This page articulates WHO’s vision of and approach to its Whole-of-Syria (WoS) operations in 2020 in response to the changing situation on the ground and within the parameters of the UN engagement in Syria.

It highlights how the organization will ensure humanitarian needs are met whilst providing a clear direction on WHO’s engagement beyond early recovery towards rehabilitation of a resilient health system for all Syrians and in enhancing the organization’s and health contributions to peace outcomes. The paper outlines for WHO’s technical and financial partners key principles in the design and in the delivery of WHO’s emergency response and medium to longer-term interventions across Syria.

Regardless of the future that will play out, there will be additional demands on WHO’s health response profile and capacity in the future. We start from the assumption that severe and sustained needs for life-saving health assistance in Syria will extend far beyond the moment when widespread violence finally comes to an end; and that to properly respond to health security related emergencies with outbreaks of epidemic prone diseases, a revitalization of the public health system including IHR core capacities is essential.

In 2019 GoS made further gains of control including in the North-West and North-East; Turkish military operations in the north created new waves of displacements and increased health needs; the battles leading to the officially declared defeat of ISIS in NES was followed by new displacements and the creation of new displaced persons camps and collective shelters posing additional challenges for the scale up and sustained delivery of health care which will extend throughout 2020. Fighting continued in the Northwest throughout 2019; since 1 December 2019 to the time of writing of this document, close to 1 million people were displaced, many after several previous displacements, and are facing the consequences of a cold winter. Further destruction of health facilities and networks posed a serious challenge to the ability of providing continuity of care for an estimated 2.7 million people¹ in need of health services in this area alone. Syrian families on the run face further limited access to basic and emergency health care, lack of medicine, over-burdened health facilities, and less protection against communicable diseases as a fragile immunization network, put in place by WHO and partners, is now disrupted – coinciding with a mass displacement, further increasing the risk of outbreaks.

Thus, humanitarian and health needs are still increasing at the start of 2020.

With more than 84 health facilities closed or suspended in northwest Syria due to insecurity, lack of health staff, attacks on health care or change of control, WHO is working to fill the gap by revising and redirecting referral networks, trying to sustain stocks of life-saving medicine for those with non-communicable diseases and supporting the relocation of some of the health facilities to safer places. At the same time, WHO is also increasing the number of mobile clinics that can follow the movements of the displaced persons. While mobile clinics are less likely to be attacked, they are only able to provide a limited package of services as compared to static facilities.

So far in 2020, nine separate attacks on health care have been reported; all of them in the northwest, claiming ten lives and injuring 35. In 2019, 85 attacks against health were verified with 54 persons killed and 107 injured. A total of 66 of these incidents affected health facilities.

The Security Council Resolution governing the humanitarian cross border activities has been extended till 10 July 2021 with one remaining crossing point from Turkey into northwest Syria. Adapting to changes in the legal and operational modalities will require a high degree of flexibility from WHO’s response in 2020.

In this dynamic space, WHO’s rules of engagement in Syria continue to be framed alongside the UN posture in Syria. WHO will play a major role in addressing health needs and vulnerabilities of the affected populations throughout the Syrian Arab Republic. This includes returnees, displaced and host populations; kick-starting of essential services and revitalization of services in areas of return, newly accessible areas and where disability and longer term health needs have to be addressed, including through community involvement and engagement; and pursuing health contributions for peace outcomes.

Regardless of how the conflict evolves, additional demands will inevitably be placed on WHO. Critical needs for life-saving health assistance in Syria will persist long after the violence has ended. In continuing to meet the acute humanitarian needs of Syrians, while increasing its focus on a gradual transition to recovery, WHO will be guided by the following principles:

Flexibility and scalability. WHO will continue to respond by the most direct and efficient means of access through an agile Whole of Syria response.

Evidence-based interventions. WHO will use up-to-date health information to guide its health interventions based on global norms that are equitable, impartial and needs-based and take account of health sector severity, gender, age and vulnerability sensitivities. WHO will continue to target the groups that are more vulnerable to health consequences of emergencies.

Impact. WHO will focus on both the quality of care, coverage – aiming to meet and maintain global standards – and the sustainable impact of its interventions.

Innovation. WHO will learn from health innovations adopted during the conflict and weave them into a resilient and equitable health system in Syria.

Partnerships. WHO will continue to implement country-focused interventions with a wide range of partners, including increasing its focus on local communities and national and international stakeholders. Longer-term investments in capacity of local partners is a critical component of ensuring capacity for emergency response and maintaining a resilient health system.

Protection. WHO will advocate for the protection of patients, health workers and health care facilities during hostilities, changes of political control, and throughout the country’s transition to an early recovery. WHO will continue to provide essential life-saving health services as long as required.

Health contributions to peace outcomes. By strengthening and enhancing certain health interventions, WHO can contribute to community cohesion, inclusion and peacebuilding, especially among the most vulnerable groups. Health interventions have the highest potential to improve prospects for peace when they are explicitly designed to address well-identified causes, drivers and triggers of conflict.

Integrated efforts: WHO will continue working with partners to enhance comprehensive community-based interventions with full participation of local communities.

Decentralization: By establishing hubs closer to those in need and ensuring bottom-up planning.

Accountability to affected populations: WHO is committed to addressing Accountability to Affected Populations (AAP) and Protection from Sexual Exploitation and Abuse (PSEA) by enforcing, institutionalizing and integrating AAP approaches in the Humanitarian Program Cycle and strategic planning processes, and to support collective and participatory approaches that inform and listen to communities. WHO will continue to monitor and report on these efforts on a regular basis.

WHO’s emergency and humanitarian work is guided by several overarching and interrelated global, regional and national frameworks (see Annex 1).

¹ Whole of Syria 2020 Health Sector Severity Scale and PiN. 

Context

Nine years into the Syrian crisis, 12 million people – over half the population - require humanitarian health assistance.² 6.1 million people remain internally displaced (many of them having experienced repeated displacements) and over 5.6 million people have left the country altogether.³ More than 80% of the population live under the poverty line and at least 3.07 million people are living with disability, many of them as a consequence of injuries and trauma⁴ and up to 27% of households may be experiencing functional difficulties.⁵ Recent WHO global analysis indicates the prevalence of mental disorders such as depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia in conflict settings at 22.1%.⁶ Therefore, as many as 4.52 million people may require mental health services and one in three children, besides growing up in an environment of violence, have missed critical years of their education. For the growing number of people with lasting disabilities there is still limited access to rehabilitation services. Other vulnerable groups include pregnant women and women of reproductive age (15-49), children, girls and boys under 5 years, elderly (65+ years). Persons living with disability are especially disadvantaged. Particularly affected populations are those living in IDP camps, collective centres, informal settlements, overburdened hosting communities, locations without reliable water, sanitation and shelter, areas with high levels of explosive ordnance contamination and areas of active hostilities. The security situation remains volatile and, in some areas such as the northwest, heavy fighting continues. Humanitarian needs are severe in these locations and in places where control has recently or previously changed hands. Population movements will continue for the foreseeable future, with people simultaneously fleeing and returning; both from within Syria and from neighboring countries such as Jordan, Lebanon and Turkey. The end of 2019 also saw renewed violence where early recovery and rehabilitation had already started. At the start of 2020, approximately 75% of people in need were in areas under government control, with the remainder in areas controlled by non-state armed groups (NSAGs) and other forces.⁷

Out of 198 hospitals, 104 (53%) were fully functioning in 2019; and out of 1,807 primary health centers, 925 (51%), were fully functioning across the country.⁸ Despite early recovery activities, this figure has not markedly improved due to ongoing hostilities and displacement. While the international response continues to be UN-led, NGOs have had to step in to provide essential health care services, especially in areas that were formerly besieged, hard to reach or where UN staff are restricted from entering. Because of prolonged exposure to violence, one in 30 Syrians suffers from a severe mental health condition, and at least one in 10 suffers from a mild to moderate mental health conditions.⁹

In 2019, there have been small-scale outbreaks of measles, diarrheal diseases, occurrence of scabies and an increase of cutaneous leishmaniasis in endemic areas, exacerbated by displacement, access issues, disruption of control mechanisms due to hostilities and interrupted funding, and by poor living conditions. Immunization coverage rates remain low despite mass vaccination campaigns and routine vaccination to curb the spread of diseases such as polio and measles. 2019 saw a slight decrease of immunization rates compared to 2018,¹⁰ as access issues have not been sustainably solved. Deliberate destruction of water networks especially in northeast Syria and restrictions on chlorine transport, have left large parts of the population temporarily without access to safe drinking water and 35% - 50% of the population relying on alternative and often unsafe water sources in the long term.¹¹

Developments early in 2019 triggered significant displacements including foreign nationals in northeast Syria. Health services in IDP camps – most notably Al Hol, were effectively scaled up by WHO and partners despite challenges of access, safety of health workers and availability of health workforce. Turkish military operations initiated in October 2019 resulted in further displacements from border areas and placed increased demands and access constraints on human resources and the health response from Qamishli sub-office, and later Gaziantep hub, between October and December 2019. A humanitarian health response in much of northeast Syria is expected to be required throughout 2020 and beyond.

Although data on the burden of disease since the onset of the conflict are scarce, some studies have estimated that over one quarter of Syrians suffer from one or more noncommunicable diseases (NCDs)¹² that are treatable with medicines but life-threatening if left untreated. In many parts of the country, medical supply chains still function only sporadically, leading to widespread shortages of medicines to treat common diseases. Despite large-scale support to ensure essential medicines are available and although public health care facilities are supposed to provide medicines free of charge, many patients are forced to buy them in private pharmacies because they are not available otherwise. Out of pocket costs for health care are estimated at nearly 54%¹³ and medicines are cited as the most frequent type of health expense.¹⁴ With economic hardship, sanctions, disrupted health systems and supply, it is not surprising that NCDs are further estimated to account for 45% of all deaths.¹⁵ Availability of medicines and treatment costs are also leading determinants of child mortality in Syria.¹⁶

The entire Syrian health workforce has been disrupted. The uneven distribution of health care workers and medical specialists is particularly acute in rural and historically deprived areas, as well as areas affected by recent hostilities and displacement, with 64% of the population or 13.2 million people, living in 167 sub-districts below the SPHERE standard of 22 healthcare workers per 10 000 people.¹⁷ Overcrowding and long waiting times are top access barriers reported by patients.¹⁸

The numbers of returnees to places of origin have been fluctuating throughout the year. Much of returns are from displacements within Syria, whereas the returns from abroad remain scarce or only 14% of all returns in the month of November 2019.¹⁹

The recent global pandemic of COVID-19 puts additional stress on the health system’s capacities and readiness as well as on health actors to prepare and respond to the outbreak. It exposes the Syrian population, especially the elderly and those lacking adequate access to health services as well as health workers to additional risks for illness and increased mortality.

Key challenges

In 2020, WHO will be challenged to find operational solutions to address evolving needs in the critical areas detailed above. Key challenges are to reposition WHO’s response in light of changes to the cross-border resolution, focus on hotspot areas for humanitarian assistance delivery and to maintain the health system in all areas of control operational and adaptable to the additional COVID19 challenge; meet anticipated increase in demand for kick-starting and rehabilitating essential health services in areas where access has not been fully granted or where health services are dysfunctional or in areas of voluntary returns – and finally to expand access to populations in need and scale up response capacities in the midterm.

Long term Sanctions, devaluation of the Syrian pound and lack of cash flow are affecting operations from within Syria and will pose an impediment for rehabilitation of health systems subsectors in key areas such as service provision, medicines and pharmaceuticals, medical equipment and diagnostic capacity. There is a high vulnerability to outbreaks of epidemic prone diseases, which is met by a low response capacity given the deteriorated health infrastructure and lack of suitable health work force. Outbreaks pose a threat to Syria’s northwest, due to limited reach and capacity of health responders in governorates that are overly populated with one of the highest concentration of internally displaced people in the country.

We are entering a sensitive phase where maintaining funding streams for humanitarian response will be crucial as more people in need reside in GOS controlled areas, while maintaining a principled and needs-based approach will still be imperative. Generating new funding for non-humanitarian health interventions in line with re-vitalizing essential services, such as in areas of voluntary returns; will be sensitive to the effectiveness of the political process.

Current operational structure and area-based response

WHO’s response currently centers on joint Whole of Syria planning for different response scenarios such as geographic areas, governance structures, health needs and access modalities. In 2020, WHO implements its response through its main office in Damascus and 5 sub-offices in Syria, complemented by cross-border operations from one external hub in Turkey, and previously also from Iraq.²⁰ The Whole of Syria coordination structure for the health cluster is in Amman.²¹ WHO country offices in neighboring Jordan, Lebanon and Turkey help to meet the health needs of over 5 million Syrian refugees.

Throughout 2018 and 2019, WHO adapted its operations to meet evolving realities on the ground, while maintaining response objectives articulated in the HRPs. A brief description of the current situation in different parts of Syria, and WHO’s likely short-term interventions, follows:

• In northwest Syria, WHO’s office in Damascus, sub-offices in Aleppo and Homs, and the WHO Field Office in Gaziantep continue to implement major health operations particularly if NSAGs and other international actors retain significant control of the area. WHO has started planning for scenarios beyond the validity of the current cross border resolution. The burden on health facilities continues to be immense, considering the number of internally displaced people in dire need in Idleb and Aleppo. WHO’s offices in Gaziantep and Damascus will remain in close contact to coordinate and adapt operations based on changing conflict lines. Regional dynamics, interference of external actors and the extent and outcome of military operations in Syria’s northwest in 2020/2021, are main factor that will determine the wellbeing of millions of Syrians and WHO’s operational context and humanitarian space in coming months and year.
• Northeast Syria is characterized by continued instability, displacements and severe health needs. In addition, new military operations since October 2019 have created a new situation with challenges for access and UN monitoring. The removal of the Yaroubiya crossing from the renewed cross-border Security Council Resolution has added layers of complexity to sustain the capacity of essential services in these areas including in northern Syria. Sustainable, alternative support modalities will need to be quickly identified and scaled up to ensure full coverage of health services. Each of the four northeastern governorates has its own structure, governance, lines of control and access constraints, further complicating the health response. WHO’s Country Office in Damascus, who leads operations in the northeast, together with the sub-office in Qamishli, will work on continuing scaling up technical capacity and involvement of new health NGOs and effective delivery of supplies to the extent possible. Technical support for the implementation of COVID 19 response, as well as continuation of essential health services will be given priority in NES as in other parts of the country. Health services in formal and informal IDP camps - including Al Hol – as well as in collective centers, are envisaged to continue throughout 2020.
• Rural Damascus has been heavily affected by the conflict. Although a degree of stability has returned, insecurity and access challenges persist while needs remain immense. Health needs of people returning to areas across Eastern Ghouta that were previously densely populated, require particular consideration. The recovery of these severely damaged areas will require short- and long-term support from WHO in Damascus, which have already started with primary health care in 2019.
• In southwest Syria, the government regained almost complete control of areas previously controlled by NSAGs in 2018. As a result, all cross-border support from Jordan ended in July 2018. Although families displaced during the hostilities are gradually returning, the need for health assistance and services is increasing. Electricity and water networks remain non-functional in most areas while new violence erupted late in 2019 which may require the dual approach to humanitarian and resilience activities WHO followed in 2019 described in detail in New Directions for 2020 in this document. The shortage of general and specialized physicians continues. Revitalizing existing health care facilities, expanding primary care and reintegrating and training health care staff will remain key priorities, security and access conditions permitting
• In central Syria, there are chronic shortages of health care staff and functioning health care facilities in areas that have changed hands such as northern rural Homs. Health services are a top priority area for returnees to Homs.

Across the country, health needs of communities that have been historically underserved or are especially vulnerable, need to be specifically addressed.

² HNO 2020
³ Ibid
⁴ World Health Organization and the World Bank. World Report on Disability 2011. World Health Organization, Geneva. 2011. http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf?ua=1
⁵ HNAP, Disability: Prevalence and Impact, 2019
⁶ Charlson, Fiona et al. “New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis” Lancet vol. 394 (2019). doi: 10.1016/S0140-6736(19)30934-1
⁷ Reference: OCHA access analysis map Nov 2019
⁸ WHO Whole of Syria consolidated Health Resources and Services Availability Monitoring System (HeRAMS), 2019 Q4
⁹ Syria HNO 2020
¹⁰ WoS key performance indicators for 2019
¹¹ Syria HNO 2020
¹² Reference on Syria statistics of NCDs
¹³ EMR- Framework for HIS and core indicators for monitoring health situation and health system performance 2018)
¹⁴ 2019 MSNA
¹⁵ WHO, 2016
¹⁶ Syria Ministry of Health: The study of the causes of deaths of children under the age of five, 2019.
¹⁷ WHO Whole of Syria consolidated Health Resources and Services Availability Monitoring System (HeRAMS), 2019 Q2
¹⁸ 2019 Multi-Sectoral Needs Analysis
¹⁹ HNAP Mobility and needs monitoring, Nov 2019)
²⁰ UN Security Council Resolution 2504 ended inclusion of cross-border humanitarian efforts from Iraq to Syria.
²¹ WHO WoS hubs are: Syria (Damascus Office, Aleppo, Homs, Latakia, Qamishli field offices, presence in Deir ez Zor)), Jordan (Amman – WoS team), Turkey (Field Office in Gaziantep).

Despite widespread changes of control in Syria in 2018 and 2019, there is a continued need for a Whole of Syria approach to support harmonized, comprehensive, equitable and dynamic humanitarian action and leverage all response options to help people in need in the most direct possible way in 2020. The support system remains in place unless major triggers occur and prompt re-consideration of the approach such as major changes in lines of control, non-renewal of UNSCR for cross-border operations, etc. WHO has been working on a gradual shift towards WHO in Damascus as the center of health operations, supported by a strong footprint in Gaziantep.

WHO will continue to advocate for unimpeded access to all parts of Syria to deliver humanitarian health assistance from within the country according to assessed health needs.

COVID-19 will provide an increasing distraction from our core functions in sustaining humanitarian response over the coming weeks and it will be therefore important to ensure dedicated attention to the ongoing delivery of essential assistance. Increasing our technical, leadership and coordination capacity at country office will be vital to meet the additional needs.

Sustaining a flexible humanitarian response

WHO therefore continues to bring together all WoS hubs, plus support from two regional offices and headquarters, to ensure that its humanitarian work in Syria remains flexible, complementary and coordinated through a process of continuous operational review, as adopted since 2017. The Organization will continue to advocate on behalf of all health partners for a safe and sustained delivery of humanitarian aid to all parts of Syria. This includes (1) securing cross-line and cross-border access for supplies; (2) enhancing the protection of medical facilities and health and humanitarian workers inside conflict zones and beyond; (3) securing patients’ unimpeded access to health care facilities – including cross-line transfer of emergency and specialized cases; and (4) facilitating a smooth transition between health agencies and health care facilities when changes of political control occur.

WHO will leverage technical support and expertise from WoS hubs as well as its regional and headquarters offices to deliver the following outcomes:

• Sustained delivery of quality medicines, medical supplies, consumables and equipment across the country.
• Sustained and improved primary health care services, including for chronic diseases and reproductive, maternal and child health and disability and community health interventions.
• Scale up of COVID 19 response and technical support to implementation of all nine pillars in the COVID19 Strategic Preparedness and Response Plan
• Sustained and improved secondary health care, obstetric care and referral services, including ambulance networks and mobile service delivery.
• Support quality emergency health care and ambulatory system.
• Strengthened trauma care/mass casualty management, physical rehabilitation services and disability.
• Expanded specialized services, tuberculosis detection and treatment, dialysis, and burns care.
• Strengthened linkages between levels of care, as well as between general and specialized care providers through comprehensive service mapping, improved patient tracking and training of health care workers.
• Reinforced surveillance systems for early detection, prevention and control of epidemic-prone diseases.
• Scaled up routine immunization and emergency/mass vaccination campaigns against polio, measles and other childhood diseases.
• Enhanced mental health and evidenced-based psychosocial support services.
• Strengthened prevention and early detection of malnutrition in children under five years of age, supported by referral systems for children with severe acute malnutrition with medical complications.
• New or strengthened systems for monitoring water quality, and integrated medical waste management systems in health care facilities, areas of returnees and IDP camps.
• Emergency preparedness for public health emergencies including outbreaks.

To support the delivery of the above outcomes, WHO will:

• Continue to strengthen coordination between WoS offices and hubs, with health sector partners and the health system.
• Provide support for the chain of care for refugees and IDPs that opt to return to their homes, through WHO’s offices in Jordan, Lebanon and Turkey in cooperation with WHO in Syria.
• Improve collection and analysis of health information to support the emergency response and revitalization of health systems.
• Strengthen the monitoring and collection and analysis of information on the coverage and quality of health care services across the country.
• Conduct regular health needs assessments.
• Strengthen advocacy and resource mobilization.
• Sustain strong partnerships and coordination with UN agencies and other health partners

Clear principles of engagement are needed to ensure equitable access to essential health care services. Humanitarian needs will remain acute throughout the country.

WHO will:

• Continue to apply the four humanitarian principles of humanity, neutrality, impartiality and independence during the emergency and recovery phases.
• Deliver assistance in a transparent, equitable, non-discriminatory, respectful, dignified and non-politicized manner based on independent needs assessment and health severity.
• Prioritize geographic areas and population groups that have been hit hardest by the crisis as well as those that were disadvantaged before the crisis.
• Support health strategies, plans and policies that are inclusive, non-discriminatory and target the most urgent needs of the population, e.g., those with life-long disabilities because of the conflict.
• Advocate for the sanctity of health care facilities, patients and health workers, and take human rights and protection issues into account when delivering assistance.
• Engage at community level to help ensure that civil society has a say in revitalizing the health system.

The health perspective for WHO’s work in 2020 is on a dual approach: a flexible, needs-based and evidence-based approach to humanitarian and lifesaving response in hot spot and high severity areas and in disease outbreaks, including COVID-19, as in the past, and increasing WHO’s involvement in health system resilience and expansion of access - including kick-starting of primary and secondary level services in other areas and where access is possible. WHO will continue service provision and technical support in camps and collective centres and scale up in areas of voluntary return.

While pursuing the humanitarian response and life-saving aspect, WHO is moving in parallel towards medium to longer-term strategic operations, basing interventions on evidence for health needs and their severity in all 270 sub-districts of Syria. The severity scale, set out in the HRP, is derived from a range of data sources²² that yield information on 1) accessibility to health care, 2) number of people affected, 3) availability of health resources and services, and 4) impact of the conflict on health and morbidity.

Secondly, WHO will shift its focus from short-term partnerships that target immediate needs to sustained partnerships that increase the impact of its humanitarian interventions at community level. WHO will expand its mentoring and capacity building initiatives, especially for local and national NGOs, supported by third-party monitoring schemes to verify whether partners are working in a consistent manner, to the same standards, to deliver high-quality health care. WHO is aiming at ensuring better alignment with NGOs’ training needs, including institutional development for its capacity development initiatives.

Operationalizing the information obtained from the health service functionality data information will also serve to prioritize and coordinate support to underserved health districts and to prioritize kick-starting of essential services in areas of return and where most needed.

The health system resilience approach will entail WHO seeking to enable and engage in health sectoral platforms to foster strategic dialogue and engagement with MoH strategies for 2020-2024and in reviving policy dialogue on heath system strengthening. WHO’s provision of technical guidance will continue.

Thirdly, WHO continues to strengthen the collection and analysis of health information as the backbone of monitoring - for coverage and utilization of services and as well as quality of health care services and health outcomes across the country. WHO supports the expansion of national health information systems (HIS) in Syria and, together with relevant stakeholders. WHO is also supporting the revitalization of the Civil Records and Vital Statistics system; critical for accuracy in documentation of births and deaths. Across the Whole of Syria response, each hub carries out operational monitoring through a set of harmonized indicators. WHO issues monthly reports documenting progress measured against almost 70 key performance indicators. Other information products include integrated EWARS/EWARN epidemiological bulletins, consolidated HeRAMS reports on the functionality status of health care facilities throughout Syria, a monthly “Who does What, Where and When” report for the health cluster and a monthly infographic that illustrates data captured though WHO’s continuous monitoring of attacks on health care through the Surveillance System for Attacks (SSA)²³ in line with its mandate.

The future of WHO’s operations

Over the next year, there will be a continued need for harmonized humanitarian action from outside Syria and from within. The Whole of Syria (WoS) approach allows WHO to implement its humanitarian operations through a common framework adopted by hubs, with operational adjustments as the situation evolves.

WHO’s future WoS operations will be in line with the overall UN approach and humanitarian architecture for the Whole of Syria response as defined by the WoS Strategic Steering Group (SSG),²⁴ in line with WHO’s Emergency Response Framework (ERF) and commonly agreed IASC protocols.

The SSG has defined the scenarios that would trigger changes to the current WoS approach. They include changes in political control that would affect the scale of the multi-hub response and could lead to the discontinuation of WoS Humanitarian Response Plans and/or the non-renewal or partial renewal of UNSCRs 2165 (2014) and 2504 (2020). These changes in the UNSCRs could result in partial or total cessation of cross-border delivery of supplies by WHO. WHO’s cross-border support would instead focus on health sector coordination, information management for health partners in southern Turkey and Iraq,²⁵ technical assistance, planning, capacity building, coordinated health needs assessments and resource mobilization. WHO’s WOS health cluster coordination staff is to remain in Amman, Jordan, and as long as such coordination is required and in place at UN-wide level. In 2020, overall WoS operations will likely shift further towards the WHO country office in Damascus, supported by a strong footprint in Gaziantep, Turkey and continued advocacy for access to all areas within Syria.

Since UN cross-border operations began in July 2014, they have provided indispensable assistance and services in areas where government-services are limited or inexistent. A recent WHO country functional review in 2019 identified additional staff functions for an adaptation of WHO functions and presence within Syria. The SCR 2355 places additional requests on finding effective alternative modalities to the NES cross border delivery of assistance and supplies for WHO’s assistance in Syria.

Needs-based planning with the participation of affected populations provides a foundation for health equity and WHO’s accountability to affected populations. Strengthened information management and monitoring will provide solid inputs for longer-term health system rehabilitation. By leveraging and building on regional and global expertise throughout the response phase, WHO is well-placed to provide continuous technical assistance through the transition and recovery phases for both humanitarian assistance and building resilient health system approaches.

In the coming 6-12 months, key priorities will be to strengthen programming and advocacy on resilience, sustainable solutions, delivery of essential services, analysis and planning for services to displaced people and returnees.

Building resilience for future health emergencies

To be sustainable, Syria’s rebuilt health system must be resilient and responsive. WHO will review and recalibrate its health indicators to generate reliable evidence for protracted crisis response, health policies and programs – placing greater focus on impact and outcomes, as well as progress against global targets. WHO will also adopt a standard approach to support the restoration of health care facilities, prioritizing rehabilitation based on population needs and providing them with training for staff and essential equipment.

Strengthening country and sub-national capacities for emergency preparedness and response, including strengthening national disease surveillance and early warning systems, will increase Syria’s resilience against future health emergencies such as infectious disease outbreaks, natural disasters or other man-made hazards.

WHO will consider the innovations and successes of its WoS program with a view to streamlining them into recovery efforts and other WHO emergency response programs.

Building on innovations and successes documented during the crisis

WHO’s flexible, scalable principled and needs-based approach has been successful in meeting the health needs of millions of people and in supporting MoH, DOHs, partners and civil society in responding rapidly to outbreaks and scale up needs in a fast-moving and fluid context, demonstrating a well-coordinated response.

WHO’s Health Resources Availability Monitoring System (HeRAMS) has been crucial in tracking the status of health care facilities and directing scarce resources to where they are needed the most. Already capturing public health facilities of the MOH and MOHE, WHO will continue to expand HeRAMS to include health care facilities managed by NGO partners, private practitioners and in areas where control has shifted in 2019 and 2020. As HeRAMS has also been used in some parts of Syria to capture utilization data, it will also be used to strengthen a national health information system moving forward.

Since the beginning of the conflict, WHO has worked closely with health NGOs to support the delivery of essential health care across conflict lines and borders, maintaining continuity of care in all parts of the country. WHO’s investments in training health NGOs and building their capacity will have long-term benefits for the health system in the long run. Formalizing and expanding the role of civil society and peacebuilding initiatives, as previously highlighted, is an increased focus of attention in 2020.

WHO’s training programme for tens of thousands of health care staff from national institutions has served to maintain essential services in difficult times, strengthen national capacity, reinforce resilience and prepare for recovery. This is critically important given that more than half the health workforce is estimated to have left Syria.²⁶

Based on this experience, WHO will continue to support the development and implementation of gender responsive strategies to improve human resources for health (HRH). This will include a revised WHO training syllabus, an HRH information system and the establishment of continuous professional development plans for all health personnel.

UNSC resolutions have been instrumental in allowing aid to be delivered to people who cannot be reached by WHO in Damascus. WHO’s ability to draw on these and other international instruments such as the International Health Regulations (2005) and international humanitarian law have successfully prioritized health imperatives and depoliticized the delivery of health assistance.

The EWARS disease surveillance system has offered an operational and cost-effective means of enhancing disease surveillance and response. Its rapid expansion, achieved with the involvement of NGOs and other health partners, has helped halt the spread of epidemic-prone diseases in Syria and neighboring countries, where the risk of disease outbreaks is greatly increased by cross-border movements of highly mobile populations. WHO has been working with the Syrian MOH to assimilate EWARS/EWARN disease surveillance for priority syndromes into national surveillance systems.

WHO has invested heavily in training health professionals and community workers on mental health and psychosocial support (MHPSS). As a result, mental health services are now being offered in 578 PHC and community centres in 11 out of 14 governorates supported by WHO. These efforts have laid the foundation for the sustained integration of MHPSS services into primary and secondary health care services throughout Syria, offering vital services.

Contributing to peace outcomes

Important aspects in the work of WHO already contribute to sustaining peace in one way or another.

WHO’s support to health systems that break down economic, geographic, epidemiological and cultural barriers to access, and work towards universal health coverage, are powerful actions towards rebuilding trust and positive links between citizens and the state.²⁷ Moreover, well designed peace-responsive programming can render health outcomes more sustainable.

Lasting impact of the crisis will continue to drive resentment and grievances, particularly related to trauma and mental health. Expanding capacities to address MHPSS needs, as well as disabilities, and contributing to restore, strengthen, and protect health services in an equitable and inclusive manner are important steps towards peace outcomes. Contributing to improving social cohesion, by strengthening and enhancing the Syrian Public Health System’s capacity to deliver a package of adapted emergency response and long-term interventions that serve the most vulnerable in all 270 sub-districts of Syria could be a viable midterm goal.

The Organization can also use its convening power to foster cooperation on health issues in a given context, facilitating health-technical dialogue between various stakeholders.

Healthier lives through a whole-of-Syria recovery

Recovery needs to be driven and led by Syrians. Successful efforts will require a constructive relationship with the Syrian government and its line ministries involved in health matters under the UN Strategic Framework 2021-2023. WHO has initiated a health sector working group in Syria and will foster exchanges on strategic and longer term subjects to enable an alignment with forthcoming strategic frameworks and national health strategies.

WHO will promote a whole-of-society approach that recognizes and learns from the powerful segments of civil society that have emerged over the past seven years and will focus on areas of voluntary return. WHO will foster scientific work to assess burden of disease and create evidence that can guide longer term priority interventions. Through the private sector, WHO may seek to promote areas such as the rehabilitation of aspects of the country’s pharmaceutical industry and domestic manufacturing and maintenance of medical devices and equipment in priority areas. A well-functioning independent Drug Regulation Authority and an assessment and regulation of the private health sector will also be among WHO’s priorities.

By further strengthening and expanding programs such as mental health and psychosocial support and increasing access to assistive technology and services for people with disabilities, WHO will aim to ensure active participation of all members of society and contribute to community cohesion and peacebuilding, especially among the most vulnerable.

Universal health coverage means leaving no one behind

Equitable access to health care is a priority for WHO. In working towards the long-term recovery of the Syrian health system, WHO will promote the adoption of equity-oriented policies, programs and practices. Objectives will include advocating for the principles of equity, improving national childhood immunization coverage rates, access to an essential package of health services, ensuring a greater community engagement in rebuilding the health system, e.g. by soliciting feedback and establishing complaints mechanisms.

WHO will use its whole organizational expertise to support this effort customized to the Syrian context in humanitarian context and during the COVID19 response; based on data and evidence in the health information system.

²² Data sources include Multi-Sector Needs Assessment (MSNA), 4Ws, HeRAMS, MoH and WHO, reports, Population Task Force, and INSO reports.
²³ https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx
²⁴ SSG notes
²⁵ National and international NGOs are not bound by the UNSCRs and may decide to continue cross-border deliveries.
²⁶ WHO: Health care a casualty of 6 years of war in the Syrian Arab Republic. https://www.who.int/en/news-room/detail/15-03-2017-health-care-a-casualty-of-6-years-of-war-in-the-syrian-arab-republic.
²⁷ WHO. White paper Health and Peace. 2019.

WHO has invested in a robust network of local organizations, community-based focal points, local health authorities, other UN agencies, and international and national NGOs in Syria. This network has had a direct impact on the success of humanitarian health operations in the country. Key stakeholders include:

• Government of Syria: As per WHO’s mandate, its primary relationship is with the Ministry of Health (MOH)²⁸ MOHE and DOHs. Through this partnership, WHO will continue to influence health policies and support and advocate for the needs of all Syrians based on global standards and on the principles set out in this paper and seek entry points for engagement through forthcoming strategic frameworks and national health strategies.
• Health sector partners and other international organizations: Close coordination with other health partners for emergency response and longer term strategic interventions is essential to agree and deliver common objectives. Joint activities with agencies such as UNICEF, working on vaccination campaigns, child health and nutrition, UNFPA, working on a collaboration on reproductive health care and UNDP, focused on rehabilitation projects, result in comprehensive, complementary interventions that make the best possible use of limited resources while delivering results. WHO will also aim to engage new local and international health partners. Since 2019, a health sector group convened by WHO enables a platform for strategic discussions and longer-term planning.
• NGOs and civil society, private sector: Strengthening Syrian civil society promotes resilience and helps national systems to deliver quality services. In 2019, this collaboration ensured a rapid scale up of response in new hotspot areas and availability of human resources where availability was not sufficient – particularly in Al Hol. Expanding engagement with civil society and giving it a greater contribution in rebuilding the health system and contributing to peace outcomes will be a key component of WHO’s strategy in Syria. WHO has partnered with private sector and private health providers to expand capacities for response and map health service availability.
• Academia and institutions: Fostering collaboration with national, regional and global academic institutions promotes longer-term educational and development goals. It also helps ensure that standard health indicators are integrated into national surveys and data collection efforts.
• Donors: The landscape is changing as humanitarian contributors make way for development donors such as the World Bank and the European Union. WHO will continue to seek to engage with new stakeholders in the donor community to secure funding for the objectives.

²⁸ WHO maintains working relationships with other line ministries responsible for health, such as the Ministry of Higher Education.

As of December 2019, WHO had received 60% of the funding required under the HRP for 2019. For non-earmarked funding, 61% of the funds have been allocated to WHO’s country office in Damascus, with 30% going to Gaziantep, 2% to Iraq and 7% to the Eastern Mediterranean Region, including for the Whole-of-Syria health cluster coordination team Amman.

WHO’s offices in Damascus and Gaziantep are in the process of planning operations and mapping funding requirements under the 2020 HRP. The distribution of funds in 2020 has been be determined based on the following scenarios:

• UNSCRs 2165, 2253. WHO will distribute funds to its offices in Syria and Turkey based on funding requirements set out in the 2020 HRP;

WHO’s Emergency Response Framework sets out the Organization’s ten core commitments and six core response functions in emergencies.

The Thirteenth General Program of Work for 2019-2023 sets out WHO’s global objectives over the next six years . Its three overarching goals are: universal health coverage; lives made healthier; and people better protected from health emergencies.

The 2005 International Health Regulations set out the specific responsibilities and obligations of WHO and Member States to prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.

The joint annual Humanitarian Response Plans (HRPs) guide WHO’s response in Syria. The strategic objectives in the HRPs are themselves guided by the annual Humanitarian Needs Overviews.

The “Strategic Framework for Cooperation between the Government of Syria and the UN” describes how both parties will work together to transition to recovery and development as well as restore, improve and maintain basic services and social infrastructures. It is valid until end of 2020.

The “Strategic Framework for Cooperation between the Government of Syria and the UN 2021-2023” is the follow up cooperation framework to above.

UN Security resolutions authorize cross-border operations to deliver humanitarian assistance to people in need in Syria.

The four humanitarian principles of humanity, neutrality, impartiality and independence underpin WHO’s work in Syria and all countries facing emergencies. The Inter-Agency Standing Committee (IASC) is the primary mechanism for inter-agency coordination of humanitarian assistance. As the lead agency for the Global Health Cluster, WHO is accountable to the IASC.

WHO follows a human rights-based approach in all phases of its humanitarian work.

The Humanitarian-Development-Peace Initiative (HDPI) is a joint effort by the United Nations and the World Bank Group—two institutions with distinct yet complementary roles—to work together in new ways across the humanitarian-development-peace nexus in countries affected by fragility, conflict and violence.

WHO Grand Bargain Commitments for participation and inclusion, localization in protracted crises

2017 IASC Principals’ commitments on Accountability to Affected People and Protection from Sexual Exploitation and Abuse

• UNSCR 2165, adopted in July 2014, authorized cross-border and cross-line access to reach people in Syria by the most direct routes. UNSCR 2393, adopted in December 2017, renewed resolution 2165. It expires on 10 January 2019. In preparation for a UNSC decision on the matter, key messages on the renewal have been defined at the inter-agency level.
• Syria Humanitarian Needs Overview, 2017, https://hno-syria.org/data/downloads/en/full.pdf
• OCHA, The Humanitarian Response in Syria - Key Messages, September 2018.
• HeRAMs WoS data from August 2018.
• WHO and HI, 2017, http://www.emro.who.int/syr/syria-news/the-world-health-organization-and-handicap-international-draw-attention-to-the-needs-of-people-in-syria-living-with-injuries-and-disabilities.html and WHO, World Report on Disability, http://www.who.int/disabilities/world_report/2011/report.pdf
• Bulletin of the World Health Organization 2016; 94:6-7. doi: http://dx.doi.org/10.2471/BLT.16.020116
• Syria HNO, 2017, https://hno-syria.org/data/downloads/en/full.pdf
• Doocy, S. et al., Conflict and Health, 2016, 10:21; and Rehr, M. et al, Conflict and Health, 2018 12:33 who highlight the burden of chronic disease among Syrian refugees.
• WHO WoS hubs are: Syria (Damascus Office and Aleppo, Homs, Latakia, Qamishli field offices), Jordan (Amman –non-operational field office and WoS team), Turkey (Field Office in Gaziantep).
• Data sources include Multi-Sector Needs Assessment (MSNA), 4Ws, HeRAMS, MoH, WHO, INGO reports, Population Task Force, Surveillance of Violence against Health.
• https://publicspace.who.int/sites/ssa/SitePages/PublicDashboard.aspx
• Discussion Paper: Whole of Syria functions and way forward. SSG, September 2018.
• These scenarios have already been observed through a scale-down of WoS Amman-based operations after June 2018, as the Government of Syria extended its control across southwest Syria, and a transition of programming to country-based operations.
• National and international NGOs are not bound by the UNSCRs and may decide to continue cross-border deliveries.
• One of the most likely outcomes of a partial renewal would be the cessation of cross-border activities in some (but not all) geographical locations.
• WHO maintains working relationships with other line ministries responsible for health, such as the Ministry of Higher Education.
• Emergency Response Framework, 2nd Edition. World Health Organization, 2017. Available at http://www.who.int/hac/about/erf/en/
• WHO's Thirteenth General Programme of work, 2019–2023 is available at http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_4-en.pdf?ua=1. Its three overarching goals are: universal health coverage; lives made healthier; and people better protected from health emergencies.
• 2019 Humanitarian Response Plan for the Syrian Arab Republic. 2018 HRP available at https://reliefweb.int/report/syrian-arab-republic/2018-syrian-arab-republic-humanitarian-response-plan-january-december
• 2020 HRP and 2021 Health Sector HNO.