Reconstruction of the health system in Syria after the war

Access to the health sector is a major problem in developing countries. The health structures, in their actual state, cannot guarantee the health service to the whole population as far as the quality and the quantity of services are concerned.

This will be the case for Syria after the end of the civil war and the start of reconstruction.

If interested, please check the french version of this post Reconstruction du système de la santé en Syrie après la guerre

Below some information about the health system in Syria according to WHO data:

Total population (2016)	18.430.000
Gross national income per capita (international PPP $, 0)	Not available
Life expectancy at birth m / f (years, 2016)	59/69
Infant and child mortality ratio (per 1,000 live births, 2018)	17
Mortality quotient 15-60 years m / f (per 1000, 2016)	388/202
Total expenditure on health per capita (int. $, 2014)	376
Total expenditure on health as% of GDP (2014)	3.2%

Data according to WHO (2)
 

The damage and needs assessment report by the World Bank indicates that only 33% of public hospitals were partially functioning at the end of 2014. Regarding the damage, almost a third of hospitals, medical centers and pharmacies were affected, causing a closing beds and a shortage of drugs to treat patients. The situation has worsened since then, due to increased isolation and poor service. The UN estimates that 42% of the population has no access to basic health services (OCHA, 2015). In addition, an estimated 4.5 million people are in hard-to-reach areas, including 400,000 Syrians under siege, with extremely limited access to medical and humanitarian services. The majority of requests submitted by WHO for delivery of medicines and supplies remain unanswered. (2)

The state does not have sufficient financial resources for the reconstruction of health structures completely or partially destroyed during the war.

In any case, it must guarantee health services for citizens in a country where this sector was still considered to be mainly public.

The disadvantages of using traditional EPC-type formulas for reconstruction are numerous:

It is not enough to rebuild / rehabilitate out-of-service health facilities. After 10 years of civil war, demographic change is inevitable. Several villages are uninhabited and uninhabitable. There is a high population density in the big cities. This makes it necessary to study the entire health system and the distribution of its infrastructure.

On the other hand, during the years of the war, the number of qualified people with expertise in the country is obviously decreased. As a result, the ability of countries to do a comprehensive national study of this level is in turn diminished. The same conclusion can be reached in relation to the specific study of each hospital.

Carrying out health projects can be complicated for the same reasons indicated above in addition to insufficient financial resources.

These resources will be used, at least a large part, to more important projects of strategic perspective as road infrastructure, rehabilitation of ports and airports, urban rehabilitation etc.

This inadequacy may delay the start or end of health projects.

The skills problem could also generate a deficit in the operation and maintenance of health facilities.

The most immediate and easiest way to avoid all of these problems would be to privatize much of the health care system. This solution could attract local and foreign investors and would enable structures to be put into operation in a relatively short time.

On the other hand, this solution has two very important drawbacks. First, the inevitable concentration of health facilities in major cities and the heterogeneous distribution of care to offer the national territory and, secondly, the loss of control of the industry by the state, which is the most critical disadvantage because there will be no control / verification of the quality of the services and the reception capacity provided by the private sector.

Privatization would then transform the health of a citizen's right to a commercial good.

The solution, in my opinion, is in the PPP (Public-Private-Partnership) formula.

The state must rely on international skills for the study, implementation and operation phases.

It must set performance targets and verify their achievement by the private sector.

The projects will be funded by the private sector so that the state does not increase its public debt and uses its available resources to finance other economic development projects.

Since the remuneration of the private partner in the health sector cannot be paid directly by taxpayers, it must, in any case, be borne by the state. PPP solutions offer several possibilities with a large margin of adjustment in this regard please check the Indian experience in PPP.

There are a lot of examples in the world about successful PPP projects in healthcare that could be taken as reference for wider implementation as the Syrian case.

In conclusion, the index for successful reconstruction of the health system in Syria is based on the transformation of the role of the state from a service provider to a service controller. State control is ensured by its partnership with the private investor in each project.

References
1. World Health Organization. Syrian Arab republic. World Health Organization [Online] [Cited: 04 May 2020.] https://www.who.int/countries/syr/fr/. (Original in French)
2. World Bank Middle-East and North-Africa Region. Reconstruire la Syrie dans une perspective de paix. s.l.: Banque Mondiale, 2016. (Original in French)