Fourth Quarter, 2019 Report Turkey Health Cluster for Syrian Arab Republic OCTOBER - DECEMBER 2019 WHO Gaziantep Field Presence, Turkey Population moving from southern Idleb towards Turkey border. (source: local media report) Health Resources Availability Monitoring System H e RAMS
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Fourth Quarter, 2019 Report
Turkey Health Cluster for Syrian Arab Republic
OCTOBER - DECEMBER 2019
WHO Gaziantep Field Presence, Turkey
Population moving from southern Idleb towards Turkey border. (source: local media report)
Health Resources Availability
Monitoring System
HeRAMS
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Health Resources Availability Monitoring System (HeRAMS) is a health cluster standardized
approach supported by a software-based platform that aims at strengthening the collection,
collation and analysis of information on the availability of health resources and services in
humanitarian context. It aims to address the needs/gaps expressed by the health cluster on
coordination and management by providing timely, relevant, and reliable information.
HeRAMS provides a tool for assessing, monitoring, and processing a comprehensive set of available
data collected at health facility level. It covers; geographical location of the HF, demographic data
on catchment area, type, functionality, building type, inpatient capacity, managing and supporting
partners, health personnel, access and security, and health services provided at different levels of
healthcare.
This report provides a summary of the analysis of the available health resources and services in
northwest Syria. The report is produced with the data provided mainly by Turkey hub health cluster
members and partners which includes national and international non-governmental organizations.
Dr Mahmoud Daher Emergency Coordinator World Health Organization Mobile: +90 530 011 4948 Email: [email protected]
Dr Jorge MARTINEZ Health Cluster Coordinator World Health Organization Mobile: +90 530 238 8669 Email: [email protected]
Mr Mohamed Elamein Information Management Officer World Health Organization Mobile: +905343554947 Email: [email protected]
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Acronyms ANC Antenatal care
BEmONC Basic Emergency Obstetric and Newborn Care
CEmOC Comprehensive emergency obstetric care
CHW Community Health Worker
CPHC Comprehensive Primacy Health Center
HeRAMS Health Resources Availability Monitoring System
HF Health Facility
HIV Human Immunodeficiency Virus
HW Health Worker
IMCI Integrated Management of Childhood Illness
MW Mid Wife
MUAC Mid-Upper Arm Circumference
PHC Primary Health Care
STD Standard
STI Sexually transmitted infection
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1. Distribution of Health facilities Primary Health Care facilities are classified into different categories based on “The Essential Primary Health Care Package”. The following table provides the distribution of type of
functional primary and secondary health care facilities (static and mobile).
Table 1.Distribution of functioning Health facilities per Goveronates Q3 2019 vs. Q4 2019
HeRAMS in this quarter consist of 547 Health facilities compared to 540 Health facilities in the previous quarter, 304 HFs functional compared to 320 in quarter one. 50 health partners managing and supporting these facilities. 54 (18%) are Hospitals, 141 (46%) are fixed PHCs, 50
(17%) are mobile clinics, 38 (9%) specialized care centres*, while 21 (7%) others health facilities**.
• Out of total functioning health facilities reported, from the Northwest Syria 51% of facilities are in Idleb and 47% in Aleppo; while six facilities (2%) health facilities reported are from Northeast (Al-Hasakeh, Ar-Raqqa, Deir-ez-Zor) governorates.
In general, by 31 December about 53 primary health care centers and hospitals had suspended and/or close the provision of services in northwest Syria due to safety constraint as the armed conflict escalates. 86% of the suspended health services were in Ariha and Al Ma’ra districts in Southern Idleb
• Out of total (547) reported health facilities, 304 HFs functioning, 205 nonfunctioning and 38*** with no reports compared to (540) health facilities, 320 HFs functioning, 163 nonfunctioning and 57 with no reports in the 3rd quarter report.
* Specialized care centre: health center provides one health service (Physical Rehabilitation centers, Leishmaniosis centers., Nutrition center, Dialysis center Etc.)
**Others health facilities: Ambulance network, Blood Bank, Central Lab. *** There is no report updated from 38 HFs at the time of issuing this report.
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Figure 1.Distribution of functioning Health facilities Q3 2019 vs. Q4 2019
2. Functionality status
Functionality has been assessed at three levels: fully functioning which mean open and providing full package of essential services, partially functioning means open but not providing the full package of essential services, or not functioning. Out of 547 assessed health facilities, 50%
(272) were reported fully functioning compared to 53%
(286) in the previous quarter, 6% (32) partially functioning compared to 6% (34) in the previous quarter, 37% (205) out of service compared to 30% (163) in the previous quarter. Note that 7% (38) of the facilities not updated their report. See Figure 2.
Figure 2. Functionality status of Health facilities
15
39
22
72
47
38
50
2120
41
18
88
46
30
55
22
0
10
20
30
40
50
60
70
80
90
100
General Hospital Specialized Hospital ComprehensiveHealth Centre
Health Centre Health Unit Specialized CareCentre
Mobile clinic(vehicle)
Other
Q4-2019 Q3-2019
53%
6%30%
10%
50%
6%37%
7%
0%
100%
Fully Functioning PartiallyFunctioning
Non-functioning No Report
Q3-2019 Q4-2019
27250%
387%
20537%
326%
Fully Functioning No Report Non-functioning Partially Functioning
547
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3. Condition of health facilities infrastructure
The condition of the health facilities infrastructure has been assessed at three levels: fully damaged: major damage requiring complete reconstruction, partially damaged: requiring substantial to large scale repair, and not damaged, out of the total facilities assessed 11% (63) health facilities were reported damaged [30
fully damaged and 33 partially damaged], 52% (285) were reported intact. See figure 3.
Figure 3: Level of Damage
4. Health facilities based on date of establishment
The health facilities have been assessed according to whether the health facility exists prior to the crisis or established after the crisis. 77% health facilities were newly established, while 23% of health facilities existed prior to the crisis in 2011. See figure 4. Out of the new established health facilities 41% were established in new building, 17% working in each of residential buildings and governmental buildings, 5% in schools and 20% in other public structures.
Figure 4: New established HFs
Fully damaged
5%
Not damaged
52%
Not relevant (e.g mobile
clinic)14%
Partially damaged
6%
No report23%
77%
23%
New established HFs Exist prior to the crisis
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5. Health facilities delivery points
Out of the functioning facilities 84% health facilities are in settlements/communities while 16% are in IDP camps. It’s worth to mention that 78% of HFs located in settlements/communities and 10% of IDP the facilities are serving both IDPs and residents.
Figure 5: Delivery point types
6. Health facilities resources
Figure 6: Accessibility to patients Figure 7: Modality of health facilites Figure 8: Water Sources
4 of functioning facilities reported difficulties in accessibility mainly due to security and distance.
12% of functioning facilities are in temporary structure building.
11% of the facilities are without/with an interrupted water supply
6%10%
6%
78%
HF located in IDP Camp andserving exclusively IDPs
HF located in IDP Camp butalso serving Residents
HF located in Settlementand serving exclusivelyResidents
HF located in Settlement butalso serving IDPs
Fully accessible
30099%
Partially accessible
41%
Permanent
structure69%
Temporary
structure12%
Question not
Applicable(eg: MC)
19%
Mobile water supply
70%No access to
water1%
Other5%
Piped Supply
Network14%
Protected well /
Borehole9%
Unprotected well1%
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Figure 9: Source of Electricity
Percentage of fixed health facilities per source of electricity. *Some facilities have more than one source
Figure 10: Electricity
46 (15%) Of the functioning fixed facilities works without/with an interrupted
electricity supply
Figure 11: Health facilites rehabilitated or/and reinforced
49% of the facilities rehabilitated or/and *reinforced.
3%
3%
12%
86%
0% 20% 40% 60% 80% 100%
Solar System
National Electricity
Neighborhood Generator
Private Generator
Fully Functioning85%
Non-functioning0%
Not available5%
Partially Functioning10%
No51%
Yes, Rehabilitated
25%
Yes, Rehabilitated
and Reinforced21%
Yes, Reinforced3%
*Reinforced: underground HFs or Strengthened for protection against the attacks
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7. Provision of General Clinical Services
Figure 12: Availbility of health facilites providing General Clinical Services
Basic Laboratory =CBC, urine analysis, stool microscopy, sputum microscopy; Basic Imaging=X-Ray and Ultrasound; Referral capacity= Referral procedures, means of communication, safe transportation
Outpatientservices:
Inpatient capacityBasic Laboratory
Services:Basic Imaging
Service:Pharmacy of
essential drugsReferral capacity
OpthalmologicServices:
Oral health anddental care
Hospital 94% 94% 93% 74% 100% 98% 17% 17%
PHC 96% 8% 57% 40% 94% 84% 4% 28%
Specialized centre 55% 5% 26% 13% 53% 68% 0% 3%
Mobile clinic 88% 0% 22% 4% 70% 92% 0% 4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic
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8. Provision of Surgery and secondary health care health Services
Figure 13: Availbility of health facilites providing Surgery and health care health Services *
Primary Injury care:Trauma , surgicalcare, and elective
surgery:Intensive Care Unit:
Post-SurgeryRehabilitation of
people with woundsor trauma:
Blood bank service: post operative care: Burns centre:
Hospital 74% 61% 59% 50% 33% 83% 13%
PHC 55% 4% 0% 5% 3% 6% 23%
Specialized centre 3% 3% 0% 13% 5% 8% 0%
Mobile clinic 30% 0% 0% 4% 0% 6% 4%
Other 14% 0% 0% 0% 10% 0% 0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic Other
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9. Provision of child health services
Figure 14: Availbility of health facilites providing child health services
Integrated Management of Childhood Illness (IMCI) is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. Screening of acute malnutrition: MUAC or Weight for Height, and/or bilateral pitting edema EPI: Routine vaccination against all national target diseases and adequate cold chain in place
IntegratedManagement ofChildhood Illness
(IMCI):
Management ofchildren (including
sick neonates)suffering from severe
and very severeillness:
EPI:Vitamin A
supplementationScreening of acute
malnutrition:
Outpatient treatmentof severe acute
malnutrition withoutmedical
complication:
Stabilization Centrefor the management
of Severe AcuteMalnutrition
Hospital 74% 67% 41% 35% 59% 57% 30%
PHC 38% 68% 48% 46% 76% 62% 19%
Specialized centre 0% 0% 8% 3% 0% 0% 0%
Mobile clinic 10% 34% 0% 12% 52% 44% 24%
Other 0% 33% 0% 10% 29% 14% 0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic Other
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10. Provision of Maternal and Newborn Health services
Figure 15: Availbility of health facilites providing Maternal and Newborn Health services
Antenatal Care: Assess pregnancy, birth and emergency plan, respond to problems (observed and/or reported), advise/counsel on nutrition & breastfeeding, self-care and family planning, preventive treatment(s) as appropriate new-born care includes: Basic new-born resuscitation + warmth (recommended method: Kangaroo Mother Care - KMC) + eye prophylaxis + clean cord care + early and exclusive breast feeding Basic Emergency Essential Obstetric Care (BEMOC) package includes Parenteral antibiotics + oxytocic/anticonvulsant drugs + manual removal of placenta + removal of retained products with manual vacuum aspiration (MVA) + assisted vaginal delivery 24/24 & 7/7 Comprehensive emergency obstetric care (CEMOC) includes BEmONC +surgery+ anesthesia+ blood transfusion. Comprehensive abortion care Safe induced abortion, uterine evacuation using MVA or medical methods, antibiotic prophylaxis, treatment of abortion complications, counselling for abortion and Comprehensive abortion care post-abortion contraception
Family planning Antenatal Care:Skilled care
during childbirthEssential new-
born careBEMOC CEMOC
Post-partumcare
Comprehensiveabortion care
Hospital 67% 69% 63% 70% 63% 61% 69% 63%
PHC 77% 87% 29% 27% 19% 0% 61% 17%
Specialized centre 5% 5% 5% 5% 5% 0% 5% 5%
Mobile clinic 64% 68% 8% 6% 0% 0% 44% 16%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic
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11. Provision of services in response to sexual violence
Figure 16: Availbility of health facilites providing services to response to sexual violence
Clinical management of rape survivors: Including psychological support
Post-exposure prophylaxis (PEP): Post exposition prophylaxis of STIs including hepatitis B and HIV infection
Clinical management of rape survivors Emergency contraception Post-exposure prophylaxis (PEP)
Hospital 57% 56% 52%
PHC 43% 62% 36%
Specialized centre 5% 5% 11%
Mobile clinic 24% 48% 30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic
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12. Provision of STI & HIV/AIDS
Figure 17: Availbility of health facilites providing STI & HIV/AIDS services
*Standard precautions: Disposable needles & syringes, safety sharp disposal containers, Personal Protective Equipment (PPE), sterilizer, hand hygiene
Syndromicmanagement of
sexually transmittedinfections
Standardprecautions
Availability of freecondoms
Prophylaxis andtreatment ofopportunistic
infections
HIV counselling andtesting
Elimination ofmother-to-child HIV
transmission(EMTCT)
Antiretroviraltreatment (ARV)
Hospital 54% 65% 57% 41% 33% 22% 19%
PHC 53% 72% 60% 37% 10% 5% 10%
Specialized centre 5% 16% 5% 5% 3% 0% 5%
Mobile clinic 32% 46% 58% 18% 0% 0% 0%
Other 29% 38% 24% 10% 0% 0% 0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic Other
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13. Provision of treatment for non-communicable diseases and mental health Figure 18: Availbility of health facilites providing non-communicable diseases and mental health services
Physical rehabilitation service: Disabilities rehabilitation & support; Mental Health Care: Support of acute stress and anxiety, front line management of common and severe mental disorders
Hypertensionmanagement
Diabetes managementآ
Cardiovascularservices
Treatment ofCancer
Mental HealthCare
Physicalrehabilitation
servicesDialysis Unit
RespiratoryDiseases
Hospital 63% 70% 48% 11% 31% 11% 15% 70%
PHC 84% 87% 70% 4% 40% 7% 0% 79%
Specialized centre 5% 3% 0% 0% 18% 37% 13% 18%
Mobile clinic 50% 50% 32% 0% 14% 2% 0% 50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic
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14. Provision of diagnosis and treatment for communicable Diseases
Figure 19: Availbility of health facilites providing diagnosis and treatment for communicable Diseases
Diagnosis andtreatment ofLeishmaniasis
Diagnosis andtreatment of
measles:
Diagnosis andtreatment ofpneumonia
Diagnosis andtreatment of
cholera:
Diagnosis andtreatment ofacute bloody
diarrhoea:
Diagnosis andtreatment of
Viral HepatitisB&C:
Diagnosis andtreatment of
Typhoid
Diagnosis andtreatment of TB:
Diagnosis andtreatment of skin
diseases
Hospital 31% 69% 74% 57% 76% 56% 76% 30% 41%
PHC 62% 67% 69% 36% 67% 33% 77% 24% 62%
Specialized centre 0% 0% 0% 0% 0% 3% 0% 5% 0%
Mobile clinic 38% 30% 30% 16% 26% 0% 26% 0% 34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic
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15. Provision of Outreach activities (Community base) health services
Figure 20: Availbility of health facilites providing Outreach (Community base) health services
Health education:screening for
malnutrition withMUAC:
follow up ofmalnourished children:
Screening forpregnancy for refferal
to ANC:
Screeing for nonvaccinated children for
referral:
Follow up of treatmentmental health patients:
Hospital 59% 65% 57% 61% 56% 33%
PHC 69% 66% 62% 71% 51% 26%
Specialized centre 39% 5% 5% 5% 8% 11%
Mobile clinic 50% 56% 52% 64% 36% 14%
Other 38% 24% 14% 14% 14% 10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital PHC Specialized centre Mobile clinic Other
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16. Availability of Health Staff
Figure 21: Percentages of Health Facilities by available Health Staff
* e.g.: 54% of the hospitals have at least one general medical doctor.
Figure 22: Number of Full time Health Staff per Types of Health Facility
*Health staff figures represent total of health staff reported working in the health facilities, and not represent total number of health staff as one staff may work on more than one health facilities.
*Source for population: Estimated population data of HNO 2020 (September 2019), population of Jebel Saman district is for the area of operation by Turkey hub.
**PHC: Total of the 3 levels of fixed PHCs (Comprehensive Health Centre, Health Centre and health unit)
***Health staff figures represent total of health staff reported working in the health facilities, and not represent total number of health staff as one staff may work on more than one
health facilities.
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17. Global health indicators and benchmarks for Aleppo and Idleb
a. Number of health workers (medical doctors + nurse + midwife) per 10,000 population, by administrative
unit (benchmark >22 HWs for 10,000 population)
Governorates District Population Number of Available health workers (A)
Available for every 10,000 pop
STD No of HWs benchmark >22 HWs for 10,000 population (B)
Gap in Health Workers (B-A)
%Gap
Ale
pp
o
Afrin 217,064 323 15 499 176 35%
Al Bab 213,229 162 8 490 328 67%
A'zaz 428,892 306 7 986 680 69%
Jarablus 97,335 41 4 224 183 82%
Jebel Saman 510,762 416 8 1,175 759 65%
Aleppo Total 1,467,282 1,248 9 3,375 2,127 63%
Idle
b
Al Ma'ra 281,900 13 0 648 635 98%
Ariha 238,331 68 3 548 480 88%
Harim 1,101,356 958 9 2,533 1,575 62%
Idleb 685,045 832 12 1,576 744 47%
Jisr-Ash-Shugur 262,246 265 10 603 338 56%
Idleb Total 2,568,878 2,136 8 5,908 3,772 64%
Grand Total 4,036,160 3,384 8 9,283 5,899 64%
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b. Number of Community health workers per 10,000 population, by administrative unit (benchmark >=10 CHWs
for 10,000 population)
Governorates District Population Number of Available CHWs (A)
Available CHWs for every 10,000
pop
STD No of CHWs benchmark >=10 CHWs for 10,000
population (B)
Gap in CHWs (B-A)
%Gap
Ale
pp
o
Afrin 217,064 86 4 217 131 60%
Al Bab 213,229 33 2 213 180 85%
A'zaz 428,892 83 2 429 346 81%
Jarablus 97,335 16 2 97 81 84%
Jebel Saman 510,762 155 3 511 356 70%
Aleppo Total 1,467,282 373 3 1,467 1,094 75%
Idle
b
Al Ma'ra 281,900 0 0 282 282 100%
Ariha 238,331 5 0 238 233 98%
Harim 1,101,356 175 2 1,101 926 84%
Idleb 685,045 149 2 685 536 78%
Jisr-Ash-Shugur 262,246 78 3 262 184 70%
Idleb Total 2,568,878 407 2 2,569 2,162 84%
Grand Total 4,036,160 780 2 4,036 3,256 81%
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c. Number of hospital beds per 10,000 population (inpatients & maternity), by administrative unit
(benchmark >=10 beds for 10,000 population)
Governorates District Population #Hospitals #PHCs Total number
of beds Total hospital
beds (A)
STD no. of beds
(B) Gap (B-A) %Gap
Ale
pp
o
Afrin 217,064 4 21 75 71 217 146 67%
Al Bab 213,229 2 7 71 48 213 165 77%
A'zaz 428,892 6 17 404 396 429 33 8%
Jarablus 97,335 1 2 46 39 97 58 60%
Jebel Saman 510,762 6 27 191 154 511 357 70%
Total 1,467,282 19 74 787 708 1,467 759 52%
Idle
b
Al Ma'ra 281,900 0 2 6 0 282 282 100%
Ariha 238,331 3 2 27 24 238 214 90%
Harim 1,101,356 16 34 626 562 1,101 539 49%
Idleb 685,045 12 19 554 513 685 172 25%
Jisr-Ash-Shugur 262,246 4 10 137 130 262 132 50%
Total 2,568,878 35 67 1,350 1,229 2,569 1,340 52%
Grand Total 4,036,160 54 141 2,137 1,937 4,036 2,099 52%
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d. Number of HF with Basic Emergency Obstetric Care/ 500,000 population, by administrative unit
benchmark >= 4 BEmOC/500, 000)
Governorates District Population HFs with
Available BEmOC
STD no. of BEmOC HFs benchmark >= 4
BEmOC /500, 000
Ratio_ Available BEmOC for 125,000
pop
Ale
pp
o
Afrin 217,064 9 2 5.2
Al Bab 213,229 6 2 3.5
A'zaz 428,892 4 3 1.2
Jarablus 97,335 1 1 1.3
Jebel Saman 510,762 8 4 2.0
Aleppo Total 1,467,282 28 12 2.4
Idle
b
Al Ma'ra 281,900 0 2 0.0
Ariha 238,331 2 2 1.0
Harim 1,101,356 17 9 1.9
Idleb 685,045 11 5 2.0
Jisr-Ash-Shugur 262,246 5 2 2.4
Idleb Total 2,568,878 35 21 1.7
Grand Total 4,036,160 63 32 2.0
At least one BEmOC per 125,000
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e. Number of HF with Comprehensive Emergency Obstetric Care/500,000 population, by administrative unit