / Homs ............................................................ 103 Fig. 106.4 Number of ICU Equipment / Homs ............................................................... 103 Fig. 107.4 Number of Operating Room Equipment / Homs ............................................ 104 Fig. 108.4 Number of Laboratory Equipment / Homs .................................................... 104 Fig. 109.4 Number of Shared Equipment / Homs .......................................................... 105 Fig. 110.4 Number of Available Blood Banks / Homs ..................................................... 106 Fig. 111.4 Number of Available Physiotherapy / Homs .................................................. 106 Fig. 112.4 Number of Available Renal Dialysis Units / Homs ........................................... 106 Fig. 113.4 Number of Outpatient Visitors and Admission / Homs.................................... 107 Fig. 114.4 Number of Surgeries without Details (depend on Hospital Record) / Homs ....... 107 Fig. 115.4 Number of Surgeries with Details (depend on Hospital Record) / Homs ............ 108 Fig. 116.4 Number of Hospital Deliveries / Homs .......................................................... 109 Fig. 117.4 Financial Support Staff / Homs..................................................................... 109 Fig. 118.4 Financial Support Running Cost / Homs ........................................................ 109 Fig. 119.4 Financial Support Consumables / Homs ........................................................ 110 Fig. 120.4 Human Resources Surgical Doctors / Homs ................................................... 111 Fig. 121.4 Human Resources Non-Surgical Staff / Homs................................................. 112 Fig. 122.4 Human Resources Nursing Staff / Homs ........................................................ 113 Fig. 123.4 Human Resources Technicians / Homs.......................................................... 113 Fig. 124.5 Number of Available Departments / Hama .................................................... 114 Fig. 125.5 Number of Surgical Out Patient Department / Hama ...................................... 115 Fig. 126.5 Number of Non-Surgical Outpatient Department / Hama ................................ 116 Fig. 127.5 Number of Beds / Hama .............................................................................. 116 Fig. 128.5 Number of X-Ray Equipment / Hama ............................................................ 117 Fig. 129.5 Number of ICU Equipment / Hama ............................................................... 117 Fig. 130.5 Number of Operating Room Equipment / Hama ............................................ 118 Fig. 131.5 Number of Laboratory Equipment / Hama .................................................... 118 Fig. 132.5 Number of Shared Equipment / Hama .......................................................... 119 Fig. 133.5 Number of Available Blood Banks / Hama ..................................................... 120 Fig. 134.5 Number of Emergency Visitors and admission / Hama.................................... 120 Fig. 135.5 Number of Outpatient Visitors and Admission / Hama ................................... 120 Fig. 136.5 Number of Surgeries with Details (depend on Hospital Record) / Hama............ 121 Fig. 137.5 Number of Hospital Deliveries / Hama .......................................................... 122 Fig. 138.5 Financial Support Staff / Hama .................................................................... 122 Fig. 139.5 Financial Support Running Cost / Hama ........................................................ 122 Fig. 140.5 Financial Support Consumables / Hama ........................................................ 123 Fig. 141.5 Human Resources Surgical Doctors / Hama ................................................... 124 Fig. 142.5 Human Resources Non-Surgical Staff / Hama ................................................ 125 Fig. 143.5 Human Resources Nursing Staff / Hama........................................................ 126

Fig. 144.5 Human Resources Technicians / Hama ......................................................... 126 Fig. 145.6 Number of Available Departments / Latakia .................................................. 127 Fig. 146.6 Number of Surgical Out Patient Department / Latakia .................................... 128 Fig. 147.6 Number of Non-Surgical Outpatient Department / Latakia .............................. 128 Fig. 148.6 Number of Beds / Latakia ............................................................................ 129 Fig. 149.6 Number of X-Ray Equipment / Latakia .......................................................... 129 Fig. 150.6 Number of ICU Equipment / Latakia ............................................................. 130 Fig. 151.6 Number of Operating Room Equipment / Latakia........................................... 130 Fig. 152.6 Number of Laboratory Equipment / Latakia .................................................. 131 Fig. 153.6 Number of Shared Equipment / Latakia ........................................................ 132 Fig. 154.6 Number of Available Blood Banks / Latakia ................................................... 133 Fig. 155.6 Number of Emergency Visitors and admission / Latakia .................................. 133 Fig. 156.6 Number of Outpatient Visitors and Admission / Latakia .................................. 133 Fig. 157.6 Number of Surgeries without Details (depend on Hospital Record) / Latakia ..... 134 Fig. 158.6 Number of Surgeries with Details (depend on Hospital Record) / Latakia .......... 135 Fig. 159.6 Financial Support Staff / Latakia................................................................... 136 Fig. 160.6 Financial Support Running Cost / Latakia ...................................................... 136 Fig. 161.6 Financial Support Consumables / Latakia ...................................................... 136 Fig. 162.6 Human Resources Surgical Doctors / Latakia ................................................. 137 Fig. 163.6 Human Resources Non-Surgical Staff / Latakia ............................................... 138 Fig. 164.6 Human Resources Nursing Staff / Latakia ...................................................... 139 Fig. 165.6 Human Resources Technicians / Latakia ........................................................ 139 Fig. 166.7 Number of Available Departments / Idleb ..................................................... 141 Fig. 167.7 Number of Surgical Out Patient Department / Idleb ....................................... 141 Fig. 168.7 Number of Non-Surgical Outpatient Department / Idleb ................................. 142 Fig. 169.7 Number of Beds / Idleb ............................................................................... 142 Fig. 170.7 Number of X-Ray Equipment / Idleb ............................................................. 143 Fig. 171.7 Number of ICU Equipment / Idleb ................................................................ 143 Fig. 172.7 Number of Operating Room Equipment / Idleb.............................................. 144 Fig. 173.7 Number of Laboratory Equipment / Idleb ..................................................... 144 Fig. 174.7 Number of Shared Equipment / Idleb ........................................................... 145 Fig. 175.7 Number of Available Blood Banks / Idleb ...................................................... 145 Fig. 176.7 Number of Available Physiotherapy / Idleb ................................................... 146 Fig. 177.7 Number of Available Renal Dialysis Units / Idleb ............................................ 146 Fig. 178.7 Number of Emergency Visitors and admission / Idleb ..................................... 146 Fig. 179.7 Number of Outpatient Visitors and Admission / Idleb ..................................... 147 Fig. 180.7 Number of Surgeries without Details (depend on Hospital Record) / Idleb ........ 147 Fig. 181.7 Number of Surgeries with Details (depend on Hospital Record) / Idleb ............. 148 Fig. 182.7 Number of Hospital Deliveries / Idleb ........................................................... 149 Fig. 183.7 Financial Support Staff / Idleb...................................................................... 149 Fig. 184.7 Financial Support Running Cost / Idleb ......................................................... 149 Fig. 185.7 Financial Support Consumables / Idleb ......................................................... 150 Fig. 186.7 Human Resources Surgical Doctors / Idleb .................................................... 150 Fig. 187.7 Human Resources Non-Surgical Staff / Idleb .................................................. 151 Fig. 188.7 Human Resources Nursing Staff / Idleb ......................................................... 152 Fig. 189.7 Human Resources Technicians / Idleb ........................................................... 152 Fig. 190.12 Number of Available Departments / Daraa .................................................. 153 Fig. 191.12 Number of Surgical Out Patient Department / Daraa .................................... 154

Fig. 192.12 Number of Non-Surgical Outpatient Department / Daraa.............................. 154 Fig. 193.12 Number of Beds / Daraa............................................................................ 155 Fig. 194.12 Number of X-Ray Equipment / Daraa .......................................................... 155 Fig. 195.12 Number of ICU Equipment / Daraa ............................................................. 156 Fig. 196.12 Number of Operating Room Equipment / Daraa .......................................... 156 Fig. 197.12 Number of Laboratory Equipment / Daraa .................................................. 157 Fig. 198.12 Number of Shared Equipment / Daraa ........................................................ 158 Fig. 199.12 Number of Available Blood Banks / Daraa ................................................... 159 Fig. 200.12 Number of Available Renal Dialysis Units / Daraa ......................................... 159 Fig. 201.12 Number of Emergency Visitors and admission / Daraa .................................. 159 Fig. 202.12 Number of Outpatient Visitors and Admission / Daraa.................................. 160 Fig. 203.12 Number of Surgeries without Details (depend on Hospital Record) / Daraa ..... 160 Fig. 204.12 Number of Surgeries with Details (depend on Hospital Record) / Daraa .......... 161 Fig. 205.12 Number of Hospital Deliveries / Daraa ........................................................ 161 Fig. 206.12 Financial Support Staff / Daraa................................................................... 162 Fig. 207.12 Financial Support Running Cost / Daraa ...................................................... 162 Fig. 208.12 Financial Support Consumables / Daraa ...................................................... 162 Fig. 209.12 Human Resources Surgical Doctors / Daraa ................................................. 163 Fig. 210.12 Human Resources Non-Surgical Staff / Daraa............................................... 164 Fig. 211.12 Human Resources Nursing Staff / Daraa ...................................................... 165 Fig. 212.12 Human Resources Technicians / Daraa........................................................ 165 Fig. 213.14 Number of Available Departments / Qunaitra .............................................. 166 Fig. 214.14 Number of Surgical Out Patient Department / Qunaitra ................................ 166 Fig. 215.14 Number of Non-Surgical Outpatient Department / Qunaitra ......................... 167 Fig. 216.14 Number of Beds / Qunaitra ....................................................................... 167 Fig. 217.14 Number of X-Ray Equipment / Qunaitra ...................................................... 168 Fig. 218.14 Number of Operating Room Equipment / Qunaitra ...................................... 168 Fig. 219.14 Number of Laboratory Equipment / Qunaitra .............................................. 169 Fig. 220.14 Number of Shared Equipment / Qunaitra .................................................... 170 Fig. 221.14 Number of Available Blood Banks / Qunaitra ............................................... 170 Fig. 222.14 Number of Emergency Visitors and admission / Qunaitra.............................. 171 Fig. 223.14 Number of Outpatient Visitors and Admission / Qunaitra ............................. 171 Fig. 224.14 Number of Surgeries without Details (depend on Hospital Record) / Qunaitra. 171 Fig. 225.14 Number of Surgeries with Details (depend on Hospital Record) / Qunaitra ..... 172 Fig. 226.14 Number of Hospital Deliveries / Qunaitra .................................................... 173 Fig. 227.14 Financial Support Staff / Qunaitra .............................................................. 173 Fig. 228.14 Financial Support Running Cost / Qunaitra .................................................. 173 Fig. 229.14 Financial Support Consumables / Qunaitra .................................................. 174 Fig. 230.14 Human Resources Surgical Doctors / Qunaitra ............................................. 174 Fig. 231.14 Human Resources Non-Surgical Staff / Qunaitra .......................................... 175 Fig. 232.14 Human Resources Nursing Staff / Qunaitra.................................................. 176 Fig. 233.14 Human Resources Technicians / Qunaitra ................................................... 176

Maps Map 1 Hospital Distribution ........................................................................................ 22 Map 2 Intensive Care Units Distribution and Functional Status......................................... 27 Map 3 Functional CT Scan Distribution .......................................................................... 28 Map 4 Non-Functional CT Scan Distribution .................................................................. 29 Map 5 Functional Central Oxygen Generator Distribution ................................................ 35 Map 6 Non-Functional Central Oxygen Generator Distribution......................................... 36 Map 7 Advance Blood Bank Distribution and Functional Status (inside and Outside Hospitals) ................................................................................................................................. 39 Map 8.1 Hospital Distribution/Damascus and Rural Damascus ......................................... 55 Map 9.2:Hospital Distribution / Aleppo ......................................................................... 70 Map 10.1 Hospital Distribution/Damascus and Rural Damascus ....................................... 86 Map 00.4 Hospital Distribution / Homs ....................................................................... 100 Map 00.4 Hospital Distribution / Hama ....................................................................... 114 Map 13.7 Hospital Distribution/ Idleb ......................................................................... 140 Map 14.12 Hospital Distribution/ Daraa ...................................................................... 153

Tables Table 1 Number of Surgical Doctors who work in one or more than Hospital ..................... 49 Table 2 Number of Non-Surgical Doctors who work in one or more than Hospital .............. 49 Table 3 Number of Nursing Staff who work in one or more than Hospital .......................... 50 Table 4 Number of Technicians who work in one or more than Hospital ........................... 50

Annex 1. Acronyms and Abbreviations Acronyms

Definitions

A ABB ABGs ADULT VENT ADULT WARD ADULT WARD BEDS ALP ANASTH ANESTH AUDIOMETER AUTOCLAVE

Advanced Blood Banks Arterial Blood Gases Adult Ventilator Adult Ward Adult Ward Beds Aleppo Anesthesiologist Anesthesia Machine AUDIOMETER Wet Sterilizing

C C.ARM CARD SUR CARDIO CHEST CLINIC CRASH CART CT.SCAN

C-Arm Cardiac Surgery Cardiology Chest Clinic Crash Cart CT-Scan

D DAM DEFEB DENTAL CLINIC DEPT DERMA DIATHERMY DOP DRY-STERIL DWL

Damascus Defibrillator Dental Clinic Department Dermatology / Dermatologist Diathermy Doppler Ultrasound Dry Sterilizing Detailed Work Load

E ECG EL SUR DEP. EM SUR DEP. EMG ENDOCRIN ENT ER ER BEDS

Electrocardiography Elective Surgery Department Emergency Surgical Department Electromyography Endocrinology / Endocrinologist Ear, Nose and Throat Emergency Room Emergency Room Beds

F FIX X-RAY FUN

Fix X-Ray Functional

G GENS SUR GI GP GS

General Surgeon Gastrointestinal / Gastroenterologist General Practitioner General Surgery / General Surgeon

H HCT CENTF HR HR ANESTH HR ER HR ICU HR LAB HR PSYCH HR RDIO

Hematocrit Centrifugation Human Resources Anesthesiologist Emergency medicine specialist Intensive care medicine specialist Laboratory medicine specialist Psychologist Radiologist

I INCUBATOR FUN INCUBATOR. NOT FUN INFUSION PUMPS INTERN MD

Functioning Incubator Not Functioning Incubator Infusion Pumps Internal Medicine

L LAB CENTF LAB CHEMO LAB ELECTRO LAB HEM LAB INCUB LAB MIC

Laboratory Centrifugation Laboratory Chemical Analysis Equipment Laboratory Electrolyte analyzer Laboratory Hematology Analyzer Laboratory Incubator Laboratory Microscope

M MAXF MED MED INTERN MED STUD BAS MED STUD CLINIC MONITOR

Maxillofacial Surgery / Maxillofacial Surgeon Non-Surgical internist Medical Students in Basic Science Level Medical Students in Clinical Level Monitor

NEBUL NEPHRO NEUR MED NEUR SUR NEW N VENT NEW N. ICU BEDS NO MED No. No. AVAILABLE OF BLOOD BANKS

Nebulizer Nephrology / Nephrologist Neurology / Neurologist Neurosurgery / Neurosurgeon Neonatal Ventilator Neonatal Intensive Care Unit Beds No Medical (non-surgical) Number Number of Available Blood Banks

NO. OF BEDS No. OF HR No. OF ICU EQUIP No. OF LAB EQUIP No. Of NON S. OPDs No. OF OR EQUIP No. Of S. OPDs No. OF SHARED EQUIP No. OF X RAY EQUIP NON SUR ER NON SUR ICU NON SUR ICU BEDS NOT FUN NT NURS NURS ER NURS INCUB NURS OPD NURS WARD

Number Of Beds Number of Human Resources Number Of Intensive Care Unit Equipment Number Of Laboratory Equipment Number of Non-Surgical Out-Patient Departments Number Of Operating Room Equipment Number of Surgical Out-Patient Departments Number Of Shared Equipment Number of X-Ray Equipment Non-Surgical Emergency Room Non-Surgical Intensive Care Unit Non-Surgical Intensive Care Unit Beds Non-Functional Non-Traumatic Nurses Emergency room Nurses Incubator Nurses Out-Patient Department Nurses Ward Nurse

O O2 CENTRAL GEN O2 CONCENT O2 CYLENDERS OBS GYN ONCO SUR OPD OPD OPTH OR FIX LAMP OR PORT LAMP OR TABLE ORTHO

Central Oxygen Generator Oxygen Concentrator Oxygen Cylinders Obstetric and Gynecological Surgery /Obstetrician & Gynecologist Oncologic surgery / Oncologic surgeon Out-Patient Department Out-Patient Department Ophthalmic surgery / Ophthalmologist Operating Room Fixed Lamp Operating Room Portable Lamp Operating Room Table Orthopedic Surgery / Orthopedic Surgeon

P PANORAMA PBB PEDIA PEDIA / NEW N. PEDIA SUR PEDIA VENT PEDIA WARD PEDIA WARD BEDS PHARMA

Panorama Primary Blood Banks Pediatric / Pediatrician Pediatric / Neonatal Intensive Care Unit Pediatric Surgery / Pediatric Surgeon Pediatric Ventilator Pediatric Ward Pediatric Ward Beds Pharmacist

PORT X-RAY PSS CLINIC

Portable X-Ray Psychosocial Support Clinic

Q QUAL

Qualified

R RAPID HEM RDU RECON RES RHEUM RURAL DAM.

Rapid Hemoglobin Analyzer Renal Dialysis Units Reconstructive Surgery / Reconstructive Surgeon Resident Rheumatology / Rheumatologist Rural Damascus

S SKIL SP STUD SUCTION SUR SUR ER SUR ICU SUR ICU BEDS

Skilled Specialist Student Suction Surgery/ Surgeon Surgical Emergency Room Surgical Intensive Care Unit Surgical Intensive Care Unit Beds

T T TECH TECH ANASTH TECH ICU Tech Lab TECH OR TECH PHARMA TECH PHYSIO TECH RDIO TECH RDU THX SUR TRAC TABLE

Traumatic Technicians Anesthesia technicians Intensive Care Unit Technician Laboratory Technicians Operation Room technicians Pharmacy Technicians Physiotherapy Technicians Radiology Technicians Renal Dialysis Unit Technicians Thoracic Surgery / Thoracic Surgeon Traction Table

U URO US OTHER

Urologic Surgery / Urologic surgeon Other Ultrasound Devices

V V SCAN VAS

Focused Assessment with Sonography in Trauma(FAST) Vascular Surgery / Vascular Surgeon

W WL WoS

Work Load Whole of Syria

1- Executive Summary Hospitals in Syria continue to operate under severe human and material resource constraints. In order to more accurately allocate scarce resources a nation-wide survey was conducted of hospitals providing emergency and routine medical and surgical care. The survey was conducted by the Union of Medical Care and Relief Organizations (UOSSM) and Physician Across Continent (PAC) in August 2015. The survey was conducted through site visits to 113 hospitals by trained data collectors who surveyed hospital administrators regarding patient volume, services provided, number and functionality of medical equipment, hospital staffing, as well as levels of financial support provided to each facility.

The survey was a follow-up to a survey conducted in April 2015. The April survey of 90 hospitals yielded some of the first information on hospital capacity inside Syria but identified several definitional problems that resulted in results that were difficult to verify. Using lessons learned from the prior survey the July 2015 survey formalized definitions of variables collected and utilized an electronic data collection platform (KoBo Toolbox) to collect and analyze data on 113 hospitals nation-wide.

The results of the survey highlighted many important new findings. Throughout Syria, there are shortages of human resources at participating hospitals. While the overall number of physicians and surgeons was low, there were critical shortages of both medical and surgical subspecialists. For example only 169 general surgeon recorded in the surveyed hospitals, this number should corrected as 50 % of them are working in more than one hospitals. While nurse staffing was better than that of physicians there were significant numbers of non-professional nurses whom were providing care in Syrian hospitals â&#x20AC;&#x201C; including non-medical personnel who had received some training in nursing tasks who took on this role. In addition, there was significant variability noted across Syria with certain regions with critical shortages in medical staff â&#x20AC;&#x201C; e.g. only two alternative trained anesthesiologist in Aleppo. In addition, there were shortages of critical medical equipment including ventilators, oxygen generators, arterial blood gases test machines and newborn incubators. A critical need for biomedical engineering support was identified in this survey. Despite the dire security situation, many hospitals have managed to obtain medical equipment in adequate numbers but much of this equipment is currently

non-functional. Much of this equipment is salvageable but is in need of simple maintenance and repair. For example there more than fifty X- ray machine, six CT Scan and nineteen ventilators should be maintenance. Provision of biomedical engineering support for these facilities will recruit significant numbers of devices back into service and can enable redistribution of these resources to other facilities that lack critical devices.

While the majority of hospitals surveyed reported receiving external support in the form of funding for staff salaries, pharmaceuticals, medical consumables, medical equipment, and/or non-medical supplies (27% full, 36% partial), fully 36% reported operating without any external funding. Many of these hospitals reported limitations in providing services due to lack of financial support. Only 124 ventilators were available for almost twice the number of ICU beds and their distribution was uneven across Syria. There are critical shortages of central oxygen generators with only 22 found in this survey nation-wide with 23% out of service with several surveyed hospitals without the ability to provide any form of supplemental oxygen other than cylinders. Other critical repair needs were noted with 35 out of 226 anesthesia machines non-functional; 40 out of 214 defibrillators non-functional. While all hospitals included in this report are in need of additional material and financial support, this survey detailed several opportunities for the future. Specifically, there were opportunities for some hospitals in close proximity to pool resources and to coordinate the provision of care to reduce duplication and to provide complementary services. In addition, the large number of devices that are in need of repair are a challenge but also represent an opportunity if a proper investment is made to recruit these devices back into service at much lower cost than the procurement, importation and distribution of new devices to Syrian hospitals.

Further work is needed to outline how best to coordinate services across hospitals and to engage facilities into a network of care to provide the greatest amount of medical care for the greatest number. In addition, future work should be done to detail a plan for regular maintenance and repair of critical medical equipment. Finally, the results of this survey need to be analyzed along with data that takes into account geographic isolation, the security situation on the ground and current population patterns to identify the appropriate level of support for hospitals in each region.

2- Introduction The collapse of the health care system in Syria, across the country, particularly in Syrian-opposition controlled areas, demonstrates the absence of a strong governance and strategic planning in addressing the health care crisis in Syria. This is evident by the following: 

Poor strategic planning with too large a focus on reactive short-term responses without adequate planning for medium and long term needs.



Unbalanced distribution of medical resources which are often provided based on incomplete or inaccurate information



Poor and / or insufficient health care services to the general public and increase in mortality rates among the population



Migration of doctors, nurses and other health personnel further complicating the health care crisis in the sector.

The absence of reliable and verifiable data on hospital capacity in Syria has been a major challenge to planning health services. The Union of Medical Care and Relief Organizations (UOSSM) and physicians Across Continents )PAC), took up this challenge to conduct a systematic survey of hospital capacity in partnership with other organizations working on ground, including Syrian American Medical Society ( SAMS), Syrian Expatriate Medical Association (SEMA), and local Health Directorates.

3- Survey Objectives 1. Determine the number of hospitals operating in Syria, their distribution in the country and types of services provided. 2. Identify key health needs in Syria and compare to data from first survey of hospitals in April 2015 3. Determine the number and functionality of key medical equipment 4. Detail the financial and material support to Syrian hospitals 5. Characterize the human resources and workload at Syrian hospitals

4- Defining the Different Regions in Syria Syria is currently divided functionally into three regions, based on supply lines and access: 1. The Northern Region is the largest region, where the Turkish Border is considered the main line of supply into the area. This region includes all the provinces of Aleppo, Idlib, Raqqa, Deir ez-Zor, Hasaka, Latakia, and Hama. The eastern section of this region, which extends from the eastern suburbs of Aleppo to the Iraqi Border, is under the control of the Islamic state (ISIS), limiting its access from outside. Therefore, the survey was not conducted in ISIS-controlled area. We surveyed 59 out of 671 hospitals in the Northern region. 2. The Central Region is smaller than the Northern region, and the Lebanese Border is considered the main line of supply into the area. This region includes Damascus, Damascus suburbs, and Homs, where 32 of 35 hospitals were surveyed, including several besieged areas, which are isolated from each other. For the purposes of this report, they were analyzed as one independent population unit. 3. The Southern Region is the smallest, and its supply line is from the Jordanian Border. It includes Daraa and Quneitra. We surveyed 22 hospitals, which represents all the hospitals in this region. A comprehensive survey was conducted on all hospitals that are accessible in the three regions.

5- Project Staff Project staff consisted of teams of trained data collectors who reported survey results to Regional Directors who oversaw collection of data and provided oversight in the field to ensure data accuracy and security. The three regional directors were overseen by the Director of Information Management and Scientific Research Department in UOSSM. The staff also include the Governorate Officers in the Northern region. The field data collectors were distributed as per the following: 16 in the Northern region, 6 in the Central region and 3 in the Southern region. The Northern region, which is the biggest region, is divided into governorates, headed by a governorate officers that report to the Northern Regional Director. However, the

Does not include ISIS-controlled regions

Central and Southern regions, with a smaller scale of work, have only Regional Directors, who are monitoring the data collectors directly. The data flow starts from the field data collectors, and is fully audited by the Governorate Office Director of the Northern Region, and the Central and Southern Regional Directors. In addition, a sample of collected data was audited in real-time by the regional directors to ensure the completeness and accuracy of the responses. Data were collected electronically at the regional level and uploaded to a central database for cleaning and analysis.

6- Methodology The surveying process was conducted over a three-month period in 3 phases:

Phase I: Preparation of the Survey (One-month) Survey questions were developed by a group of medical specialists including Dr. Anas Alkassem, MD (trauma surgery, Canada), Dr. Hani Mowafi, MD, MPH (Emergency Medicine & Global Health, USA) and Dr. Abdul Aziz, MD (trauma surgeon, Syria) on the following themes: A. Type of Services provided: Services characterized into surgical and non-surgical and by level of service â&#x20AC;&#x201C; from ambulatory to intensive care. In addition, support services, such as hemodialysis, physiotherapy and laboratory, were identified when available. B. Availability and functional status of devices Devices were classified according to the different departments or sections at the hospital, with a special focus on their number and functional status. 1. Radiology (Fixed X-Ray, Portable X-Ray, Doppler, ECHO, CT-scan) 2. Operating Room (Anesthesia Machine, Mechanical Ventilator, diathermy, Operation lights) 3. Intensive Care Unit (Mechanical Ventilator, IV Pump, Blood gas device) 4. Laboratory (Centrifuge, Microscope, Lab incubator) 5. Common devices or devices that could be used in more than one departments (Suction, Monitor, Ambulance, Oxygen concentrator, Oxygen generator, Electric generator)

C. Work Load of Services Several methods were adopted to evaluate the work volume of services provided by the hospital 1. Number of patients at the emergency department and clinics 2. Number of emergency and non-emergency admissions 3. Number of surgical operations of all kinds according to terms of reference 4. Total number of patient-hospital days and occupation rates in each section

D. Financial Support of the Hospital Support has been classified into three categories: 1. Staff salaries 2. Running costs support. 3. Consumables support. Answers were classified into full support, partial support, and no-support. E. Human resources: Human resource data was included only for medical staff in the survey, without counting for other administrative staff at the hospital. Medical personnel are classified into: 1. Physicians - specialists or residents in addition to medical students. 2. Technicians, whether they hold diplomas or experience certificates 3. Nurses holding diplomas or experience certificates 1- Survey questions were entered into the KoBo Toolbox data collection platform 2- Survey questions were reviewed by the specialist team. 3- Training was provided to data collectors on the survey instrument, use of the KoBo platform, and on the devices used for data collection (laptops and handheld devices). Data collectors in the Northern region received in-person training while those in the Central and Southern regions were trained using video-conferencing due to inability to travel due to insecurity.

4- The survey instrument was piloted in 15 hospitals in all three different regions. After reviewing the pilot survey results, further modifications and revisions were done on the test questionnaire prior to field implementation.

PHASE II: Conducting the Survey (One-month duration) 5- The full survey implementation was conducted over one month and audits of the data collected were conducted at three levels: a. 1st level: Full audit of the collected data by the Governorate officers in the Northern region and/ or the Central and Southern Regional Directors b. 2nd level: A randomly selected sample was audited by Regional Directors. c. 3rd level: A randomly selected sample was audited by the Department of Scientific Research. After the completion of the research survey, the project was ended and the collected data were exported into a database.

Phase III: Data analysis and reporting (One-month duration) The collected data were analyzed for missing and outlier values. Cleaned data were then exported for analysis (505 variables) in SPSS . Descriptive statistics and geomapping of results were generated. The data in this report are classified into groups for comparisons at the hospital, provincial and regional levels. The survey results were studied at three levels: 1. Overview of the medical situation of the hospitals in Syria 2. At the governorate level in terms of hospitals distribution and services with regards to the besieged areas as one comprehensive community 3. At the hospital level, through a descriptive display of the status of the hospital, its infrastructure, availability of services, and the volume of its work. We issued a data card for each hospital on silk.co website, with private access

The difference between this survey and April 2015 survey: A comparison between this survey and the previous survey, which was introduced in April 2015, in terms of: 1. Survey mechanism: Adopting the paper format in the previous survey for data collection, and as entering the data on the Excel file, a lot of mistakes were discovered that could not be corrected. In addition, in the prior survey many

questions were left unanswered making certain domains impossible to analyze reliably. This survey adopted the KoBo Toolbox for data collection. It required the person, filling out the survey, to answer all the questions in the survey before submitting the form, resulting in more accurate information and less data loss. 2. 113 hospitals were surveyed in August 2015 in comparison to 90 hospitals in the April survey 3. The results of the survey: Focusing on the number of medical staff, in addition to, the medical services provided, helped avoid as much as possible â&#x20AC;&#x153;falseâ&#x20AC;? doubling in the number of staff, which happened in the previous survey.

The difference between this survey and HeRAMS: 1. This survey was based on direct visits of the data collectors to the hospitals, where surveys were filled directly by hospital directors or hospital health information staff. The prior HeRAMS survey relied on data provided by NGOs supporting facilities, not the hospitals themselves. This scenario resulted in some gaps in information as well as allowed the possibility of discrepancies between NGO and hospital data. In addition, such a methodology excluded hospitals not supported by NGOs. 2. This survey examined in greater detail medical services that had not been previously addressed; including the number of medical staff, work volume in hospitals of all kinds, and days of bed occupancy to calculate occupation rates. 3. This survey focused exclusively on hospitals to provide a clearer picture of these facilities. 4. This survey included additional data on support services, such as blood banks, dialysis and physiotherapy services, available at hospitals. Additional separate questionnaire, for such services outside hospitals will be conducted later on. 5. The survey highlighted the besieged areas and considered it as one demographic unit, in order to assess its available health care services.

7-Results Whole of Syria

This survey of 113 out of 124 hospitals in all disciplines â&#x20AC;&#x201C;surgical and non-surgical. Only hospitals not included in the survey were those that either ceased operations or remain inaccessible due to security reasons. Most excluded hospitals were in the Northeastern region of Syria, where access is extremely hard, as well as, the hospitals in the Government-controlled area, where access is impossible.

Map 1 Hospital Distribution

Hospitals are distributed in the 3 different regions as follows: A. Northern Region, 59 Hospitals. B. Central Region, 32 Hospitals. C. Southern Region, 22 hospitals.

Services available per hospital

Fig. 1 Number of Available Departments / Whole of Syria

The Outpatients department in the Hospitals were divided into two types, surgical and non-surgical, and were distributed numerically as follows:

Fig. 2 Number of Surgical Outpatient Department / whole of Syria

Fig. 3 Number of Non-Surgical Outpatient Department / Whole of Syria

Hospital Beds a. The total number of adult hospital beds in Syria is 1406 b. The total number of incubators in Syria reached 114, including 16 nonfunctional, which need maintenance c. The total number of intensive care beds (ICU beds) from all types was 251 distributed as follows: 113 surgical, 110 internal, 28 pediatric and 55 neonates ICU.

Fig. 4 Number of Beds / Whole of Syria

Matching the number of mechanical ventilators available with total number of adult ICU beds, it was found that there were only 124 mechanical ventilators available at all the 223 ICU beds that were spread over 42 surgical and 38 non-surgical intensive care units. Also, matching the number of hospitals containing central oxygen generators with the availability of ICUs of any kind, there were only 22 generators, of which five were out of service, requiring urgent maintenance.

The distribution of surgical ICUs is mapped as follows:

Map 2 Intensive Care Units Distribution and Functional Status

Devices: Radiology Devices 1- There were 57 mobile and fixed X-ray machines in need of maintenance in all regions, distributed by provinces. 2- There were 8 CT-scans in Syria that were not working, out of 14 CT-scans. There were, however, some CT-scans at few private hospitals that still didnâ&#x20AC;&#x2122;t address the current needs.

Fig. 5 Number of X-Ray Equipment / Whole of Syria

Functional and not functional CT Scans are mapped as follows:

Map 3 Functional CT Scan Distribution

Map 4 Non-Functional CT Scan Distribution

Intensive Care Unit Devices 1. Number of mechanical ventilators available for adults was 124, of which 19 required maintenance. 2. Very few arterial blood gases (ABG) devices were available at the hospitals, in proportion to the number of ICU beds. They did not exceed 12 ABG devices; half of which were out of order. Number of mechanical ventilators for newborns and pediatrics was 31 only, where 3 out of the 31 were out of order, and only 6 were neonatal mechanical ventilators at all the hospitals that have been surveyed.

Fig. 6 Number of ICU Equipment / Whole of Syria

Operating Room Devices 1. About 40% of the surveyed hospitals relied on portable operating lights, given the circumstances of the war, although the portable lights are less effective in hospitals, but easier to transport. However, 43 of all operating lights, fixed and portable, will require maintenance. 2. There were a total of 35 anesthesia machines that will require maintenance, out of 226 anesthesia machines available. 3. Traction tables that are used by orthopedic surgeon were 47. There were 33 hospitals that need such specialized tables, when an orthopedic surgeon is available.

Fig. 7 Number of Operating Room Equipment / Whole of Syria

Laboratory Devices 1. Most of the existing laboratory devices provided only basic analysis of hemoglobin, blood sugar, blood group, urea and creatinine. 2. Almost half of the electrolyte analysis devices did not work. 3. There were no hormone analysis devices in the operating hospitals. However, few private laboratory centers had these devices, which were costly and unaffordable.

Fig. 8 Number of Laboratory Equipment / Whole of Syria

Shared Devices There are devices that are used in more than one department, such as defibrillators and monitors, as well as, devices that provide services to the hospital, in general, such as electric generators, oxygen generators and other equipment. Results are summarized as follows: 1. The total number of defibrillators was 214, of which 40 required maintenance. When matched with the number of hospitals having defibrillators, there were 3 hospitals in the suburbs of Damascus and 5 in the Northern region that did not have any defibrillator. 2. The total number of monitors was 386, of which 66 required maintenance. This number does not cover the real needs, with regards to the number of ICU beds and the number of operating rooms. 3. The number of dry and wet autoclaves was proportional to the number of hospitals, except for one hospital, which is inherently a non-surgical hospital. However, about 53 autoclave machines required maintenance. 4. The number of suction devices that needed maintenance was 76, and the total number of devices relatively covered the needs of the hospitals. 5. The number of nebulizer devices that required maintenance was 51 and the total number of devices relatively covered the needs of the hospitals. 6. The number of crash carts was still relatively few and did not exceed 55 crash carts in all hospitals. However, the number of crash carts did not seem to have direct impact on the lives of the patients. 7. As noted, the total number of central oxygen generators was 22, including 5 generators that required maintenance. This translates that most of the hospitals that have intensive care units of different kinds do not have oxygen generators. Rather, they depend on oxygen cylinders, which increase the financial burden and the need for extra cash to fill the cylinders and provide generators for packaging. This issue needs further analysis at provincial and regional levels, and study the possibility of filling the cylinders in each province. 8. Acceptable number of ECG devices were available, of which 27 required maintenance.

Fig. 9 Number of Shared Equipment / Whole of Syria

The availability of central oxygen generators, functional on non-functional, are mapped as follows:

Map 5 Functional Central Oxygen Generator Distribution

Map 6 Non-Functional Central Oxygen Generator Distribution

Electric Generators: Concerning the electric generators, they were available in all hospitals with varying

numbers and various capacities, except for one hospital located in the Central Region that was supplied with electricity from high-tension electric lines. We studied the capacities of these generators and put a rough schedule to determine the amount of consumption of fuel, whether diesel or gasoline per working hour. Therefore, we estimated the needs of each hospital based on this table. The number of total generators was 233 and if they were to run at the same time, we would need about 1290 liters of diesel per hour, that is, on average of 10,340 liters if they were to run 8 hours, and 31,120 liters if they were to run for the whole day.

Approximate depreciation schedule for generators of fuel:

Fig. 01 Electric Generator Capacity and Fuel Consumption

Blood Banks 1. Primary blood banks that offer whole blood only with rapid tests existed in 82 hospitals out of 113 distributed in Syria, as depicted below. 2.

Advanced blood Banks, which provide components of blood plasma and packed red blood cells, were in six hospitals. It should be noted, however, that the survey also examined the advanced blood banks, located outside the hospitals, and are depicted in the map.

Fig. 11 Number of Available Blood Banks / Whole of Syria

The complete information about advanced blood banks, available in Syria, outside the framework of hospitals is depicted in the following map. There were 3 advanced blood banks found outside the hospitals in all regions

Map 7 Advance Blood Bank Distribution and Functional Status (inside and Outside Hospitals)

Physiotherapy An inquiry was made about the availability of physiotherapy equipment in hospitals without raising the available hardware details, and referrals were as follows:

Fig. 12 Number of Available Physiotherapy / Whole of Syria

Also, in a different survey, the questionnaire that examined the availability of physiotherapy devices outside hospitals in the regions will be completed.

Renal Dialysis Unit (RDU): An inquiry was made about the availability of dialysis machines in hospitals, and the results are in the following figure:

Fig. 01 Number of Available Renal Dialysis Units / Whole of Syria

Out of 15 hospitals containing dialysis machines, six hospitals had stopped providing dialysis services, which requires follow-up. There are no information about number and functionality of dialysis machines in these hospitals. Through a complementary survey questionnaire, the number of dialysis devices in the hospitals and their compatibility with the desalination devices, as well as, the number of dialysis devices outside hospitals, will be examined. This could be further analyzed, at a later stage, by the nephrology team group.

Workload: We adopted several methods to estimate the volume of work in the services provided by the hospital. 1. Number of patients visiting emergency department and outpatient departments, in addition to, the number of emergency and non-emergency admissions.

Fig. 01 Number of Emergency Visitors and admission / Whole of Syria

Fig. 15 Number of Outpatient Visitors and Admission / Whole of Syria

2. The number of surgical operations according to the specialties. An inquiry was made about the availability of detailed medical records at the hospitals. In the hospitals that had detailed medical records, the number of trauma and nontrauma cases, and emergency and non-emergency cases were recorded. In hospitals that did not maintain detailed medical records, the total number of surgeries were recorded based on available specialties.

In general, 60% hospitals had detailed records, while 40% were lacking such records. However, this result was widely variable among the different governorates as shown in this figure:

Fig. 16 Hospital Documentation Availably / Whole of Syria and governorates

The figures represent the percentages of the availability of the different documents during the month of August 2015 only. However, to be able to come up with the average percentages, these figures should be compared with the data, we compiled through our surgical coding system we had for the last 2 years and during our monthly visits to the hospitals. The electronic medical record system that is currently in place is only for trauma-related surgeries. We will be working on expanding the electronic medical system to include all types of surgeries. ď&#x201A;ˇ

Hospitals that had abridged patient medical records o Highest numbers of surgeries were in general and orthopedic surgeries o Lack of oncology and pediatric surgical records were noted. due to lack of specialists

o The number of reconstructive surgeries did not match with the expected numbers o There were no real cardiac surgery medical records and no elective cardiac surgery records, due to lack of specialists

Fig. 17 Number of Surgeries without Details (depend on Hospital Record) / Whole of Syria

ď&#x201A;ˇ

Hospitals that has detailed patient medical records: The following table provides an overall idea of the diversity of operations and their numbers in hospitals that provided details of their operations (a more profound study and analysis of the figures at different provincial levels will be conducted).

Fig. 18 Number of Surgeries with Details (depend on Hospital Record) / Whole of Syria

The number of hospital normal deliveries were integrated with the number of caesarean sections (C-sections) as follows:

Fig. 19 Number of Hospital Deliveries / Whole of Syria

High rates of Caesarean sections were noted, accounting for almost one third of hospital deliveries. However, this figure doesnâ&#x20AC;&#x2122;t reflect the real number of deliveries, as many births occur outside the hospitals and clinics, in homes by midwives.

Total number of Hospital Days and Bed Occupancy Rates in Each Department: We will study and calculate the number of occupancy days and Bed Occupancy Rates, at hospital level. These ratios, if based on total figures, wonâ&#x20AC;&#x2122;t give meaningful analytical indices. Occupancy ratios are determined by the following equation:

Occupancy Ratio of Sectionâ&#x20AC;&#x2122;s Beds= Number of Occupancy Days recorded at the facility / Number of Beds * 30 Days

Hospitals Financial Support: 1.

Staff support: Full support of the staff existed in 31 hospitals and partial support in 41 hospitals, while 41 hospitals had no staff support, whatsoever.

Support of running costs: About 17 hospitals had no support of their running costs, while 62 hospitals had partial support and 34 hospitals had full support.

Most of the medical consumables were fully or partially supported.

These results were based on direct answers by the surveyed hospitals and requires further verification with the other working with organizations.

Fig. 01 Financial Support Staff / Whole of Syria

Fig. 21 Financial Support Running Cost / Whole of Syria

Fig. 00 Financial Support Consumables / Whole of Syria

Human Resources: Two types of questions were formulated according to hospital preference: 1. Number of medical staff 2. Detailed information about the hospital medical staff Such questionnaire purposed to know the real number of medical staff at the hospital and to know whether the staff were working in more than one hospital. Almost 64 % of the surveyed hospitals refused to give detailed information about their staff, primarily for security reasons, whereas 36 % hospital gave the information.

Fig. 23 Human Resources Full Details Hospitals

The following figure shows the percentage of staff who were working at a single hospital versus working at multiple facilities.

Fig. 24 Number of Human Resources who work in one or more than Hospital

This graph illustrates in general that almost 26% of medical staff had worked at more than one hospital. However, when you look further into the data and perform additional data analysis, the percentage in the graph above will be different.

ď&#x201A;§

When analyzing the data for surgical staff, it showed that almost 50 % of the surgical staff were working in more than one hospital in the given sample.

Table 1 Number of Surgical Doctors who work in one or more than Hospital

ď&#x201A;§

30% of non-surgical staff were working in more than one hospital

Table 2 Number of Non-Surgical Doctors who work in one or more than Hospital

ď&#x201A;§

Technical and nursing staff images reduced to less than 20 %

Table 3 Number of Nursing Staff who work in one or more than Hospital

Table 4 Number of Technicians who work in one or more than Hospital

Surgical Medical Staff: 1. Survey of medical surgical staff implicated a good accuracy in the survey of hospitals due to the link between the works of surgeons with the hospitals in different specializations. However, there is a 50% possibility of over-estimation due to the work of a number of surgical staff in more than one hospital according to the given detailed sample. 2. We noted that the specialists outnumber residents in all disciplines. 3. Most of the specialists were general, orthopedic or obstetrician surgeons, followed by urologists and otolaryngologists, and the rest of specialties were very few, in general. 4. Pediatric, oncology, maxillary and neurosurgery specialists were scarce. 5. There were about 150 residents in diverse surgical specialties.

` Fig. 02 Human Resources Surgical Doctors / Whole of Syria

Non-Surgical Medical Staff: The number of non-surgical did not reflect the precise number, as many of them were also working outside the hospital in their PHCs or private clinics. 1. There were 90 medical students that had stopped their study. 2. Most of the specialists, except for pediatricians and internists, were in small numbers. 3. There were only 24 specialized anesthesiologists. 4. The number of non-surgical staff were less than the true figure because most of them also worked outside hospitals.

5. There were approximately 50 residents in various non-surgical specialties.

Fig. 26 Human Resources Non-Surgical Staff / Whole of Syria

1- Nursing staff: 1- The number of nursing staff who are licensed nurses is almost equivalent to nonlicensed, which shows the great need for the training of nurses. 2- The number of incubator and pediatric nurses is very few.

Fig. 27 Human Resources Nursing Staff / Whole of Syria

Technicians: 1- Good number of anesthesiology and radiology technicians has been noted and this figure may be more than real for being some of them are working in more than one hospital. 2- Evaluation of dialysis and pharmacy technicians does not be considered real unless the rest of medical facilities have been surveyed. 3- The number of experienced midwives is less than expected because they are not obligated to work in hospitals. 4- The proportion of experienced technicians is equivalent to almost one-third of all technicians and they need to be trained.

Fig. 28 Human Resources Technicians / Whole of Syria

On the Governorate Level 1- Damascus

Map 8.1 Hospital Distribution/Damascus and Rural Damascus

Only three hospitals were surveyed in Damascus city appear in blue part of this map

Fig. 29.1 Number of Available Departments / Damascus

Fig. 30.1 Number of Surgical Out Patient Department / Damascus

Fig. 31.1 Number of Non-Surgical Outpatient Department / Damascus

Fig. 32.1 Number of Beds / Damascus

Fig. 33.1 Number of X-Ray Equipment / Damascus

Fig. 34.1 Number of ICU Equipment / Damascus

Fig. 35.1 Number of Operating Room Equipment / Damascus

Fig. 36.1 Number of Laboratory Equipment / Damascus

Fig. 37.1 Number of Shared Equipment / Damascus

Fig. 38.1 Number of Available Blood Banks / Damascus

Fig. 39.1Number of Available Physiotherapy / Damascus

Fig. 40.1 Number of Emergency Visitors and admission / Damascus

Fig. 41.1 Number of Outpatient Visitors and Admission / Damascus

Fig. 42.1 Number of Surgeries without Details (depend on Hospital Record) / Damascus

Fig. 43.1 Number of Surgeries with Details (depend on Hospital Record) / Damascus

Fig. 44.1 Number of Hospital Deliveries / Damascus

Fig. 45.1 Financial Support Staff / Damascus

Fig. 46.1 Financial Support Running Cost / Damascus

Fig. 47.1 Financial Support Consumables / Damascus

Fig. 48.1 Human Resources Surgical Doctors / Damascus

Fig. 49.1 Human Resources Non-Surgical Staff / Damascus

Fig. 50.1 Human Resources Nursing Staff / Damascus

Fig. 51.1 Human Resources Technicians / Damascus

2- Aleppo

Map 9.2:Hospital Distribution / Aleppo

In Aleppo Governrate 24 hospitals were surveyed in the northen, southren, and westren part only as the eastren part under ISS control and part of the maen city under governmental control.

Fig. 52.2 Number of Available Departments / Aleppo

Fig. 53.2 Number of Available Departments / Aleppo

Fig. 54.2 Number of Non-Surgical Outpatient Department / Aleppo

Fig. 55.2 Number of Beds / Aleppo

Fig. 56.2 Number of X-Ray Equipment / Aleppo

Fig. 57.2 Number of X-Ray Equipment / Aleppo

Fig. 58.2 Number of X-Ray Equipment / Aleppo

Fig. 59.2 Number of Laboratory Equipment / Aleppo

Fig. 60.2 Number of Shared Equipment / Aleppo

Fig. 61.2 Number of Available Blood Banks / Aleppo

Fig. 62.2 Number of Available Physiotherapy / Aleppo

Fig. 63.2 Number of Available Renal Dialysis Units / Aleppo

Fig. 64.2 Number of Emergency Visitors and admission / Aleppo

Fig. 65.2 Number of Outpatient Visitors and Admission / Aleppo

Fig. 66.2 Number of Surgeries without Details (depend on Hospital Record) / Aleppo

Fig. 67.2 Number of Surgeries with Details (depend on Hospital Record) / Aleppo

Fig. 68.2 Number of Hospital Deliveries / Aleppo

Fig. 69.2 Financial Support Staff / Aleppo

Fig. 70.2 Financial Support Running Cost / Aleppo

Fig. 71.2 Financial Support Consumables / Aleppo

Fig. 72.2 Human Resources Surgical Doctors / Aleppo

Fig. 73.2 Human Resources Non-Surgical Staff / Aleppo

Fig. 74.2 Human Resources Nursing Staff / Aleppo

Fig. 75.2 Human Resources Technicians / Aleppo

3- Rural Damascus

Map 10.1 Hospital Distribution/Damascus and Rural Damascus

Twenty hospitals surveyed in rural Damascus, which located in besieged area. Fifteen hospitals located in the gray area seen in the map and the rest distributed individually in the other colors, which refer to small-besieged areas.

Fig. 76.3 Number of Available Departments / Rural Damascus

Fig. 77.3 Number of Surgical Out Patient Department / Rural Damascus

Fig. 78.3 Number of Non-Surgical Outpatient Department / Rural Damascus

Fig. 79.3 Number of Beds / Rural Damascus

Fig. 80.3 Number of X-Ray Equipment / Rural Damascus

Fig. 81.3 Number of ICU Equipment / Rural Damascus

Fig. 82.3 Number of Operating Room Equipment / Rural Damascus

Fig. 83.3 Number of Laboratory Equipment / Rural Damascus

Fig. 84.3 Number of Shared Equipment / Rural Damascus

Fig. 85.3 Number of Available Blood Banks / Rural Damascus

Fig. 86.3 Number of Available Physiotherapy / Rural Damascus

Fig. 87.3 Number of Available Renal Dialysis Units / Rural Damascus

Fig. 88.3 Number of Emergency Visitors and admission / Rural Damascus

Fig. 89.3 Number of Outpatient Visitors and Admission / Rural Damascus

Fig. 90.3 Number of Surgeries without Details (depend on Hospital Record) / Rural Damascus

Fig. 91.3 Number of Surgeries with Details (depend on Hospital Record) / Rural Damascus

Fig. 92.3 Number of Hospital Deliveries / Rural Damascus

Fig. 93.3 Financial Support Staff / Rural Damascus

Fig. 94.3 Financial Support Running Cost / Rural Damascus

Fig. 95.3 Financial Support Consumables / Rural Damascus

Fig. 96.3 Human Resources Surgical Doctors / Rural Damascus

Fig. 97.3 Human Resources Non-Surgical Staff / Rural Damascus

Fig. 98.3 Human Resources Nursing Staff / Rural Damascus

Fig. 99.3 Human Resources Technicians / Rural Damascus

4- Homs Map 00.4 Hospital Distribution / Homs

Homs Governorate have eight hospitals mainly on the northern west region and difficult to access to this area.

111

Fig. 100.4 Number of Available Departments / Homs

Fig. 101.4 Number of Surgical Out Patient Department / Homs

111

Fig. 102.4 Number of Surgical Out Patient Department / Homs

Fig. 103.4 Number of Beds / Homs

112

Fig. 104.4 Number of X-Ray Equipment / Homs

Fig. 105.4 Number of ICU Equipment / Homs

113

Fig. 106.4 Number of Operating Room Equipment / Homs

Fig. 107.4 Number of Laboratory Equipment / Homs

114

Fig. 108.4 Number of Shared Equipment / Homs

115

Fig. 109.4 Number of Available Blood Banks / Homs

Fig. 110.4 Number of Available Physiotherapy / Homs

Fig. 111.4 Number of Available Renal Dialysis Units / Homs

116

Fig. 14.4 Number of Emergency Visitors and admission / Homs

Fig. 112.4 Number of Outpatient Visitors and Admission / Homs

117

Fig. 113.4 Number of Surgeries without Details (depend on Hospital Record) / Homs

Fig. 114.4 Number of Surgeries with Details (depend on Hospital Record) / Homs

118

Fig. 115.4 Number of Hospital Deliveries / Homs

Fig. 116.4 Financial Support Staff / Homs

Fig. 117.4 Financial Support Running Cost / Homs

119

Fig. 118.4 Financial Support Consumables / Homs

111

Fig. 119.4 Human Resources Surgical Doctors / Homs

111

Fig. 120.4 Human Resources Non-Surgical Staff / Homs

112

Fig. 121.4 Human Resources Nursing Staff / Homs

Fig. 122.4 Human Resources Technicians / Homs

113

5-Hama

Map 00.4 Hospital Distribution / Hama

Fig. 123.5 Number of Available Departments / Hama

114

Fig. 124.5 Number of Surgical Out Patient Department / Hama

115

Fig. 125.5 Number of Non-Surgical Outpatient Department / Hama

Fig. 126.5 Number of Beds / Hama

116

Fig. 127.5 Number of X-Ray Equipment / Hama

Fig. 128.5 Number of ICU Equipment / Hama

117

Fig. 129.5 Number of Operating Room Equipment / Hama

Fig. 130.5 Number of Laboratory Equipment / Hama

118

Fig. 131.5 Number of Shared Equipment / Hama

119

Fig. 132.5 Number of Available Blood Banks / Hama

Fig. 133.5 Number of Emergency Visitors and admission / Hama

Fig. 134.5 Number of Outpatient Visitors and Admission / Hama

121

Fig. 135.5 Number of Surgeries with Details (depend on Hospital Record) / Hama

121

Fig. 136.5 Number of Hospital Deliveries / Hama

Fig. 137.5 Financial Support Staff / Hama

Fig. 138.5 Financial Support Running Cost / Hama

122

Fig. 139.5 Financial Support Consumables / Hama

123

Fig. 140.5 Human Resources Surgical Doctors / Hama

124

Fig. 141.5 Human Resources Non-Surgical Staff / Hama

125

Fig. 142.5 Human Resources Nursing Staff / Hama

Fig. 143.5 Human Resources Technicians / Hama

126

6- Latakia

Fig. 144.6 Number of Available Departments / Latakia

127

Fig. 145.6 Number of Surgical Out Patient Department / Latakia

Fig. 146.6 Number of Non-Surgical Outpatient Department / Latakia

128

Fig. 147.6 Number of Beds / Latakia

Fig. 148.6 Number of X-Ray Equipment / Latakia

129

Fig. 149.6 Number of ICU Equipment / Latakia

Fig. 150.6 Number of Operating Room Equipment / Latakia

131

Fig. 151.6 Number of Laboratory Equipment / Latakia

131

Fig. 152.6 Number of Shared Equipment / Latakia

132

Fig. 153.6 Number of Available Blood Banks / Latakia

Fig. 154.6 Number of Emergency Visitors and admission / Latakia

Fig. 155.6 Number of Outpatient Visitors and Admission / Latakia

133

Fig. 156.6 Number of Surgeries without Details (depend on Hospital Record) / Latakia

134

Fig. 157.6 Number of Surgeries with Details (depend on Hospital Record) / Latakia

135

Fig. 158.6 Financial Support Staff / Latakia

Fig. 159.6 Financial Support Running Cost / Latakia

Fig. 160.6 Financial Support Consumables / Latakia

136

Fig. 161.6 Human Resources Surgical Doctors / Latakia

137

Fig. 162.6 Human Resources Non-Surgical Staff / Latakia

138

Fig. 163.6 Human Resources Nursing Staff / Latakia

Fig. 164.6 Human Resources Technicians / Latakia

139

7-Idleb Map 13.7 Hospital Distribution/ Idleb

141

In Idleb governorate thirty two hospitals were surveyed.

Fig. 165.7 Number of Available Departments / Idleb

141

Fig. 166.7 Number of Surgical Out Patient Department / Idleb

Fig. 167.7 Number of Non-Surgical Outpatient Department / Idleb

Fig. 168.7 Number of Beds / Idleb

142

Fig. 169.7 Number of X-Ray Equipment / Idleb

Fig. 170.7 Number of ICU Equipment / Idleb

143

Fig. 171.7 Number of Operating Room Equipment / Idleb

Fig. 172.7 Number of Laboratory Equipment / Idleb

144

Fig. 173.7 Number of Shared Equipment / Idleb

145

Fig. 174.7 Number of Available Blood Banks / Idleb

Fig. 175.7 Number of Available Physiotherapy / Idleb

Fig. 176.7 Number of Available Renal Dialysis Units / Idleb

Fig. 177.7 Number of Emergency Visitors and admission / Idleb

146

Fig. 178.7 Number of Outpatient Visitors and Admission / Idleb

Fig. 179.7 Number of Surgeries without Details (depend on Hospital Record) / Idleb

147

Fig. 180.7 Number of Surgeries with Details (depend on Hospital Record) / Idleb

148

Fig. 181.7 Number of Hospital Deliveries / Idleb

Fig. 182.7 Financial Support Staff / Idleb

Fig. 183.7 Financial Support Running Cost / Idleb

149

Fig. 184.7 Financial Support Consumables / Idleb

Fig. 185.7 Human Resources Surgical Doctors / Idleb

151

Fig. 186.7 Human Resources Non-Surgical Staff / Idleb

151

Fig. 187.7 Human Resources Nursing Staff / Idleb

Fig. 188.7 Human Resources Technicians / Idleb

152

12- Daraa

Map 14.12 Hospital Distribution/ Daraa

Twenty hospitals were surveyed in Daraa.

Fig. 189.12 Number of Available Departments / Daraa

153

Fig. 190.12 Number of Surgical Out Patient Department / Daraa

Fig. 191.12 Number of Non-Surgical Outpatient Department / Daraa

154

Fig. 192.12 Number of Beds / Daraa

Fig. 193.12 Number of X-Ray Equipment / Daraa

155

Fig. 194.12 Number of ICU Equipment / Daraa

Fig. 195.12 Number of Operating Room Equipment / Daraa

156

Fig. 196.12 Number of Laboratory Equipment / Daraa

157

Fig. 197.12 Number of Shared Equipment / Daraa

158

Fig. 198.12 Number of Available Blood Banks / Daraa

Fig. 199.12 Number of Available Renal Dialysis Units / Daraa

Fig. 200.12 Number of Emergency Visitors and admission / Daraa

159

Fig. 201.12 Number of Outpatient Visitors and Admission / Daraa

Fig. 202.12 Number of Surgeries without Details (depend on Hospital Record) / Daraa

161

Fig. 203.12 Number of Surgeries with Details (depend on Hospital Record) / Daraa

161

Fig. 204.12 Number of Hospital Deliveries / Daraa

Fig. 205.12 Financial Support Staff / Daraa

Fig. 206.12 Financial Support Running Cost / Daraa

Fig. 207.12 Financial Support Consumables / Daraa

162

Fig. 208.12 Human Resources Surgical Doctors / Daraa

163

Fig. 209.12 Human Resources Non-Surgical Staff / Daraa

164

Fig. 210.12 Human Resources Nursing Staff / Daraa

Fig. 211.12 Human Resources Technicians / Daraa

165

14- Qunaitra

Fig. 212.14 Number of Available Departments / Qunaitra

Fig. 213.14 Number of Surgical Out Patient Department / Qunaitra

166

Fig. 214.14 Number of Non-Surgical Outpatient Department / Qunaitra

Fig. 215.14 Number of Beds / Qunaitra

167

Fig. 216.14 Number of X-Ray Equipment / Qunaitra

Fig. 217.14 Number of Operating Room Equipment / Qunaitra

168

Fig. 218.14 Number of Laboratory Equipment / Qunaitra

169

Fig. 219.14 Number of Shared Equipment / Qunaitra

Fig. 220.14 Number of Available Blood Banks / Qunaitra

171

Fig. 221.14 Number of Emergency Visitors and admission / Qunaitra

Fig. 222.14 Number of Outpatient Visitors and Admission / Qunaitra

Fig. 223.14 Number of Surgeries without Details (depend on Hospital Record) / Qunaitra

171

Fig. 224.14 Number of Surgeries with Details (depend on Hospital Record) / Qunaitra

172

Fig. 225.14 Number of Hospital Deliveries / Qunaitra

Fig. 226.14 Financial Support Staff / Qunaitra

Fig. 227.14 Financial Support Running Cost / Qunaitra

173

Fig. 228.14 Financial Support Consumables / Qunaitra

Fig. 229.14 Human Resources Surgical Doctors / Qunaitra

174

Fig. 230.14 Human Resources Non-Surgical Staff / Qunaitra

175

Fig. 231.14 Human Resources Nursing Staff / Qunaitra

Fig. 232.14 Human Resources Technicians / Qunaitra

176

Conclusion and recommendation From the data obtained in this report we identified the need to: 1. Incorporate regular updated data from hospitals inside Syria to inform the strategic plan for delivery of health services as an integral part of all medical relief efforts 2. Set minimum requirements for the work of hospitals and to develop the health sector based on these minimum standards. 3. Analyze the health sector en bloc with the goal of providing quality, integrated health services for the largest number of beneficiaries 4. Foster cooperation between all international and local organizations through joint ventures and coordination of services provided and sharing of data 5. Balance distribution of available resources to achieve the greatest possible savings in light of the scarcity of donor resources 6. Increase donor confidence by providing real-time evidence of need for specific health services 7. Develop biomedical engineering capacity to leverage the large number of medical devices that are available in Syria but not in use due to maintenance and repair needs 8. Augment capacity for documentation and information management to raise capacity of hospitals to continually improve the quality of health data and to more effectively match resources to health needs 9. Significantly increase support for the limited human resources for health remaining within Syria 10. Develop and expand training programs for cadres of health professionals based on geographic distribution of health needs

Future Plan: 1. Planning for the next stage of data collection will take place in November 2015 and will include both follow-up to the core elements of this survey as well as allow for the inclusion of additional survey questions to be implemented in February 2016 2. The coming survey will focus on several issues that came to light in the current survey including, for example, the types and capacity of ventilators available in various hospitals inside Syria

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3. Revisions will be made to the coding system used to capture they types and extent of injuries of patients presenting to Syrian hospitals 4. Detailed surveys will be conducted on the implementation of dialysis inside Syria to include data on the number and type of dialysis units in operation, the number of hours of dialysis provided, the availability of desalination units, as well as the number of dialysis patients served by Syrian hospitals. 5. A dedicated portion of the survey will focus on unmet need for biomedical engineering services to catalog all non-functional devices and categorize them by the type of malfunction and the feasibility for repair 6. Implement a proposed project to mobilize Oxygen generators with an appropriate geographical distribution to ensure the mobilization of oxygen cylinders needed for each area 7. Launch a campaign to increase the number of infant incubators, specifically for the besieged hospitals in the Southern region of Syria where occupancy rates revealed critical shortages 8. Project to expand intensive care capacity throughout Syrian hospitals with increased numbers of central oxygen generators and ventilators 9. Project to increase the capacity of the data collection teams to regularly collect, audit and analyze health data from Syrian hospitals 10. Campaign to increase financial support for human resources for health in Syria with a focus on standardizing salary scales and expanding support for critical services in areas of geographic need

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