In 2018, the rate of TB was 18 per 100 000 people while in 2017, it was 15.8. In 2019, the National TB Programme (NTP) in Damascus reported that 2681 patients had registered for treatment, suggesting a notification rate of 15 for every 100 000 people. The governorates of Damascus, Aleppo and Rural Damascus reported the highest numbers of TB patients (708, 582 and 380, respectively). Based on MoH statistics, Aleppo represents a third of the entire caseload of TB patients in Syria. A survey in Al-Sheikh Maqsood in Aleppo governorate, conducted in July and August 2019, found 300 suspected cases out of 15 000 individuals tested, of which 19 patients were confirmed and treated.

In 2019, 165 NTP staff in Damascus, Homs and Rural Damascus were trained on managing TB patients based on WHO’s global guidelines, conducting laboratory diagnosis and following up on multi-drugresistant TB patients.

Explosive remnants of war will continue be a threat to individuals, especially children, and strain the health system in Syria for years to come. A national household survey carried out in June 2019 found that over half of all households surveyed had a member who was living with a disability and almost half of households surveyed had two or more members who were living with a disability. The report also found that 27% of people aged 12 and above had a disability. Today’s and future victims will require comprehensive care, including trauma services, mental health support and long-term rehabilitation. To help maintain access to trauma stabilization and emergency surgical care services, WHO donated 21 ambulances to the MoH and the Syrian Arab Red Crescent, and supported five field surgical units in rural Hama governorate that stabilized 4112 patients, including 2547 who required immediate surgical intervention before being referred to nearby hospitals.

In northwest Syria, WHO’s office in Gaziantep delivered specialized trauma and surgical kits and medicines to provide more than 180 000 treatments. In areas accessible from within Syria, WHO supported trauma care for 474 669 patients and delivered 2 354 029 courses of treatment and 108 pieces of medical equipment to health facilities providing trauma care services. A total of 2571 health care workers were trained on trauma care, treatment of patients with disabilities, first aid, prostheses, basic life support, mass casualty events, burns, war wounds and spinal cord injuries. WHO also supported 22 000 physiotherapy sessions and delivered nearly 2300 disability devices.

Due to improved access to areas regained by the Syrian government, over half of public hospitals were functioning in 2019, albeit many of them at minimum capacity and with severe shortages of staff, medicines and supplies3. Hospitals in Aleppo, Dar’a, Homs, Idleb, Rural Damascus and northeast Syria were some of the worst affected. WHO delivered more than 230 pieces of medical equipment4 to over 60 hospitals in areas under government control and trained staff in 38 hospitals on neonatal resuscitation. Some 100 hospitals and health facilities in 12 governorates received intravenous fluids, NCD medicines and other supplies. The Organization assessed the status of the national cancer registry in five oncology facilities in Aleppo, As-Sweida, Damascus and Lattakia, and completed a study of the care experiences of cancer patients and their families. It also delivered cancer medicines and diagnostic equipment to the Ministry of Health (MoH) and one NGO and supported 15 287 referrals. The Essential Medicines List was updated in close collaboration with the MoH.

Reproductive, maternal, newborn and child health services are critically important in humanitarian settings, which typically see increases in maternal deaths, unintended pregnancies, sexually transmitted infections, unsafe abortions and GBV. In 2019, most governorates showed considerable progress in providing these services. In 2018, 32 hospitals across the country had neonatal resuscitation programmes; in 2019, this number rose to 38. The number of patients referred to specialized hospitals almost doubled, from 2821 to 5437. There was a similar rise in the number of mothers and newborns benefiting from home care (from 6361 in 2018 to 12 358 in 2019). An estimated 15% of deliveries and 15% of newborns will continue to require life-saving emergency interventions in 2020.

To enhance the coverage of affordable basic PHC services, WHO donated over 2.1 million treatment courses of life-saving medicines (including NCD kits) to health partners and delivered 406 pieces of equipment such as nebulizers, laboratory and ultrasound equipment, pulse oximeters, X-ray machines and generators to ministries, the Syrian Arab Red Crescent and NGOs. The Organization also supported over 5.2 million consultations in PHC centres throughout Syria.

Among the PHC efforts most appreciated by beneficiaries during 2019 was WHO’s donation of 27 mobile clinics to health responders across the country. WHO also provided 12 medical caravans to health partners working in the major IDP camps and informal settlements in the northeast. Each set of two caravans consisted of three clinics and a pharmacy.

Among the mobile medical teams supported by WHO were four teams in Homs and Hama that were providing services for people from Rukban settlement and two teams deployed to schools in eastern Ghouta as part of an oral health project.

WHO integrated NCD treatment services into nine PHC facilities in northwest Syria. More than 23 000 patients were screened for cardiovascular diseases and more than 15 000 NCD consultations were provided. In 2020, WHO intends to replicate the model in other centres in the northwest. WHO also piloted an NCD emergency kit in 12 PHC centres in northwest Syria and trained almost 200 health workers on risk factors for chronic diseases and managing patients with thalassaemia. In line with restoring PHC services, WHO supported centres in Aleppo and Homs with essential medical equipment. During the year, these centres provided health care services to nearly 100 000 people, including physiotherapy for amputees as well as services for patients with artificial limbs and movement disorders. The core package of services at each health centre was reviewed and updated on a quarterly basis. These services covered general clinical services, child health, immunization, nutrition, NCDs, communicable diseases, sexual and reproductive health, mental health and essential trauma care.

WHO’s preparedness for chemical events focused on the two regions that saw the greatest number of hostilities in 2019: the northeast and the northwest. A total of 628 health workers in Idleb and Aleppo were trained on responding to chemical events, while approximately 450 clinicians and health workers in the governorates of Aleppo, As-Sweida, Damascus, Hama, Homs, Lattakia and Tartous received advanced bio-chemical training. WHO developed online and print guides in Arabic and Kurdish on the clinical management of chemical events and distributed them to health facilities in the northeast. In the northwest, 18 referral hospitals were provided with 2000 sets of PPE and essential medicines and antidotes.

WHO paid special attention to its staff working in hazardous areas. It stocked staff protection algorithms and chemical escape kits in all WHO offices and vehicles, and pre-positioned 500 sets of PPE, medicines, supplies and antidotes. Medical staff continued as in previous years to be trained on types of commonly used chemical weapons, chemical exposure, trauma care and how to provide a sound public health response to the health consequences of chemical exposure. In addition, WHO senior personnel participated in a training-of-trainers course in Amman on chemical exposure and trauma care.

Syria has a robust surveillance system for acute flaccid paralysis (AFP). Stool specimens are collected and sent to the WHO-accredited National Polio Laboratory (NPL) in Damascus to determine whether poliovirus infection is the cause of paralysis. Surveillance indicators reached global targets for 2019 with a detection rate of >3/100 000 children under the age of 15. Sewer samples were collected from 16 sites in 13 governorates to exclude the possibility of poliovirus circulating unnoticed within the community. While the Syrian MoH is responsible for training, supervising and managing surveillance staff, WHO provides financial support for transport, incentives for timely collection and analysis, and capacity building.

Massive population displacements in northwest Syria served to emphasize the need to keep AFP surveillance indicators at the highest level. In 2019, 427 cases were detected with a high non-polio-AFP rate. No cases of Sabin type 2 or vaccine-derived wild polio virus were detected. However, the risk of polio remains. Despite limited access to some areas in the northwest, WHO and partners are continuing their monitoring efforts.

The 2019 SMART survey revealed several pockets of emerging chronic and acute malnutrition. The survey confirmed that infant and young child feeding practices remained poor, with only 28.5% of mothers choosing early initiation of breast feeding. Similarly, only 18% of mothers exclusively breastfed their infants during the first six months of life. To date, 38 hospitals have been trained on the baby-friendly hospital initiative to increase the initiation of breastfeeding within the first hour of birth.

At the end of the year, the nutrition surveillance system consisted of a network of 827 health centres serving 980 000 beneficiaries. A total of 707 health facilities offered infant and young child feeding counselling, up from 592 in 2018. Three new stabilization centres for the treatment of SAM with medical complications were established in Aleppo, Al-Hasakeh and Ar-Raqqa, bringing the total number of centres supported by WHO to 25. In 2019, these centres treated 2145 children under the age of five, compared with 905 in 2018. The highest number of admissions was in Al-Hasakeh governorate (more than 650), reflecting the dire health status of children in Al-Hol camp who escaped ISIL’s last stronghold in early 2019. WHO is working with other UN agencies including UNICEF and WFP, both of which are supporting therapeutic and supplementary feeding programmes.

A total of 19 440 cases of global acute malnutrition (GAM) were detected and referred for treatment in 2019 (GAM means both severe acute and moderate acute malnutrition). The number of cases fluctuated only slightly compared with previous years. The 25 stabilization centres distributed across the country covered most needs but required regular support for nutrition therapeutic supplies, equipment and training of staff. Stabilization centres are still needed in Ar-Raqqa and Idleb.

In northwest Syria, WHO supported 45 health facilities with regular supplies of mental health medicines and covered the operational costs of the acute inpatient unit in Sarmada mental health centre, as well as four mental health mobile clinics and a 24-hour telephone helpline. With the support of the Turkey Humanitarian Fund and the United Nations Office for the Coordination of Humanitarian Affairs, in 2019, this number rose to 38. The number of patients referred to specialized hospitals almost doubled, from 2821 to 5437. There was a similar rise in the number of mothers and newborns benefiting from home care (from 6361 in 2018 to 12 358 in 2019). An estimated 15% of deliveries and 15% of newborns will continue to require life-saving emergency interventions in 2020.

MHPSS services were integrated into 42 PHC centres, 32 mobile clinics, 20 hospitals and eight specialized centres. Overall, approximately 280 psychosocial workers now work in 118 facilities in northwest Syria that provide MHPSS services. WHO trained 945 humanitarian and community health workers on psychological first aid, enabling them to provide immediate support to the newly displaced and refer them for MHPSS. In addition, 28 mh-GAP-trained doctors in Afrin underwent six months of training, field supervision and coaching.

Late in 2019, WHO took over six non-specialized MHPSS services in northern Syria from an international NGO whose future was threatened by insufficient funds. Today, all six facilities are continuing to provide quality MHPSS services.