contents...this report provides descriptive analysis of the situation of the public health centres...

HeRAMS| Public Health Centres Reports, April to June 2015 Page 1 of 29

Contents

Exceutive Sumamry ................................................................................................................................. 2

1. Completeness of reporting ............................................................................................................. 4

2. Functionality Status ........................................................................................................................ 5

3. Accessibility Status .......................................................................................................................... 7

4. Infrasturctual Patterns .................................................................................................................... 9

4.1 Condition of the building ........................................................................................................ 9

4.2 Water sources and functionality status ................................................................................ 11

4.3 Availability of electricity generators ..................................................................................... 12

4.4 Availability of Refrigerators .................................................................................................. 13

5. Availability of Health Human Resources ....................................................................................... 14

6. Availability of Health Services ....................................................................................................... 16

6.1 General Clinical services........................................................................................................ 18

6.2 Emergency services ............................................................................................................... 19

6.3 Child Health ........................................................................................................................... 19

6.4 Nutrition ................................................................................................................................ 21

6.5 Sexual & Reproductive Health .............................................................................................. 21

6.6 Non Communicable Diseases (NCDs) .................................................................................... 24

6.7 Mental health care ................................................................................................................ 24

7. Availability of Medical Equipment ................................................................................................ 25

8. Availability of Priority Medicines .................................................................................................. 27

9. Conclusions and Recommendations ............................................................................................. 28


Exceutive Sumamry

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

accessibility, condition status, availability of resources and services, are conducted using HeRAMS

(Health Resources & services Availability Mapping System) tool.

This report provides descriptive analysis of the situation of the public health centres of MoH

(Ministry of Health), from all 14 governorates of Syria, during the 2nd Quarter 2015. The total

assessed health centres have increased in the 2nd Quarter 2015 to reach 1,783 compared to 1,777 in

the 1st Quarter 2015, due to establishment of new health centres.

Completeness of Centre's reporting

The completeness of reporting of health centres has increased in the 2nd Quarter to reach 96%,

compared to 92% at the end of 1st Quarter.

Functionality status of the health centres

By end of the 2nd Quarter 2015 and out of 1,783 assessed public health centres, 47% (836) were

reported fully functioning, 23% (411) partially functioning, 26% (464) non-functioning (completely

out of service), while the functionality status of 4% (72) of health centres were unknown.

Accessibility status

By end of the 2nd Quarter 2015, 76% (1,348) health centres were reported accessible, 1% (12) hard-

to-access, and 21% (385) were inaccessible, while the accessibility status of 2% (38) health centres

were unknown.

Infrastructure of Health Centres

By end of the 2nd Quarter 2015, 22% (393) health centres were reported damaged [6% fully damaged

and 16% partially damaged], 66% (1,172) of public health centres were reported intact, while the

building’s condition of 12% (218) health centres were unknown.

Assessing the availability of water sources at functional public centres indicated that 85% (1,060) are

using main pipelines, 2% (27) are mainly using wells, while 8% (95) are using both (main pipeline and

well).

Availability of electricity generators and refrigerators were monitored at health centres’ level. Gaps

were observed in many governorates.

Human Resources

By end of the 2nd Quarter 2015, the proportions of different categories of health staff among the

total functional (fully and partially) health centres (1,247 /1,783), remained almost the same as 1st

Quarter 2015. The resident doctors represented (1%) of total health staff at centres’ level, followed

by general practitioners (4%); pharmacists (6%); laboratory (7%); specialists (8%); dentists (10%);

midwives (11%); and nurses (53%).


Availability of Health Services

The availability of core health services is monitored through HeRAMS at health centre’s level,

considering a standard list of health services [includes: General Clinical and Emergency Services,

Child Health, Nutrition, Sexual & Reproductive Health, Non-communicable Diseases and Mental

Health].

As a result of disrupted healthcare delivery, limited provision of many health services, even within

the functional health centres were observed.

Availability of Medical Equipment

Analysis of availability of essential equipment has been measured across all functioning health

centres [fully and partially functioning] (1,247 /1,783), in terms of functional equipment out of the

total available equipment in the health centre. The produced analysis provides good indication of

the current readiness of the health centres to provide the health services, and also to guide focused

planning for procurement and distribution of equipment and machines, to fill-in identified gaps that

were observe even within the functional health centres.

Availability of Priority Medicines

Availability of medicines and consumables at health centres’ level has been evaluated based on a

standard list of identified priority medicines and medical supplies for duration of one quarter. Gaps

of medicines and medical supplies are identified even within the functional health centres (i.e., gap

of 71% gap of Anti-diabetic preparations, 65% of Cardiac and /or Vascular Drugs, 59% of Antibiotics,

49% of Anti-allergic including Steroids, 49% of ORS, and 34% of Antiseptics).


1. Completeness of reporting

The completeness of reporting of health centres has increased

in the 2nd Quarter to reach 96%, compared to 92% at the end

of 1st Quarter, due to slight improvement of reporting in Idleb

governorate [Figure 1].

The total number of assessed public health centres has

increased in the 2nd Quarter to reach 1,783 compared to

1,777 in the 1st Quarter 2015, due to establishment of new

health centres.

The classification of health centres (1,783) per type is

presented in [Figure 2], of which the majority is Primary

Healthcare Centres (85%), followed by medical points (8%),

specialized centres (5%), and comprehensive/ polyclinics (2%).

The levels of completeness of reporting of health centres at

governorate level are presented in [Figure 3]. Out of a total

reported 1,711 health centre, 1,445 (84%) are PHC centres.

The security escalations and accessibility remain a key

challenge for completeness of reporting; the main gap of

reporting is observed in Idleb (46%), while minor gaps were in

Hama (4%), Rural Damascus (3%), Aleppo (1%), Al-Hasakeh

(1%), and Homs (1%).

Figure 3: Completeness of reporting of health centres at governorate level, 2nd

Quarter 2015

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

accessibility, and infrastructure of the public health centres, availability of resources & services, and

available equipment and medicines by end of the 2nd Quarter 2015.

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

resources, and contributes to significant and focused humanitarian response by WHO and health

sector partners.

227 222

181 169 165

116 114 103 103 97 93

73 61 59

224 219

175 162 165

116

62

103 103 96 93

73 61 59

0

50

100

150

200

250

Aleppo Homs RuralDamascus

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

Total Centres Total Reported

Comprehensive Clinic 2%

(43)

Specialized Centre 5%

(85)

Medical Point 8%

(141)

Primary Health Care Center, 85%

(1,514)

Figure 2: Classification of centres

Reported 96%

(1,711)

Gap 4% (72)

Figure 1: Completeness of Reporting- Q2 2015


2. Functionality Status

Functionality of the health centres has been defined and

assessed at three levels;

Fully Functioning: a health centre is open, accessible, and

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

equipment, and infrastructure).

Partially functioning: a health centre is open and provides

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

shortage of staffing, equipment, or damage in

infrastructure).

Not functioning: a health centre is out of service, because it

is either fully damaged, inaccessible, no available staff, or no

equipment.

By end of the 2nd Quarter 2015 and out of 1,783 assessed public health centres, 47% (836) were

reported fully functioning, 23% (411) partially functioning, 26% (464) non-functioning

(completely out of service), while the functionality status of 4% (72) of health centres were

unknown [Figure 4].

Detailed analysis on the functionality status of the health centres at governorate level is shown

in [Figure 5] and [Map 1].

Figure 5: Functionality status of health centres per governorate, 2nd

Quarter 2015

165

89

104

51

128

135

27

79

19

11

11

14

3

0

0

3

3

1

15

42

4

38

59

39

21

101

66

19

0

1

9

9

19

42

28

58

25

46

30

109

34

54

0

0

0

0

7

3

0

6

0

1

52

3

0

0

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

Tartous

As-Sweida

Lattakia

Damascus

Hama

Homs

Quneitra

Rural Damascus

Dar'a

Al-Hasakeh

Idleb

Aleppo

Deir-ez-Zor

Ar-Raqqa

Fully Functioning Partially Functioning Non-functioning No Report

Fully Functioning 47% (836)

Partially Functioning 23% (411)

Non-functioning26% (464)

No Report 4% (72)

Figure 4: Functionality Status- Q2 2015


Map 1: Functionality status of the public health centres, 2nd

Quarter 2015

The number of non-functioning health centres increased from 419 to 464 (between 1st Quarter 2015

and 2nd Quarter 2015) [Figure 6]. This indicates the direct impact of the deteriorating security

situation in Idleb, Al-Hasakeh, Deir-ez-Zor, and Ar-Raqqa governorates.

Figure 6: Trend analysis of functionality status, between 1st

Quarter 2014 and 2nd

Quarter 2015

876 887 857 862 832 836

291

376

374

466

392 411

161

311

387

385

419 464

416

170 132

63 134

72 0

100

200

300

400

500

600

700

800

900

1000

Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015



3. Accessibility Status

Accessibility to health centres is defined at three levels:

Accessible: a health centre is easily accessible for

patients and health staff.

Hard-to-reach: a health centre is hardly reached, due to

security situation or long distance.

Inaccessible: a health centre is not accessible because

of the security situation, or a centre is accessible only to

a small fraction of the population, or military people

(inaccessible to civilians).

By end of the 2nd Quarter 2015, 76% (1,348) health centres were reported accessible, 1% (12)

hard-to-access, and 21% (385) inaccessible, while the accessibility status of 2% (38) health

centres were unknown [Figure 7].

Detailed analysis on the accessibility status of the health centres at governorate level is presented in

[Figure 8] and [Map 2].

Figure 8: Accessibility status of the health centres per governorate, 2nd

Quarter 2015

165

91

107

66

52

141

85

178

77

121

58

67

112

28

0

0

0

0

0

3

1

1

1

0

0

0

3

3

0

2

9

7

9

23

17

42

25

59

39

16

109

28

0

0

0

0

0

2

0

1

0

1

0

31

3

0

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

Tartous

As-Sweida

Lattakia

Ar-Raqqa

Damascus

Hama

Deir-ez-Zor

Homs

Dar'a

Rural Damascus

Al-Hasakeh

Idleb

Aleppo

Quneitra

Yes Hard to access No No Report

Accessible 76%

(1,348)

Hard-to-access 1% (12)

Inaccessi-ble

21% (385)

No Report 2% (38)

Figure 7: Accessibility status- Q2 2015


The trend analysis of accessibility status of health centres from 1st Quarter 2014 to 2nd Quarter

2015 is presented in Figure 9.

Figure 9: Trend analysis of accessibility status of health centres between 1st


Quarter

2015

The number of inaccessible health centres declined from 478 (end of 1st Quarter 2015) to 385 (end

of 2nd Quarter 2015), which is due to slight improvement of reporting in Idleb governorate.

Map 2: Acecssibility to public health centres , 2nd

Quarter 2015

1162

1374 1396 1397 1266

1348

0 0 7

5 13 12

208

324 342 342 478

385 374

46

5

32 20 38 0

200

400

600

800

1000

1200

1400

1600

Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015

Yes Hard to access No No Report


4. Infrasturctual Patterns

The following sub-sections provide analysis on infrastructural patterns of health centres, including

building’s condition, water sources, avalability of electricity generators, and availability of

refrigrators.

4.1 Condition of the building

The level of damage to health centres’ buildings was

measured at three levels:

Fully damaged: either, all the building is destroyed,

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

damage of the essential services’ buildings.

Partially damaged: where part of the building is

damaged.

Intact: where there is no damage in the building.

Analysis of the level of damage provides good indication

on the potential costs for reconstruction.

By end of the 2nd Quarter 2015, 22% (393) health centres were reported damaged [6% fully damaged

and 16% partially damaged], 66% (1,172) of public health centres were reported intact, while the

building’s condition of 12% (218) health centres were unknown [Figure 10].

The completeness of levels of damage reporting of health centres has increased in the 2nd Quarter to

reach 88%, compared to 81% at the end of 1st Quarter 2015, due to improvement of reporting in

Rural Damascus, Aleppo, and Idleb governorate.

Key gaps on reporting the levels of damage of the health centres are observed in Quneitra 44%

(26/59), idleb 39% (44/114) and Aleppo 32% (73/227).

Detailed analysis on the damaged status of the health centres at governorate level is presented in

[Figure 11] and [Map 3].

Figure 11: Damaged status of the health centres per governorate, 2nd

Quarter 2015

0

1

9

0

7

4

14

6

12

26

2

13

7

5

1

0

3

2

12

20

9

18

37

39

2

59

29

56

164

92

104

52

180

131

78

67

54

93

29

82

34

12

0

0

0

7

23

14

2

6

0

23

26

73

44

0

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

Tartous

As-Sweida

Lattakia

Damascus

Homs

Hama

Deir-ez-Zor

Al-Hasakeh

Dar'a

Rural Damascus

Quneitra

Aleppo

Idleb

Ar-Raqqa

Fully damaged Partially damaged Not damaged No Report

Fully damaged 6% (106)

Partially damaged 16% (287)

Not damaged

66% (1,172)

No Report 12% (218)

Figure 10: Level of Damage - Q2 2015


Map 3: Distribution and Level of damage of the public health centres, 2nd Quarter 2015

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

the functionality status (i.e. provision of services). Some health centres have resiliently continued to

provide services regardless of the level of damage of the building and by optimizing intact parts of

the building or in a few cases operating from other neighboring facilities. The national figures

translate as follows:

Out of the 287 partially damaged health centres, 131 health centres were reported partially

functioning, 131 out of service (non-functioning), functionality status of 10 of health centres

were unknown, while 15 health centres were reported to be fully functioning providing all

services through salvaging medical equipment from the damaged section of the health centre

with full staffing capacity.

Out of the 106 health centres with fully damaged buildings, 86 were reported non-functioning

while 17 health centres have opted for innovative ways to continue providing health services to

populations in need through partially functioning from other nearby temporary locations and

provide health services with limited staff capacity and resources (details of the 17 health centres

are available in the HeRAMS database), while functionality status of 3 of health centres was

unknown.

Then again, health centres with intact buildings (1,172 health centres) does not directly reflect

full functionality, only 821 of the 1,172 intact health centres are fully functioning, while 263 are

partially functioning and 75 health centres are not functioning all together, due to limited access

of patients and health staff to the facilities resulting from the dire security situation as well as

critical shortage of supplies, while functionality status of 13 of health centres were unknown.


The trend analysis of infrastructural damage of health centres from 1st Quarter 2014 to 2nd Quarter

2015 is presented in Figure 12.

Figure 12: Trend analysis of buildings’ damage of health centres, between 1st


Quarter

2015

4.2 Water sources and functionality status

Availability of water sources at health centres was

assessed using a standard checklist of main types of water

sources (i.e., main pipeline, well, or both (main pipeline

and well)).

By end of the 2nd Quarter 2015 and out of 1,247

functional health centres, 85% (1,060) are using main

pipelines, 2% (27) are mainly using wells, while 8% (95)

are using both (main pipeline and well) [Figure 13].

Detailed analysis on distribution of water sources at

functional health centres is presented at governorate

level on [Figure 14].

Figure 14: Distribution of water sources/ types at functional health centres, per governorate, 2nd

Quarter

2015

17 33 39 75 93 106

345 400 330

312 261

287

910 973

1063 1177

1092 1172

472

338 318 212

331

218

0

200

400

600

800

1000

1200

1400

Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Q2 2015

Fully damaged Partially damaged Not damaged No Report

19

21

26

42

49

54

55

69

83

103

104

124

147

164

0

4

2

1

3

31

12

3

2

9

0

13

14

1

0

1

0

1

0

8

2

3

5

2

1

1

3

0

0

4

3

6

0

22

0

3

2

3

2

5

13

0

0

2

0

0

0

0

0

0

0

0

0

0

0

0

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

Ar-Raqqa

Idleb

Quneitra

Al-Hasakeh

Damascus

Aleppo

Deir-ez-Zor

Dar'a

As-Sweida

Rural Damascus

Lattakia

Hama

Homs

Tartous

Main Pipeline Main Pipeline and Well Well Other No Report

Main Pipeline

85% (1,060)

Main Pipeline and

Well 8% (95)

Well 2% (27)

Other 5% (63)

No Report 0.2% (4)

Figure 13: Main Sources of Water - Q2 2015


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

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

functional health centres, (1,247 /1,783) per governorate.

Figure 15: Functionality status of the water sources at health centres, 2nd

Quarter 2015

4.3 Availability of electricity generators

Electricity generators turned to be highly demanded with the current situation, where electricity

power is widely disrupted and majority of public health centres are dependent on generators'

power. Availability of electrical generators was measured at functional health centres [Figure 16].

Figure 16: Availability of generators in the functional health centres, per governorate, 2nd

Quarter 2015

165

101

98

84

63

55

50

29

23

16

16

9

7

0

0

37

67

8

44

59

2

15

40

93

15

16

12

69

0

5

12

0

0

3

0

3

15

6

0

6

0

0

0

0

0

0

0

0

0

3

0

0

0

1

0

0

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

Tartous

Hama

Homs

As-Sweida

Lattakia

Rural Damascus

Damascus

Al-Hasakeh

Dar'a

Aleppo

Quneitra

Idleb

Ar-Raqqa

Deir-ez-Zor


37

23 23

6 9 1

40

16 10

26

4

19 10 11

15

93 89

26

98

164

137

127

40 43

15

59

82

20

0 1 3 0 0 0 0 0 0 0 0 0 0 0 0

20

40

60

80

100

120

140

160

180

Damascus RuralDamascus

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

Available Not-available No Report


4.4 Availability of Refrigerators

Availability of refrigerators in health centres is measured through HeRAMS at three levels: available

and functioning, available but not-functioning, or not-available. The summary figures of availability

of refrigerators in functioning health centres are presented [Figure 17].

The health centres with gap on refrigerators, seek support of the area municipality, a nearby school,

or a nearby house to store vaccines and medicines.

Figure 17: Availability of refrigerators in the functional health centres, per governorate, 2nd

Quarter 2015

51

111

78

23

102

154 155

138

43

69

19

61

81

24

0 2

24

5 2 1 7

1 2 0 0

12 3 1 1 3

10 3 3

10 15

4 5 0 0

5 8 6 0 1 3 1 0 0 0 0 0 0 0 0 0 0

0

20

40

60

80

100

120

140

160

180



Available Available but not-functioning Not-available No Report


5. Availability of Health Human Resources

Availability of health human resources has been analyzed

across functional health centres considering different

staffing categories.

Analysis of proportions of available health staff, by end of

the 2nd Quarter 2015, within the functional health centres

(fully and partially) is shown in [Figure 18].

The resident doctors represented (1%) of total health staff

at centres’ level, followed by general practitioners (4%);

pharmacists (6%); laboratory (7%); specialists (8%); dentists

(10%); midwives (11%); and nurses (53%).

The Distribution of the total health staff, by end of the 2nd Quarter 2015, per staff category and

governorate is shown in [Figure 19].

Figure 19: Distribution of total health staff at health centres per governorate, June 2015

The distribution of medical staff [a total of general practitioner, specialist, resident doctor, dentist],

in functional health centres per governorate is presented in Map 4. The highest density of medical

staff is observed in Tartous [total functional centres is 165], followed by Homs [total functional

centres is 177], and Damascus [total functional centres is 52].

49

75

96

27

15

3

14

2

14

3

15

1

56

30

22

25

26

25

27

2

21

7

14

7

6

15

3

24

1

29

2

16

9

65

64

16

64

56

33

14

4

14

44

0

1 18

30

20

3 10

0 17

14

1

17

6

23

3

13

6

25

20

8

52

7

25

1

28

0

72

78

36

92

15

2

50

43

7

10

34

44

7

34

7

15

85

20

97

20

86

10

25

24

7

67

6

12

6

74

1

13

40

27

2

13

1 2

92

55

12

72

23

9

26

9

13

6

61

47

14

86

78

53

98

17

3

24

9

75

31

5

34

5

40

8

27

2

13

4

13

4

34

15

5

79

48

60

33

18

5 15

17

0 3

18

14

9

60

19

9

25

97

80

71

28

7

50

5

41

72

11

8

75

5

81

9

46

8

72

14

4

5

14

6

14

8

87

0

500

1000

1500

2000

2500



Practitioner Specialist Doctor Resident Doctor Dentist Nurses Laboratory Midwives Pharmacists Technicians

Practitioner 4%

Specialist Doctor

8% Resident Doctor

1%

Dentist 10%

Nurses 53%

Laboratory 7%

Midwives 11%

Pharmacists 6%

Figure 18: Health Staff, June 2015


Map 4: Distribution of medical staff [a total of general practitioners, specialists, resident doctors, and

dentists] per governorate, June 2015

By analyzing the proportion of male to female doctors (a total of: general practitioners, specialists,

resident doctors, and dentists), lowest proportions were seen in Al-Hasakeh, Ar-Raqqa, and Deir-ez-

Zor governorates [Figure 20].

Figure 20: Proportion of Doctors by gender, per governorate, June 2015

307

334 234

40

214

544 472 401

161 139 58

144 181 76

334

205 189

18

301

384 244 219

35 43 16

54 67 33

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Male Female


6. Availability of Health Services

Availability of the core health services is monitored through HeRAMS at a health centre’s level,

considering a standard list of health services, as follows:

General Clinical and Emergency Services,

Child Health: EPI, screening of MUAC, and Diarrhea management,

Nutrition: screening of malnutrition for pregnant and lactating women,

Sexual & Reproductive Health: Syndromic management of sexually transmitted infections, Antenatal care, Emergency contraception,

Non-communicable Diseases: Surgical care, Cardiovascular services, Hypertension management, Diabetes management,

Mental health care

Figure 21 shows the percentage of availability of health services across all functional (fully and

partially) health centres (1,247 /1,783).

Figure 21: Percentage of availability of health services, across all public functional health centres, 2nd

Quarter 2015

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

Database.

26%

44%

51%

55%

56%

59%

63%

63%

64%

67%

70%

73%

78%

78%

79%

87%

88%

92%

93%

Syndromic management of sexually transmitted infections

Basic laboratory

Cardiovascular services

Referral capacity

Emergency contraception

Screening of malnutrition for pregnant & lactating women

Screening of under nutrition/malnutrition (growth monitoring orMUAC or W/H, H/A)

Diabetes management

Prophylaxis and treatment of opportunistic infections

Surgical care

Hypertension management

Diarrhea Management

Antenatal care

Tetanus Shot

Emergency services for Accidents and Injuries

EPI: routine immunization against all national target diseasesand adequate cold chain in place

Regular reporting to the national surveillance system

Solid waste management

Standard precautions


The following sections provide descriptive and trend analysis for the workload of the functional

health centres throughout 2015, per governorate and quarter of reporting. It includes reported

consultations/ cases for general clinical services, emergency, child health, nutrition, sexual &

reproductive health, non-communicable diseases, and mental health.

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

in all functional health centres during January and June 2015 [Figure 22]. The total reported number

of consultations across all governorates is 6,286,816; disaggregated as 3,081,920 in the 1st Quarter

and 3,204,896 in the 2nd Quarter 2015.

Figure 22: Estimated workload of functional health centres (consultations), January to June 2015

The proportion of workload of functional

health centres per governorate is

provided on Figure 23.

Detailed analysis on utilization of the core health services is provided on the following sub-sections,

including:

General Clinical and Emergency Services, Child Health, Nutrition, Sexual & Reproductive Health, Non-

communicable Diseases and Mental Health

770,252 748,211 729,240 715,977 711,849

614,835 583,224

310,515 309,759

251,569

185,832 178,588

102,224 76,897

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

Homs RuralDamascus

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

Homs 12%

Rural Damascus 12%

Hama 12%

Damascus 11% Lattakia

11%

Tartous 10%

Aleppo 9%

Al-Hasakeh 5%

Dar'a 5%

As-Sweida 4%

Deir-ez-Zor 3%

Quneitra 3%

Ar-Raqqa 2%

Idleb 1%

Figure 23: Proportions of workload in health centres, January to June 2015, per governorate


6.1 General Clinical services

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

centres at governorate level.

i. Outpatient

The number of outpatients was assessed at a health centre level, and the total reported number in

the 2nd Quarter 2015 is 1,266,102; disaggregated at governorate level in Figure 24.

Figure 24: The number of Outpatients in health centres, 2nd

Quarter 2015

ii. Basic laboratory services

The number of patients received services in health centres’ laboratories, was assessed at a health

centre level. The total reported number in the 2nd Quarter 2015 is 694,290; disaggregated at

governorate level in Figure 25.

Figure 25: The number of patients received services in laboratories in health centres, 2nd

Quarter 2015

195,746 194,919

152,196

126,714 126,035 118,499 116,734

61,863 58,039

35,135 27,284 23,383 19,437

10,118

0

50,000

100,000

150,000

200,000

250,000

RuralDamascus

Aleppo Hama Homs Tartous Damascus Lattakia Idleb Quneitra As-Sweida Dar'a Deir-ez-ZorAl-Hasakeh Ar-Raqqa

140,854

101,630 95,357

85,619

57,538 53,209 52,928

46,918

31,297

13,878 12,692

1,848 522 0 0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

Homs Hama As-Sweida Dar'a RuralDamascus

Lattakia Damascus Tartous Aleppo Al-Hasakeh Quneitra Idleb Deir-ez-Zor Ar-Raqqa


iii. Referral capacity

Referral capacity and number of referred cases was measured at a health centre level. The total

reported number in the 2nd Quarter 2015 is 12,157; disaggregated at governorate level in Figure 26.

Figure 26: The number of referred cases, 2nd

Quarter 2015

6.2 Emergency services

The number of cases and injured people reported in emergency units of health centres was assessed

at a health centre level. The total reported number in the 2nd Quarter 2015 is 151,335; disaggregated

at governorate level in Figure 27.

Figure 27: The number of accidents and injuries reported in health centres, 2nd

Quarter 2015

6.3 Child Health

Availability and utilization of child health services in health centres is assessed for EPI, screening of

under nutrition/malnutrition, and diarrhea management for children.

i. EPI: routine immunization against all national target diseases and adequate cold chain in

place:

The number of children received routine immunization service through EPI was assessed at a health

centre level. The total reported number in the 2nd Quarter 2015 is 589,252 children; disaggregated

at governorate level in Figure 28.

3,253 3,013

1,361

1,055 938 869 861

396 245

59 55 52 0 0 0

500

1,000

1,500

2,000

2,500

3,000

3,500

Hama Damascus As-Sweida RuralDamascus

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

56,713

19,257 18,415

12,713 9,205 8,450 8,050 6,543

4,691 2,730 2,444 2,049

75 0 0

10,000

20,000

30,000

40,000

50,000

60,000

Homs Hama RuralDamascus

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


Figure 28: The number children received routine immunization service in health centres, 2nd

Quarter 2015

ii. Screening of under nutrition/malnutrition (growth monitoring or MUAC or W/H, H/A):

Screening of children for under nutrition/malnutrition was assessed at a health centre level. The

total reported number in the 2nd Quarter 2015 is 105,284; disaggregated at governorate level in

Figure 29.

Figure 29: The number of screened children for under nutrition/malnutrition in health centres, 2nd

Quarter

2015

iii. Diarrhea Management:

Diarrhea Management for children was assessed at a health centre level. The total reported number

in the 2nd Quarter 2015 is 26,548; disaggregated at governorate level in Figure 30.

Figure 30: The number of diarrhea cases (children) in health centres, 2nd

Quarter 2015

90,101

72,372 67,400

61,758 59,895

51,024 46,709

36,765 36,061

27,203

18,952

11,511 7,800

1,701

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Aleppo Al-Hasakeh RuralDamascus

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

30,362

21,278

13,786

10,480

6,716 6,517 6,320 4,204 3,537

1,186 300 233 185 180

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Hama Damascus Homs RuralDamascus

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

5,641

4,614

3,362 3,208

2,102 1,640 1,499 1,464

1,126

611 457 413 411 0

0

1,000

2,000

3,000

4,000

5,000

6,000

RuralDamascus

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


6.4 Nutrition

Screening of malnutrition for pregnant & lactating women was assessed at a health centre level.

The total reported number in the 2nd Quarter 2015 is 27,828; disaggregated at governorate level in

Figure 31.

Figure 31: The number of screened pregnant & lactating women for of malnutrition, 2nd

Quarter 2015

6.5 Sexual & Reproductive Health

Availability and utilization of sexual & reproductive health care in health centres is assessed at a

health centre level for syndromic management of sexually transmitted infections, antenatal care,

normal deliveries, essential newborn care, BEmOC, and tetanus shots.

i. Syndromic management of sexually transmitted infections:

The number of patients with sexually transmitted infections (STIs) was assessed at a health centre

level. The total reported number in the 2nd Quarter 2015 is 4,256; disaggregated at governorate level

in Figure 32.

Of note: the availability of Syndromic management of STIs is reported in six governorates and

mainly in comprehensive/ poly clinics. In other governorates, if any case reported to a health centre,

they refer it to the hospitals based on available capacity.

The high number of reported STIs cases in Lattakia is due to high numbers of IDPs who reside in

shelters that lack hygiene and cleanness.

Figure 32: The number of cases reported with sexually transmitted infections in health centres, 2nd

Quarter

2015

5,561

4,463

3,619 3,527

2,926

2,156 2,146

1,012 881 770 460

253 113 0 0

1,000

2,000

3,000

4,000

5,000

6,000

Hama Lattakia Homs RuralDamascus

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

2,642

672 615

308

11 8 0 0 0 0 0 0 0 0 0

500

1,000

1,500

2,000

2,500

3,000

Lattakia Tartous Damascus Hama RuralDamascus

As-Sweida Aleppo Idleb Homs Al-HasakehDeir-ez-Zor Ar-Raqqa Dar'a Quneitra


ii. Antenatal visits:

The number of antenatal visits was assessed at a health centre level. The total reported number of

visits for pregnant women received the service in the 2nd Quarter 2015 is 59,251; disaggregated at


Figure 33: The number of Antenatal visits in health centres, 2nd

Quarter 2015

iii. Tetanus Shots:

The number of pregnant women received Tetanus Shots was assessed at a health centre level. The

total reported number of women received the service in the 2nd Quarter 2015 is 28,782;

disaggregated at governorate level in Figure 34.

Figure 34: The number of pregnant women received Tetanus Shot in health centres, 2nd

Quarter 2015

iv. Normal deliveries:

The number of Normal deliveries was assessed at a health centre level. The total reported number

in the 2nd Quarter 2015 is 1,139; disaggregated at governorate level in Figure 35.

Figure 35: The number of Normal deliveries in health centres, 2nd

Quarter 2015

10,541

8,053 7,187

6,204 5,345

4,790 4,757 4,407

2,581 2,309 1,791

720 446 120

0

2,000

4,000

6,000

8,000

10,000

12,000

Hama Lattakia Homs RuralDamascus

Tartous Aleppo Dar'a Damascus Idleb As-Sweida Al-HasakehDeir-ez-Zor Quneitra Ar-Raqqa

5,932

4,806 4,603

3,015 2,584

1,975 1,800 1,338 1,186

547 339 308 203 146

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Aleppo Hama Homs RuralDamascus

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

465 438

79 49 35 30 16 13 10 4 0

0

50

100

150

200

250

300

350

400

450

500

Dar'a Homs Damascus As-Sweida Hama Idleb Lattakia RuralDamascus

Al-Hasakeh Quneitra Ar-Raqqa Aleppo Tartous Deir-ez-Zor


v. Essential newborn care:

Availability and utilization of essential newborn care service (including basic newborn resuscitation

+ warmth (recommended method: Kangaroo Mother Care - KMC) + eye prophylaxis + clean cord care

+ early and exclusive breast feeding 24/24 & 7/7)), was assessed at a health centre level. The total

reported number of women received the service in the 2nd Quarter 2015 is 703; disaggregated at


Figure 36: The number of women received essential newborn care in health centres, 2nd

Quarter 2015

vi. Basic Emergency Obstetric Care (BEmOC):

Availability and utilization of BEmOC service (including parenteral antibiotics +

oxytocic/anticonvulsivant drugs + manual removal of placenta + removal of retained products with

manual vacuum aspiration (MVA) + assisted vaginal delivery 24/24 & 7/7), was assessed at a health

centre level. The total reported number of women received the service in the 2nd Quarter 2015 is

150; disaggregated at governorate level in Figure 37.

Figure 37: The number of women received BEmOC in health centres, 2nd

Quarter 2015

465

99

49 42 18 16 10 4 0 0 0

0

50

100

150

200

250

300

350

400

450

500

Dar'a Damascus As-Sweida Homs Hama Lattakia Al-Hasakeh Quneitra RuralDamascus

Idleb Ar-Raqqa Aleppo Tartous Deir-ez-Zor

125

20

3 2 0 0 0 0 0 0 0

20

40

60

80

100

120

140

Dar'a Hama Damascus RuralDamascus

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


6.6 Non Communicable Diseases (NCDs)

Availability and utilization of NCDS health care services in health centres is assessed at a health

centre level for surgical care [minor surgeries, dressing services, …], cardiovascular, hypertensions,

and diabetes.

The total reported number of NCDs’ consultations in the 2nd Quarter 2015 is as follows: surgical care

[105,829] cardiovascular [34,539], hypertensions [96,480], and diabetes [218,940]; disaggregated

figures are provided at governorate level in Figure 38.

Among all NCDs, Diabetes patients’ consultations are the highest reported figures, mainly in Lattakia,

Damascus and Rural Damascus.

Figure 38: The number of NCDs consultations (Surgical care, Cardiovascular, Hypertension and Diabetes) in

health centres, 2nd

Quarter 2015

6.7 Mental health care

Availability and utilization of mental health care services was assessed at a health centre level. The

total reported number in the 2nd Quarter 2015 is 5,877; disaggregated at governorate level in Figure

39.

Figure 39: The number of mental health cases in health centres, 2nd

Quarter 2015

6884

2059

6

1738

483

1579

7

1550

6

1384

8

4939

215

1248

0

5452

1436

2

4761

1027

2

4393

325

173 17

03

1018

7

2784

2023

148

50

0 207

68 22

06

2058

8

1330

1

2182

418

1059

8 1588

1

1302

4

7194

592

1443

0 647

5450

5162

315

84

2308

8

2185

6

2477

5385

2

2255

6

1524

3

1413

8

1058

9

32

0

5659

1317

9

4687

0

10000

20000

30000

40000

50000

60000



Surgical care Cardiovascular Hypertension Diabetes

1,071

782 768

666 642

513 502 470 457

6 0 0 0 0 0

200

400

600

800

1,000

1,200

Quneitra Hama Tartous Damascus Dar'a Aleppo RuralDamascus

Homs Lattakia As-Sweida Idleb Al-HasakehDeir-ez-Zor Ar-Raqqa


7. Availability of Medical Equipment

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

centre level, based on a standard checklist1.

In its fifth year of crisis, Syria’s public health centres are still suffering from shortages and/or

malfunction of medical devices/ equipment to provide health care services. In insecure

governorates, medical devices are either destroyed, burned, or malfunctioned, while in safe areas

the medical devices are overburdened by increased numbers of people (actual numbers of people in

the area, in addition to IDPs and patients /injured people from surrounding areas).

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

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

Analysis of availability of essential equipment was measured across all functional health centres

(1,247 / 1,783), in terms of functional equipment out of the total available equipment in the health

centre. The produced analysis provides good indication of the current readiness of the health

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

and machines, to fill-in identified gaps.

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

centres. Further details are provided in Figure 40.

Figure 40: Percentage of functional essential equipment/ total available equipment in functional health

centres, 2nd

Quarter 2015

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

71%

78%

84%

87%

88%

89%

91%

93%

93%

94%

94%

94%

95%

95%

95%

Blood_pressure machine

Oxygen cylinders

Ambu bag (Paediatric and Adult)

Weighing Scale for infants

Weighing Scale for adults

Light source (flashlight acceptable)

Pulse Oximeter

Safe / Clean delivery kit

Sterilizer/ Autoclave

Delivery_table

Height Measurement Device

Minor_surgical

Vaginal examination set

Fetoscope

Length Measurement Device


Map 5: Percent of functional specialized equipment/ total available equipment in functional health centres,

end of June 2015


8. Availability of Priority Medicines

Availability of medicines and consumables at health centres’ level has been evaluated based on a standard list of identified priority medicines (driven from the national Essential Medicine List), and medical supplies for duration of one month. Gaps of medicines and consumables are observed even within the functional health centres; 71% gap of Anti-diabetic preparations, 65% of Cardiac and /or Vascular Drugs, 59% of Antibiotics, 49% of Anti-allergic including Steroids, 49% of ORS, and 34% of Antiseptics [Figure 41].

Figure 41: Availability of medicines and medical consumables at functional health centres, 2nd

Quarter 2015

**More details on availability of medicines and consumables at a health centre level are available in HeRAMS Database. Percentages of available medicines in functioning health centres by end of the 2nd Quarter 2015, at governorate level, are presented in Map 6. Map 6: Percentage of available medicines at functional health centres, end of June 2015

29%

35%

41%

51%

51%

66%

Anti-diabetic preparations

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

Antibiotics

ORS

Anti-allergic including Steroids

Antiseptics


9. Conclusions and Recommendations

Rehabilitation of the damaged health centres’ infrastructure is highly needed to improve

functionality of health centres and availability of essential health services at primary care level.

Provision or maintenance of electricity generators for health centres in need (identified in the

HeRAMS database) could result in significant improvement of availability of services.

Increasing provision of specialized medical equipment and machines, in addition to spare parts

(in certain cases) will improve readiness of health centres’ primary level of care, and accordingly

fill-in the highlighted gaps and urgent needs reported at different governorates.

Conducting a qualitative survey on provision of health services to measure the impact of the

crisis on the population across the country, using HeRAMS data as a baseline.

Increasing supply of ICT means for health districts and reporting facilities especially in hard-to-

reach and inaccessible areas, to improve timeliness & completeness of reporting, quality of data,

and flow of information.


© World Health Organization 2015. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

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