Country profiles

Syrian Arab Republic

Overview

The Syrian Arab Republic has a total area of 185 180 km² of which approximately 80 000 km² is cultivable land; the remainder is desert and rocky mountains. The country’s population in 1998 was estimated at 15.6 million. It has one of the highest population growth rates in the world: 3.3% in 1994. In 1994, 42.4% of the population were below 15 years of age and 3.4% of the population were above 65 years of age. In 1990, half of the population was living in urban areas. In 1996, the total adult literacy rate and the adult female literacy rates were estimated at 79.4% and 68.7%, respectively. In 1995, the crude death rate was estimated to be 6.1 per 1000 population and in 1995, the crude birth rate was estimated to be 42 per 1000 population. In 1998, the infant mortality rate was 28 per 1000 live births and the under-5 mortality rate was 32 per 1000 live births. Also in 1998, the maternal mortality rate was estimated at 9.5 per 10 000 live births. In the same year, the total life expectancy at birth was calculated as 68 years.

The main causes of hospital morbidity in 1989 were as follows: complications of pregnancy, childbirth and puerperium (18.5%); injury and poisoning (13.8%); diseases of the digestive system (11.5%); infectious and parasitic diseases (9.8%); and diseases of the respiratory system (9.7%).The per capita gross national product in 1995 was US$ 1490.

The health strategies are included in the sixth five-year development plan ending in 1990. This plan is basically a continuation of the fifth plan and emphasizes continuing with work in progress and improving performance of existing programmes. Within the framework of development, the health objectives can be summarized as follows:

• increase the quantity and quality of health services provided, with special emphasis on vulnerable groups

• achieve more equitable coverage of health services between urban and rural areas

• decrease morbidity and mortality due to infectious diseases and environmental pollution, and decrease the infant morality rate to the lowest possible

• use existing resources more efficiently by improving performance of health human resources and updating equipment as well as improving management

• increase availability of drugs and concentrate on local manufacture of essential drugs.

The health system is based on primary health care and is delivered at three levels: village, district and provincial. At village level, there are rural health centres and health units. At district level, there are larger health centres including training facilities and specialized physicians. District health centres are staffed with at least one physician, one nurse, one public health technician . Some larger centres are additionally staffed with dentists, paediatricians, obstetricians, pharmacy technicians, laboratory technicians, midwives and health visitors. On average, there are 9.8 health workers per district health centre. A small district general hospital also exists in each district.

At provincial level, there are urban health centres staffed with specialized physicians and dentists in addition to various technicians. Among the services provided in health centres are immunization, maternal and child health, family planning, control and prevention of communicable diseases, environmental control, preventive care for chronic noncommunicable diseases, and health education. At the provincial level, there are also large general hospitals and specialized hospitals. At the national level, there is a network of ambulance, blood bank and drug distribution services.

In 1990, a district health system was introduced in order to decentralize health care delivery. The health centres belonging to each of the country’s 14 districts report to one main district health centre. Each district is allocated its own budget, and each district director of health is given enough authority and flexibility to implement programmes within the present development strategy.

A special committee, the health care committee, is chaired by the Minister of Health and comprises five directorates from the Ministry of Health: the Directorate of Primary Health Care, the Directorate of Communicable Diseases, the Directorate of Planning, the Directorate of Training and the Directorate of Laboratories. The people’s and syndicate organizations, representing all sectors of the population, are represented on the Higher Health Council and its committees.

In 1988, 3.5% of recurrent government expenditure was devoted to health and health-related services. The per capita Ministry of Health expenditure, in 1989, was calculated at US$ 29, while the per capita government expenditure on health was US$ 42. The per capita national health expenditure (including private expenditure) for the same year was US$ 1433 which indicates the considerable share of the private sector in health care delivery.

With respect to human resources, in 1989 there were a total of 10 114 physicians, 3362 dentists and 14 816 qualified nurses and midwives. About 77% of physicians and 94% of dentists are in the private sector. Of the total physicians employed by the public sector, almost 30% were working in health centres. The overall rate per 10 000 population of physicians, dentists, and nursing and midwifery personnel was 10.9, 5.6 and 21.2, respectively in 1995.

In 1990, there were 41 general hospitals (8 of which were private), 152 specialized hospitals (136 of which were private), 391 rural health centres, 151 urban health centres, 79 rural health units and 49 specialized health centres. The total number of beds in the country was 13 164, 77% of which were in the public sector. Overall, there were 11 beds for every 10 000 inhabitants in 1990. Distribution of beds among governorates was also uneven. Some governorates had four times more beds, serving the same population than others.

There has been a significant improvement in the health status of the population.

A new diploma in community medicine has been institutionalized to develop cadres more oriented towards public health problems and primary health care.

The Syrian Arab Republic is the only country in the Eastern Mediterranean Region where medical education at all levels is in the national language, Arabic, which again facilitates the process of training and education.

MENTAL HEALTH

The rules governing mental health and psychiatric treatment in the Syrian Arab Republic are derived from the health legislation issued in 1981 by the Ministry of Health.

A meeting was organized by WHO in Damascus in 1985 in order to develop a national mental health programme. Another important development was the assignment of a psychiatrist as director of research and planning and head of the newly established Mental Health Department, Ministry of Health. This stimulated further interest and support on the part of the officials concerned at the Ministry of Health as regards the programmes of mental health development and psychiatric care in the country.

Among the important decisions, taken within the framework of the sixth five-year plan, ending in 1990, was the allotment of a special budget for the development of mental health care and rendering it accessible by the largest possible number of citizens. The relevant plan of action included the following: reconsideration of the managerial structure of mental health services, supporting them with capabilities and equipment; initiation of psychosocial clinics in Damascus and Aleppo to serve as centres for mental health studies; incorporation of psychiatric clinics within polyclinics, and ensuring the availability of at least one such clinic in each governorate; initiation of two centres for the treatment of addiction in Damascus and Aleppo; and initiation of intensive courses in the field of psychiatry in Damascus and Aleppo for qualifying general practitioners and nurses.

A national committee was formed to review mental health services and formulate a national programme for the promotion of mental health in the Syrian Arab Republic. The committee was chaired by the director of the national mental health programme, and had, as members, psychiatrists working in the mental health sector, such as the director of Ibn Sina’a Hospital; the head of the Department of Psychiatry, University of Damascus; the head of the Department of Psychiatry, Military Medical Services; and a representative from the Ministry of Work and Social Affairs (Social Insurance Foundation). Significant developments also took place in the classification of narcotic substances, in conducting relevant studies and in issuing new laws on abuse of narcotic and other medical substances.

The project profile for the national mental health programme was prepared by WHO and a national committee in Damascus in November 1987. The objectives are: to extend mental health services throughout the country at the primary health care level, in full coordination with the general health system; to provide training to basic and auxiliary medical cadres in order to equip them with the necessary information and suitable skills in the field of primary health care; to strengthen specialized mental health services, enabling them to achieve effective participation, fulfil their basic tasks and implement the programme; and to promote mental health education in the community and stimulate community participation, so as to achieve the objectives of the national mental health programme.

Under the overall general objective, the services objectives included: establishment of four mental treatment units in the four governorates where such services were not available; establishment of four psychiatric outpatient clinics in four selected hospitals; establishment of a referral system to specialized hospitals from these centres; preparation of a card to facilitate collection of information and develop statistical aspects for mental health care; preparation of a list of essential neuropsychiatric drugs to serve the purpose of the programme; and preparation of a manual on mental health services in the country.

Long-term objective activities during the seventh five-year plan (1990-95) for mental health care were as follows:

The assessment and evaluation operation, which will be conducted at the end of 1989 (during the short-term plan), will strengthen and support the long-term objective activities, will focus on the following.

• Provision of suitable specialized mental health cadres that shoulder the responsibility of mental health service delivery at governorate level. These cadres will be assigned the task of establishing the administrative and technical units required for the guidance of services at the therapeutic and preventive levels and for extending services to the governorate population within the context of primary health care, particularly to underserved groups.

• Organizing relevant specialized postgraduate medical education in universities and for trained Ministry of Health physicians (part-timers); as well as establishing specialized branches of psychiatry which set out to meet the service needs of community and provide the sufficient number of qualified specialists who can carry out mental health services at the country level.

• Seeking to establish a mental health research centre for conducting practical mental health surveys, with a view to identifying the prevalence of mental diseases, the nature of mental problems (psychological, social, and so on) and the suitable practical solutions that help promote the mental health of citizens.

• Establishing two centres for addiction treatment and research in Damascus and Aleppo, and organizing programmes for addiction prevention at country level.

There are 800 beds at Ibn Sina Hospital in Damascus distributed over 18 wards allotted for the treatment of 600 male patients and 200 female patients-out of whom 100 are under legal confinement. Treatment of such patients is mainly conducted through the use of psychoactive drugs, rehabilitation by work and other social and artistic activities.

Ibn Khaldoun Hospital, in Aleppo, includes 400 beds, 250 of which are for male patients and 150 for female patients, receiving more or less the same type of medical treatment used at Ibn Sina Hospital in Damascus.

Damascus includes a psychiatric department providing therapeutic psychiatric services at the Ministry of Health Hospital of Ibn Al-Nafees; a teaching psychiatric department which provides similar services at Al-Moassat Hospital of Damascus University; as well as two more mental health departments providing such services at two military hospitals affiliated to military medical services.

In addition to these hospitals, there are special foundations attached to the Ministry of Work and Social Affairs, which provide treatment and rehabilitation to the mentally handicapped and delinquents, under the supervision of licensed psychiatrists.