Syria: "The health system is on the ground after years of war"

Since the fall of the Bashar Al-Assad regime on December 8, 2024, Médecins Sans Frontières (MSF) teams have been deploying medical and material aid in several regions formerly controlled by Damascus.

Hakim Khaldi, emergency coordinator, and Ahmed Rahmo, medical coordinator, were able to visit the main hospitals in major Syrian cities.

What is the state of the health system in the regions you visited?

Ahmed Rahmo: We went to Damascus, Aleppo, Hama, Deir ez-Zor, Tartous and Latakia, but also to Idlib, where MSF has been working for more than ten years. This is a region that was already controlled by Hayat Tahrir al-Sham (HTC), the armed group that brought down Bashar Al-Assad and is now in power.

The health system is on its last legs after years of war. The medical facilities we visited in these cities face many challenges, including a lack of medical supplies, medicines and staff. In particular, we noted a significant shortage of specialist staff, including anaesthetists and surgeons. This is not new, as some of the medical staff had left the country at the beginning of the civil war, which broke out in March 2011, and have still not returned to Syria.

Moreover, the Syrian Ministry of Health officially has 82,000 employees, but in reality there are far fewer medical personnel on the ground. One of the common practices of the Bashar Al-Assad regime was to fictitiously employ people close to the government by registering them on the lists of the Ministry of Health, while the latter served in militias or held several jobs, some of which were fictitious.

Hakim Khaldi: Beyond corruption, massive embezzlement by the regime, shortages and lack of resources, the economic sanctions that still affect Syria today are the main obstacle to the reconstruction of the health system. This is one of the main reasons why most Syrians live below the poverty line, which is two dollars a day.

The average salary of a civil servant in Syria today is $20 per month. Since the beginning of the war, the population has lived in the heart of a nightmarish economic system that combines rationing and the black market: the price of bread, for example, was regulated by the government, but you had to queue for three or four hours to buy it. One gas bottle was allowed per person every three months, which was largely insufficient to meet needs. These restrictions have had consequences for the general health of Syrians and for the health system. Today, the Syrian health system needs to be rebuilt. The government has also promised civil servants a 400% salary increase, which is to be implemented in several stages.

What were the supply difficulties encountered by health structures?

Ahmed Rahmo: In the past, there was a state monopoly on imports of medicines and everything was centralized in Damascus, which supplied all the public hospitals in the country. In addition, due to the sanctions and the high level of corruption, the prices were very high. For example, a 50 ml bottle of albumin costs almost $100 in Syria, while in Europe, it can be found for half that price.

The state was the only entity able to import certain medicines and medical equipment. This system, which is one of the legacies of the Bashar Al-Assad regime, has not yet been reformed, which causes supply delays and shortages for certain medicines.

Another practice put in place by the previous regime was to centralize humanitarian aid, store it in warehouses and sell it to the private sector. Patients who went to the public hospital, for dialysis for example, had to buy medicines and medical supplies from the private sector. Thousands of dialysis kits were thus found in warehouses, ready to be sold.

Hakim Khaldi: Patients in public hospitals must buy all the items necessary for their care, including those of the medical team: syringes, gloves, cotton, bandages, anesthetics, medications, and even the mask for the operating doctor. It can be more expensive for the patient to go to a public hospital rather than to a private establishment.

Some warehouses in the north of the country, for example, a region that was not controlled by the regime, do not operate on this state monopoly model; unfortunately, they do not have the capacity to supply all the hospitals located in the areas previously controlled by the regime. The government in place must end the monopoly on supplies and choose its suppliers of medical equipment and medicines. For our part, we have used the reserves of our warehouse in Idlib to make the first medical donations, including four trauma kits to hospitals in Aleppo, Deir ez-Zor and Hama.

After years of war and decades of dictatorship, what are the concerns of the Syrians you met?

Ahmed Rahmo: It’s security: there are a lot of weapons circulating in the country that are out of the government’s control. When the regime fell, the army’s warehouses were opened and many people helped themselves. There are many armed groups and militias and Syrians are afraid of a new civil war. The country is still unstable. For example, we don’t know what the outcome of the negotiations between the new government and the Kurdish forces, who control part of the country, will be. There is still a front line in the north and fighting around Kobane as well as tensions around Deir ez-Zor, for example.

Hakim Khaldi: Another concern of the Syrians is the economic situation and reconstruction. Life is very expensive in Syria, much more than in Turkey for example. On the other hand, the country has several hundred thousand displaced people who have been living in precarious conditions for years. Many of them come from the south of Idlib, the north of Hama and Ghouta. Those who were able to return to their places of origin, which were badly affected by the war, have seen the extent of the destruction. These people have therefore been forced to return to live in a tent in a displacement camp. Many have lost all hope of living in their homes or even in their towns again. For the moment, in the camps, the situation is almost the same as before the fall of the regime. The population expects the new government and donors to support Syria in this period of recovery.

In this context, what actions is MSF taking?

Ahmed Rahmo: We have carried out several emergency interventions, with donations, such as at the Yacine hospital in Aleppo, located in the Sheikh Maqsoud district and controlled by Kurdish fighters. This territory is completely isolated from the rest of the city and several hundred thousand people live there. We then began a three-month support to the public hospital through the supply of fuel, which allows the hospital's generators to operate, medicines and we cover the salaries of certain health professionals (surgeon, anesthetist, doctor and intensive care nurse).

Hakim Khaldi: We are also focusing on the Deir ez-Zor region, which is the most marginalized territory we have visited in Syria. There are only two partially functional hospitals in this city. We have also provided them with a month’s worth of medicines and laboratory supplies and a trauma care kit. A biomedical team will also work on repairing several essential medical devices, such as oxygen concentrators and those needed for X-rays. The new government does not have the means to finance these repairs. We have also drafted a project proposal to support a hospital located south of Deir ez-Zor, in the city of Mayadine. If the proposal is accepted by the authorities, it would relieve the burden on the other two hospitals in Deir ez-Zor. People in this region have few alternatives for receiving treatment, and traveling to Damascus from there is very expensive.

Recently we went to the Mediterranean coast in Tartous and Latakia. We visited several hospitals, including the three public hospitals in Tartous and the one in the city of Banias. We found services in decline, such as the dialysis center in Tartous. There are also needs in terms of care for malnourished children in the pediatric hospital as well as in the maternity ward in this city. We are currently working on drafting a proposal to support these structures.

Ahmed Rahmo: We have also proposed to the Ministry of Health to intervene in the treatment of major burns victims, one of our areas of expertise. This includes support for the burns units in hospitals in Damascus, Aleppo, Tartous and Deir ez-Zor. This proposal responds to a need linked to the precarious conditions in which a large part of the population lives, who heat their homes with fuel, often of poor quality, which increases the risk of explosions and domestic accidents (scalding water, electrocution, etc.). Other Médecins Sans Frontières teams work in the territories formerly controlled by the Bashar Al-Assad regime, particularly in Damascus, where they have made medical donations and are in discussions with the Ministry of Health to support several hospitals in Aleppo, Damascus and Homs.