War and Health System Deterioration

~Written by J. La Juanie Hamilton, PhD Candidate (Contact: lajuaniehamilton@gmail.com)

Twitter: @jasminogen

Health systems are somewhat country-specific. Each one is developed, guided by and operates out of the politics, available personnel and resources of the community in which it is implemented. This is a critical feature to ensure sustainability. However in times of war, this may be an over-simplified way of envisioning health systems. One of the greatest lessons arising from current global health crises is that in many cases, health systems of two different, often neighbouring countries may interact in ways that result in significant change for one or both countries. Furthermore, in extreme cases, one crumbling health system may “beget” another. The evidence for this is strong when considering the changes to several states due to the ongoing wars in the Middle East.

The fact that a robust health system can rapidly disintegrate into a fragile one, or disappear altogether during times of war is well demonstrated by Syria. Before the current crisis which began in 2011, Syria had an excellent vaccination program, produced 90% of the pharmaceutical products needed by its people and access to medical services for the general population was good (1). In 2013, after 2 years of unrest, over 600 public hospitals and 78% of Syria’s ambulances had been destroyed or damaged and Syria’s production of pharmaceutical products has dropped to 10%. Most importantly, infectious diseases like measles, hepatitis A, and polio have re-emerged, with 17 recently confirmed cases of paralysis in children (1-2). This deterioration of Syria’s health systems and the exodus of its people mean that the effects of Syria’s crumbled health system will be felt elsewhere as refugees flee and are in need of care. Furthermore, it guarantees that other health systems in the Middle East, especially in neighboring countries will face new challenges.

With 3,300 refugees arriving in neighbouring countries every day, the range effects on the health, education and water supply sectors have been significant. A recent publication in Forced Migration Review by Oxford University describes the range of effects that the current crisis has exerted on neighboring countries (3).

Lebanon for example, which is currently hosting Syrian refugees, is estimated to have had striking economic atrophy due to the influx of people. Prior to the current crisis, 25% of the Lebanese population lived on less than US $4 per day and the migration of Syrian refugees to Lebanon is estimated to have caused an additional 170,000 Lebanese to go into poverty. In addition this report suggested that Lebanon’s economic growth rate (GDP) was reduced by 2.9% per annum from a predicted growth rate of 4.4% in 2012 to14 (1, 3). This undoubtedly strains health resources and makes the control emerging diseases like polio increasingly difficult.

Conceptualizing health systems in general terms is simple. Health systems refer to the health care facilities, health care workers, information systems, medicines and maybe most importantly, a financing mechanism to ensure health service delivery. But envisioning a health system that is somewhat sustainable during times of political unrest and war is significantly more challenging. The future of health systems strengthening and development must consider ways to deliver health more effectively in the midst of war.

Fortunately, organizations like the UN Refugee Agency are addressing some of these challenges. In a recent report by SciDev.net, the organization is utilizing innovative approaches toward keeping track of refugees. From collecting biometric data to rapidly sharing that data with other NGOs, there is a move toward more effective monitoring of movement and creating the environment for more rapid responses to the needs of the displaced (4). This will also likely enable improved efforts at combating and efficiently monitoring the spread of infectious diseases.

The heavy toll of this war is impossible to ignore and will be felt by the region in many ways for many years, maybe even decades to come. As a result, it is important for those of us engaged in the health systems dialogue to develop new ways of envisioning health systems and new ideas for meeting the health needs of those affected by civil unrest and war.


1.) Taleb, Ziyad Ben, et al. "Syria: health in a country undergoing tragic transition."International journal of public health (2015): 1-10.

2.) Syrian Arab Republic: put polio risk above all other interests: http://www.who.int/features/2013/syria-polio-vaccination/en/

3.) Forced Migration Review, The Syria Crisis, displacement and protection, Issue 47, 2014, University of Oxford: http://www.fmreview.org/syria

4.) View on Migration: UN takes refugees’ fingerprints: http://www.scidev.net/global/migration/analysis-blog/migration-un-refugees-fingerprints.html