Health Resources Availability Mapping

System

[HeRAMS ]

Report: Fourth Quarter, 2017

Turkey Health Cluster for Syria

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HeRAMS (Health Resources Availability Mapping System) is a standardized approach supported

by a software-based platform that aims at strengthening the collection, collation and analysis of

information on the availability of health resources and services in humanitarian context. It aims to

address the needs/gaps expressed by the health cluster on coordination and management by

providing timely, relevant, and reliable information.

HeRAMS provides a tool for assessing, monitoring, and processing a comprehensive set of

available data collected at health facility level. It covers; geographical location of the HF,

demographic data on catchment area, type, functionality, building type, inpatient capacity,

managing and supporting partners, health personnel, access and security, and health services

provided at different levels of healthcare.

This report provides a summary of the analysis of the available health resources and services in

Syria, the report is produced with the data provided mainly by Turkey hub health cluster members

national and international non-governmental organizations as well as health authorities.

Dr Annette Heinzelmann Emergency Coordinator World Health Organization Mobile: +90 530 011 4948 Email: heinzelmanna@who.int

Dr Jamshed Tanoli Health Cluster Coordinator World Health Organization Mobile: +90 530 238 8669 Email: tanolij@who.in

Dr Abd Arrahman Alomar HC Co-coordinator Mobile: +90 538 052 9213 Email: aalomar@sams-usa.net

Mohamed Elamein Information Management Officer World Health Organization Mobile: +905343554947 Email: Elameinm@who.int

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Acronyms

ANC Antenatal care

BEmONC Basic Emergency Obstetric and Newborn Care

CEmOC Comprehensive emergency obstetric care

CHW Community Health Worker

CPHC Comprehensive Primacy Health Center

HeRAMS Health Resources Availability Mapping System

HF Health Facility

HIV Human Immunodeficiency Virus

HW Health Worker

IMCI Integrated Management of Childhood Illness

MW Mid Wife

MUAC Mid-Upper Arm Circumference

PHC Primary Health Care

STD Standard

STI Sexually transmitted infection

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1. Distribution of Health facilities Primary Health Care facilities are classified into different categories based on “The Essential Primary Health Care Package”. The following graph provides the distribution of type of

the functional primary and secondary health care facilities (static and mobile).

Figure 1.Distribution of functioning Health facilities

There are 54 main managing health partners, 48 reported for this quarter. 448 Health facilities reported compared with 414 in September 2017, out which 382 HFs ctionalare fun compared to 374 in September 2017. 84 (22%) are Hospitals, 167(44%) are fixed PHCs, 76 (20%)

are mobile clinics, 37 (10%) specialized care facility * while 18 (5%) ** other health facilities.

• Out of total functioning health facilities, 50% of facilities are in Idleb , 29% in Aleppo, 7% in Rural Damascus, 6% in Hama, 4% in Homs, 2% in Dar'a while about 1% in each Al-Hasakeh, Ar-Raqqa, Damascus, Quneitra and Lattakia

• Overall the reporting rate increased by 8% as compared to the last quarter.

• Increase in the number of the supported hospitals from 79 to 84.

• Slight increase in the number of fixed PHCs from 165 to 167.

• Decrease in the mobile clinics from 80 to 76.

• Total number of not functioning facilities increased from 40 to 66.

* Specialized health centers (Physical Rehabilitation centers, Leishmaniosis centers .Etc.) **Ambulance network, Blood Bank, Central Lab

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Table 2.Distribution of reported Health facilities per Goveronates

Governorate Hospitals PHCs Mobile clinic Specialized Care Facility Other Facilities

Grand Total F NF Total F NF Total F NF Total F NF Total F NF Total

Idleb 39 10 49 82 6 88 33 4 37 27 2 29 11 1 12 215

Aleppo 20 10 30 52 7 59 29 3 32 6 5 11 4 2 6 138

Rural Damascus 8 6 14 15 1 16 3 3 1 1 34

Hama 3 3 6 8 4 12 11 11 29

Homs 8 8 3 3 2 2 1 1 2 2 16

Dar'a 2 2 4 4 1 1 7

Damascus 2 2 2 2 4

Al-Hasakeh 3 3 3

Lattakia 1 1 1

Quneitra 1 1 1

Grand Total 84 29 113 167 20 187 76 7 83 37 7 44 18 3 21 448

* F: Functioning, NF: Not Functioning

2. Functionality status

Figure 3. Functionality status of Health facilities

Functionality has been assessed at three levels: fully functioning which mean open and providing full package of essential services, partially functioning means open but not providing the full package of essential services, or not functioning. Out of 448 assessed health facilities, 71% (318) were reported fully functioning compared to 75% in Q3 , 14%

(64) partially functioning, 15% (66) out of service compared to 10% in the last quarter ( means that 29% of the facilities were non-functioning or partially functioning). See Figure 2.

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3. Condition of health facilities infrastructure

The condition of the health facilities infrastructure has been assessed at three levels: fully damaged: major damage requiring complete reconstruction, partially damaged: requiring substantial to large scale repair, and not damaged, 25% (109) health facilities were reported damaged [2% fully damaged and 23%

partially damaged] showing an increase of 10 facilities damaged mainly due to attacks on health facilities, 61% (274) were reported intact, while 14% (65) of health facilities were not relevant to evaluate. See figure 3.

Figure 4 Level of Damage

4. Health facilities based on date of establishment

The health facilities have been assessed according to

whether the health facility exists prior to the crisis or established after the crisis. 67% health facilities were newly established, while 33% of health facilities existed prior to the crisis. See figure 4. Out of the new established health facilities 34% were established in new building, 24% work in residential buildings, 14% in governmental buildings, 5% in schools and 24% in other public buildings.

Figure 5 New established HFs

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5. Health facilities delivery points

Out of the functioning facilities 85% health facilities are in settlements while 15% are in IDP camps. It’s worth to mention that 61% of HFs located in settlement are also serving IDPs and 10% of IDP facilities are also serving residents

Figure 6 Delivery point types

6. Health facilities resources

Figure 7: Accessibility to patients Figure 8: Electricity Figure 9: Water

2% of functioning facilities reported difficulties in accessibility mainly due to security reasons.

About 36% of the functioning facilities works without/with an interrupted electricity services

22% of the facilities are without/with an interrupted water sources

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Figure 10: Source of Electricity

Percentage of health facilities per source of electricity. *Some facilities have more than one sources

Figure 11: Modiliaty of health facilites

25% of facilities are in temporary structure building.

Figure 11: Health facilites rehabilitated or/and reinforced

180, 47%

72, 19%

112, 29%

18, 5%

No Yes, Rehabilitated Yes, Rehabilitated and Reinforced Yes, Reinforced

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7. Provision of General Clinical Services

Figure 12:Outpatient services:

79% of the reported facilities are providing outpatient services.

Figure 13: Inpatient capacity

77% of the comprehensive health centers are not providing inpatient service but it’s necessary as per essential primary health care package.

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Figure 14:*Basic Laboratory Services

41% of fixed PHC facilities providing basic laboratory services. While 95% of SHC facilities providing the service. *CBC, urine analysis, stool microscopy, sputum

microscopy

Figure 15: *Basic Imaging Service

On average 88% of the hospitals provide basic imaging services while 25% of fixed primary health facilities providing this service. *X-Ray and Ultrasound

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Figure 16: Pharmacy having Essential Drugs

Most of the reported health facilities are with pharmacy of essential drugs.

Figure 17:Referral capacity

72% of the facilities have referral mechanism in place compared to 75%

in the last quarter. (referral capacity such as communication and safe transportation). The main reason for inadequate referral mechanism in some facilities is non availability of ambulance or lack of running cost for ambulance system.

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8. Provision of Surgery Services

Figure 18: *Primary Injury care 82% of the SHC facilities and 61% of PHCs are providing primary injury care. *Treatment of open wounds, fracture immobilization, patient stabilization and proper referral (including antibiotics and tetanus toxoid when needed)

Figure 19:*Trauma, surgical care, and elective surgery

On average 83% of the hospitals are providing trauma care , surgical care, and elective surgery. 17% of the CPHC supporting the hospital by providing the services compared to 14% in the previous quarter. *At least 1 operation room with/without gas anesthetic.

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Figure 20:Intensive Care Unit

On average 38% of the hospitals are without intensive care unit.

Figure 21:Blood Bank services

40% of the hospitals provide blood bank services compared to 47% in the last quarter.

There are three blood banks, one in Idleb and 2 Aleppo governorates outside the health facilities.

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Figure 22: *Physical rehabilitation services Only 13% of the facilities provide physical rehabilitation services. 24% of the hospitals provide these services. *Disabilities rehabilitation & support

9. Provision of maternal, newborn and child health services

Figure 23:*IMCI

57% of the PHC facilities provide IMCI, of which 32% partially, mainly due to lack of finances and trained health staff. *Integrated Management of Childhood Illness IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age.

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Figure 24:*Screening of acute malnutrition

66% of the facilities provide screening of acute malnutrition. Highest provided by CPHC 91% *MUAC or Weight for Height, and/or bilateral pitting edema

Figure 25: Outpatient treatment of acute malnutrition

49% of the facilities provide outpatient treatment of acute malnutrition, 51% of PHC facilities and 45% of the hospitals providing the service.

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Figure 26: *Antenatal Care 76% of the PHC facilities provide antenatal care, while to 64% of the hospitals providing the service. *Antenatal Care: Assess pregnancy, birth and emergency plan, respond to problems (observed and/or reported), advise/counsel on nutrition & breastfeeding, self-care and family planning, preventive treatment(s) as appropriate

Figure 27: *BEmONC 63% of the hospitals and Comprehensive PHCs are providing BEmONC, while 44% of the fixed PHCs providing the service. *Basic Emergency Obstetric and Newborn Care (BEmONC) package includes Parenteral antibiotics + oxytocic/anticonvulsant drugs + manual removal of placenta + removal of retained products with manual vacuum aspiration (MVA) + assisted vaginal delivery 24/24 & 7/7 new-born care includes: Basic new-born resuscitation + warmth (recommended method: Kangaroo Mother Care - KMC) + eye prophylaxis + clean cord care + early and exclusive breast feeding

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Figure 28:Comprehensive emergency obstetric care (CEmOC)* 55% of the hospitals and the comprehensive health centers are providing CEmOC. *CEmOC includes BEmONC +surgery+ anesthesia+ blood transfusion.

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10. Provision of treatment for non-communicable diseases and mental health

Figure 29: Treatment of High Blood Pressure and Cardiovascular Diseases 81% of the facilities provide treatment of HBP and cardiovascular diseases.

Figure 30:Treatment of diabetes 82% of the facilities provide treatment of diabetes.

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Figure 31:Mental Health Care* Only 20% of the total health facilities provide mental health services. 22% of PHCs and 14%

hospitals providing mental health services. Mental health includes: Support of acute stress and anxiety, front line management of common and severe mental disorders.

11. STI & HIV/AIDS and sexual violence

Figure 32: Syndromic management of sexually transmitted infections 37% of the SHC facilities provide this service. While 30% of the PHC facilities providing the service.

Figure 33: HIV counselling and testing 26% of the hospitals providing HIV counselling and testing. While the provision on PHC is only 9%.

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Figure 34: Clinical management of rape survivors* 29% of the facilities provide clinical management of rape survivors compared to 31% in the last quarter. 27% of the PHC facilities and 36% of hospitals providing the service. *Including psychological support

12. Community health services

Figure 35: Health Education

Out of functioning HFs 68% of the facilities provide health education services.

71% of the PHC facilities and 64% of hospitals provide health education services.

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Figure 36:Screening for malnutrition (MUAC) 53% of the facilities provide screening for malnutrition through outreach services compared to 50% in quarter three. 58% of the PHC facilities providing the service compared to 54% in quarter three. While 57% of the SHC facilities providing the service

Figure 37: Follow up of malnourished children

54% of the facilities follow malnourished children compared to 52% in quarter three. 60% of the PHC facilities and 53% of hospitals provide the service.

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Figure 38:Screening for pregnancy for referral to ANC:

61% of the facilities provide screening for pregnancy and referral for ANC. 68% of the PHC facilities and 63% of hospitals provide the service. The highest provision of this service through Comprehensive centers (100%).

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Availability of Health Staff

Figure 39: percentage of HFs without general medical doctors Figure 40:percentage of HFs without nurses

Figure 41: Percentage of HFs without internists Figure 42: Percentage of HFs without Paediatricians

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Figure 43:Percentage of HFs without Gynaecologist Figure 44:percentage of HFs without Midwife

Figure 45: :Percentage of hospitals without surgeon

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Table 1: Distribution of health staff by districts/populations (Aleppo/Idleb)

Governorates

District Populatio

n* #Hospitals #PHCs**

General medical doctor

General surgeon

Orthopedic surgeon

Pediatrician

Gynecologist

Internist Midwife Nurse CHWs Pharmacist/

dispenser

Ale

pp

o

Afrin 306,209 1 5 14 2 2 5 7 8 8 36 7 9

Ain Al Arab 131,646 0 1 1 0 0 0 0 0 0 3 0 1

Al Bab 172,713 0 2 1 0 0 2 0 1 2 4 0 1

A'zaz 390,133 9 26 45 25 10 38 18 15 48 196 94 37

Jarablus 108,408 1 12 18 0 0 13 0 2 14 37 38 9

Jebel Saman

404,450 9 35 36 16 10 26 14 12 42 247 47 32

Total 1,513,559 20 81 115 43 22 84 39 38 114 523 186 89

Idle

b

Al Ma'ra 493,274 7 28 159 22 15 20 14 21 42 274 120 34

Ariha 172,331 4 13 17 9 5 18 12 14 34 123 43 13

Harim 665,772 15 39 144 14 21 47 35 46 68 404 144 74

Idleb 540,977 9 23 108 16 18 32 28 25 55 339 58 34

Jisr-Ash-Shugur

213,697 4 12 16 9 5 14 8 9 27 140 66 19

Total 2,086,051 39 115 444 70 64 131 97 115 226 1280 431 174

Grand Total 3,599,610 59 196 559 113 86 215 136 153 340 1,803 617 263

*Source for population: Estimated population data of HNO, population of Jebel Saman district is for the area of operation by Turkey hub.

*Total of the 4 levels of PHCs

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13. Global health indicators and benchmarks for Aleppo and Idleb

a. Number of health workers (medical doctors + nurse + midwife) per 10,000 population, by administrative

unit (benchmark >22 HWs for 10,000 population)

Governorates District Population* Number of health

workers Available for every

10,000 pop STD No of HWs

Gap in Health Workers

%Gap

Ale

pp

o

Afrin 306,209 82 3 704 622 88%

Ain Al Arab 131,646 4 0.3 303 299 99%

Al Bab 172,713 10 1 397 387 97%

A'zaz 390,133 395 10 897 502 56%

Jarablus 108,408 84 8 249 165 66%

Jebel Saman 404,450 403 10 930 527 57%

Total 1,513,559 978 6 3,481 2,503 72%

Idle

b

Al Ma'ra 493,274 567 11 1,135 568 50%

Ariha 172,331 232 13 396 164 41%

Harim 665,772 779 12 1,531 752 49%

Idleb 540,977 621 11 1,244 623 50%

Jisr-Ash-Shugur 213,697 228 11 492 264 54%

Total 2,086,051 2,427 12 4,798 2,371 49%

Grand Total 3,599,610 3,405 9 8,279 4,874 59%

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b. Number of Community health workers per 10 000 population, by administrative unit (benchmark >=10 CHWs

for 10,000 population)

Governorates District Population CHWs Available for every

10,000 pop STD No of

CHWs Gap in CHWs %Gap

Ale

pp

o

Afrin 306,209 7 0 306 299 98%

Ain Al Arab 131,646 0 0 132 132 100%

Al Bab 172,713 0 0 173 173 100%

A'zaz 390,133 94 2 390 296 76%

Jarablus 108,408 38 4 108 70 65%

Jebel Saman 404,450 47 1 404 357 88%

Total 1,513,559 186 1 1,514 1,328 88%

Idle

b

Al Ma'ra 493,274 120 2 493 373 76%

Ariha 172,331 43 2 172 129 75%

Harim 665,772 144 2 666 522 78%

Idleb 540,977 58 1 541 483 89%

Jisr-Ash-Shugur 213,697 66 3 214 148 69%

Total 2,086,051 431 2 2,086 1,655 79%

Grand Total 3,599,610 617 2 3,600 2,983 83%

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c. Number of hospital beds per 10 000 population (inpatients & maternity), by administrative unit

(benchmark >=10 beds for 10,000 population)

Governorates District Population #Hospitals #Comprehensive

PHCs

Total available

beds

STD no. of beds

Gap %Gap A

lep

po

Afrin 306,209 1 1 28 306 278 91%

Ain Al Arab 131,646 0 0 1 132 131 99%

Al Bab 172,713 0 0 2 173 171 99%

A'zaz 390,133 9 1 523 390 -133 -34%

Jarablus 108,408 1 1 26 108 82 76%

Jebel Saman 404,450 9 4 249 404 155 38%

Total 1,513,559 20 7 829 1,514 685 45%

Idle

b

Al Ma'ra 493,274 7 4 291 493 202 41%

Ariha 172,331 4 2 93 172 79 46%

Harim 665,772 15 2 524 666 142 21%

Idleb 540,977 9 4 320 541 221 41%

Jisr-Ash-Shugur 213,697 4 4 97 214 117 55%

Total 2,086,051 39 16 1,325 2,086 761 36%

Grand Total 3,599,610 59 23 2,154 3,600 1,446 40%

d. Number of HF with Basic Emergency Obstetric Care/ 500 000 population, by administrative unit

benchmark >= 4 BEmOC/500 000)

Governorates District Population HFs with BEmOC STD no. of BEmOC HFs Gap

Ale

pp

o

Afrin 306,209 4 2 -2

Ain Al Arab 131,646 0 1 1

Al Bab 172,713 1 1 0

A'zaz 390,133 8 3 -5

Jarablus 108,408 3 1 -2

Jebel Saman 404,450 13 3 -10

Total 1,513,559 29 12 -17

Idle

b

Al Ma'ra 493,274 16 4 -12

Ariha 172,331 6 1 -5

Harim 665,772 23 5 -18

Idleb 540,977 14 4 -10

Jisr-Ash-Shugur 213,697 9 2 -7

Total 2,086,051 68 17 -51

Grand Total 3,599,610 97 29 -68

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e. Number of HF with Comprehensive Emergency Obstetric Care/500 000 population, by administrative unit

(benchmark >= 1 CEmOC/500 000)

Governorates District Population HFs with CEmOC STD no. of CEmOC HFs

Ale

pp

o

Afrin 306,209 1 1

Ain Al Arab 131,646 0 0

Al Bab 172,713 0 0

A'zaz 390,133 7 1

Jarablus 108,408 4 0

Jebel Saman 404,450 9 1

Total 1,384,203 21 3

Idle

b

Al Ma'ra 493,274 9 1

Ariha 172,331 5 0

Harim 665,772 15 1

Idleb 540,977 9 1

Jisr-Ash-Shugur 213,697 4 0

Total 2,086,051 42 4

Grand Total 3,599,610 63 7

EhsemMhambal

Jisr-Ash-ShugurBadama

DarkoshJanudiyeh

Harim DanaSalqin Qourqeena

Armanaz

AbulThohur

BennshTeftnazMaaret

TamsrinSarminIdleb

Ma'arratAn Nu'man

KhanShaykun

SanjarKafrNobol

TamanaahHeish

Amuda

Jawadiyah

Darbasiyah

Al-Khashniyyeh

Rabee'a

AghtrinSuranA'zaz

Mare'

Ar-Ra'ee

Al Bab

TallEd-daman

Zarbah

DaretAzza

Atareb

HaritanJebel

Saman

JarablusGhandorahRajuMa'btali

Jandairis

Sharan

Afrin

Ain alArab

Ziyara

MadiqCastle

As-SaanKafrZeita Suran

Hamra

Ar-RastanTalbiseh

Homs

Taldu

Izra'

Hrak

As-Sanamayn

Dar'a

Raheiba

DumaHarasta

DhameerSa'sa'

Bait Jan KiswehBabella

Damascus

Idleb

Al-Hasakeh

Ar-Raqqa

As-SweidaQuneitra

Lattakia

Aleppo

Hama

Homs

Dar'a

Deir-ez-Zor

RuralDamascus

Tartous

Damascus

MediterraneanSea

Iraq

Jordan

Lebanon

Turkey

µ

Availability of Minimum Service Package(MSP)

MSP:OPD+Referral cap+Trauma+EPI+ANC+HBP and Cardiovascular+diabetes+Cancer+MH+Health educationMSP source: HNO 2018

MSP Score

non_populated_areas

0123456

Acute and immediate need of humanitarian assistance

Not in need of external assistance

In need of humanitarian assistance