By Sharif Ismail (member of the HSG Health Systems in Fragile and Conflict Affected States Thematic Working Group), Aula Abbara, Adam Coutts, Fouad Fouad, Diana Rayes and Miriam Orcutt on behalf of the Steering Committee of the Syria Public Health Network
Six years of conflict in Syria has left the Syrian health workforce in crisis. Over half of all qualified doctors (to take one workforce cadre) working in Syria in 2011 have left the country. Repeated targeting of health care workers (HCWs), health facilities, and ambulances inside Syria mean that it is now one of the most dangerous countries in which to practice. In the most insecure parts of the country health worker shortages are dire: the 400,000 Syrians living in besieged Eastern Ghouta near Damascus are served by fewer than 10 surgeons. But health worker protection is also a fundamental issue in neighbouring frontline countries, where many Syrian HCWs are barred from formal practice and instead work informally without regulatory oversight.
Responding to the Syrian health workforce crisis: theory versus reality
The case for sustained investment in health workers in the Syrian context is clear – and was reaffirmed by the Dublin Declaration from the Fourth Global Forum on Human Resources for Health which concluded in Ireland a little over a week ago. Research evidence shows that robust mechanisms for health worker training, attraction, equitable distribution and retention are perhaps the most important determinants of long-term health system performance. Syrian HCWs can deliver life-sustaining interventions now, and could make substantial contributions to managing health needs among both host country and refugee populations in countries such as Jordan and Lebanon, where domestic health systems struggled to meet demands even before the crisis. They will be also be cornerstones of health service provision in a post-conflict Syria. For both Syria and its neighbours, realising universal health coverage will depend on the readiness of host country health systems and politicians to utilise Syrian human resources for health.
In reality, however, the regional response to the health workforce crisis has been under-resourced and poorly coordinated, contributing to a generational gap in health workforce supply. Opportunities to continue training – for example, for medical students forced to drop out of their studies due to conflict-related insecurity – are ad hoc and micro-scale. Even for qualified HCWs who are able to secure residency status in neighbouring countries, barriers to practice are substantial. In Lebanon, for example, permit renewal has become an increasingly onerous and expensive administrative process with medics registering as concierges or menial labourers to secure work permits and visas, and there is no formal mechanism for Syrian HCW licensing or accreditation in either Lebanon or Jordan.
The need for evidence and solutions
Any response to the Syrian health workforce crisis needs to start with better evidence. Six years into the conflict there is still no formal mechanism for gathering information on Syrian health workforce numbers, their specialties or geographical distribution in neighbouring countries to support workforce planning. At a minimum, detailed survey work will be required to understand the Syrian health workforce profile, alongside a commitment from those organisations gathering data to share it with partners.
We also need a clearer view of how to support health workers. A remarkable feature of the crisis so far has been the capacity of ordinary Syrians, grass-roots organisations and Syrian non-governmental organisations (NGOs) to innovate in response to health systems challenges created by the conflict. To give just a few examples:
- Medical doctors in non-government controlled areas inside Syria (NGCAs) have, over several years, developed a new accreditation system to support trainee doctors, overseen by the Syrian Board of Medical Specialties (SBOMS).
- There has been extensive work – often in partnership with academic institutions in other countries – on telemedicine and tele-training of health professionals.
- The Syrian American Medical Society, other Syrian NGOs and the WHO have supported continuing medical education courses in Turkey on range of topics including surgery, paediatrics, anaesthetics and microbiology.
- In Lebanon, a Syrian neurosurgeon founded Multi Aid Programs (MAPs) in 2013, a grass-roots organisation that sponsors health centres and mostly employs Syrian health workers to cater to the needs of Syrian refugees living in rural areas throughout Lebanon.
Many of these interventions now need formal evaluation to determine to what extent wider roll-out should occur.
Changing the humanitarian response narrative
For the most part, Syrians have themselves – correctly – driven support for displaced HCWs, but often without effective institutional and financial backing from major agencies and donors or meaningful coordination between country governments. Partly, this is because of the way the humanitarian response is framed; training is mostly short-term, non-accredited and addressed to urgent health needs such as mental health and trauma. Narratives emphasising economic livelihoods and education for Syrians have overlooked the importance of links between these domains in health and healthcare, and the need to invest consistently across the continuum from education, accreditation, through continuous professional development to workforce replenishment.
This narrative needs to change: a new approach should draw on frameworks including the World Health Organization’s (WHO) Global Code of Practice on migrant healthcare workers, and must also emphasise the importance of regional solutions between frontline recipient countries (particularly Jordan, Lebanon and Turkey), to improve joint working and share evidence of good practice.
Over the coming months the Syria Public Health Network will be working with donors, civil society and health professional bodies to address some of the most urgent challenges in this complex arena. This includes mapping work to gather data on health workforce numbers and to understand some of the practical barriers to practice for Syrian HCWs in those countries. Most importantly, we will be developing an action plan including tangible measures to strengthen Syrian health workforce support – and encourage contributions from HSG readers to this effort.
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