The Syria Crisis is considered as the worst, most complex and dynamic humanitarian crisis of the 21th century, it is all began when anti- government protests against arresting and torture of some teenagers; who painted revolutionary slogans on the school wall in March 2011; was faced by intensive shooting and handed force by government force. In summer many governmental soldiers defected and start fighting the government which escalated the crisis into full scale civil war (BBC, 2016).
In summer of 2011, an opposition government in exile was formed. But having many divisions that formed based on ideological, ethnic and Sectarian background, prevented this council from functioning and take the lead. The situation exacerbate more by the appearance of Islamic State (IS), the extremist group of Jihadist that grew out of al-Qaeda in Iraq and now it is controlling many areas across northern and eastern Syria , in addition to some areas in Iraq.
The involvement of international powers like Russia, United State of America (USA), Iran and China, division of the rebels groups based on ethnic and religious backgrounds, appearance of Islamic state and other jihadist groups and the savagery and brutality nature of this war that targeted civilians in most of the times, makes Syria Crisis the worst humanitarian crisis after since the Second World War.
According to United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) more than 250,000 Syrian were killed (including 12000 children), 4.8 million Syrians had been forced to flee the country seeking protection from protracted violence, 6.5 million are internally displaced, and an estimated 13.5 million people, including 6 million children, are in need of humanitarian assistance. Of these 5.47 million people are in hard-to-reach areas, including close to 600,000 people in 18 besieged areas.
“According to current figures, 11.5 million Syrians require health care, 13.5 million need protection support and 12.1 million require water and sanitation, while 5.7 million children need education support, including 2.7 million who are out of school in Syria and across the region. About 2.48 million people are food insecure, while more than 1.5 million need shelter and household goods” (OCHA, 2016)
The majority of the Syrian refugees seek asylum in the 5 neighboring countries to Syria, current figures shows 2.5 million Syrians are registered in Turkey, 1.1 million are in Lebanon, 635324 refugees in Jordan which constituting nearly a 10% population increase, while Iraq and Egypt hosts 245022 and 117658 refugees ( Amnesty, 2016).
Available data in host countries show the demographic break down of the population is as following: males (51.4%), females (48.6%), of which under five compose 14.6%, 18.6% are 5-11 years of age, 14.2% are 12-17 years of age, 49.2% are 18-59 years of age, and 3.2% are 60 years of age and more (UNHCR, 2016).
At the beginning of Syrian crisis, all neighboring countries faced a large influx of refugees. Although many Syrians thought it will be a matter of days or weeks ;when they decided to leave their homes and they will be back home; it is very obvious now that this is not the case anymore. 5 years almost passed and the impact of this influx negatively affected the host communities leaving all basic services like education, water and sanitation, shelter, electricity and energy, health and municipal waste overstretched, increased pressure on existing infrastructure and decrease provision of public services. This influx also affected all citizens working in informal labor market by increasing competition for jobs and downward pressure on wages, which increased social tensions in areas with large refugee population that is normally suffering from high unemployment and poor economic conditions.
Donors fund and policies exacerbate this social tension between refugee and host communities by directing all received humanitarian aids to refugees only, leaving vulnerable people in hosting communities without assistance, especially in early stage of this crisis. In addition to that, the shortage of international fund directed to Syria response that seen in the last couple of years; as a result of the protracted nature of this crisis and refugees immigration to European Union countries; which placed more burden on UN agencies, International non- governmental organizations (INGO’s) and host government. According to regional monthly updates on 3RP (Regional Refugee & Resilience plan) achievements published in August 2016, only 48% of the requested fund was secured and received, this mean that have of the refugees and host communities’ needs will remain unmet. As a result, World Food Programme (WFP) decrease its food aid and voucher values to refugees in Jordan and Turkey, which forced families to eat one meal per a day or rely on cheaper food without any access to adequate nutrients.
Since the situation of Syrians both as internally displaced or refugees is very complicated and it has its negative effect on each one of the basic need services, this paper will explore the major health challenges facing this group inside Syria and in the host communities, their major health needs and what are the strategies that taken or need to be taken to address and respond to them.
The demand for health services from Syrian refugees in hosting communities continues to place acute pressure on the national health system and its ability to respond. This is aggravated by high health care expenditure and the prevalence of non-communicable diseases (NCDs) and mental health problems such as depression, anxiety and bipolarity among refugees resulted from war memories, harsh displacement, loss of family members and constant struggle to survive. Disabled, war-wounded, and older refugees also present significant challenges, particularly as war-related injuries require costly surgical treatment and lengthy rehabilitation. Many pregnant women reported no access to antenatal health care or post- natal care, breast feeding or infant and young child feeding Programmes post-delivery. Anemia and Vitamin A and iron deficiency considered a significant health issue among children under-five. Low tetanus toxoid vaccination coverage among women of reproductive age group poses a serious public health risks and concerns regarding protection of women and their newborn infants from tetanus. Gender based Violence (GBV) and sexual violence that face women and girls in case of emergencies also considered among major challenges that face IDPs and refugees. The needs of the national population are also growing with a changing population demographic and changing epidemiology of disease. Rising healthcare costs, of both services and supplies, also raise issues of sustainable financing mechanisms for this increased demand. In addition to that the risk of infectious disease outbreaks, including polio, measles, H1N1 and Middle East respiratory syndrome coronavirus (MERS-CoV), remains high due to overcrowded, living in unhealthy and substandard houses, and lack of vaccination or medical supplies. Determinants of poor health such as tobacco use, obesity, and other unhealthy behaviors are becoming increasingly prevalent are contributing to the increased incidence of NCDs.
The health situation inside Syria continued to deteriorate in 2016. Over 11.8 million people in Syria require health assistance, 1 out 4 children need mental health assistance, 45,000 pregnant women at risk of complications or death, and 654 medical personnel killed since start of conflict (HNO, 2015). Despite repeated appeals to respect and protect health care, attacks on health care facilities in the country continued unabated in 2016, “it is estimated that 57 percent of public hospitals reported to be partially functioning or completely out of service, while 63 per cent of public basic Emergency Obstetric Care Centers are non-functional”. Attacks on health care – whether deliberate or the results of collateral damage – risk the lives of health care workers and their patients and affect millions of others. Those at increased risk include wounded patients whose injuries go untreated, leading to an estimated 30% of them developing permanent disabilities; those with life-threatening, chronic diseases such as diabetes, kidney failure, asthma, epilepsy, cancer and cardiovascular illness; children who are not vaccinated; and pregnant women who have no access to life-saving obstetric care or essential reproductive health care. A severe shortage in skilled-birth attendants and obstetricians especially female doctors means pregnant women do not have access to critical childbirth services. Security threats have had an extreme impact on maternal and newborn health with Cesarean section rates rising from 15% in pre-war Syria to a current rate of nearly 40% due to fears about remaining in the hospital for the normal labor period (HNO, 2015)
In addition, while 2016 saw health assistance delivered to all 18 besieged areas, access was sporadic and the removal of essential medical supplies from aid packages and blockage of medical evacuations continued. Access for cross-border actors was also further restricted in 2016, with Jordan, Lebanon, Iraq and Turkey based actors facing increasing challenges getting supplies and staff across the border and interruption of medical evacuations. Health care provision in ISIL-controlled areas ranged from extremely limited to non-existent at all.
In Lebanon, Syrians
Health sector in cooperation with host governments must set a strategy that support durable solutions and aims to maintain humanitarian programming and continue to meet the immediate and short term health needs of individual refugees whilst also undertaking health systems strengthening and promoting resilience. It should aim to reinforce centrality of the national health system to the Syria crisis response. The response spans a range of activities from direct interventions that ensure the short-term critical needs of citizens and Syrian refugees are met, through support for primary, secondary, and tertiary health services both in camps, rural and urban settings and systematic investments that reinforce the capacity of the national health system. The response also aims to build the resilience of the public health system through investments in information management and logistics systems.
Below are some areas of intervention that are aligned with Regional Public Health strategy and 3RPs, that will help host governments and Syria to address and respond to major health needs and challenges facing Syrians IDPs and Refugees :
1. To provide high quality, integrated health services that can respond to the growing needs of a changing demography and epidemiology, expansion of infrastructure capacity in primary, secondary and tertiary care in impacted areas, that include:
– Delivery of effective interventions and programs for the control and prevention of non-communicable diseases
– Continuous capacity development for health care providers on RH, GBV, Minimal Initial Standards Packages (MISP) and Clinical management of Rape (CMR).
– Delivery of essential reproductive health, newborn, maternal and child and adolescent health and nutrition services, including infant and young child feeding, micronutrients deficiency control, routine immunization, and family planning to meet increased demand for services
– Improved capacity of emergency and triage services including in border areas to respond to immediate health needs of new arrivals including those with injuries, NCDs, pregnant women and other specific needs.
– Improve capacity to access mental health and psychosocial services at both primary and secondary level.
2. Support the delivery of essential secondary and tertiary care for Syrians not covered, including emergency obstetrics and neonatal care; post-operative, convalescent and reconstructive care and rehabilitation for war-wounded; acute and severe mental health conditions; malignancies, and palliative care including psychosocial support, symptomatic relief and pain management
3. Strengthen disability-related interventions for Syrian women, girls, boys and men with moderate to severe sensory, intellectual and physical impairments to ensure their physical, psychosocial, educational and health needs are met in a way that promotes dignity and inclusion.
4. To establish effective, interoperable health information systems that include implementation of maternal, perinatal death and epidemiological surveillance and responses to outbreaks of communicable diseases.
5. To ensure equitable access to essential medical supplies, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, this include reproductive health supplies, NCD and mental health medicines, vaccines for routine immunization, including polio and measles and neonatal screening of refugees in camp and non-camp settings.
6. To ensure effective health financing for universal health coverage of vulnerable populations through reviewing of the health insurance benefits package, to reflect changes in the epidemiology of disease and population demographic associated with Syria Crisis.
7. To deliver strong leadership and governance through establishment of effective partnerships between relevant private and public sectors including Ministries, UN agencies and INGO partners, development of evidence-based plans, policies and decisions for disaster risk reduction and preparedness, development of a community awareness plan to reach all vulnerable groups with health promotion messaging for early detection of non-communicable disease, enhancement of coordination and referral mechanisms across the health sector and with other sectors.
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