Abstract
Years of political turmoil, conflicts, and mismanagement in Syria led to a catastrophic situation in all aspects of life including population health. The political change that occurred in December 2024 brought hopes for reform and prosperity. In this article, the authors report the findings on the status of the ESKD dialysis facilities in the country from a Syrian Ministry of Health committee charged with improving kidney care. The committee identified major problems in all aspects of care. About one fourth of the surveyed 116 facilities had no physicians, and none of them had a peritoneal dialysis program. Only 36% of the facilities had adequate water treatment systems, and only 42% of the available machines were assessed to be in good condition. Most buildings had structural problems. Shortages of disposable supplies and essential medications were noted in all the government facilities. No electronic records system for patients care and supplies inventory existed. The reported number of patients was about 6000 with an estimated prevalence of 300 patients per million population. The proportion of patients who receive dialysis three times a week was 22%. The reported prevalence of hepatitis C was 15% (range 0%–100%). Three percent of the patients were <18 years of age, and 7% were over 70 years. Diabetics constituted 29% of patients. Solutions to these problems are discussed. The authors prioritize a “do no harm” approach and recommend first addressing dangerous building structural problems, water treatment quality issues, infection control gaps, and workforce quantitative and qualitative shortages.
Keywords: chronic dialysis, economic impact, ESKD, health policy, peritoneal dialysis
Introduction
Syria is an eastern Mediterranean country1 with economic growth and prosperity that has been negatively affected by episodes of political turmoil and conflicts. Most recently, in 2011, peaceful civilian demonstrations calling for political and economic reform escalated to a violent conflict and an international proxy war. In December 2024, the regime collapsed and the country was taken over by a new government.
In 2010, the country had a population of close to 22.5 million. Health care was provided by a combination of a government sector that provided free or deeply subsided care and a fee-for-service private sector. The health care sector had several problems such as the large emigration of the workforce outside the country due to economic and civil rights barriers,2 inequities, and quality of care problems.3 Despite these issues, there were positive achievements at the public health levels. For example, infant mortality dropped from 132 per 1000 live births in 1970 to 17.9 per 1000 in 2009 and maternal mortality fell from 482 per 100,000 live births in 1970 to 52 in 2009.3
The conflict that started in 2011 had a devastating effect on the country's economy and health infrastructure. The gross domestic product per capita, which was close to $3000 United States dollars (USD) in 2011, dropped by about two thirds after the conflict and was as low as $572 in 2020.4 Population health suffered both because of direct violence and deterioration of preventive and therapeutic services for communicable and noncommunicable diseases.5 In 2024, 16.7 million people across Syria were assessed as needing humanitarian assistance. Of the 16.7 million people in need, 5.5 million were displaced, including over 2 million who live in last resort sites.6 Over time, the country became divided into nongovernment controlled areas in the northeastern and northwestern parts of the country and government controlled in the southern, western, and central parts of the country. The nongovernment controlled areas were more open to help provided by international and nongovernment organizations (NGOs). In December 2024, a sudden collapse of the Syrian regime that ruled the country for over 50 years opened the potential for rebuilding and prosperity.7 Sanctions imposed by the United States and the European Union aimed at punishing the old Syrian regime for its violations of human rights had negative unintended consequences on the health care system and economy. The United States and European Union are lifting sanctions at the time of the writing of this manuscript.8
Dialysis for ESKD in Syria
Before 2010, the medical literature on kidney care in Syria was scarce. The subsequent conflict raised significant interest by the medical community in kidney care, especially hemodialysis, where NGOs increased financial and logistical support and peer reviewed literature increased publications of manuscripts on this topic.9–12 Investigators of dialysis programs in the then non–government-controlled area of northwestern Syria in 2023 identified problems with quality of care, equity, records keeping, infection control, governance, and other areas.10 Most patients who were treated free of charge had the cost covered by various NGOs. The peritoneal dialysis (PD) penetration was <1%, and most were treated by hemodialysis.
In 2023, the country as a whole was reported to have 4.6 nephrologists per million population.13
The new government faces numerous political, security, economic, and health care provision challenges. Within health care, kidney services present specific complexities that require targeted expertise and strategic planning.
The Ministry of Health (MoH) had many offers from individuals and NGOs to help improve the provision of care (personal communication ZK). Ultimately, the Ministry decided to form an advisory committee made up of a representative from the Ministry and ten volunteer nephrologists. Seven of the ten nephrologists are Syrian practitioners, and the other three are expatriates from the United States and Europe. The committee is tasked with coordinating the efforts of the NGOs and giving them directions. This article describes the committee's initial data collection and analysis of outpatient dialysis facilities along with recommended solutions.
Methods
The first project conducted by the taskforce was an evaluation of all MoH and non-MoH facilities in the country. Teams of seven volunteer NGOs were tasked with conducting in-person visits to all hemodialysis facilities. Each team consisted of a nephrologist, a dialysis nurse, and a biomedical engineer. The visits' goal was to inspect the status of buildings, machines, staffing, supply needs, and patient loads using a predesigned questionnaire administered in Arabic using a Kobo tool. A summary of the questions is presented in Table 1. The survey did not include patient-level data. The conditions of the existing machines were classified according to the judgement of the head nurse of the facility and the bioengineer on the team. In addition to conducting the surveys, the NGOs paid for some of the immediate needs in their assigned areas.
Table 1.
A summary of the questions used to evaluate the dialysis facilities
| Identifying Information about the Center |
|---|
| Ownership (MoH, NGO, private) |
| Number of dialysis beds |
| Number of dialysis beds dedicated for hepatitis+ patients |
| Availability of isolation rooms for hepatitis+ patients |
| Availability of CPR equipment |
| Availability of oxygen delivery |
| Availability of appropriate waste disposal containers |
| Energy source (municipal, fuel, solar) |
| Number of shifts per d |
| Number of treatments per mo |
| Number of work d |
| Availability of protocols for infection control |
| Availability of protocols for patients' connection and disconnection to the circuit |
| Availability of protocols machines' disinfection |
| Availability of protocols for cleaning beds/chairs |
| Quality of patients' medical records |
| Number of available dialysis machines per manufacturer |
| Proportions of machines according to condition (good, average, bad, inoperable) |
| Usage hours on the machines |
| Water treatment system information (condition, capacity, maintenance, storage tanks) |
| Disposable supplies availability and monthly consumption |
| Medications availability and monthly consumption |
| Number of blood transfusions per mo |
| Availability of hepatitis testing |
| Availability of hepatitis B vaccine |
| Supervising physician and specialty |
| Number of nurses (total and per shift) |
| Number of patients (total) |
| Number of patients per hepatitis status (B,C, both) |
| Number of patients per age category |
| Total number of treatments per mo |
| Number of patients dialyzing once per wk |
| Number of patients dialyzing twice per wk |
| Number of patients dialyzing three times per wk |
| Number of patients dialyzing simultaneously at other centers |
| Number of patients dialyzing through a fistula |
| Number of patients dialyzing through a catheter |
CPR, cardio-pulmonary resucitation; MoH, Ministry of Health; NGO, nongovernment organization.
Findings
The total number of visited facilities was 116. These include all government, NGO, and private units in the country with the exception of six facilities in the northeastern region which could not be reached for political reasons. All government facilities were hospital based. None of the facilities in the country had an active PD program. Additional findings are summarized in Table 2.
Table 2.
Hemodialysis treatment characteristics in Syria
| Variable | Total | Government | NGO | Private |
|---|---|---|---|---|
| Number of facilities | 116 | 81 (70%) | 18 (16%) | 17 (14%) |
| Average number of patients per center | 54 | 67 | 36 | 10 |
| Number of patients | 6222 | 5401 (87%) | 646 (10%) | 175 (3%) |
| Diabetics | 1804 (29%) | 1518 (28%) | 223 (35%) | 63 (36%) |
| + hep B | 93 (1.5%) | 80 (1.5%) | 13 (2%) | 0 (0%) |
| + hep C | 933 (15%) | 864 (16%) | 61 (9%) | 8 (5%) |
| Dialyzing once a wk (%) | 326 (5%) | 235 (4%) | 60 (9%) | 31(18%) |
| Dialyzing twice a wk (%) | 4520 (73%) | 3917 (73%) | 482 (75%) | 121 (69%) |
| Dialyzing three times a wk (%) | 1376 (22%) | 1249 (23%) | 104 (16%) | 23 (13%) |
| Machines | 1829 | 1514 (83%) | 238 (13%) | 77 (4%) |
| Machines in good condition | 771 (42%) | 587 (39%) | 132 (55%) | 52 (68%) |
| Isolation beds | 220 | 198 (90%) | 17 (8%) | 5 (2%) |
| Number of technicians | 1055 | 954 (90%) | 67 (6%) | 34 (3%) |
+ hep B, hepatitis B positive; + hep C, hepatitis C positive; NGO, nongovernment organization.
Three percent of the patients were younger than 18 years, and 7% were older than 70 years. Diabetics constituted 29% of patients. The prevalence of hepatitis C-positive patients was reported to be 15%. Ten facilities reported a prevalence of over 40%, including two facilities with 100 prevalence. The number of facilities that reported no hepatitis C patients was 56. The reported prevalence of hepatitis B positivity was 1.5% and both B and C positivity 0.5%. Some of the facilities with a reported zero prevalence of hepatitis have policies of not accepting any hepatitis-positive patients.
Grafts for arteriovenous (AV) accesses are rarely used. In total, 95% of patients had an AV fistula (including those used for dialysis and maturing) and 5% had catheters without the presence of any AV access.
Thirty-one of the government facilities (27%) did not have physicians and were solely run by nurses. The physicians who supervised the government facilities were either nephrologists or internists.
The water treatment systems were assessed to be in adequate conditions in only 36% of the facilities. Only 42% of the available machines were assessed to be in good condition.
Most buildings had many deficiencies, including unsafe plumbing and electrical wiring and structural problems (Figure 1). All government facilities had ongoing issues with the availability of disposable supplies, laboratory testing, and essential medications. Dialysis duration mode was 4 hours per session, but this was often shortened for logistical reasons such as machines malfunctions.
Figure 1.
A photograph taken during one of the visits showing exposed electrical wiring and a plumbing drain.
All the MoH facilities still use paper medical records. Data entry was assessed to be in poor quality, including complete omission of data on whole dialysis sessions in some cases. Electronic inventory monitoring of supplies did not exist.
The availability of supplies and laboratory testing in many MoH facilities was erratic, and shortages were covered by donations from NGOs, individual donors, omitting essential services, and patients buying some of their own dialysis supplies from vendors and getting their laboratory tests at private laboratories. Erythropoietic agents are available sporadically, the maximum dose that is allocated per patient is 8000 units of erythropoietin per week. Transportation from and to the facilities was the responsibility of patients and their caretakers.
Challenges and Opportunities
Data
Care of patients with ESKD is complex and expensive, so it is important to determine the prevalence of this condition. Our survey does not allow for an accurate calculation of this metric for many reasons including lack of current census data on the Syrian population, lack of data on patients living with a renal allograft, and inaccuracies in the number of dialysis patients in our survey due to possible double counting of patients who use more than one facility simultaneously.14 With all these limitations and assuming a current population of 20 million, the prevalence of dialysis ESKD patients seems to be about 300 patients per million population. It is hard to predict how this number will change in the future given unknown variables such as the return of refugees receiving dialysis patients treated in other countries,15 improving survival with better care, and other factors.
One of the notable problems is the poor documentation in the medical records system, which clearly causes compromises in care. Efforts should be made in establishing a single electronic medical records system for at least the ESKD dialysis population. Similarly, the absence of a digital inventory system for supplies management increases inefficiencies and facilitates theft and corruption.
Financial
The cost of taking care of an ESKD dialysis patient in the developed countries is over $20,000 USD annually.16 According to this estimate, the Syrian government should allocate over $100 million USD per year to provide full coverage for this population. Given the current economic situation of the country, dedicating such an amount of funds to this program is impossible. Some compromises, such as partial coverage of services and setting up suboptimal goals for dialysis dose, anemia, mineral and bone disorders management, and other parameters, might be necessary.17 Establishing clear rules for accepting patients with ESKD into government-sponsored dialysis programs and using conservative kidney management in certain patients might be necessary steps in the short term.18 The knowledge about conservative kidney management and its implementation are generally lacking in the Middle East, including Syria.19
Administrative
For over 10 years, the volunteering NGOs on this project provided and/or managed kidney care for patients in Syrian areas that were out of the control of the previous government. Some of these were established and run by expatriate Syrians in North America, Europe, and the Gulf states and concentrated their work on Syrians. Their funding comes from individuals, other charities, and in some situations, government agencies such as the US Agency for International Development. Other more global NGOs volunteering on this project have many sources of donation or are affiliated with the dialysis industry (Bridge of Life, the Charitable arm of DaVita, Inc.). The NGOs presently operating dialysis facilities inside Syria are local and funded by various sources of donation. The MoH must provide guidance and supervise NGOs that may have goals, priorities, and views that differ from goals set by the government. A strong private-public partnership in operating dialysis and other health care facilities should be considered.
Quality of Care
The reported utilization of fistulas in Syria is high compared with most developed countries such as the United States, where fistulas are used in about 60% of patients.20 This difference is probably due to the younger age of the Syrian patients and lower prevalence of diabetes. A shortcoming of the survey was not having a question that differences between the use of tunneled and nontunneled catheters. However, comments made by some of the visiting teams noted a high prevalence of prolonged use of nontunneled catheters in patients with maturing fistulas and patients who are not able to get a fistula for medical or financial reasons. Medical missions by expatriate surgeons and interventional nephrologists to create fistulas and convert nontunneled to tunneled catheters are underway. The specialty of interventional nephrology does not exist in Syria; many nephrologists can place nontunneled catheters, most procedures otherwise are conducted by surgical specialists in hospital operating rooms.
Our findings may underestimate the prevalence of viral hepatitis, given the lack of routine testing in many centers. Efforts to test all patients regularly, treat positive patients with antiviral agents, and enforce infection control practices should be a top priority in the near future.
The visiting teams found that over a half of the water treatment systems in the government facilities were inadequate, which constitutes a direct danger to patients' lives. To dig further into this problem, the committee invited an expert in dialysis water treatment systems to evaluate the conditions in one of the major hospitals (Figure 2). He identified structural design problems such as blind loops and poor maintenance due to lack of parts and testing capabilities. Chemical water analysis discovered concentrations of several minerals that exceeded the Association for the Advancement of Medical Instrumentation standards. The expert highly recommended building a completely new system. The need for new water systems seems to be an issue in a large proportion of the facilities.
Figure 2.
A photograph provided by Mr. Christopher Atwater during his visit to the Syrian dialysis facility taken with a patient in the pediatric unit accompanied with the words: “It's tough saying goodbye knowing about the issues but I am motivated to do everything in my power to help!” (approval to publish the photograph obtained from the patient and her mother).
Modalities Choice
PD offers many advantages over hemodialysis. However, its penetration into Syria is negligible due to several misconceptions about the modality and cost of supplies.9 These issues are not unique to Syria and have been reported in other areas.21 Local manufacturing of solution bags with proper connection methods and education of patients and providers should remove most barriers to implementation of PD.21 The committee is currently conducting an evaluation of the kidney transplant patients and programs.
Workforce
Syrian physicians constitute about 1.6% of the international medical graduates (IMGs) in the United States.2 Assuming that their likelihood of going into nephrology is similar to other IMGs, and based on the facts that over the half of the 12,000 US nephrologists are IMGs,22 we estimate that the United States has over 100 Syrian nephrologists. This number is close to that of the nephrologists practicing in Syria.13 Since the beginning of the Syrian crisis, expatriate Syrian nephrologists have made significant contributions to kidney care in their home country in the fields of education, provision (telemedicine and missions), and publications.9–12,23 These contributions are expected to increase with recent political change, given the enthusiasm for the future and the more welcoming attitude of the new government toward foreign assistance. Specific examples where Syrian American physicians can help include covering dialysis facilities that do not have nephrologists through telemedicine and periodic visits, training fellows, assisting internists working as dialysis physicians, writing treatment protocols, and quality improvement activities.
In Table 3, we summarize the main barriers and challenges our survey found and suggested solutions.
Table 3.
Problems and suggested solutions
| Barriers | Examples | Suggested Solutions |
|---|---|---|
| Patients-related | Negative attitude toward PD | Education, exemplary programs |
| Cultural barriers | Culturally sensitive educational activities aimed at removing misconceptions about organ donations and end-of-life care | |
| Policy-related | Policy barriers toward using modalities other than hemodialysis | PD, CKM, and diseased donor transplantation programs |
| Inadequate monetary compensation of employees, which forces them to work elsewhere including private practices | Adequate compensations and encouragement of full-time employment | |
| Tendency of government to directly manage all dialysis facilities | Partnership with nonprofit NGOs and private sector | |
| Lack of supervision | Quality monitoring systems | |
| Lack of clear acceptance criteria to ESKD treatment programs | Establishment of transparent criteria | |
| Workforce | Inadequate nephrologists presence in facilities | Telemedicine, help from expatriates nephrologists, dialysis-oriented educational activities for internists working in dialysis facilities |
| Inadequate presence of vascular access services | Fellowship training to include skills in vascular access placement, interventional nephrology programs | |
| Poor infection control practices and poor sanitation | Re-education of nurses and technicians, dedicated cleaning crew support | |
| Inadequate biomedical support | Dialysis pathways education in bioengineering schools | |
| Financial | Inability to provide three times a wk hemodialysis to all | Incremental dialysis, criteria for patients who must get more frequent dialysis |
| Inability to meet international quality standards | Accept certain compromises, especially in recommendations not supported by high quality evidence | |
| Reliance on NGOs and individuals not familiar with kidney problems | Coordinate how support is allocated, educate funders on needs. Expanding funders pool to charitable entities specializing in kidney care | |
| Infrastructural | Dated buildings, machines, and water treatment systems | Clear criteria for repairing existing facilities and equipment versus building new facilities and purchasing new equipment |
| Dangerous electrical and plumbing conditions | Work on immediate repair and regular maintenance | |
| Data-related | Lack of digitization of medical records and inventory systems | Help from expatriates IT personnel |
| Knowledge gaps in the epidemiology of ESKD in the country | Involve epidemiologists in designing, conducting, and analyzing studies |
CKM, conservative kidney management; IT, information technology; NGO, nongovernment organization; PD, peritoneal dialysis.
Conclusions
Our findings identify significant problems in the delivery of dialysis to the patients with ESKD in Syria including human resources shortages, inadequate supply of disposables, insufficient diagnostic testing, dated machines and structural problems in the buildings and water treatment systems, and poor maintenance of equipment. Although many of these issues are similar to those seen in resource limited contexts,24 the present Syrian situation differs in that we are dealing with an inadequate preexisting, rather than a nonexisting, system. Some of the dilemmas in fixing a broken health care system include having to repair machines or buying new ones, rehabilitating preexisting facilities versus building state of the art units, and re-educating staff accustomed to bad habits and misconceptions. Expectations must be realistic to improve this imperfect system and the government should have clear priorities set.
No matter how limited the resources are, following the principle of “do not harm” is critical. Measures that follow this principle include obeying infection control practices, repairing dangerous structural building problems, repairing dated water treatment systems, avoiding wasting resources, and addressing workforce shortages and retraining.
Acknowledgments
The authors are indebted to the members of the Syrian National Kidney Foundation for their input on the survey design and setting the committee objectives, to Mr. Christopher Atwater from Bridge of Life DaVita, Inc. for conducting comprehensive onsite evaluation of the water treatment system and machines at one of the large dialysis centers in Syria, and to the following NGOs for their help in conducting the surveys, visiting the facilities, and providing needed emergency help: AFAQ Humantarian Relief Organization, Al-Ameen Foundation, Islamic Relief, MedGlobal, Shafak Organization, Syrian American Medical Society, Union of Medical Care and Relief Organizations.
Disclosures
Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/B312.
Author Contributions
Conceptualization: Zuhair Al Karrat, Muawya Alahmad, Saleh Kaysi, Wajih Khatib, Khaled Haj Nasan, Muhammad Sheekh Yousef.
Data curation: Ahmad Musa Al-Araj, Muawya Alahmad, Fouad Alali, Saleh Alyousef, Saleh Kaysi, Wajih Khatib, Khaled Haj Nasan, Muhammad Sheekh Yousef.
Formal analysis: Saleh Kaysi.
Investigation: Saleh Alyousef.
Methodology: Muawya Alahmad, Wajih Khatib.
Project administration: Ahmad Musa Al-Araj, Muawya Alahmad, Khaled Haj Nasan, Muhammad Sheekh Yousef.
Supervision: Zuhair Al Karrat, Fouad Alali.
Validation: Muawya Alahmad, Fouad Alali, Mohamed Sekkarie.
Visualization: Mohamed Sekkarie.
Writing – original draft: Mohamed Sekkarie.
Writing – review & editing: Saleh Kaysi.
Funding
None.
References
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