Syria’s public health system is under severe strain. Although the quality of its health care remains regionally strong, growing budget deficits, ballooning demographics and the influx of an estimated 1.5 million Iraqis, all of whom qualify for free healthcare, means the need for state hospitals and clinics is soaring, even as the money to pay for them grows less each year.Syria’s budget deficit has gone from bad to worse in recent years. Annual deficits have increased from 1.7 percent of gross domestic product (GDP) in 2001 to 5 percent in 2005 and with spending increases in 2006 Damascus-based economists estimate the deficit will reach 7.6 percent.
Annual spending on healthcare is just 5 percent of GDP, a slight increase from the 2.5 percent estimated as of 1999, but considerably less than neighbouring countries. According the World Health Organization, Jordan spent 9.8 percent and Lebanon 11.6 percent of GDP on health in 2004.
The deficits are growing as Syria’s demographics experience massive change. Syria’s population of 19 million is growing at 2.5 percent a year, around 475,000 people, while the influx of up to 1.5 million Iraqi refugees has further swelled the population by around 8 percent since 2003 and put an unsustainable strain on public services.
“Though there are a lot of public hospitals, which are free of charge, the quality is not so good and is decreasing,” said Syrian economist, Samir Seifan. “When you have 2.5 percent population growth each year you need to improve the budget by more than 2.5 percent at minimum. But the state budget doesn’t have enough resources; we’ve had a deficit for the last few years.”
Among a population long weaned on low salaries and state subsidies few are able to afford private health care.
Modernisation drive
With the soaring demand for healthcare, a European Union (EU)-funded modernisation programme is helping the government run its state hospitals and clinics more efficiently.
On a hill overlooking Damascus the recently opened Centre for Strategic Health Studies (CSHS) is the most visible result of an ongoing two-year 30 million euro health modernisation programme that aims to boost efficiency in cash-strapped hospitals and clinics by improving their management.
The CSHS is aiming to become the region’s most advanced hub of health studies, training health sector staff in three key areas - health economics, public health and health systems management.
The CSHS has been funded through the Health Sector Modernisation Programme (HSMP), receiving 5 million euros from the EU and operating in partnership with the UK’s Liverpool University, which has provided academic and institutional expertise, including professors for the current crop of 24 students.
Six CSHS staff members have been dispatched to Europe to complete masters’ degrees to prepare them for academic, research and consultancy work. The curriculum will focus on health management issues aimed at improving efficiency and providing better services within the health sector, leaving the medical care itself to the doctors.
“Health management research is very weak in Syria,” said CSHS director Reem Akras. “We need people to be specialised in these areas so we can support the health sector.”
The HSMP, launched in 2005, is financed by a 30 million euro donation from the EU, 22.5 million of which went to the Ministry of Health and 7.5 million towards other organisations, including the German development agency GTZ.
Changing attitudes
At the heart of the programme is the belief that by improving the management of, and attitudes in, the Syrian health sector, services and the utilisation of public facilities on the ground will improve.
“Modernisation needs a long time and it’s difficult sometimes to see tangible results on the ground because you are dealing with changing mind-sets,” said Omar Ballan, programme coordinator at the Ministry of Health. “People have been working for 40 years under this system and you can’t change that in one day.”
Six areas have been identified as central to the HSMP, according to Ballan: improving policy and planning capacities; better matching the primary health care system with the population needs; improving the performance of hospitals and other health centres; enhancing management capabilities; strengthening quality management and accreditation processes; and creating sustainable health financing.
Family clinics
Within the six target areas, the role of primary health care systems and health insurance has taken centre stage in the debate over reform.
Officials estimate that around half of Syrians unnecessarily finance their own health needs by buying medicine from pharmacies and going to private doctors before they enter largely-free public hospitals.
The HSMP aims to improve the quality and availability of public primary health care systems, or family clinics, and create “a rationalised pre-payment” system to help relieve the poor of the financial burden of private care.
Health insurance schemes, both private and public, are being considered as a means of covering the individual and public financial burden of health care.
Initially intended to be completed by November 2007, the project has been extended to 2009 and could well continue beyond.
“We’re finally at the stage where we’re starting to deliver things on the ground,” said Ryan Knox, programme officer for the HSMP at the European Commission in Damascus. “The first two years were mainly policy work to come up with a vision for how the health sector should change.”
New equipment
The Health Ministry’s Ballan said 30 health centres in the pilot governorates of Lattakia, on the west coast, and Daraa, in the south, have been renovated in readiness for new medical equipment and that 25,000 training days had been logged since the project began.
New medical equipment, from simple blood pressure machines to high-tech ultra-sound scanners, is now being delivered to the renovated health centres.
