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Dr Saladin Sawan in the operating theatre in Idlib. Photo: David Nott Foundation

Syria’s health system is on the brink


By Eleanor Nott

27 MARCH 2025
            





Syria’s health system is on the brink. For fourteen years it has contended with the triple threat of conflict, sanctions and corruption and the result is shattered infrastructure, shortages of equipment and personnel and spiralling standards of care.

Sectoral sanctions were imposed on the country because of the actions of former President Bashar al-Assad and his associates. On my second visit to Syria since its liberation in December, I spoke with dozens of healthcare workers and visited hospitals and governance bodies across five major Syria cities. There is bafflement as to why these sanctions persist months after Assad’s flight to Moscow.

Unlike sanctions targeting individuals in the former regime, or those targeting terror groups, sectoral sanctions are indiscriminate, hitting the whole economy. Despite humanitarian exemptions, in practice healthcare cannot be insulated from their effects.

Recently the Foreign Office announced the lifting of asset freezes on twenty-four previously sanctioned Syrian entities including banks and energy companies. This was welcome progress but others remain, and crucially the US retains its heavy ‘Caesar’ sanctions regime. This has a chilling effect on all engagement with the country, and for recovery to begin there should be an immediate lifting of all indiscriminate sectoral sanctions.

It’s obvious—war affects healthcare. But healthcare was weaponised in the Syrian conflict to a degree not witnessed before. A vivid manifestation of this was the sight, on a busy street in Aleppo, of the charred remains of the hospital known as M1. The hospital was the last standing in besieged eastern Aleppo until it was destroyed by a Russian missile in December 2016.

Physicians for Human Rights (PHR) estimate more than 949 healthcare workers have been killed directly during the conflict, with more than 92 percent killed by the Syrian government and its allies. A 2012 law passed by the Syrian parliament criminalised the provision of healthcare to wounded protestors. Doctors were detained, tortured and killed in the ‘human slaughterhouse’ prisons like Sednaya.

The security situation remains fragile, with unrest in the northeast and Israeli incursions into the southwest of the country. There have also been coordinated attacks by former regime loyalists in the coastal region, leading to violence in which hundreds of civilians were killed. Unexploded ordnance and landmines result in dozens of admissions each week at hospitals we visited in Hama and Aleppo.

There are shortages of equipment and consumables. Surgical instruments that would be used one time in the UK are re-used on dozens of patients in Syria. They use formalin, powdered formaldehyde, to sterilise instruments, but residue is left behind that causes irritation for patients and hospital staff.

Prior to an operation, patients are given a list and told to buy the consumables needed themselves. Syringes, dressings, suture; patients are asked to source. At the specialist cancer hospital in Damascus, two children share beds meant for one.

Shortages extend to staff as well. There are very few anaesthetists in the country, and a shortage of all surgical specialisms. Healthcare workers are exhausted and morale is low.

The physical state of hospitals is shocking. Dimly lit, dilapidated, crowded and dirty. In central Damascus, a hospital had drains in the floor as the basement level flooded so often. Panels hung from doors and windows were broken.

There are constant power cuts. Hospitals face a daily struggle to secure enough fuel for the generators essential to guarantee power supply to the hospital. Energy is an area where the lifting of sanctions will make a real impact, allowing for investment and repair of infrastructure.

Eleanor Nott outside the ruins of the M1 Hospital in Aleppo. Photo: David Nott Foundation

Humanitarian aid was exempt from sanctions, but strict regulations governing items that could have a dual use meant pharmaceuticals and medical equipment could be caught up in them. Western companies did not want to risk contravening sanctions, so when medical equipment broke down, or bills for repair went unpaid, machines sat idle and gathered dust. Even remote assistance to Syria is frustrated by the fact that many online applications and learning management systems are blocked by sanctions, so unavailable in Syria.

Sanctions only go part of the way toward explaining the shortages though. Under Assad there was a permissive environment for corruption. In Aleppo, a doctor told us how the regime “drained the system.”

Corruption extended to the medical training system where gaining a place on a surgical residency programme could be dependent on contacts rather than merit. There is an over-supply of residents in former regime areas, demonstrated in the number of residents to number of hospital beds ratio. Students are leaving university study and entering residency programmes but not receiving specialist training. This presents a risk to patient safety.

A change of culture has been initiated with the ouster of the regime. Doctors we met spoke of how people are returning to work and putting in long hours. You can no longer ‘smell the corruption,’ said a surgeon in Hama; ‘dignity is returning.’

The health system in northwest Syria is under-resourced but is marked by minimal corruption, greater accountability and has been sustained by a range of Syrian and diaspora civil society organisations and charities. The new government will need their continued engagement to make the necessary reforms and investment in the health system nationally.

Syrians are only too aware of the cuts to international aid by the US, UK and others. They are not expecting transfusions of development assistance. They need engineers, economists, construction companies, doctors, educators from the mighty Syrian diaspora and beyond to be able to freely contribute their skills and resources to the rebuilding of the country. For that to happen the sanctions that are stifling Syria’s opportunity for recovery need to be lifted, now.

Eleanor Nott is Senior Advisor and Co-Founder of the David Nott Foundation, established in 2015 to improve access to safe, skilled surgical care in conflict-affected communities.
https://davidnottfoundation.com