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UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health - Visit to Syria, 6-14 November 2010

Preliminary observations

Damascus, 14 November 2010

Members of the press, ladies and gentlemen, let me begin by warmly thanking the Government for inviting me to Syria and for facilitating a rich and interesting programme of meetings and visits in Damascus, Aleppo, Qamishli and Al Hassake.  During my visit, I have met with the Minister of Health, Deputy Minister for Foreign Affairs, Deputy Minister for Higher Education, a number of senior Government officials, representatives of health professionals’ organizations, as well as with representatives of the international organizations and civil society. Throughout my visit, I have been met with warm hospitality and courtesy. There has been a candid exchange of views. I take this opportunity to thank all those who have given my colleagues and me the benefit of their time and experience. I would also like to thank the United Nations Resident Coordinator’s Office for their tireless efforts in ensuring the smooth running of this mission.

You will find in this room a short document that explains my UN responsibilities as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (for short the Right to Health). In brief, I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly. Although appointed by the Human Rights Council, I am not employed by United Nations and the position I hold is honorary. As an independent expert, I exercise my professional judgement and report directly to the UN Human Rights Council and the UN General Assembly on the realization of the right to health.

Today, I would like to confine myself to a few preliminary remarks on some of the issues that, along with others, will be explored in more detail in the final report which will be presented to the Human Rights Council in June 2011.

The purpose of the mission was to understand, in the spirit of co-operation and dialogue, how Syria has implemented and endeavours to implement the right to health. The focus of the mission was on two major issues that I find of particular importance: access to healthcare for vulnerable groups, including persons in detention, and women’s health, focusing on sexual and reproductive rights.

From the outset, I would congratulate the Syrian Arabic Republic for the explicit provision of the right to health, including access to medications, in its Constitution. Syria’s Constitution also provides for equality and non-discrimination, fundamental to human rights. However, the implementation of these provisions is still a challenge.

I would also like to note Syria’s commendable work in the last three decades to improve the health system as a whole, and its commitment to ensure access to healthcare for all. A functioning health system is the basis for the exercise of the right to health and data indicates that admirable advances have been made amongst nearly all key health indicators. The Syrian health system is structured such that the government provides, free of charge, nearly all health goods, services and facilities to all people in Syria. The government operates a network of public hospitals and clinics that provide all Syrians with health care.  Coverage rates are extremely high – upwards of 90 per cent – and the centres in Syria that I visited were well staffed and well maintained.

I was also informed that the government is developing a long-term, coordinated strategy in its next five-year plan to ensure that all Syrians receive health care. When visiting Aleppo, doctors told me that waiting times for just about any surgery are never much more than a week.  These numbers are not only excellent for a developing country, but also globally. There are inconsistencies in availability and accessibility throughout Governorates, and between primary and secondary or tertiary services, but health care provision is largely commendable. However, quality of health services has to be improved at all levels. The Government acknowledges that the 3.6% of GDP allocated to health has to be increased to improve service delivery.
During the mission, I was informed of the Government’s plan to introduce a new medical insurance scheme, which will initially cover public officials. I would urge the Government to ensure that human rights principles are adhered to in its design, and that special care is taken to ensure that access to healthcare of the most vulnerable members of society, particularly the poor, is not impeded in its implementation.

The health care services that the government is committed to providing to all Syrians on a non-discriminatory basis are commendable, and this is reflected in the national indicators. However, while some health indicators may confirm that the average health condition of the population is satisfactory, these indicators may not reveal the lack of availability, accessibility, acceptability or quality of health services with respect to vulnerable groups. The right to health approach in human rights is particularly concerned about vulnerable groups. Therefore, it is of utmost importance to ensure that data regarding vulnerable groups is collected and analyzed.

The most successful targeted interventions around the world are based on collection of information that reveals problems unique to certain communities. This then allows such problems to be addressed on a non-discriminatory basis.  The collection of disaggregated data is critical in order to best serve the needs of groups of individuals who may need special attention and care. It reinforces the right to health approach and helps in identification and design of the most appropriate health policies and programmes. Though some of the health data collected by the Syrian Government is disaggregated, data collection should be more comprehensive and include a broader range of demographic indicators. This would not be discriminatory.

It is clear that the Syrian Government strives to achieve its constitutional goal of non-discrimination in all aspects of healthcare delivery. However the right to health approach requires more than that. For instance, although the incidence of HIV/AIDS remains extremely low in Syria, the Syrian experience with this illness is indicative of some concerns at a systemic level; specifically, the lack of community participation. Unfortunately, there are still insufficient numbers of civil society or community-based organisations participating in the development of health policies and programs.  For instance, there is little or no community participation of vulnerable groups and their input into decision-making surrounding delivery of HIV/AIDS services. This appears to be the norm for service delivery in all aspects of the Syrian healthcare system, but it is of particular concern in relation to HIV/AIDS, an illness for which patient empowerment and participation are necessary and successful.

I note particular improvement in key health indicators in the areas of women and children’s health, two focus areas of the Millennium Development Goals.  Since 1980, the infant mortality rate has decreased by nearly 75 per cent.  Equally impressive are decreases of the maternal mortality rate, which has decreased from 107 to 56 deaths per 100,000 live births since 1993.  These decreases are admirable, and place Syria close to the top of the developing world in terms of health-related achievements. However, problems in these areas persist.

Although the maternal mortality rate has substantially reduced, and is amongst the best in the region, there is still significant room for improvement, especially in regard to Syria’s high fertility rate.  It must be stressed that community participation in decision-making is critical to improving maternal health, and is a core component of a right to health approach. A lack of awareness, education and empowerment of women in relation to maternal health, particularly in relation to post-natal care, need to be overcome. This can be more effectively achieved through providing extensive community-based outreach services. 

Women may regularly visit skilled health workers leading up to and for childbirth, but certain aspects of post-natal care may not necessarily beaccessed as consistently in the post-partum period. Similarly, although the rate of contraceptive use has improved, at around 58%, there is still more work to be done in the context of sexual and reproductive rights, including promotion of birth spacing and other methods of family planning.

Moreover, nearly all indicators point to a persistent urban/rural divide, where the former areas are performing much better than the latter.  For example, data on maternal mortality indicates that while at the national level there has been a significant decrease in total maternal deaths, at the regional level deep disparities still exist.  By way of example, in Raqqa the maternal mortality rate is approximately 78 deaths per 100,000 live births, whereas in Damascus it is around 33.

I am also concerned that Syrian’s public health policies do not consider the issue of gender-based violence, which has grave consequences in respect of women’s health. However, no data is available on this vital issue. I believe that the Government could do much more to address the right to health dimensions of gender-based violence. Due attention must be given to the protection of human rights of women in this process, and adequate attention given to prevention, treatment and rehabilitation. Other important aspects include access to justice for those who are at risk of, or have been affected by violence, along with expeditious enactment of legislation, and promotion of policies addressing this issue.

Although I understand that, upon the request of the Government, the Office of the High Commissioner for Human Rights has conducted training in human rights in 2010 for all Ministries and government officials, health professionals in Syria have not had the same opportunity. As they are bound by treaties bearing closely upon duties of health professionals, I would recommend that institutions responsible for health care education include training concerning the right to health within their curricula.

Given that non-communicable diseases, such as cardiovascular disease, are on the rise amongst the Syrian population I noted with dismay that smoking is still highly prevalent in Syria.  Though the government has passed legislation restricting tobacco use, its implementation, including within enclosed public spaces such as restaurants, remains inadequate. There is much space for improvement in relation to reduction and cessation of tobacco use, and enforcement of existing laws. 

The situation of one of the vulnerable groups in Syria – currently some 300,000 persons of Kurdish origin – is of particular concern to me. Originally, over 100,000 persons of Kurdish origin were rendered stateless by decree in 1962, and as a result, they have been deprived of the enjoyment of many rights, including the right to health. While I trust that all Syrians have access to health care without discrimination, which the Government is clearly committed to, access to healthcare for these most vulnerable individuals is seriously hindered. They are precisely the kind of disadvantaged group that international human rights law is designed to protect.

While stateless Kurds with red identification cards, known as the ajanib, have access to health care, but not to treatments for chronic diseases, the stateless Kurds, those without any identification cards, known as the mauktoumeen have very limited, or no, access to healthcare. I have also received information that access to justice for the purposes of accessing health services for this group is also hindered. While the President himself has committed to resolve the issue, I urge the Government to follow up on that resolve, as it otherwise casts a shadow over the many remarkable accomplishments in the context of the enjoyment of the right to health.

I commend the Syrian government’s commitment to provide health care and support to what at one point may have been upwards of almost 1.5 million Iraqi refugees, in a country whose population itself is just over 20 million.  This is especially the case in light of resource constraints, as Syria is a middle-income country.  Working in coordination with UNHCR, and a number of other UN agencies and NGOs, has allowed the government to ease resources pressures and fill gaps in those spaces where it cannot provide adequate coverage to this community. 

I am very grateful to the Government of Syria for inviting me to visit, enabling me to deepen my understanding of the right to health-related issues. The Government’s invitation – and much of what I have learnt on my visit – confirms how seriously it is taking the issues related to the enjoyment of the right to health. I would like to use this opportunity to encourage the Syrian Government to extend a standing invitation to all special procedures mandate holders, to afford others the same opportunity I have had. While the Government has already accomplished much in the context of the enjoyment of the right to health, there is still more to be done.

Thank you.