Health sector in northern Syria… rivalry over administration hinders coordination amid limited funding

Ali Darwish | Zeynep Masri | Saleh Malass

The medical sector in northern Syria has great importance, being the Syrian regime’s and its Russian allies’ favorite path for military control through repetitive attacks, which paved the way to tighten its grip on opposition factions’ areas of influence. This importance also resides in being a tempting corridor for dominant political actors that use this sector as a tool to establish legitimacy.

Both governments in northern Syria have tried for years to impose their weight on the medical sector, for being a pivotal sector in a volatile security and military situation. However, their governmental forms proved to be a curse on receiving funds and support, allowing non-governmental administrative bodies to play significant roles in this sector, such as the case with Idlib health directorate.

Today, with the fight against the novel coronavirus (COVID-19) tops the scene in Syria, competition over who is present and who is not in the medical sector has become more transparent, as well as rivals’ hidden struggle for legitimacy and support, which Enab Baladi tries to highlight in this file. 

For the preparation of this investigation, Enab Baladi has contacted 20 different sources from the three parties as well as independent doctors, most of whom declined to answer the questions. At the same time, a number of them preferred not to disclose their personal information out of fear for their safety. 

Three administrations in search of support..

Who’s to answer?

Many medical organizations and bodies along with three main governmental entities emerge on the medical scene in northwestern Syria, represented by the ministry of health of the “Syrian Interim Government” (SIG), the ministry of health of the “Salvation Government” (SG) and the health directorate in Idlib city. 

The SIG-linked health ministry operates mainly in the northern countryside of Aleppo, alongside with some medical organizations directly supported by Turkey or independent ones which receive support from organizations. 

The Directorate of Health has an active role in Idlib, next to some other medical organizations, the ministry of health of the “SG” has a less active role, according to what has been monitored or concluded from interviews by Enab Baladi. 

The financial support these entities obtain has a significant role in determining their effectiveness, next to other factors related to their military independence or dependence, security stabilities, and their needs.

Organizations…cornerstones

Various are the parties operating in the medical sector within the opposition-held areas in northwestern Syria as well as their roles divided into regions controlled by the “Syrian National Army” (SNA) backed by Turkey. Besides, vast areas in Idlib are under the control of Hayat Tahrir al-Sham (HTS), which is represented by its undeclared affiliate the “SG.” 

In all cases, financial support is the primary key to activate the medical sector in opposition-held areas, which both “SIG” and “SG” cannot gain easily for not being recognized internationally. 

Meantime, the support has ceased from the Idlib health directorate since July 2019, as a result of the complications which occurred in the northern part of Syria in the last phase, an expert in civil society organizations told Enab Baladi. Consequently, leaving only a limited number of channels through which this directorate obtains funding for its work. This will be scrutinized in the next paragraph.  

In an interview with Enab Baladi, an expert, who preferred to remain anonymous, said that both governments, “SG” and “SIG,” have negatively affected the process of obtaining support through their pursuit of legitimacy in ways that lack “expertise and lawfulness.”

In addition to their rivalry over legitimacy and their lack of material, moral and human resources, both governments are unable to provide support with their lack of technical and managerial expertise. 

As for the Idlib health directorate, it has a close collaboration with organizations that can provide the most significant share of support through the United Nations (UN) and donors in general. As a body, the Idlib health directorate can be supported under the international law provided that any form of support comes through organizations. 

How do both governments fund their medical sectors?

Enab Baladi could not have access to information about the SG-affiliated ministry of health and failed to communicate with its current minister, Ayman Gibbs, while its former minister, Dr. Ahmed al-Jarak, did not respond to our questions. 

Muhammed al-Assaf, deputy health minister of the “SG,” responded to Enab Baladi, but he did not talk about the mechanisms used to obtain support. Al-Assaf emphasized that the ministry’s readiness “below the expected level” was due to its significant weak and limited capabilities, amid the absence of a “serious interaction” from international organizations, such as the World Health Organization (WHO) and others. 

Al-Assaf pointed out that there “are pledges to provide aid, but nothing has been delivered so far.”

In his talk about SIG’s mechanism to support its affiliated health ministry, Dr. Maram al-Sheikh told Enab Baladi, that funds provided for this sector depend primarily on humanitarian financing, where Syria’s fund for reconstruction has a major role. 

Al-Sheikh also talked about the support provided by some foreign ministries, pointing out that the different forms of support go through humanitarian organizations to health directorates in Idlib, Aleppo, Hama, al-Sahel and the medical office in Tal Abyad affiliated to “SIG.” 

Aleppo countryside..

Turkish Health Ministry is an effective actor in medical services

Both the northern and western countryside of Aleppo include many hospitals and medical centers affiliated to the Turkish Health Ministry, where large ones are located in the main cities and usually contain all specialties such as; Afrin Hospital, Azaz National Hospital, Marea New Hospital, al-Bab New Hospital, al-Ra’ee Hospital and lastly Jarablus Hospital. These medical institutions receive monthly more than 2,700 patients according to average statistics by doctors in the area, obtained by Enab Baladi. 

While health centers in the northern and eastern rural areas of Aleppo, which are also affiliated to the Turkish Ministry of Health, are often located in large towns and villages, they receive an average of about 500 patients per month.

Other organizations also support several independent hospitals in the countryside of Aleppo, such as “the Blue Crescent” Hospital at “Bab al-Salama” crossing and Women’s and Children’s Hospital in Ghandoura town, east of Aleppo, which both receive Independent Doctors Association’s (IDA) support. However, some organizations have several affiliated medical centers in Soran and border camps, like “Al-Ameen Organization of Humanitarian support” which has centers in the Afrin countryside, and Syria Relief and Development (SRD). It is an organization that provides support to Akhtarin Hospital along with other medical points in Aleppo countryside.  

A doctor from the area, who preferred to remain anonymous, told Enab Baladi that the Turkish medical authorities equipped large hospitals in the main cities to become their leading operator, through the provision of medical services in the rural areas of Aleppo. However, they try at the same time to control medical organizations’ support for two main reasons:  first to standardize work and second to benefit from the support these organizations provide. 

The same doctor believes that the health directorates’ role of the health ministry in SIG, which works with organizations and contributes to offsetting shortfalls in rural areas of Aleppo, cannot be overlooked. 

The health ministry also works with Turkish authorities and organizations to prepare plans to manage medical needs in the rural areas of Aleppo.

 Idlib Health Directorate, the only source of medical services in the province…

How does it maintain support?  

In Idlib governorate, two departments run the medical sector mainly, Idlib health directorate and health ministry of “SG,” in addition to third entities represented by organizations that operate through independent medical bodies. 

The “SIG” have tried to contribute to medical services provided in the governorate through implementing precautionary measures to curb the coronavirus spread, based on what has been monitored by Enab Baladi. 

Although the support has been stopped from the Idlib health directorate since July 2019, it is still the operational hub of the medical sector in the city, next to some organizations’ work. 

In an interview with Enab Baladi, the head of Idlib’s health directorate, Munther Khalil, talked about the factors the directorate relied on for the provision of technical support, after halting the financial support to it. He said that these factors consisted primarily of his institution’s dependence on volunteer staff and the local resources the directorate developed during past years.

In addition to the good material, human and knowledge resources, the directorate also used the previous health directorate properties such as buildings and equipment, before the opposition factions took control of the governorate. It also managed over the past few years to attract many high-skilled workers on board and developed their skills through long-term training programs, and used Syrian experts around the world as volunteer consultants.

The head of Idlib’s health directorate considers that the degree of maturity this medical institution reached ensured services’ provision continuity to northern Syria’s residents in all circumstances. It also prevented the directorate’s collapse amid shortfalls of operational costs, which many governmental institutions struggled within opposition-controlled areas in the past years. 

As for the administrative level, at this point, the directorate works on different paths simultaneously; through setting the general targets and strategic plans, as well as laws and standards. The directorate also seeks to find and develop coordination mechanisms between partners, and identify roles related to the concept of management, to delegate most of them to other administrative layers based on the ability of the directorate and departments of medical facilities and organizations active on the ground at each stage and each matter. 

The directorate also works on carrying out some vital central projects directly, which cannot be implemented through partner organizations, such as forensic medicine, pharmaceutical control, the management of biomedical waste as well as both referral and health information systems. 

Many medical organizations play an active role in opposition-held areas, namely, SAMS, which supports the most prominent hospitals in Idlib in an attempt to supplement the healthcare-care shortages in general. Next to a number of other organizations such as Syria Relief and Development (SRD), Hand in Hand (HIHFAD), Union of Relief and Medical Care Organizations (UOSSM), Sustainable International Medical Relief Organization (SIMRO) and “Shafak” and “Qatar Charity,” as well as Social Development International (SDI), the Independent Doctors Association (IDA), Al-Ameen Organization of Humanitarian Support (AOHS) and Syrian Expatriate Medical Association (SEMA).

 Facilities’ destruction was not a hindrance

A general assessment of medical effectiveness in Idlib

According to the head of Idlib’s health directorate, Munther Khalil, the medical sector in Idlib was substantially damaged since April 2019 under the attacks of the Syrian regime forces and its Russian ally on opposition-held areas. Such attacks have destroyed over 70 medical facilities, some of them were restored while the majority turned into ruins. In the meantime, the directorate in Idlib has suffered losses as well in terms of medical personnel, buildings, and the necessary medical equipment. 

The displacement crisis caused by successive military campaigns on the city put medical centers under a lot of pressure, which was eased later on by the movement of medical personnel with what is left of the equipment from hospitals under the regime’s shelling to safer areas. In these areas, medical services were provided quickly, such as in Maarrat al-Numan and Kafr Nabl hospitals in the southern countryside of Idlib, according to what was explained to Enab Baladi by a female doctor (who preferred to remain unknown). 

Effectiveness limited by circumstances 

There are many medical professionals in Idlib able to perform all sorts of surgeries, except for conducting medical follow-ups after operations related to tumors. Meanwhile, the chemotherapy sector suffers from a deficiency, as there are no divisions for chemotherapy except for breast tumors’ section, which has opened recently.

There are also a number of surgeries hard for doctors to perform, such as liver transactions and some types of eye surgeries that usually take place in Turkey. Nowadays, due to the novel COVID-19, country-to-country transfer of patients became more difficult, which has led to the death of several children due to a shortage in the number of incubators as a result for not allowing them to enter the Turkish soil, according to a female doctor whom Enab Baladi contacted. 

The head of Idlib’s directorate pointed out that the capabilities of the health sector have become limited due to the destruction it suffered from in the past year, where most of the medical facilities in services hardly respond to their local communities’ needs.   

Among the defensive mechanisms adopted by the health sector to preserve its effectiveness was through the establishment of small medical facilities widely distributed inside Syria to facilitate people’s access to them from one hand and prevent massive losses in case targeted from the other side.  

Idlib includes about 46 hospitals, 38 specialized medical centers, 56 primary health care centers, and over 70 mobile clinics, additionally to 220 ambulances and evacuation vehicles. These institutions and vehicles provide approximately 500 thousand medical services free of charge per month for the governorate residents, according to the head of Idlib’s directorate. 

What about cases of emergency? 

About Idlib’s capabilities versus its residents’ needs, Munther Khalil said that in each facility, there is only one hospital bed available for every 1600 citizens, less than the minimum, which is one bed per 1000 inhabitants.

He added that there are only 123 beds for intensive care units (ICU), with 47 ventilators for adults and another 33 for children. Generally, these figures are less than the estimated needs. In 2019, hospital bed occupancy rate reached 88 percent for regular beds, while reached 98 percent for beds for intensive care units, a clear indicator that the available potentials remain insufficient to deal with the COVID-19 pandemic, which threatens the region. 

In a series of video recordings published on the directorate’s official page on Facebook, Khalil talked about the importance of protecting healthcare-care workers, which are estimated by 600 registered doctors. They serve more than 4.2 million people in northern Syria, at a rate of 1.4 physicians per ten thousand people, below the minimum acceptable number of physicians in times of crisis which set in at least five doctors.  

Khalil also pointed out that the medical sector is at the brink of losing more healthcare-care workers in the coming period due to the “coronavirus” pandemic. He also shouldered the burden of protecting medical staff on “Idlib’s health directorate” and medical organizations, which according to him, “should make every possible effort” to secure the protection means for medical personnel.  

This responsibility falls on medical facilities’ shoulders too, which must follow instructions “firmly,” as well as on medical staff themselves who should take all precautionary and protection measures and finally upon society, as Khalil put it.  

 A hidden struggle over management hinders coordination

Healthcare sector confined by tensions

The multiplicity of bodies operating on the ground has implications on the medical sector, such as lack of organization, which leads to a disparity between the medical services provided across regions, as it is the case between Harem and Salqin areas in the northwestern countryside of Idlib.

Both regions contain relatively large population centers with low medical services, with the absence of any public hospital with adequate services. Regions like Sarmada, Atama, and Ad-Dana, near the Turkish borders, receive considerable medical support at the expense of other areas of Idlib, based on what was monitored by Enab Baladi. 

Munther Khalil, the head of Idlib’s health directorate, said that having “some disparity” in the level of medical services provided across different regions is primarily linked to the availability of appropriate infrastructure. It is worth noting that the directorate lacks empty buildings suitable for receiving medical facilities which were transferred from southern Idlib to its northern part, as a result of the recent military campaign. 

Cooperation between Idlib Directorate organizations 

According to Khalil, the directorate seeks to compensate such inequalities through the provision of mobile clinics for areas in need. These clinics will be supported by referral systems, additionally to enhancing efforts to secure buildings, either public or even private, in the regions that lack medical services.  

Khalil stressed that there are a continuous collaboration and an integrative relationship between his directorate and several organizations operating in the region from one hand and medical facilities, which play a crucial role in serving inhabitants, on the other hand.  This collaboration is conducted through daily communication and periodic meetings to discuss the current routine programs as well as response plans.   

Recently, the directorate has launched a campaign entitled “volunteers against Coronavirus” in collaboration with “Syrian Civil Defense” (SCD), which aims to provide support for health care workers and help the implementation of social distancing measures. The number of volunteers is expected to reach 8,500 volunteers, who will be deployed over one thousand local communities in the region.  

As for medical centers, they collaborate horizontally through communication rooms supervised by coordinators. For example, in case there is a need for an incubator, the request will be transferred to hospitals that can provide it through the ambulance system always available when requested with the Idlib region. Concerning collaboration between Idlib and Aleppo countryside, it is conducted at lower levels based on what has been reported by doctors serving in Idlib. 

Repulsive partnerships 

Khalil declined to make a statement concerning the collaboration and joint action between both health ministries of the “SG” and “SIG” in the healthcare-care sector in Idlib.

Meantime a doctor, who preferred to remain unknown, said in his talk to Enab Baladi that collaboration between organizations and both governments in Idlib is mediocre and limited to individual communications.  However, at the level of higher administration, this kind of cooperation does not exist, as a result of “SG” ’s attempts to impose itself as a partner in the support provided by organizations, which will eventually lead to withholding it due to this government absence of legitimacy.

Maram al-Sheikh, the minister of health in the “SIG” in a tweet on his personal account on twitter, stressed the need for a “national leadership” of the health sector, amid international “letdown” of healthcare-care institutions operating “at full capacity” despite the scarcity of resources and the disruption of financial support.

In his talk to Enab Baladi, al-sheikh denied any collaboration or joint work with the ministry of health affiliated to “SG” operating in HTS-held areas in Idlib, pointing out that “Idlib’s directorate carries out projects in the name of the ministry.” 

“SIG” imposes itself  

Al-Sheikh also said that the work of the health directorate in Idlib is directly managed by the ministry of health in the “SIG,” “It is not possible to talk about these bodies as two separate entities,” stressing that Idlib directorate is part of the health ministry, and everything this entity does is directly affiliated to it.

For his part, a department officer in Idlib health directorate and the advocacy official in the campaign against the novel “Coronavirus,” Safwat Shaikhouni, denied to Enab Baladi, the directorate’s affiliation with both governments “SIG” and “SG,” saying that the directorate is an “independent institution with no affiliations to any health ministry.”

“SG” has a mediocre role

For its part, and in order to curb “COVID-19” spread, the health ministry of “SG” seeks to play a more prominent role, based on what was monitored by Enab Baladi. 

The official website of the “SG” indicates that the ministry of development has established a community isolation center, that could be used by the ministry of health in the coming days. The same ministry also found a precautionary quarantine center for inbound travelers through borders, more precisely in the Jisr al-Shughur region, with an absorptive capacity of 100 beds at the moment, while in the next stage, this capacity will reach about 180 beds. 

In the meantime, the ministry will continue establishing other quarantine centers within its capabilities. 

According to Muhammed al-Assaf, the deputy minister of health in the “SG,” his ministry is now coordinating its work with several actors on the ground, regarding the establishment of quarantine and isolation centers. These actors include general directorates and other humanitarian organizations.

Al-Assaf believes that this step is insufficient, as it “has not reached a satisfactory level yet” due to obstacles, mainly the lack of aid and adequate support needed to provide better services, noting that the ministry’s medical readiness “below the expected level,” is due to its mediocre capabilities.

However, a doctor from Idlib, who asked to remain anonymous, explained to Enab Baladi that “SG” has no role” on the ground concerning the medical sector, except for some activities, because of “its inability to support even its workers and pay their wages. Thus, how can it provide any other form of support on the ground?” 

Organizations detaching themselves from governments 

 The same doctor, whom Enab Baladi interviewed, attributed the absence of the “SG” and “SIG” ’s role in Idlib to the lack of resources, and considered that all supporting organizations and donors “seek to marginalize the role of both governments, to prevent decentralization and work monopoly.”

He added that the amount of support provided for hospitals by the WHO and other intermediary organizations depends on their proposed projects, he also rejected all claims suggesting that these organizations’ funding comes through both governments or their affiliated health ministries.  

He also denied the existence of any collaboration or joint work between Idlib’s health directorate and “SG,” supposedly there is one, “it would be secret and not in public” where health workers had to request a building they need from “SG” being the controlling authority and party on some of the facilities in the city. 

“SG” connections forced the medical entities in the northern side of Idlib to “be very careful” in dealing or cooperating with it, being an extension of “HTS.”  

Most physicians whom Enab Baladi contacted, who confirm their independence, asserted that they do not recognize both governments unless in a forced administrative way. They expressed their “tendency” to working with “SIG” rather than “SG,” while most of them work with Idlib’s health directorate for being the only entity to provide work permits in partnership with the management of hospitals and supporting organizations.