How has a decade of attacks on healthcare provision in Syria restricted NGOs’ operational space? In this blog, Laurence Gerhardt (IRC) discusses the decimation of Syria’s healthcare system and the ongoing risk of further access restrictions for Syrians and NGOs.

A deliberate assault on healthcare provision

Ten years into the war in Syria, 13.4 million people – more than half of the country’s pre-war population – are in need of humanitarian aid. Of those, an estimated 12.4 million require health assistance. The enormous scale of health needs in Syria is driven and aggravated by insufficient access to care, a problem that has been severely compounded by the years-long assault on healthcare facilities and personnel by Syria’s warring parties.

Since the conflict began, Physicians for Human Rights (PHR) has documented a total of 599 attacks on 350 health facilities, through what the United Nations (UN) Independent International Commission of Inquiry has called a pattern of ‘deliberate and systematic targeting’ of healthcare, in violation of international humanitarian law. Attacks even continued throughout the COVID-19 pandemic, with the bombing of a surgical hospital in Aleppo in March 2021 killing seven patients and wounding 15 others, including five health workers. While the number and scale of these attacks are already shocking, those documented by PHR are merely those with enough evidence to verify them – many more likely remain uncounted. This has had major impacts on the ability to access even the most basic of healthcare provision.

Assessing the impact on civilians and health workers

In March 2021, the International Rescue Committee (IRC) launched a new report entitled A Decade of Destruction: Attacks on healthcare in Syria. The report was made possible through collaboration with the IRC’s Syrian partner organisations: the Independent Doctors Association, the Syrian American Medical Society, the Syrian Expatriates Medical Association, Sustainable International Medical Relief Organisation, Syria Relief and Development and the Union of Medical Care and Relief Organisation. It details the devastating impact these attacks have had on civilians in need of health assistance and the staff who support them.

Utilising primary data collection across the northwest governorates of Idlib and Aleppo, the report found that a staggering 78 per cent of health workers surveyed had personally witnessed at least one attack on a health facility. On average, they cited having witnessed four attacks, while some reported witnessing up to 20 separate incidents. 81 per cent reported that they had a patient or colleague who had been killed or injured in an attack. Nearly half of all civilians the IRC spoke to said that they were now afraid to access medical care for fear of an attack – while a third had directly witnessed or experienced an attack themselves.

‘Manzur, a psychosocial support worker with UOSSM, told the IRC, “Children have been exposed to moderate to severe psychological trauma that caused bedwetting and nightmares for them, and the ones who witnessed the shelling won’t visit the centre again to receive their treatment.”’

What remains of the health system in Syria today is woefully inadequate to respond to the level of need, even before the ongoing dangers of COVID-19. Only 64 per cent of hospitals and 52 per cent of primary health care centres are functioning, while the UN estimates that 70 per cent of the health workforce has fled the country. IRC and IRC-supported facilities in northwest Syria have themselves been attacked more than 20 times since late 2018.

These findings lay bare the reality for Syrian civilians and healthcare workers in the northwest: hospitals, clinics and ambulances are not areas of safety and protection but significant security risks.

Health access under threat

Broadly, humanitarian access is the ability for people in need to reach the humanitarian services necessary to survive. This includes both NGO capacity to reach those in need of programming and the ability of those in need to access essential services, such as hospitals or mobile clinics.

For NGOs, responding to a health crisis of the scale Syria faces necessitates having consistent access to populations in need. Recognising the scale of need in Syria and the barriers to principled humanitarian access, in 2014, the UN Security Council adopted resolution 2165. This resolution enabled the UN to deliver aid through four border crossing points into Syria from Jordan, Iraq, and Turkey. The cross-border routes were the fastest and most direct route to bring vital supplies and humanitarian personnel into key areas of the country. With humanitarian needs spiralling across Syria, the crossings played an essential role in delivering healthcare, providing supplies, and assisting local staff.

However, in January and July 2020, Russia and China vetoed the reauthorisation of three out of the four crossings at the UN Security Council. Today, just one crossing in northwest Syria remains available for UN use – with over three million Syrians reliant on it for assistance.

Access constraints and direct attacks

The impact of years of attacks on healthcare and the closure of border crossings is clear. The healthcare response is the second-highest sector of need in the 2021 Humanitarian Response Plan. In just one year since the only crossing in the northeast was closed, NGO-supported health facilities have faced severe shortages and stockouts of vital medicines. The overall number of people in need in the northeast has risen by 38 per cent in one year – nearly double the 20 per cent rise seen nationwide. If cross-border aid were to cease in the northwest, one of IRC’s partner organisations reports that half of their health programmes would be at risk of closure. The UN Secretary-General has warned that “a failure to extend the United Nations mandate would end the United Nations COVID-19 vaccine distribution plans for millions of people in north-west Syria.”

After a decade of attacks on hospitals, ambulances, and clinics, barriers to healthcare access have become an expected yet grim reality for many Syrians. But since the last UN vote on cross-border assistance, healthcare in the northwest of the country is under threat not only from military attacks on health facilities but from high-level bureaucratic decisions. The Security Council is preparing to vote on the reauthorisation of the cross-border resolution next month. Should the resolution be vetoed and the final crossing in the northwest closed, NGOs will struggle to fill the void left by the UN, leaving access to millions of Syrians even further constrained.

About the Author

Laurence Gerhardt is a Policy Officer working on conflict and humanitarian crises at the International Rescue Committee (IRC). His work involves policy analysis and research on IRC’s key crisis countries, including Yemen, Syria and Bangladesh, as well as the production and editing of reports on IRC’s thematic work.

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