Author: MHD Bahaa Aldin Alhaffar 

bhaa.alhafar@gmail.com

1. Introduction: Contextualizing the Public Health Crisis in Post-Conflict Syria

The Syrian Arab Republic has endured a protracted conflict spanning over a decade, resulting in a humanitarian crisis of immense proportions.1 The anticipated cessation of the Assad regime marks a pivotal juncture, presenting both urgent needs and new possibilities for the nation, particularly in the realm of public health.3 For over 14 years, the Syrian populace has faced devastating hardships, including relentless hostilities, widespread displacement, and a severely compromised infrastructure.5 As of early 2025, the scale of displacement remains one of the largest globally, with over 14 million people forcibly displaced since the conflict's inception in 2011.5 The escalation of conflict in late 2024 further strained the already dire situation, leading to another wave of displacement and severely impacting access to essential resources such as food, clean water, and sanitation, thereby placing the health of millions at heightened risk.5 An estimated 16.7 million people within Syria required humanitarian aid in 2024, a figure projected to increase in 2025, highlighting the enduring and growing needs of the population.5 The economic collapse, with over 90% of Syrians living below the poverty line, exacerbates these vulnerabilities, making access to healthcare and basic necessities increasingly challenging.5 The cumulative impact of conflict, displacement, and socioeconomic decline has severely weakened the health system and essential services, necessitating a swift and strategic approach to public health early recovery.7 This literature review aims to analyze the multifaceted public health crisis in Syria resulting from years of conflict and to identify concrete, actionable steps for early recovery. By examining the experiences of other countries that have navigated similar conditions and achieved positive outcomes, this review seeks to provide valuable insights and recommendations for rebuilding a resilient public health system in Syria.

2. The Devastating Impact of 14 Years of War on Syria's Public Health

The prolonged conflict in Syria has inflicted catastrophic damage on the nation's public health infrastructure. More than half of the country's hospitals and primary care centers have been either destroyed or significantly damaged, severely limiting the capacity to deliver essential healthcare services.3 This widespread destruction, often resulting from intentional targeting of healthcare facilities, has crippled the health system's ability to respond to the growing needs of the population.8 In September 2021, approximately 45% of the nearly 1,800 available public health centers were reported to be not fully functioning, further underscoring the scale of infrastructural damage.10 The consequences extend beyond the physical destruction of buildings; vital medical equipment, including infant incubators, CT scans, anesthesia equipment, and ambulances, are in urgent need, and shortages of drugs and medical supplies due to sanctions have further compromised the quality of care.14 The functionality of medical equipment has deteriorated due to a lack of spare parts and maintenance, exacerbating the challenges faced by the remaining healthcare facilities.14

Compounding the infrastructural devastation is the significant depletion of the health workforce. A majority of healthcare providers, fearing for their safety and seeking refuge from the conflict, have fled the country.3 It is estimated that over 50% of physicians have left northeast Syria, and in Aleppo, only a fraction of the pre-war number of doctors remained by mid-2013.8 This exodus includes not only physicians but also nurses, medical technicians, and other essential health personnel, leaving the healthcare system severely understaffed.8 The remaining health workers often operate under immense pressure, working long hours and frequently performing tasks outside their areas of specialization.11 The constant threat of violence has also instilled fear among both healthcare providers and patients, further hindering access to and provision of medical care.10

The protracted conflict has led to a significant increase in morbidity and mortality across Syria. Malnutrition, exacerbated by food insecurity affecting nearly 13 million people, has become a major concern, particularly among children.5 Poor sanitation and hygiene, coupled with limited access to clean water, have created ideal conditions for outbreaks of communicable diseases such as cholera, diarrheal diseases, and respiratory infections.1 The interruption of vaccination programs has also increased the risk of vaccine-preventable diseases.14 Furthermore, the burden of non-communicable diseases has risen, with limited access to services and treatments for chronic conditions like cancer, diabetes, and hypertension contributing to increased mortality.8 The psychological toll of the conflict is profound, with widespread reports of trauma, anxiety, depression, and post-traumatic stress disorder, particularly among children who have known nothing but war.5 Access to mental health services remains severely limited, further compounding the suffering of those affected.5

The war has also led to a significant breakdown in essential public health systems. Disease surveillance has been severely weakened, hindering the ability to detect and respond to potential outbreaks effectively.14 Vaccination programs have been disrupted, leaving large segments of the population vulnerable to preventable illnesses.14 Basic public health functions such as ensuring access to safe water and sanitation have been severely compromised due to damaged infrastructure and ongoing hostilities.14 The combination of these factors has created a complex and dire public health crisis in Syria, demanding immediate and sustained attention in the early recovery phase.

3. Comparative Analysis: Successful Public Health Early Recovery in Post-Conflict Nations

Examining the experiences of countries that have navigated prolonged periods of conflict and successfully implemented early public health recovery strategies can provide valuable lessons for Syria. Post-genocide Rwanda and post-war Bosnia and Herzegovina offer compelling case studies in rebuilding health systems amidst immense challenges.

Following the horrific 1994 genocide, Rwanda faced a near-total collapse of its health system.18 The country experienced massive loss of life, widespread displacement, and the destruction of vital infrastructure, including healthcare facilities. A significant portion of the health workforce was either killed or fled the country, leaving the nation with severely limited capacity to address the overwhelming health needs of its population.18 Despite this devastation, Rwanda achieved a remarkable recovery in its public health sector through several key strategies. Strong government leadership and ownership of the recovery process were paramount. The Rwandan government set a clear national agenda, prioritizing health equity and demonstrating a long-term commitment to strengthening the health system.19 The implementation of a community-based health insurance scheme, known as Mutuelle de Santé, played a pivotal role in improving access to healthcare by pooling funds and significantly reducing financial barriers for the population.19 Investing in a large network of community health workers (CHWs) was another crucial strategy. These CHWs, trained to provide basic primary care and health education at the village level, effectively extended healthcare access to remote and underserved populations, addressing the severe shortage of doctors and nurses.19 Strategic partnerships and coordinated aid from international organizations, aligned with Rwanda's national priorities, were also instrumental in the recovery process.19 Furthermore, the establishment of robust health information systems enabled effective monitoring and evaluation of health programs, facilitating data-driven decision-making.25

Bosnia and Herzegovina, following the devastating Balkan Wars of the 1990s, faced a complex post-conflict landscape characterized by a fragmented political and administrative structure.39 The Dayton Peace Agreement established a decentralized system with multiple entities and cantons, which presented significant challenges for national-level health policy and coordination.42 Early recovery efforts in the health sector focused on reforming the primary care system, often with substantial support from international organizations.47 Recognizing the widespread psychological trauma resulting from the conflict, initiatives were also undertaken to integrate mental health services into the primary healthcare framework.49 However, the highly decentralized nature of the health system posed persistent obstacles to effective national planning, equitable resource allocation, and ensuring uniform access to services across the country.39 International non-governmental organizations (NGOs) played a crucial role in delivering healthcare services and supporting reconstruction efforts in the aftermath of the war.49 Despite their significant contributions, challenges related to coordination among numerous actors and ensuring the long-term sustainability of these initiatives persisted.49

Uganda and South Sudan, both having experienced prolonged periods of conflict, offer further insights into the complexities of post-conflict health system recovery.67 In these contexts, recovery efforts have emphasized the importance of comprehensive health system strengthening (HSS), encompassing coordination mechanisms, governance structures, and the enhancement of service delivery.67 Recognizing the ongoing vulnerabilities in post-conflict settings, the integration of disaster risk reduction (DRR) into health recovery interventions has been identified as crucial for building long-term resilience.67 Efforts have also been directed towards addressing the specific health needs arising from the conflict, including war-related injuries, mental health disorders, and the particular vulnerabilities of women and children.67 However, significant challenges related to coordination among a multitude of actors and securing predictable and sustainable funding have often hampered the progress of recovery initiatives.68

4. Applicability of International Experiences to the Syrian Context

The experiences of Rwanda, Bosnia and Herzegovina, and Uganda/South Sudan offer valuable, though nuanced, lessons for the anticipated public health early recovery in Syria. While each nation's journey through and after conflict presents unique characteristics, several parallels exist that can inform the Syrian response. Similar to these case studies, Syria has suffered extensive destruction of its healthcare infrastructure and a significant exodus of its health workforce.3 The Syrian population faces a heightened burden of both communicable and non-communicable diseases, alongside widespread mental health issues, mirroring the health challenges observed in the comparative countries.5 The need for strong leadership, effective coordination of aid, and the establishment of robust health information systems are recurring themes across all these contexts, holding significant relevance for Syria's recovery efforts.

Several strategies implemented in these countries could be potentially transferable and effective in the Syrian context. Rwanda's success in establishing a community health worker program to extend healthcare access in the face of severe workforce shortages could be adapted to address the significant depletion of health professionals in Syria.19 The focus on achieving universal health coverage through a community-based insurance model, as seen in Rwanda, could also provide a framework for improving access to care and reducing financial barriers for the Syrian population.19 Bosnia and Herzegovina's efforts in reforming primary care and integrating mental health services into this framework highlight the importance of building a comprehensive and accessible healthcare system that addresses both physical and psychological needs in the aftermath of conflict.47 The emphasis on health system strengthening and disaster risk reduction in the recovery efforts of Uganda and South Sudan underscores the need for a holistic approach that builds resilience and prepares the Syrian health system for future shocks.67

However, the Syrian context also presents unique challenges that will necessitate careful adaptation of these international experiences. The ongoing potential for instability and political fragmentation in a post-Assad Syria may complicate national-level planning and coordination, mirroring some of the challenges faced by Bosnia and Herzegovina.79 The potential for continued sanctions and funding limitations could also hinder the implementation of comprehensive recovery programs.2 Furthermore, the pre-conflict health system in Syria, while impacted by the war, may have had different strengths and weaknesses compared to the systems in the studied countries, requiring tailored approaches.8 Therefore, while the experiences of Rwanda, Bosnia and Herzegovina, and Uganda/South Sudan offer valuable guidance, a thorough understanding of the specific Syrian context and its evolving challenges will be crucial for developing effective and sustainable public health early recovery strategies.

5. Actionable Steps for Public Health Early Recovery in Syria (Structured by WHO Pillars)

Based on the analysis of the Syrian public health crisis and the lessons learned from comparable post-conflict settings, the following actionable steps are recommended for early recovery, structured according to the WHO's six pillars of a health system.

Service Delivery: The immediate priority is the restoration of essential healthcare services. Rapid assessments of existing functional facilities should be conducted to identify and support their operational capacity.3 Mobile health clinics can be deployed to reach populations in underserved areas and those displaced by the conflict.29 Establishing clear referral pathways between different levels of care will ensure that patients receive appropriate treatment without undue delay.3 In the longer term, a phased scale-up of comprehensive care should be planned. This includes developing protocols for the management of chronic diseases, given their increasing prevalence in the Syrian context.1 Integrating basic mental health care into primary healthcare settings, coupled with the establishment of specialized mental health services, is crucial to address the widespread psychological trauma.1 Preventative care services, including health education and screenings, should also be gradually reintroduced to promote long-term health and well-being.33

Health Workforce: A critical first step is to conduct a rapid needs assessment and mapping of the current health workforce within Syria and among the refugee population in neighboring countries.86 Strategies to incentivize the return and retention of Syrian healthcare professionals are essential. These could include financial incentives, guarantees of safety and security, and opportunities for professional development and specialization.8 Drawing inspiration from Rwanda's experience, accelerated training programs for various cadres of healthcare workers, including community health workers, should be implemented to rapidly increase the number of personnel capable of delivering essential services.19 Standardized training curricula for CHWs, focusing on primary care skills and community outreach, will be vital. Furthermore, addressing the mental health needs of the remaining and returning healthcare workers, who have likely experienced significant trauma, is crucial for their well-being and their ability to provide effective care.11

Information: Establishing a robust national health information system is paramount for effective public health management. This system should be capable of collecting, analyzing, and disseminating essential health data, including disease surveillance, mortality rates, and healthcare service utilization.14 Implementing early warning and response systems for the prompt detection and management of disease outbreaks is also critical in the post-conflict environment, where vulnerabilities to infectious diseases are heightened.1 Training healthcare workers on data collection and reporting procedures and leveraging technology for efficient data management will be essential components of this pillar.

Medical Products, Vaccines and Technologies: Securing reliable supply chains for essential medicines, medical supplies, vaccines, and medical equipment is fundamental.3 A thorough needs assessment for these products should be conducted, and partnerships with international organizations can be leveraged for procurement and distribution. Establishing a national drug management system will ensure efficient allocation and prevent shortages. Comprehensive vaccination campaigns targeting children and other vulnerable populations are crucial to prevent outbreaks of vaccine-preventable diseases.5 This will require developing a national immunization schedule, conducting catch-up campaigns, and ensuring the integrity of the cold chain for vaccine storage and transport.

Financing: Diversifying funding sources will be essential for the sustainability of public health early recovery efforts. This includes exploring domestic resources, actively engaging with international donors for financial assistance, and considering innovative financing mechanisms.2 The potential for establishing a national health insurance scheme, possibly drawing lessons from Rwanda's community-based model, should be explored.19 Strategic allocation of available resources to address the most pressing public health needs and ensure equitable access to services is paramount.15 This will necessitate a detailed budget analysis and the establishment of transparent resource allocation mechanisms.

Leadership and Governance: Establishing a unified and inclusive health authority with a clear mandate to lead and coordinate the public health early recovery efforts is crucial.68 This authority should ensure representation from government agencies, non-governmental organizations, international organizations, and community leaders. Developing clear policies and regulatory frameworks to guide the recovery process, ensuring accountability, transparency, and adherence to international standards, will provide a solid foundation for rebuilding the health system.67 Establishing a national health coordination committee will facilitate collaboration and alignment of efforts among all stakeholders.

6. Conclusion: Synthesizing Findings and Recommendations for a Resilient Public Health System in Syria

The 14 years of conflict have left Syria with a public health system in crisis, characterized by widespread destruction, a depleted workforce, increased disease burden, and a breakdown of essential public health functions. The experiences of Rwanda, Bosnia and Herzegovina, and Uganda/South Sudan in navigating their post-conflict recoveries offer valuable lessons for Syria. Strong government leadership, community engagement, innovative financing mechanisms, investment in the health workforce, and effective coordination of international aid have been identified as critical factors for successful recovery.

Actionable recommendations for Syria's public health early recovery, structured by the WHO's health system pillars, include the immediate restoration of essential services, a phased scale-up of comprehensive care, strategies to incentivize the return and retention of health workers, the rapid training of community health workers, the establishment of a national health information system, securing reliable supply chains for medical products, implementing comprehensive vaccination campaigns, diversifying funding sources, prioritizing resource allocation, and establishing a unified and inclusive health authority with clear policies and regulatory frameworks.

The early recovery phase in Syria presents a unique opportunity to not only rebuild what was lost but also to lay the foundation for a more resilient and equitable public health system.67 By adopting a phased, context-specific, and coordinated approach, drawing upon the lessons learned from other post-conflict nations, Syria can strive towards a future where all its citizens have access to quality healthcare services, contributing to the overall stability and well-being of the nation. 

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