Primary health care centers survey by UOSSM

Report of The Survey of The Primary Healthcare Centers in the Non-Governmental and Non ISIS Controlled areas (Opposition Controlled Territories) March 2016

Contents Executive Summary: ��4 Introduction: ��4 Survey Objectives: ��4 Regional Divisions: ��5 Project Team: ��5 Methodology: ��5 Stage One (the questionnaire stage) ��5 Stage Two or Actual Survey Stage ��7 Stage Three (Data analysis and Report) ��8 Results: ��8 PHCs governorate distribution: ��8 Security situation: ��8 Accessibility: ��9 Services: ��10 Facility Type: ��10 Basic Services: ��10 Additional Services: ��14 Extra Services: ��15 Workload and Documentation: ��18 Daily working hours: ��18 Type of Available Documentation: ��18 Number of Beneficiaries in Each clinic: ��19 Chronic diseases and Distribution: ��20 Human Resources: ��22 Doctors: ��22 Nursing Staff: ��22 Technicians: ��23 Funding: ��24

Figures

Table 1 Security Situation.................................................................................................................................8 Map 1 PHCs Governrate Distribution...............................................................................................................8 Figure 2 Indirect Shelling..................................................................................................................................9 Figure 3 Accessibility........................................................................................................................................9 Figure 1 Direct Shelling....................................................................................................................................9 Figure 6 Labarotory........................................................................................................................................10 Figure 4 Types of PHCs.................................................................................................................................10 Figure 5 Pharmacy.........................................................................................................................................10 Figure 9 Reproductive health......................................................................................................................... 11 Figure 7 Lab Equipment................................................................................................................................. 11 Figure 8 Emergency Room............................................................................................................................ 11 Map 2 Refrigrators distribution by governerate..............................................................................................12 Figure 10 Nutrition..........................................................................................................................................12 Figure 11 Vaccination.....................................................................................................................................12 Table 2 Cold Chain and vaccination human resources..................................................................................13 Figure 12 Vaccination Human resource.........................................................................................................13 Figure 13 EWARN..........................................................................................................................................13 Figure 15 Labour............................................................................................................................................14 Figure 16 Physiotherapy................................................................................................................................14 Figure 17 leishmania......................................................................................................................................14 Figure 14 Comunity health.............................................................................................................................14 Figure 19 X- ray equipment............................................................................................................................15 Figure 21 other equipment 2..........................................................................................................................15 Figure 18 Radiology.......................................................................................................................................15 Figure 20 Other Equipment 1.........................................................................................................................16 Figure 23 Available clinics 1...........................................................................................................................16 Figure 22 other equipment 3..........................................................................................................................16 Figure 25 weekly working days 1.................................................................................................................17 Figure 26 weekly working days 2...................................................................................................................17 Figure 24 Available clinics 2...........................................................................................................................17 Figure 28 Working Hours per Governorate....................................................................................................18 Figure 30 documentation Type by Governerate.............................................................................................18 Figure 27 Daily Working Hours.......................................................................................................................18 Figure 29 Documentation...............................................................................................................................18 Figure 31 No. of consultations in different clinics...........................................................................................19 Figure 32 No of consultaions in diferent clinics 1...........................................................................................20 Figure 33 No. of patients with chronic diseases.............................................................................................21 Figure 34 Population, workload, PHC per population....................................................................................21 Figure 35 Non Surgical Medical Staff.............................................................................................................22 Figure 36 No. of Obstetricians........................................................................................................................22 Figure 39 No. of Midwives..............................................................................................................................23 Figure 38 No. of Technicians..........................................................................................................................23 Figure 37 No. of Nursing Staff........................................................................................................................23 Figure 41 Medications & Consumbles...........................................................................................................24 Figure 42 Running Cost.................................................................................................................................24 Figure 40 Staff Support..................................................................................................................................24

EXECUTIVE SUMMARY: The Primary Healthcare Centers (PHCs) in Syria have been under a great pressure due to the lack of human resources and financial support. In addition to this, there is no systematic process or international standards to set up these centers. To do an efficient assessment of the needs in these services and fair distribution of available resources this survey has been conducted. This survey has been carried out by the UOSSM-international and across continents physicians in Turkey in January 2016. One hundred and twelve centers have been surveyed and data have been collected by trained data collectors. These data include the workload, type of services, medical equipment and its functioning status, in addition to the delivered medical programs and working medical staff along with the financial support for these centers. Results showed that there was considerable number of advance PHCs. Whereas 78% out of 112 surveyed PHCs provided five basic services on average. The advance PHCs provided one extra service to the basic services. On the other hand, the essential vaccination service was available in 41 centers, which are incomplete service. Also major shortage was found in many essential services such as nutrition, community health worker, EWARN in addition to important programs like IMCI. This is the first detailed survey of primary healthcare services in the areas outside the control of the Syrian government or the ISIS. It also complements the HeRMS Survey. It looked into general data regarding the primary healthcare services of the surveyed centers

INTRODUCTION: The failure of the healthcare system in general and in particular the primary healthcare in Syria in general and in particular in the areas outside the control of the Syrian opposition controlled territories is an indicator of the lack of efficient management and strategic planning in determining the dimensions of the healthcare crisis. This failure can be demonstrated through the following points •

Poor strategic planning and greatly focusing on reactive and short term response strategy without midterm and long term planning to fulfill the needs.

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The unbalanced distribution of medical resources that is often based on incomplete or baseless data. This can be seen in particular in the data related to the chronic illnesses and communicable diseases.

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The lack of the healthcare services in general and the poor quality of services lead to increase the mortality rate.

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The disparate need for full primary healthcare service and in particular child and women care along with full scale vaccination program in addition to healthcare awareness that are considered the essentials of these centers.

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The migration of medical and nursing staff and other healthcare staff for their safety or for better lives for their families that has worsened lately due to systematic targeting of the healthcare facilities and medical staffing in addition to the death of healthcare workers has significantly worsened the healthcare crisis.

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The changing and repeated displacement of communities due to the changing of the war situations and changing things on the ground make it difficult to assess the needs

The data is considered to be the corner stone in any strategic planning. It is also extremely difficult to do any suitable or valid statistical analysis or evaluation to determine the problems in the healthcare system or the solutions for it without systematic and trusted source of information. In the absence of a specific and a unified resource of these data and in the absence of centralized management for the healthcare services, the medical organizations that are working on the ground will often find themselves facing big challenges in term of the need for documented and up-to-date information to function and to do strategic planning. Given the above, The UOSSM-international along with Physicians Across the Continents PAC in corporation with other NGOs working on the ground in Syria such as Syrian American Medical Society (SAMS) and Syrian Expatriates Medical Associations have taken this task as a challenge and have done this survey of the primary healthcare centers in the areas outside the control of Syrian government or ISIS. Furthermore, the local healthcare directorates have been essential partner in this survey to build up their capabilities to take over this task in the future.

SURVEY OBJECTIVES: The main objective is to determine the resources needed to meet the needs of population in the areas controlled by the opposition from the primary healthcare point of view according to SPHERE Project criteria. 4

Detailed Objectives: •

To survey the geographical distribution of the primary healthcare center and the populations served by them

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To survey the services provided by these centers

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To assess the available resources in the surveyed centers (fund, human resources, medical indicators, medical equipment, medicines and essential consumables)

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To assess the surplus of resources in the PHCs (Equipment, human resources, fund)

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To assess the risks the these centers faced (Lack of specialist human resources, bombardment, lack of fund, lack of technical support, supply routes and accessibility, the reaction of communities and patients transfer)

REGIONAL DIVISIONS: The surveyed areas have three main divisions geographically and taking into account the supply routes and accessibility •

The Northern Province

This is the largest area. It consists of Governorates of Aleppo, Idlib, Deer Alzour, Raqqa, Hasaka, Latakia and Hama. Support is mainly delivered via and Turkish borders. The eastern part of this province that extend from the eastern country sides of Aleppo to the Iraqi borders is under the control of ISIS and all centers have been excluded from the survey. This makes it very difficult to reach and impossible to do the survey. In this region, 75 out of (142 ) centers have been surveyed. •

The Middle Province

It is smaller than the Northern Province. The main route of supply is Lebanon. There are three governorates. These are Damascus, Countryside of Damascus (Ghouta), and Homs. Twenty one centers out 32 have been surveyed. The areas in this province are separated from each other due besiege and therefore the besieged areas have been divided into independent residential regions where their data have been analyzed separately. •

The Southern Province

It is the smallest province. The Jordanian borders are the main supply routes for these areas. There are only two governorates in this province. These are Quenatra and Daraa. All 16 centers have been included in this survey.

PROJECT TEAM: The team was formed of the following: •

Trained enumerators to collect the data (16 in Northern region, 6 in the Middle area and 3 in southern region)

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Provinces Directors to receive the data from each province and they verify these data. They also present a general view of the work on ground to ensure the quality and the safety of data. In the Southern Province and the Middle Province, there has been only the province director who has been responsible for data verifying for these provinces. However, as the Northern Province is large there was a need for one officer for each governorate in this Province in addition to the Province Director.

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Director of Data and Research in UOSSM-International. All data have been passed to the director of Data the research and these data have been verified again.

METHODOLOGY: The survey has been conducted over three months and at three stages.

Stage One (the questionnaire stage) The survey questionnaire has been discussed and designed by group of medical specialists working in the medical field. This includes Dr Abdullah Mawas Consultant Gastroenterologist and General Physician from UK and Primary Healthcare Committee UOSSM-Interntional, Mr Abdulrazzak Qentar Administrative Director of Primary Healthcare UOSSM-international, Dr Maan Kanjo The Medical Liaison Officer in primary healthcare UOSSM international, Dr Jamal Qoli (General Internist) Administrative Director of Hospitals UOSSM-International, DR Yasser Najeeb Specialist in Internal Medicine from SRTF, Dr Mahmood Hariri Trauma Surgeon and director of Data and research UOSSMInternational. The questionnaire has focused on the following 5

a. The geographical location of center and security status This focuses on the location and the direct and indirect targeting of these centers b. Center Accessibility This means the supply routes for Medicines and medical consumables and according to the international criteria, the centers are classified as easy accessible, or hard to reach and besieged c. Type of Service provided the center 1. Basic Primary Healthcare Centers (Where primary healthcare basic services are provided) In these centers, there should be at least a general practitioner, with or without a specialist doctor in addition to three or more of the following basic services: 1. Childcare 2. Reproductive Healthcare 3. Nutrition 4. Routine Vaccination services 5. Free essential medicines (or symbolic charge) 6. Wounds Dressing Services 7. Healthcare Education and communities healthcare workers groups 8. Basic Laboratory 9. EWARN 2. Advanced Primary Healthcare Centers In these centers and in addition to what is available in the basic centers, there should be one of the following services: 1. 24/7 Labour Room 2. Advanced Laboratory 3. Weekly specialist clinic 4. Physiotherapy services 5. Dental care services (preventive and emergency care) 6. Leishmaniasis clinic 3. Others centers: where they have not met the criteria for the basic or the advanced centers d. Available Services: 1. Pharmacy: availability, cost (free, or fully paid and symbolically paid) 2. Laboratory: (equipment and its function and validity and the cost) 3. Dressing Room 4. Children Care 5. Basic: Children Healthcare Services or 6. Advanced: where a paediatrician is available and IMCI (integrated medical care for children) 7. Reproductive Healthcare 8. Basic: Services is provided by midwives 9. Advanced: Availability of Obstetrician and Gynecologist or 24/7 labour room 10. Nutrition 11. Basic: Trained staff on child nutrition, nutrition program for infants and children, availability of malnutrition assessing tools (MUAC tape, weight scale, height measuring tool) 12. Advanced: In addition to the basic, there should be a nutrition specialist 13. Vaccination Services 14. Trained Staff availability (BCG vaccination experience) 6

15. Cold chain: this is considered complete when all six elements available (functioning fridge to keep the vaccines, vaccines carrier bag, cooling or refrigerating box, thermometer for the fridge, ice cubes and freezing indicator in addition to 24 hour electric power availability). Absence any element of this chain will make it incomplete. 16. EWARN (System Early reporting of Communicable diseases reporting) : the question was about whether it is available or not 17. Community Healthcare Workers (availability) 18. Dental Care: (preventive measures in addition to dental work with or without x-ray machines 19. Labour and delivery services for 24/7 20. Physiotherapy (available or not) 21. Leishmaniasis (available or not) 22. Additional services or surpluses (X-ray services, Defibrillator, nerve conduction study machines, Gynae USS without a gynecologist) Specialist clinics e. The Work Load 1. Number of the working days of the center 2. Daily working hours of the center 3. Documentation (paper or electronic or nil) 4. Number of patients seen in each center 5. Number of people benefited from additional services such as pharmacy, laboratory, physiotherapy 6. Number of people benefited from vaccination services 7. Number and distribution of some chronic conditions such as Diabetes type1 and 2, Hypertension, Thalassemia, Epilepsy, Ischaemic heart diseases. f. Human Resources (Medical and healthcare workers classification) 1. Doctors, Dentists and Pharmacists: GPs, Internists, and other Specialists, residents, colleges students 2. Nurses: Fully Qualified, or experience certificate 3. Technicians: Fully Qualified, or experience certificate g. Financial Support 1. Wages of healthcare workers 2. Running cost support 3. Medical and pharmaceutical consumables The answer options include: a. Full Supported b. Partial Supported c. No Supported During this stage, the survey questionnaire has been designed on KoBo Toolbox platform. The questionnaire has been reviewed and verified from the designated team. The data collectors have been trained how to collect the data and how to conduct the survey and how to use The KoBo Toolbox on Laptops and smart phones. The training in the Northern Province has been conducted at Bab Alhawa Hospital training center. However, in the Middle and Southern Province the training has been via the internet due the inability to travel as they live in besieged areas or due security reasons. There has been as pilot survey initially on 30 centers in all provinces and after reviewing the results of this pilot survey the questionnaire has been accepted without any amendments to be used for the second stage.

Stage Two or Actual Survey Stage This has been conducted over a month time when all data have been collected. Verification has taken place at three levels 7

1. The first Verification was done by Governorates officers in the Northern Province and Provinces directors in the Middle and Southern Provinces. 2. Second Verification was done by Provinces directors 3. Third Verification was done the Director of Research at UOSSM-International At the end of this stage when the data have been collected, verified and transferred to the central data port.

Stage Three (Data analysis and Report) The data have been analyzed using Excel. Following the analysis, there has a description statistics along with geographical map projection for results. In this report, the data has been categorized into comparative groups according to the questions and merging data of governorates under each parameter. The Survey results have been looked into at three levels a. National Level: Presents a general picture for the primary healthcare in the areas outside the control of the Syrian government or ISIS b. Regional Assessment: Describes the quality of healthcare services in Governorates and taking into account that the besieged areas are looked at individually c. Centers Related: Presents a description of the center itself including functioning status, infrastructure, availability of services, and the workload in the center. A certificate from KoBo toolbox has been issued for each center taking into account the respect of the confidentiality and security of the data.

RESULTS: 1. PHCs governorate distribution: The surveyed PHCs were concentrated among Aleppo and Idleb governarates with few in Hama, Homs and Qunitra. In Rural Damascus we reached only 9 centers in Eastren Ghouta. We do not have clear information on the eastren part of Syria which is under ISIS control.

2. Security situation: Most PHCs were shelled either directly or indirectly by shelling the area of the PHC. The direct shelling was reported in 29% of the surveyed centers while indirect shelling was encountered in 71% of the centers.

Map 1 PHCs Governrate Distribution

Table 1 Security Situation 8

Figure 2 Indirect Shelling

Figure 1 Direct Shelling

3. Accessibility: The term accessibilty means: according to our questionaire as the ability to provide the center with medication and conumables, however we did not consider patient accessibilty. PHCs classified as follow: •

Beseiged centers: 9 centers goes under this category in Rural Damascus and 12 in Northern Homs.

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Hard to reach centers: only one center in Tamana ,Idleb

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Accessible: 80% of the surveyed PHCs were accessible.

Figure 3 Accessibility 9

4. Services: a. Facility Type: According the recommended classification, centers are classified into basic, advanced, and others. Seventy eight percent 78% of the surveyed centers were found to be advanced and provided five basic service on average in addition to one or more advance service. On the other hand, the total basic centers are 14. Ten more center did not match the two types such as availability of two basic services, only 6 centers and three centers with two basic services and one advanced service. Finally one center had labour service only.

Figure 4 Types of PHCs

b. Basic Services: 1. Pharmacy: Pharmacy with free basic medications was available in 88% centers except three centers were providing medicine for charity price. Only 13 centers did not have pharmacy. We did not query about medication source.

Figure 5 Pharmacy 2.

Laboratory:

Basic labaratory services were provided by 40% of the centers, 47 centers, matching with lab equipent which were simple enough for basic tests. Tests are done by professional technicians in all centers except nine centers where tests were done by nurses. Some centers had more than one technician.

Figure 6 Labarotory 10

Figure 7 Lab Equipment

3. Dressing and Emergency Room: Most centers had room for emergency and dressing which was almost all free of charge. 4. Pediatric Service: Twenty centers provide simple pediatric service through general practitioners only, whereas, 75 centers provide advanced service through pediatricians either specialists or residents with or without general practitioners. Therefore, 103 centers provide pediatric service out of 112 surveyed centers. There was no clear information about the experience of pediatricians in IMCI program; however, five centers claim to have IMCI expert staff. 5. Reproductive Health: Reproductive health service either basic or advanced was provided by 65% of the surveyed centers, mainly in Aleppo governorate centers and in half of the rest governorates centers. Questions about reproductive health tools such as Pap smear, pregnancy follow up and contraceptive tools are available in 18 centers only. Reproductive health services provided by midwives without labour in 39 centers and provided by specialists or midwives with labour in 39 centers.

Figure 9 Reproductive health 11

Figure 8 Emergency Room

6. Nutrition: Only 20 centers (17%) were found to provide nutrition service. The nutrition equipment such as MUAC ,and pediatric scale were available in these centers. Eleven centers had nutrition technicians, however no nutrition specialists were available.

Figure 10 Nutrition

7. Vaccination Vaccination is most important service in the primary health care. In this survey, 41 PHCs (36%) were found to provide this service. These centers were distributed as follow: •

13 centers in Aleppo

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10 in idleb

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7 in Daraa

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6 in Homs

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4 in eastren Ghota

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One in Hama

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None in Qunitra

A deep analysis for this service was done as follow: •

Cold chain composed of six items refrigerator is the most important one in addition to 24 hours seven days electricity. There are 41 refrigerators distributed on 35 centrs out of 41centers providing vaccination service with five are not functional and six centers have two refregerators. Map 2. The rest components of cold chain prsented in differnet number as in table2

Figure 11 Vaccination

Map 2 Refrigrators distribution by governerate

Table 2 Cold Chain and vaccination human resources

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Only 38 vaccination experts are available in 38 centers, which considered as the experience in tuberculosis vaccine as an indicator. Figure 12

Figure 12 Vaccination Human resource In conclusion, completing cold chain and training three vaccination staff in addition to 24 hours electricity will make the 41 centers in different area in Syria able to provide vaccination program.

Looking for electricity we found almost one electric generator in each center. Seven generators required maintenance. However, two centers did not have any generator and they might have another electric source. One of them provides vaccination service in Idleb. No more information about electric source was available in the surveyed centers.

8. Ewarn: 45% PHCs were involved in EWARN programm. No more details provided. ACU supports with the structure of EWARN system.

Figure 13 EWARN 13

9. Community Health: Community health service is one of uncommon services in Syria. Only 24% of the PHCs were found to have CHW.

Figure 14 Comunity health c. Additional Services: 1. Dental care: Dental clinics were available in 38 centers out of 112 surveyed centers. There were 51 dentists encountered in 38 centers as more than one dentists were found to be working in more than one center. Only two dental x-ray were available. 2. Labour: Labour service had been provided by only 32% PHCs and depends on midwives and rarly on specialists. This service was free except in two centers where service was supported by charity. Some centers work 24/7. In Rural damascus one center is dedicated for reproductive nealth only.

Figure 15 Labour

3. Physiotherapy: Physiotherapy were available in 20 PHCs 18% . This service had been surveyed in Hospital survey August 2015 which revealed physiotherapy in 44 hospitals out of 113 hospitals. There are some other seprate physiotherapy centers.

Figure 16 Physiotherapy

4. Lishmaniasis: Leishmaniasis diagnosis and\or therapy have been provided by 38 centers in Aleppo and 18 centers in Idleb which is compatible with the epidemiology of this disease. Few centers in the rest governerates , two in Hama and Damascus countryside and three in Homs. Non of Qunitra or Daraa centers provided such service. The total number of Leishmaniasis technicians are 95.

Figure 17 leishmania 14

d. Extra Services: 1. Radiology: Thirty one percent of the surveyed centers were found to provide free radiology service except two centers are prtially paid and one fully paid. Such service is not part of primry health care according to internationl criteria and could be shifted to the hospital nearby. Regarding radiology equipment, either fixed or mobile , there are seven machines require maintenance. Moreover, there are 37 ultrasound machines of diferent sizes and ten require maintenance. Inspite of prsence of 38 dental clinic only two dental x-ray available. Some other radiology equipment such as panorama and mamography which are rare. The number of available ultrasound have been matched with availability of either internists or obstetricians and the result revealed that there are ultrasound machines in 23 centers three with obstetricians and 12 with internists. Finally nine centers had ultrasound without the trained staff to use them.

Figure 18 Radiology

Figure 19 X- ray equipment

Other Equipment: There are essential equipment and extra equipment in some centers. Some of these equipment required maintenance such as 15 sterlisation machines and autoclaves , 23 nebulisers and 12 ECG machines. On the other hand, around forty centers had dry and wet sterilization machines. Nebulisers were almost available in all centers, however, 41 centers only had ECG machine.

Figure 21 other equipment 2 15

Figure 22 other equipment 3 Figure 20 Other Equipment 1

Basic and Additional Clinics: More than half of the centers had general practitioners where the GPs or internists do the most consultations (pediatric, internal or dermatologic diseases). The internal medicine clinic was available in 73 centers and pediatric clinic in 75 centers. Dental clinics were available in one third of all surveyed centers. Regarding obstetrics and gynecology or reproductive healthcare clinics, were available in 69 PHCs. Services provided by midwives or specialists.

Figure 23 Available clinics 1 16

Figure 25 weekly working days 1

Figure 24 Available clinics 2

With regard to the weekly working days, we found that most basic clinics such general practitioner, pediatric and internal medicine have almost five to six working days per week. However, the rest clinics work less days as doctors

Figure 26 weekly working days 2 17

usually working in more than one center.

5. Workload and Documentation: a. Daily working hours: Working hours in health centers were categorised into 3 categories: •

Health centers that work for less than 6 hours a day (20% of health centers)

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Health centers that work between 6 and 12 hours a day, which are most of the centers with average of 8 working hour per day.

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Health centers that work more than 12 hours a day (20% of health centers, which provide labour services work 24 hours a day).

Figure 27 Daily Working Hours

Figure 28 Working Hours per Governorate b. Type of Available Documentation: Only one health center out of all surveyed centers did not have any medical records, while 35% of centers use paper records only and 8% use electronic records only. The rest use both paper and electronic records.

Figure 29 Documentation

Figure 30 documentation Type by Governerate 18

c. Number of Beneficiaries in Each clinic: 1. The total number of consultations during the month in which the survey was conducted (January 2016) is 380.000, with 308.000 consultations in pediatric, internal medicine, and general medicine clinics. 2. Significant increase of consultations in some of the subspecialties such as ENT, cardiology, and dermatology. This increase is not compatible with the available human resources, However, GPs and internists were dealing with these consultations. 3. The total number of beneficiaries in dental clinics was 19.000 beneficiaries. 4. The total number of beneficiaries in gynecology clinics was 49.000 women, in addition to 9.000 women benefited from childbirth and labor unit (Not verified if these figures represent only deliveries that happen in the health center). 5. More than 250.000 beneficiaries benefited from prescribed medications that were distributed by centersâ&#x20AC;&#x2122; pharmacies by free. 6. Around 32.000 children benefited from vaccinations (No information in term of types of vaccinations).

Figure 31 No. of consultations in different clinics 19

Figure 32 No of consultaions in diferent clinics 1 d. Chronic diseases and Distribution: In term of chronic diseases, there were six main diseases that were included in this survey: 1. Diabetes type I, and II: Average number is 22.000 people, more than half of them from Idelb governorate (Possibly due to high population density and high number of internally displaced people in Idelb) 2. 17.000 Cases of Hypertension 3. 6.500 Cases of Asthma 4. 3.300 cases of MI 5. 1.500 cases of epilepsy 6. 281 cases of thalassemia. 20

Previous numbers may not represent the real incidence or prevalence or caseload of these chronic diseases, due to some possible errors in records that cannot distinguish between new cases and routine visits. However, this numbers could be used to estimate the workload with future monthly follow-up to determine approximate real numbers and subsequently define the need for medications and equipment.

Figure 33 No. of patients with chronic diseases

Figure 34 Population, workload, PHC per population 21

Comparison with Sphere Criteria: Comparing the results of the survey with “SPHERE Health Sector” minimum standards: The following comparison was done as following: •

Number of population for each governorate and expected workload according to “SPHERE Health Sector” minimum standards, and the current coverage of health facilities.

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The proportion of the number of health centers to the population in each governorate

With deep analysis for the available data: •

Expected number of annual consultations according to population with considering two consultations per year per capita according to SPHERE criteria.

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Comparing the current workload in the surveyed centers to the expected workload the result in Aleppo, as an example, the surveyed 43 centers out of 84 centers were covering less than 30 % from the expected workload. Moreover, all Daraa PHCs were covering 50% from the expected workload.

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Finally, we compare the number of PHCs to the population, with considering SPHERE as guidelines.

HUMAN RESOURCES: Medical human resources were studied in term of number, specialties, skills, and working in one or multiple facilities. For those who work in multiple facilities it was considered that they work in two facilities only, for statistical reasons, and Statistical adjustment was done on these numbers.

Doctors: 1. The focus was on general practitioner, internists, and pediatricians as main elements for PHCs: •

25 GPs

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15 Medical students from different levels

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58 internists, 3 of them are residents

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70 pediatricians, 6 of them are residents

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23 Dermatologists, 2 of them are residents

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18 Cardiologists

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40 Pharmacists, 2 of them are not yet graduated

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51 dentists, 7 of them are not yet graduated

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Small numbers of medical staff from other specialties, not exceeding 2 for each specialty.

Figure 35 Non Surgical Medical Staff

2. In term of obstetricians and gynecologists, the total number was 14 including either specialists or residents, after statistical adjustment. 3. Numbers of surgeons were not taken into consideration, due to their direct relation to hospitals, which was covered in our previous Hospital Survey.

Nursing Staff: Nursing staff was categorised according to their specialties, skills, and working in one or multiple facilities. In addition, it was noticed that most of the nursing staff work in one facility unlike doctors.

Figure 36 No. of Obstetricians 22

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The total number of nurses who worked on Leishmaniasis is 93 half of them are not qualified. They worked in diagnosis and treatment without dermatologists. These centers were mainly in Aleppo and Idleb, as expected.

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There are 8 nurses qualified or skilled in IMCI.

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The total number of nurses working in emergency department, dressing room, and out-patient clinics was 536, half of them have no nursing degree.

Figure 37 No. of Nursing Staff Technicians: •

The total number of laboratory technicians was 72, 12 out of them were not qualified

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The total number of Community Health Workers who were officially registered in medical centers is only 73, 2/3 of them were not qualified. This figure is not meeting the minimum standard of SPHERE (which is 1/1000 population). This number is expected to be higher than this, and will be verified during the next surveys

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The total number of midwifes is 113, and 16 of them were not qualified

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Half of pharmacy technicians, out of 70, were not qualified.

Figure 38 No. of Technicians

Figure 39 No. of Midwives 23

FUNDING: Funding are considered to be the most important issue that faces the medical work in Syria, not only for the human resources but also for the running costs. This is due to difficulties in money transferring to Syria, and difficulties in doing proper documentation for all expenses. On the other hand, most NGOs tend to support with medications and consumables because it’s easy to be bought and transferred although it’s not enough in general. This is considered as a reason for doctors to work in multiple facilities or even leave Syria with inability to meet the minimum requirement for living.

1. Staff: The survey shows that 39% of medical staff were fully supported in term of salaries, while 31% partially supported and 30 not supported at all, which indicates a gap that need to be filled.

Figure 40 Staff Support

2. Medication and consumables: The survey shows that 65% of PHCs were partially supported, while only 18% fully supported with medications and consumables, and 17% were not supported at all. So these figures will be compared with the workload of each facility to determine the priorities for funding and the needs for support in term of medications and consumables.

Figure 41 Medications & Consumbles

3. Running Costs: Of the surveyed enters, 28% were fully supported, while 34% were partially supported, and 38 were not supported at all. Taking into consideration that supporting the running costs for PHCs do not require high fund.

Figure 42 Running Cost

—End of the Report— 24