[Syria: Gains in Healthcare 2]
[Sadhna Shanker]
[Continued]
The short point of highlighting this data is to suggest that Syria in terms of size, complexity and resources available is like a medium sized state of India. Its progress and achievements in the arena of primary health can be a good example for any of our individual states still struggling below national averages.
It can be argued that Syria has the advantage of being a homogeneous society in terms of language and religion. In Syria the population comprises of 70 per cent Sunni Muslims, other Muslim sects are 16 per cent, Christians are 14 per cent and it has a tiny Jewish community. There exists a sizeable Palestinian refugee population and also the nomadic Bedouin people, who are provided health services.
A recent survey that appeared in the Economist rated Syria eight out of 10 in terms of religious freedom and seven out of 10 in the area of women's level of political, economic and social equality. Arabic is the main language, (most of our states also have linguistic homogeneity). In sum, it is a society that has diversity of cultures and also respects them. National health programmes have taken into account these differences and succeeded here.
Primary Healthcare Structure
The primary healthcare structure in Syria is three-tier, much like our own. Presently, a health centre exists where the population is between 5,000-10,000. The actual size and composition of each health centre depends on the area and population it covers. There is at least one doctor at every health centre, with paramedical staff including a midwife, nurse, pharmacist and helper. When the health centre is more than five kms from a habitation or settlement, often a health post is opened. A doctor visits the health post two-three days a week. The health post is staffed by a nurse and a trained midwife. They provide basic reproductive health and immunisation services. The health post is in the nature of our sub-centres, while the health centre is akin to our primary health centre. For remote far-flung areas and the nomadic people there are mobile teams. These teams consist of only paramedical staff. Referrals from the health centre can be to the district health centre or 'polyclinic' as it is normally called. There may be one or two in a health district - these have many specialties and are on the pattern of our community health centres. A referral can also be made to the governorate level hospitals depending on the emergency. In terms of structure they are like our district hospitals. In order to provide quality healthcare there is a proposal to standardise the existing health centres into three categories. Working on the basic norm that 600 families or 2,500 people should have access to at least one doctor, the first category will be at 5,000 population. The next at 10,000 and 20,000 population. In the first category, it is proposed to have a minimum of two doctors with a building of 16 rooms and 23 staff. The numbers would proportionately increase. From mere coverage and access issues of primary healthcare, in Syria slowly the focus is shifting towards quality.
The ministry of health at the centre and the directorates of health in the governorates, face the same resource and personnel problems that exist in many of our states. The salary structure of the health staff is quite low. On an average doctors are paid the equivalent of 100-200 $ per month. There is a reluctance to serve in remote and far away places.
I had the opportunity to visit health centres in the rural areas of Damascus and in the governorate of Qunetra, south of Damascus (bordering the area of Golan Heights). Whether near the capital or in remote areas, the health centre is a clean and running building. It has the basic requirements for proper functioning in terms of electricity, a functioning telephone, and at least one functioning computer. The furniture is in good condition. In other words the health centre provides a reasonably conducive atmosphere for both the clients and health workers. Unlike our auxiliary nurse midwives (ANMs), the staff does not have any prescribed 'outreach' duties. This ensures that they are available at the centre and cannot be missing on the excuse that they are out in the community. The local schools and mosques are the main channels for campaigns for health. The reliance is on inter-personal communication.
Like in many of our states, promoting institutional deliveries is an uphill task in Syria. In 2000 home deliveries accounted for 49.9 per cent of all childbirths. In the rural areas this figure was 59.6 per cent. Taking this into consideration strategies have been implemented so as to ensure that at least a trained person, whether a mid-wife, nurse or 'daya' (traditional birth attendant) attends at home deliveries. As a result, in 2000, a trained attendant attended 86.5 per cent of all deliveries. The break-up being 45.3 per cent doctors, 38.5 per cent trained midwives, 11.5 per cent by 'dayas', 2.7 per cent by trained nurses and the rest by relatives. The success of these strategies is also clearly reflected in the impressive decline in maternal mortality in this country. The rural areas in Syria present similar challenges in maternal health as in some of our states. Many states have had programmes for training 'dais' and other providers at the time of delivery with mixed results. Our national maternal mortality rate remains alarmingly high.
Syria, with a similar socio-economic milieu and with state funded health services has demonstrated how progress can be achieved, in the provision of primary healthcare services, with political and bureaucratic commitment. For some of our states, especially those in the northern belt, there are definitely some lessons to be learned here.
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