SYRIA COVID-19 SITUATION ANALYSIS - CRISIS TYPE:EPIDEMIC - IMMAP
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Main Implementing Partner
COVID-19
SITUATION ANALYSIS
SYRIA
CRISIS TYPE:EPIDEMIC
JANUARY 2021
Photo: Corona Virus In Red Background - Microbiology And
Virology Concept - 3d Rendering. Source: iStock
Better Data Better Decisions Better Outcomes
The outbreak of disease caused by the virus known as Severe Acute Respiratory Syndrome (SARS-CoV-2) or COVID-19 started in China in December 2019. The virus quickly spread across the world, with the WHO Director-General declaring it as a pandemic on March 11th, 2020. The virus’s impact has been felt most acutely by countries facing humanitarian crises due to conflict and natural disasters. As humanitarian access to vulnerable communities has been restricted to basic movements only, monitoring and assessments have been interrupted. To overcome these constraints and provide the wider humanitarian community with timely and comprehensive information on the spread of the COVID-19 pandemic, iMMAP initiated the COVID-19 Situational Analysis project with the support of the USAID Bureau of Humanitarian Assistance (USAID BHA), aiming to provide timely solutions to the growing global needs for assessment and analysis among humanitarian stakeholders.
3 // 57
CONTENTS
1. COVID-19 and containment measures
overview
Page 4
A. COVID-19 Cases 4
B. Containment measures 8
C. Preventative measures 11
2. Drivers and humanitarian consequences
Page 15
D. Displacement 20
E. COVID-19 related humanitarian consequences 21
vi. Health: Overwhelmed healthcare system 23
vii. Livelihoods: Inflation and reduced employment opportunities
resulting in lower purchasing power 27
viii. Food security: Sharp increase in food insecurity levels, notably
due to increase in food prices and shortages of staple foods 30
ix. Nutrition: Rising malnutrition due to inadequate and less diverse diets 33
x. Agriculture: Rise in agricultural inputs’ prices 34
xi. Education: Lack of affordability and challenges with remote
learning leading to high rates of school drop-out 35
xii. Protection: Rise in protection issues and restriction of services 37
xiii. WASH: Lack of infrastructure and affordable WASH items
contributing to the spread of the infection 40
xiv. Shelter: Overcrowding and harsh winter conditions exposing
IDPs to a greater risk of COVID-19 infection 43
xv. Logistics: Fuel crisis leading to severe shortages and skyrocketing prices 46
3. Information gaps: what are we missing?
Page 47
Better Data Better Decisions Better Outcomes4 // 57
HIGHLIGHTS
1. COVID-19 and containment measures overview
A. COVID-19 CASES and clinics are being tested and with limited
testing and accurate information from the
Infection remains widespread despite a government, the real scale is likely even
decreasing rate of newly reported cases greater (The Syria report 16/12/2020). Reports
of 100% bed occupancy rates increased in
and positivity rates
December, notably in As-Sweida and Homs
As of 31 January a total of 43,5001 cases (211 governorates (OCHA 16/12/2020).
per 100,000) were recorded across the country
(MoH GoS, WHO, NES COVID-19 Dashboard). Northwest Syria: increased number of
While testing remains too limited to COVID-19 deaths despite decreasing number of
understand the true extent of the outbreak, confirmed cases
there are indications that Syria may be
experiencing a renewed wave of infections, As of 31 January, about 21,0001 total confirmed
with continued widespread community cases in Northwest Syria were reported,
transmission. Cases reported in schools mostly in Aleppo and Idlib governorates
continue to increase, although at a slower rate, (Assistance Coordination Unit 31/01/2021), an
almost doubling since mid-December reaching increase of only a few hundred compared to a
2,1001 cases by mid-January, including 80 month ago. Although the rate of new cases
deaths. Of these, half were reported among between December and January declined
teachers and staff (WHO & OCHA 01/02/2021). sharply compared to November and December
(7% increase compared to 47%), the number of
deaths associated with COVID-19 increased by
Government-held areas: still high positivity
46%, reaching 380 COVID-19 associated deaths
rates despite decreasing number of confirmed
half of which were in just two districts, Harim
cases
and Idlib (WHO & OCHA 26/01/2020 &
As of 31 January, more than 14,0001 confirmed Assistance Coordination Unit 31/01/2021).
cases had been recorded in government-held However, anecdotal information suggests that
areas, including 921 deaths (MoH 31/01/2021), COVID-19 remains widespread, notably due to
about double the caseload as of the end of people still being reluctant to seek testing and
November. While daily reported cases have treatment due to stigmatisation and concerns
decreased in January (WHO & OCHA about the loss of livelihoods (OCHA 26/01/2021).
01/02/2021), more than 50% of tests are Cases in camps continue to represent about
coming back positive in As-Sweida and 10.5% of all confirmed cases, a stable
Tartous governorates and 60% in Homs proportion compared to December, with most
governorate (OCHA 20/01/2021). As only being reported in Harim camp (OCHA
patients with severe conditions in hospitals 26/01/2021).
1 Large numbers (1,000+) have been rounded to the nearest 100. There is a possibility of instances where cases are double-counted across
areas of control.
Better Data Better Decisions Better Outcomes5 // 57
Northeast Syria: infection rate slowed down Cases are under-reported due to limited
after more than two months of lockdown testing capacities and social stigma
As of 31 January, 8,0001 cases have been Considering the limited number of tests being
reported in the northeast, including almost performed the actual number of cases and
400 deaths (NES COVID-19 Dashboard deaths is likely to far surpass official figures.
01/02/2021) with around 13-30 daily cases High positivity rates and death reports suggest
(SANES 31/01/2021). The transmission rate has that the true scale of the epidemic is largely
been continuously slowing down since late underestimated. Community stigmatisation,
November following a lockdown (OCHA & WHO fear of income loss, and reluctance to go to
09/12/2020). The weekly average number of hospitals continue to participate in the
cases had significantly reduced, starting from underreporting of cases alongside limited
140 at the end of October, to 21 as of 3 January, testing capacities.
then to 10 as of 31 January. Camps continue to
report cases in northeast Syria, especially
Limited testing capacities
Washshukanni camp in Al-Hassakeh, where
the virus is reported to be spreading Contact tracing and testing remain challenges
exponentially among the more than 10,000 across the country, notably in remote
displaced people living there (The Syria report governorates and camps (WHO & OCHA
06/01/2021). No new cases have been 12/01/2021). The testing rate is still far below
confirmed as of 12 January at Al-Hol camp due what would be required to more accurately
to limited testing capacity (NES Sites and detect infection prevalence. Health authorities
Settlements Working Group 20/01/2021). A still struggle to keep up with the spread of the
decrease in transmission appears to have epidemic and to significantly scale up their
occurred in some areas, but the figures likely testing operations.
do not provide an accurate reflection of the In government-held areas, as of 25 January,
prevalence of infection across the region, as the Ministry of Health reported that
reduced testing capacity due to supply laboratories in Damascus, Aleppo, Lattakia,
shortages complicates trend analysis. Rural Damascus, and Homs had conducted a
Similarly to the other geographical areas, the total 91,400 tests since the start of the
true prevalence is likely much higher as epidemic, with 550 tests on a daily basis (WHO
testing capacity and case detection ability & OCHA 01/02/2021). However, as PCR tests
remains limited in the northeast. In December, were limited in November to only critical cases
among reported deaths at nine COVID-19 admitted in health centers (Syria TV
facilities, about 40% died within 24 hours of 20/12/2020), tests and cases do not reflect the
admission and many others died within 48 epidemic’s scale.
hours. This late presentation to the centers
may highlight patients’ reluctance to seek Two new labs in northern Aleppo and Idlib
treatment and inadequate referral from other governorates opened between September and
health facilities, resulting in delays in early November, quadrupling daily testing
admission of COVID-19 patients (OCHA & WHO capacity in northwest Syria to 1,000 tests
09/12/2020). (OCHA 21/12/2020, OCHA 09/12/2020). As of 31
January, a total of 84,400 tests have been
performed (Assistance Coordination Unit
31/01/2021).
Better Data Better Decisions Better Outcomes6 // 57
By the end of 2020 a total of 73,817 tests were hereby decreasing their chance of survival
recorded in the northeast (EWARN 31/12/2020). (OCHA & WHO 29/10/2020). Such a high fatality
Testing capacity continues to decrease in rate at COVID-19 treatment facilities is, in turn,
January 2021 due to test kit shortages, with strengthening people’s reluctance to seek
only 61 tests conducted on average per week, treatment (OCHA & WHO 09/12/2020). In the
after already a drop by 36% in December in the northeast, overall levels of hospitalizations in
number of tests performed (WHO & OCHA COVID-19 dedicated health facilities were low
12/01/2021, SANES 03/01/2021, WHO & OCHA at the end of November, despite suspicions of
23/12/2020). widespread and rising infections among the
population, due to the patients’ reluctance to
Social stigma, fear, and the reluctance of the seek treatment (OCHA & WHO 09/12/2020).
population to seek treatment continued to Awareness campaigns may have contributed in
contribute to under-reporting reinforcing this behavior in instances where
Issues with social acceptance of those going to hospitals was discouraged unless they
infected and fear of stigmatization or even had critical symptoms to avoid exhaustion of
bullying by the community continue to be healthcare resources.
reported, driving people’s reluctance to seek While anecdotal evidence continues to report
treatment or testing and to support this phenomenon, its scale remains difficult to
community members. Many now consider ascertain. 69% of the respondents to REACH
COVID-19 “shameful” and hold COVID-19 monthly surveys in the northwest and 87% in
patients responsible for their infection the northeast believed that COVID-19 is
because they did not adhere to protective generating discrimination, especially against
measures (Enab Baladi 13/11/2020). Health Covid-19 positive or suspected people and
workers and health facilities are perceived healthcare workers (REACH Initiative
negatively and seen as “spreaders” of the virus. 08/01/2021, REACH Initiative 08/01/2021).
Social stigma and patients’ reluctance to go to
hospitals mean that significant numbers of In GoS-held areas, fear and deep distrust of
people with symptoms are likely not seeking state institutions are also driving people from
care or are being treated at home. This leads reporting symptoms or seeking care, as
to further difficulty in ascertaining the real patients refuse to go to public hospitals
scale of the epidemic, as well as increases the (Physicians for Human Rights 08/12/2020, Enab
likelihood of patients to present to facilities Baladi 13/11/2020).
late and develop more severe symptoms
Better Data Better Decisions Better Outcomes7 // 57
Vaccination: plans started but campaigns vaccinations when the campaign will start and
will face significant obstacles will likely face additional security risks going to
the health centers. Opposition members and
In GoS-held areas, Government officials others targeted by the regime will not feel safe
announced they will likely receive the “Sputnik enough to access vaccines, resulting in
V” COVID-19 vaccines in the first quarter of potential large gaps in immunization coverage
2021 (Enab Baladi 09/01/2021), after (Syria Direct 14/01/2021). Doubts also remain
negotiations with Russia. High-risk groups, about Syria’s preparedness levels to receive,
such as health workers, elderly, and people store, distribute, and vaccinate, considering
with co-morbidities would be prioritized (WHO the country’s current logistic, economic, and
& OCHA 01/02/2021). social conditions. Storage is the main
Initiatives are taking place to facilitate the challenge to vaccination efforts, given the
acquisition of vaccines for the northwest by persistent power cuts in Syria and lack of fuel
local authorities and international partners and addition to cold chain challenges, limited
(Enab Baladi 09/01/2021). Plans are underway open border crossings will also be an issue.
for vaccination of about 20% of the population, (Enab Baladi 09/01/2021).
850,000 people, of which 3% will be for In addition, considering already the
frontline workers. However, this is unlikely to stigmatisation and reluctance to get tested or
be taking place before the second quarter of treated, there are concerns that vaccines
2021 due to high operational costs, lack of would not be accepted widely. In a poll,
logistics capacity and misinformation and conducted by the newspaper Enab Baladi, out
reluctance by the population to get vaccinated of 191 respondents, 72% reported that the
(WHO 28/01/2021). No arrangement has been vaccine is a source of anxiety and only a third
announced at the time of writing (05/02/2020) reported they would get vaccinated (Enab
in northeast Syria to obtain vaccines (HRW Baladi 09/01/2021), similar to the rate found in
02/02/2021). Jordan, Kuwait, and some other countries in
However, lack of storage capacity and the the region (Vaccines 12/01/2020).
security situation are likely to hinder and delay Communication campaigns have started to
the roll-out (Enab Baladi 09/01/2021, Syria also include the topic of COVID-19 vaccines to
Direct 14/01/2021). Due to the insecurity and generate public demand (OCHA & WHO
hostilities, people may not be able to access 12/01/2021).
Better Data Better Decisions Better Outcomes8 // 57
Continued increases in transmission B. CONTAINMENT MEASURES
possible
While authorities initially closed most public
As 63% of the population in the northwest are services and restricted movement,
Internally Displaced Persons (IDPs) (HNAP progressive relaxation of these containment
11/08/2020), and many live in overcrowded measures took place during the summer of
settlements (REACH 19/09/2020), contagion 2020. However since mid-October, following
potential is high, compounded by winter an acceleration of reported cases and low
crowding and recent flooding. Crowding, community compliance, tighter containment
inadequate shelter and poor access to basic and public health restrictions were imposed in
services make it nearly impossible to properly December in both GoS-controlled areas and
adhere to physical distancing or other public northeast Syria, with mandatory wearing of
health precautions and put IDPs at risk of masks in public (OCHA & WHO 23/12/2020,
COVID-19 infection (Al-Araby 20/11/2020, Xinhuanet 17/12/2020) and higher fines for
Human Rights Watch 15/10/2020). The Ministry non-abiders to the policy (up to 25,000 pounds
of Health of the Syria Interim Government in per driver and 1,000 per citizen not using a
the northwest estimated that around 64,000 facemask) (Sham FM 15/12/2020, SANES Syria
people are at critical risk of infection (The Syria 05/12/2020, Al-Khabar 02/12/2020).
report 14/10/2020). In the northwest, around
40% of the adult population is estimated to In GoS-held areas, mid-December,
have comorbidities and around 76,000 people containment measures were tightened, with
are over 60 years old. Both factors could lead new limitations imposed on gatherings such as
to poorer outcomes (MedRxiv 07/05/2020). weddings and funerals in most governorates
Nationally, 1.8 million people are over 60 (HNAP for at least one month (Al Watan 17/12/2020,
11/08/2020). According to HNAP Regional Sham FM 14/12/2020, Al-Khabar 02/12/2020),
COVID-19 Vulnerability Maps, 9,371,553 were at and public health rules were more strongly
high COVID-19 risk in GoS-controlled areas in enforced, with the penalty of arrests for
December, 1,973,610 were at high risk in SDF- anyone not complying in As-Sweida
controlled areas, and 2,918,316 were at high governorate (Al Watan 28/11/2020). Soldiers
risk in areas controlled by non-state armed were spotted circulating in the city of Busra
group and Turkish-backed armed forces (HNAP mid-December and disseminating, via
11/01/2021) (see Context). loudspeakers, awareness messages reminding
people of the necessity to wear facemask and
gloves to prevent COVID-19 transmission,
threatening non-compliant shop-owners with
shutting down their businesses (Enab Baladi
02/01/2021). A total lockdown seems unlikely to
be considered by the authorities due to the
significant economic losses accrued the
previous one led to (Syrian Observer
11/12/2020).
Better Data Better Decisions Better Outcomes9 // 57
In Dara’a governorate, rising cases in schools until 3 February 2021 (SANES 20/01/2021). Early
led local authorities to shut down education closure of food shops and markets continued,
facilities for 15 days in mid-December (Enab as well as places of worship except for the
Baladi 10/12/2020). While new restrictive weekly prayers. All major gatherings
measures were put in place, travel remains (weddings, funerals, conferences, etc.)
relatively unimpeded. The domestic airports in continue to be strictly prohibited but
Aleppo, Lattakia and Qamishli reopened on 21 education facilities are allowed to open as long
December, at a rate of four flights per day, with as strict health procedures are implemented.
no PCR test required for domestic travel, Authorities continued to require all citizens to
which could result in further spread of the wear masks in public transports and weekly
virus across the country (Syria TV 21/12/2020, prayers, and use personal protection measures
Syria TV 16/12/2020). (SANES 20/01/2021). Due to continued low
In the northwest, education facilities were levels of mask-wearing, coordinated
closed mid-December for a month and held campaigns were implemented to promote the
only remotely online due to rising cases (also importance of face masks to prevent COVID-19
see Education) (Syrian Interim Government infection (WHO & OCHA 12/01/2021).
15/12/2020). As preventive measures were Most international land borders continue to be
mostly not abided by, in Tartous governorate, a closed, with some limited exemptions for
new compromise was implemented with cafes humanitarian movements. While movements
allowed to remain open until midnight if the with Turkey at specific checkpoints continue,
occupancy rate was reduced and physical in January, the Government of Turkey required
distance was maintained (Albaath Media a negative COVID-19 test for crossing from
13/01/2021). Syria into the country, which could lead to a
In northeast Syria, containment measures significant reduction in movements as most
were further tightened in November, with a Syrians cannot afford testing (OCHA
partial lockdown announced on 30 October 12/01/2021).
2020, and since then extended three times,
Better Data Better Decisions Better Outcomes10 // 57
Timeline
COVID-19 January 2021
SYRIA
2020 Measurements
October 30
Containment Curfew and partial lockdown reinstated in the northeast until 23 November
measures
November 3
Containment Lockdown implemented for two weeks in Derik city, northeast
measures
Containment Idlib authorities called for urgent additional support.
November 6
measures Closure of markets and schools
November 8
Containment Three schools closed in Aleppo, GoS-controlled areas, following rise in cases
measures
November 23
Containment Extension of partial lockdown in NES until 20 December
measures
November 30 Economic Extension of partial lockdown in NES until 20 December
December 10
Containment Closure of schools for 15 days in Dara’a governorate (GoS-held areas)
measures
Containment Limitations of gatherings for a month in GoS-held areas
December 15
measures Closure of schools in Northwest
Containment Reopening of domestic airports in GoS-controlled areas (Aleppo, Lattakia
December 21
measures and Qamishli)
2021
January 20
Containment Lockdown in northeast Syria extended until 3rd February
measures
January 27 Economic SYP at an all-time low of 3,000 SYP/USD
January 30
Containment Turkey requires negative PCR result at the border
measures
Better Data Better Decisions Better Outcomes11 // 57
C. PREVENTATIVE MEASURES While campaigns have adapted to the
heavy reliance on social media, outreach
Despite communication campaigns, gaps in limitations continue to be reported
knowledge remain In northwest Syria, in October, almost all of the
In the northwest, according to data collected population reported receiving COVID-19
in October, gaps in COVID-19 understanding information from social media messaging
remained, as 52% of the respondents (97%) and 76% from relatives and family.
continued to believe that all patients with However, health workers at health facilities
COVID-19 show symptoms and two-thirds only were most frequently mentioned as a most
mentioned the possibility of airborne trusted source (65%) (REACH Initiative
transmission. However, ways of contracting 07/12/2020). In Al-Hassakeh governorate
COVID-19 and people most at risk were rightly (northeast) in October, 88% reported to
identified. Despite evidence of misinformation receive most of their COVID-19 information
surrounding preventative measures, from social media messaging and 73% from
respondents were also fairly aware about the relatives and family. While television was the
correct preventative measures and identified most frequently mentioned as a most trusted
wearing masks (79%), washing hands (77%), source to receive COVID-19 information (66%),
avoiding crowds (72%) as strategies to reduce the proportion of respondents indicating
the chance of getting infected with COVID-19 social media as a trusted source increased
(REACH Initiative 07/12/2020). significantly between the August (45%) and
In the northeast, according to data collected in October (65%) rounds (REACH Initiative
October in Al-Hassakeh governorate, gaps in 06/12/2020). Protection actors also report
COVID-19 understanding were also high, as adapting their way of working due to the
50% of the respondents continued to believe pandemic, increasing their reliance and use of
that all patients with COVID-19 show symptoms social media to raise protection awareness.
and only two-thirds mentioned the possibility According to a survey conducted in December
of airborne transmission. However, people among 213 protection partners and staff, more
most at risk, elderly, people with pre-existing than 70% reported using Whatsapp and social
conditions and health workers were rightly media platforms, like Facebook and Youtube,
identified, at higher proportions than in at a slightly lower rate (64%). As a result, poor
August. Despite evidence of misinformation internet connection and lack of smartphones,
surrounding preventative measures, notably in rural areas, have been barriers to
respondents were fairly aware about the access information and services (Protection
correct preventative measures and identified and Community Services Sector Inside Syria
wearing masks (80%), avoiding crowds (56%) 01/02/2021).
and washing hands (47%) as strategies to In GoS-held areas, Dara’a governorate, due to
reduce the chance of getting infected with limited efforts, the people themselves are
COVID-19 (REACH Initiative 06/12/2020). carrying out Covid-19 prevention campaigns
(Enab Baladi 02/01/2021). In the northeast, in
informal settlements in Ar-Raqqa, Deir-ez-Zor,
and Menbij governorates, lack of materials and
unclear COVID-19 information ranked the
highest among the reported reasons for a
difficulty in understanding it (REACH Initiative
18/01/2021).
Better Data Better Decisions Better Outcomes12 // 57
Limited uptake on application of preventive 61% of respondents reported wearing a face
measures mask when out of the house for shopping or
when participating in social gatherings or
While most people report being aware and visits, an increase to previous months (REACH
having sufficient understanding about self- Initiative 07/12/2020).
protection and preventive measures, only
between 50-60% of the sub-districts report In the northeast, in October, Al-Hasakeh
having sufficient knowledge of COVID-19 risk governorate, 95% of respondents indicated
across the areas of control end of January that they undertook preventive measures to
(HNAP 28/01/2021), and not all community mitigate the risk of contracting COVID-19.
members report to be fully committed to Among the measures taken, wearing a mask
adhering to protective measures. While ranked first (75%), avoiding crowds (61%),
general awareness of preventative measures wearing gloves (54%) and washing hands
seems to be improving, critical gaps remain in (50%). 87% of respondents also reported using
abiding to the mitigation measures, with hand sanitizer if available before entering a
reluctance to isolate when exposed to public building. A higher proportion of
COVID-19 cases notably still reported. respondents (58%) reported wearing a face
mask when out of the house for work than in
In the northwest, in October, 72% of August or when participating in social
respondents indicated that they undertook gatherings or visits (REACH Initiative
preventive measures to mitigate the risk of 06/12/2020). In informal camps, only 2% of the
contracting COVID-19, 10 percentage points respondents mentioned that everyone
higher than in August. Among the measures practised physical distancing in their everyday
taken, washing hands ranked first (78%), life, with the most reported barrier to physical
followed by wearing masks (63%) and avoiding distancing being that their living conditions
crowds (58%). 96% of respondents also not allowing for it (REACH Initiative 18/01/2021).
reported using hand sanitizer if available
before entering a public building. In October,
Better Data Better Decisions Better Outcomes13 // 57
Money is the main barrier to adhere to Low risk perception
preventative measures Risk Communication and Community
Economic hardship and critical living Engagement efforts reached an estimated 15
conditions, especially in the winter season, million people by the end of September, yet
limit the extent to which people are able to survey information and anecdotal evidence
engage in such preventative efforts. The cost suggest that the risk perception across Syria is
of hygiene items, overcrowding in shelters, and very low, leading to low adherence to individual
low enforcement of mitigation measures by preventive measures that has been observed
local authorities are key barriers to adherence. in some communities. Across informal
In the northwest, in October, 67% people settlements in the northeast, the proportion of
reported they faced barriers in taking the population thinking that COVID-19 is an
preventive measures, similarly to the previous important issue varies considerably across
round. Among those who reported barriers, informal sites and settlements from around
lack of money to buy protective items and the 0% to around 100% (REACH Initiative
necessity to go to work continued to rank high, 18/01/2021). Due to a lack of strong
around 40% (REACH Initiative 06/12/2020). In enforcement and inadequate communication
Al-Hasakeh governorate, northeast, 24% of by authorities to the population about the likely
respondents reported that they face barriers scale of undetected transmission, the urgency
in taking preventive measures to mitigate the and necessity of taking precautionary
risk of contracting COVID-19, a decrease by measures is not always well understood.
almost half compared to August. Among those, Anecdotal testimonies also highlight the
lack of money to buy protective items remain apparent contradiction in measures enforced
the main barrier, although the proportion also by local authorities as a reason behind the
decreased by half over the same time period reluctance to implement measures, for
(reaching 10%) (REACH Initiative 06/12/2020). example with restaurants and coffee places
The risk of income loss is also one of the main being closed while crowded buses are still
reasons driving people from reporting allowed (Al Watan online 13/01/2021).
symptoms to avoid quarantine in the northwest
(Protection Cluster 27/11/2020), likely explained
by the overreliance on daily labour in this
region (close to 50% of the population) (OCHA
16/09/2020).
Better Data Better Decisions Better Outcomes14 // 57
Figure 1. Proportion of communities enforcing mask-wearing, as reported by community focal
points (HNAP 20/01/2020)2
Figure 2. Figure 2: Presence of social distancing measures in public places among
communities, as reported by community focal points (HNAP 20/01/2020)2
2 The maps display entire sub-districts where community focal points were surveyed and do not represent areas of control. Source reports and
subsequent methodology are available from the Humanitarian Needs Assessment Program (http://hnap.info).
Better Data Better Decisions Better Outcomes15 // 57
2. Drivers and humanitarian consequences
Drivers
An already fragile health system devaluating salaries and pushing up prices of
basic goods and increasing dependence on
The health system was neither prepared nor
negative coping mechanisms. Economic
capable of dealing with the pre-existing health
experts from Damascus University estimated
needs, and even less so the COVID-19
the economic losses due to the COVID-19
epidemic. In December 2019, about 50% of the
lockdown measures of 1 trillion Syrian Pounds
113 hospitals across the country considered
(SYP) per month, amounting to four trillion in
partially functional or non-functional (Health
total (USD 1.5 million) (Al Watan 11/04/2020),
Cluster 04/2020, WHO HeRAMS 2019) and
representing almost half of the 2021 Syrian
about 33% of health centers reportedly
Government budget (Atlantic Council
damaged (WHO HeRAMS 2019), figures that are
01/12/2020).
likely to have increased during the offensives
in both northwest and northeast that occurred As a result of the pre-existing economic crisis,
early 2020. During key informant interviews in coupled with COVID-19 restriction measures
the northwest, many participants raised the and, in June 2020, the implementation of new
problems of a lack of medical facilities and/or US economic sanctions, the Syrian Pound
the distance to any existing facilities (FAO devalued faster over the first six months of
23/12/2020). In the northeast, only 26 (9%) of 2020 than over the past nine years of the
270 public healthcare facilities were conflict (World Vision 01/07/2020). In January
functioning in April 2020 (NES Forum 2021, the US announced they will continue
16/04/2020). their sanctions policy against Syria (Enab
Baladi 04/01/2021), aiming at reducing the
flows of funding to the government in a more
COVID-19 containment measures significant manner, according to the economic
exacerbated the pre-existing economic researcher Manaf Quman (Enab Baladi
situation, significantly worsening 04/01/2021).
humanitarian needs The value of the Syrian Pound continued to
While precautionary measures against the weaken in January 2021 on the informal
spread of the virus were crucial to containing exchange rate market and reached a new
transmission, they exacerbated socio- record low on 27 January with SYP 3,000 per
economic vulnerabilities and created new USD (Syrian Observatory for Human Rights
humanitarian crises by reducing availability 27/01/2021). Despite an official exchange rate
and access to basic services and employment of 1,250 SYP per USD, the GoS itself has had no
opportunities, adding another layer of other recourse but to use the unofficial
complexity in the humanitarian response. The exchange rate. On 1 December, the Syrian
decade of conflict, inflation, and regional Central Bank issued a special US dollar official
shocks had already severely weakened the exchange rate for conscription exemption
Syrian economy, but COVID-19 restrictions payments – the new special exchange rate is
since March 2020 further heavily impacted reportedly 2,550 SYP per USD, much closer to
employment opportunities across the country, unofficial rates (Enab Baldi 14/12/2020). In
Better Data Better Decisions Better Outcomes16 // 57
January, due to the inflation, the Central Bank The regional economic downturn further
of Syria launched a new five thousand Syrian reduced economic flows into Syria. The
Pounds banknote (Syrian Observatory for estimated annual $1.6 billion of remittances
Human Rights 24/01/2021). (Syria Direct 12/04/2020) support about 1
The Turkish Lira continues to be used in the million Syrians (or 200,000 households). In
northwest as an alternative to the Syrian March 2018, it was estimated that remittances
Pound, and is often the most commonly inflows were 36% higher than total wages and
reported currency for purchasing essential salaries in Syria. However, due to the
commodities for IDP communities (REACH pandemic, labor sectors were heavily affected
31/01/2021). As with the SYP/USD exchange in the main countries of origin (Saudi Arabia,
rate, the SYP/TRY rate has also deteriorated Lebanon, Jordan and Turkey), resulting in a
with the fall in value of the Syrian Pound decrease in remittance (Mercy Corps
reaching 409 SYP for buying and 402 for selling 25/01/2021) by 50% in 2019/2020 compared to
in Idlib and Aleppo countryside (Syrian 2017 (OCHA & WHO 29/10/2020).
Observatory for Human Rights 27/01/2021).
Figure 3. Figure 3: Informal SYP/USD exchange rate on the first of each month in Damascus,
Aleppo and Idlib and the formal rate of the Central Bank of Syria (sp-today 16/02/2020; Central
Bank of Syria 16/02/2020)3
3,000
2,500
2,000
1,500
1,000
500
0
November
November
January
February
March
May
July
January
February
March
May
July
April
June
August
December
April
September
October
June
August
September
October
2019 2020
Official Idleb (Unofficial) Aleppo (Unofficial) Damascus (Unnoficial)
3 Data is captured by partners of the source who capture the rate used by money exchangers each day in Idlib, Aleppo and Damascus, and the
value on the first day of each month is visualized.
Better Data Better Decisions Better Outcomes17 // 57
In GoS-held areas, total revenue in 2020 was To ensure some influx of capital, the
83% lower than the pre-war budget of 2010. Government of Syria has been selling its debt.
The 2021 approved budget’s value decreased However, as there is no tax revenues and
by almost a third compared to last year, in foreign currency left, it is unlikely that they will
inflation-adjusted US dollar terms. While in be able to repay them (Mercy Corps 25/01/2021).
absolute value, the GoS budget doubled from The risk of economic default in 2021, and
2019 to 2020, reaching 8.5 trillion Syrian subsequent austerity measures, is high and
pounds. Due to the sharp depreciation of the could lead to further negative impact on the
Syrian Pound and the significant economic purchasing power of Syrians. Already the 2021
slowdown in 2020, the 2021 budget’s value will budget shows a 85% decrease in government
be the smallest budget since 2010 (Atlantic spending on subsidies and salaries,
Council 01/12/2020). Despite USD 30 to 105 significantly decreasing the purchasing power
billion in lending from Iran since the beginning of most Syrians (Enab Baladi 07/01/2021).
of the war (Atlantic Council 01/12/2020), the
2021 budget will likely result in additional
austerity measures on Syrians in GoS-
controlled areas. According to a political
economist, the decline in government
spending on individuals in 2021 will be close to
85% (Enab Baladi 07/01/2021), as allocation of
salaries, wages, social support allocations, and
subsidies are projected to significantly
decrease in value, resulting in an increase of
65% in the cost of living of Syrians in 2021 with
the current value of the SYP (Enab Baladi
07/01/2021), and could increase even more if
the Pound continues to depreciate as forecast.
Better Data Better Decisions Better Outcomes18 // 57
Figure 4. Syria’s general budget between 2004 and 2021 in USD informal exchange rate (Enab
Baladi 07/01/2021)
The impact of this is expected to hit hardest
for 83% of Syrians who were below the poverty
line before the COVID-19 crisis (OCHA 2019). As
a result, safety nets and livelihood resources
are more strained than ever, compounding the
humanitarian needs of 11.7 million people,
including 6.2 million IDPs.
Better Data Better Decisions Better Outcomes19 // 57
Basic infrastructure severely impacted by a actually connected to treatment plants. There
decade of conflict were only around 20 treatment facilities in
Syria (Delegation of the European Commission
A decade of conflict, multiple displacements, to Syria 04/2009). Due to the conflict, at least
economic shocks in the country and 50% of sewage systems were not functional in
neighboring countries, military operations, and 2019 and 70% of sewage was untreated: this
violence had already severely affected the results in only 9% of the population being
population and infrastructure, leading to weak served by functional wastewater treatment
capacities in handling the spread and systems (HNO 2019 01/03/2019). About 26% of
repercussions of the disease. water infrastructure has been damaged,
About 6.7 million people remained internally including 51% of wells, 23% of water towers/
displaced in 2020, and an estimated 5.65 tankers, and 9% of pumping stations (World
million people across the country have shelter Bank 06/02/2019). Regional water shortages,
needs (Shelter & NFI Sector 17/11/2020), with including a drought in Turkey, and continued
poorer conditions more prevalent in Idlib, disruptions to infrastructure under Turkish
Aleppo, Rural Damascus governorates, Ar- control that supplies water to northeast Syria,
Raqqa city and in camps in the northeast and have also decreased water availability and is
northwest (Al-Araby 20/11/2020, Human Rights further increasing the barriers to practice
Watch 15/10/2020). These needs show COVID-19 preventive measures. Gap analysis
seasonal variation and are currently at their indicates that across 27 sub-districts, 1.3
highest in winter conditions, when millions million people lack some form of WASH
face harsher conditions. services (OCHA 21/10/2020). Syria continues to
suffer from an unreliable electricity network,
COVID-19 added more pressure on a fragile
under 10%of power infrastructure fully
health care system, already deeply affected by
functioning (World Bank 06/02/2019) and
almost a decade of conflict. Before the
overall low access to the internet (about 47%
pandemic, the World Bank estimated that
as of January 2020) (DataReportal 18/02/2020).
“more people may have been killed in Syria due
to a breakdown of the health system than due Forty-three percent of the education
to direct fatalities from the fighting” (World infrastructure was estimated to be non-
Bank 10/07/2017). The deliberate targeting of functional in Syria by 2017, with secondary and
hospitals and medical workers in opposition- vocational schools among the most targeted,
held areas has contributed to more than 70% with more than 14% of the buildings fully
of the healthcare workforce leaving the damaged (World Bank 10/07/2017) (also see
country, leaving Syria vulnerable to this health Education). In the northwest, a high number of
crisis (OCHA & WHO 07/10/2020, OCHA secondary and primary schools are reported to
06/03/2020). As a result, there are few be still unavailable in January 2021 (76% and
specialists left to handle COVID-19 patients 86% of sites) (OCHA 26/01/2021). The number
(pulmonology, intensive care, infectious of teachers in the formal education system is
diseases, infection prevention and control, less than half the pre-war level (World Bank
etc.) (Migration and Health 03/07/2020) (see 06/02/2019). Given all of these challenges, the
Health). education system was unprepared to shift to
online learning,
Similarly, the poor coverage and quality of
WASH infrastructure has been driving up WASH
needs even before the pandemic. Before the
war, while most urban areas had adequate
sewage systems, only some of these were
Better Data Better Decisions Better Outcomes20 // 57
A. DISPLACEMENT While the security situation remains by far the
main push factor for displacement among IDPs
Reduced movements in 2020 who were displaced for the first time (about
half of the IDPs in 2020). For those displaced
Since February 2020, the population has been
four or more times, the main reason (34%) for
experiencing different lockdown and other
the latest displacement is related to the
COVID-19 related movement restrictions,
economic deterioration that COVID-19
which could partially explain the decrease in
exacerbated, as compared to only 15% of those
displacement flows and conflict intensity.
displaced three or fewer times. The
Between January and October, 97% of
deterioration of the economy is the dominant
estimated displacement was reported to be
push factor for latest displacement for IDPs
within-governorates, notably in Aleppo and
households in Tartous (96%) and Latakia (77%)
Idlib governorates (IDP Task Force 12/2020),
governorates, whereas it is less commonly
likely due to a combination of conflict
quoted amongst displaced persons in Deir-ez-
dynamics and ability to return increasing more
Zor (37%), Ar-Raqqa (35%), Al-Hassakeh (22%),
national movements particularly following the
and As-Sweida (20%) governorates (HNAP
offensives in early 2020, while at the same
16/12/2020).
time COVID-19 restrictions increasing the
barriers for international movements: 13 of the
29 land border crossings have been fully closed
since July 2020. The impact of these closures
on cross-border movements has been
significant: about 900 people left Syria
between March and August 2020, compared to
almost 6,800 during the same period in 2019
(WFP & IOM 09/11/2020).
There were 167 battle4 events recorded by
ACLED in November 2020 compared to close
to 383 in February. Similarly, there was a very
significant drop in explosions and remote
violence incidents recorded, by 60% between
February and March 2020, from a peak of 951
incidents to 370 (ACLED). However, since
summer 2020, both types of violence (battles
and explosions) have restarted a slow upward
trend, with 254 battles recorded in December,
close to January 2020 levels, and 460
explosions and remote violence incidents
since December (ACLED).
4 Defined by ACLED as violent interaction between two politically organized armed groups at a particular time and locations: https://acleddata.
com/2019/03/14/acled-introduces-new-event-types-and-sub-event-types/
Better Data Better Decisions Better Outcomes21 // 57
B. COVID-19 RELATED HUMANITARIAN Increased use of negative coping
CONSEQUENCES mechanisms
As the economic downturn has been impeding
Inflation and inability to meet basic needs households’ ability to meet their basic needs,
The pandemic, and its related government negative coping mechanisms are increasing.
preventive measures, added to the already While reduced Coping Strategy Index (rCSI)5
worsening economic situation has resulted in scores were on an upward trend before the
widespread inflation across all commodities COVID-19 crisis, they significantly increased in
since March 2020. The Central Bureau of 2020. The national average rCSI reached its
Statistics reported an average inflation rate of highest national average in 2020 in December
200% in 2020 with goods inflation reaching (18.5), with around 85% of the interviewed
300% (WFP 19/01/2021). A recent assessment households reportedly resorting to at least one
by Kassioun, a Syrian newspaper, estimated consumption-based coping strategy to cover
that the average Syrian family’s cost of living their essential food needs. This was more
has increased by 74% since the beginning of common amongst displaced populations, as
2020. To have a comfortable standard of living, well as female-headed households (92%) which
a Syrian family would need 700,000 SYP (USD could be explained by women being
304) per month, while currently, the average overrepresented in sectors most affected by
public sector salary is around 55,000 SYP COVID-19 such as the informal, services, and
(USD24), leaving most families unable to meet hospitality sectors and having less
their basic needs (Kassioun 05/11/2020, employment opportunities (ILOSTAT
Atlantic Council 01/12/2020). Almost all KIs in 21/6/2020; UNCTAD 14/04/2020; World
the northwest reported that their communities Economic Forum 16/12/2019; Livelihoods). The
had insufficient income, a rate slightly lower in highest rCSI average over the last six months
northeast although still very high (88%) in was reported in Al-Hasakeh (22.1), followed by
December (REACH Initiative 28/01/2021, REACH Deir-ez-zor (21.2) (northeast) and Dar’a (20.5)
Initiative 28/01/2021). Similar rates were (GoS-held areas). After months of increased
already reported in November. As a result, food prices and income losses, most people
many households are forced to prioritize their seem to have exhausted their capacities to
spending among food, heating, health or cope, with more than 80% of interviewed
abiding by COVID-19 mitigation measures. households reported having already depleted
Across Syria, 76.5% of protection partners their savings in November or December. rCSI
reported that an inability or difficulty to buy scores peaked in Al-Hasakeh in December and
basic necessities is the main impact of the remained higher than the average in Deir-ez-
COVID-19 crisis on people, 70% reporting Zor, Dara’a, As-Sweida and Rural Damascus
inability or difficulty to pay rent, 62% report (WFP 31/12/2020, WFP 30/11/2020).
loss of employment or livelihoods and 42%
report inability or difficulty to pay utilities
(Protection Cluster 01/02/2021).
5 The rCSI is an experience-based indicator measuring the behaviour of households over the past seven days when they did not have enough
food or money to purchase food. The reduced CSI uses a standard set of five individual coping behaviors that can be employed by any
household, anywhere. The maximal rCSI is 56 (WFP).
Better Data Better Decisions Better Outcomes22 // 57
In the northwest, assessed communities Among IDPs, coping mechanisms such as
reported that people borrow money to cope borrowing money or buying on credit were also
with the lack of income (72%)The highest been widely reported, as well as child labor
ranked food coping mechanism in the (HNAP 16/12/2020). In the northeast, across the
northeast was skipping meals (64%). In both informal settlements in four governorates
northwest and northeast the second most (Al-Hasakeh and Ar-Raqqa, Deir-ez-Zor, and
used food coping strategy was buying food Menbij), purchasing food on credit was one of
with money usually used for other things (64% the most used strategies (more than 60%),
and 63%), followed by borrowing money to buy followed by eating smaller meals which was
food (62%) and relying on less preferred food reported across the settlements (between
and or lower food quality (53%) (REACH 55% and 78%) (REACH Initiative 18/01/2021,
Initiative NWS 28/01/2021, REACH Initiative NES REACH Initiative 18/01/2021). In Al-Hol camp,
28/01/2021). In GoS-held areas, more than spending savings, selling assets and early
two-thirds of the population reported buying marriage were also mentioned in October
food on credit, with the highest share recorded (REACH Initiative 26/12/2020).
in As-Sweida (81%) in November (WFP Reports also highlighted that community
30/11/2020). Other most commonly reported support systems are weakening in the
food-coping strategies were buying smaller northwest, with a reduction in willingness to
quantities of goods, restricting adult support neighbours due to the risk of COVID-19
consumption to feed children, cutting meat infection, leaving elderly and vulnerable
from their diets, consuming low-quality food households even less able to cope (Protection
and selling non-productive assets (NES Cash Cluster 27/11/2020).
Working Group 20/01/2021). More extreme
coping strategies have also been reported
anecdotally, with a rising number of IDPs
engaging in dangerous labour, such as
collecting garbage in the northwest, increasing
their risk to catch the virus from medical waste
(Syria Direct 27/01/2021). Similarly, while most
of these coping strategies were used before
the COVID-19 crisis, the rates, frequency and
increased combination of multiple coping
mechanisms increased significantly in 2020.
In GoS-held areas, due to lack of employment
opportunities, households report mostly
relying on remittances (Mercy Corps
25/01/2021). Both in northwest and northeast,
IDP are the ones reporting mostly relying on
loans and remittances (51% and 35%)
compared to residents. In addition, in the
northwest, a third of IDPs report relying on
humanitarian assistance compared to 10% in
the northeast (REACH Initiative NWS
28/01/2021, REACH Initiative NES 28/01/2021).
Better Data Better Decisions Better Outcomes23 // 57
I. Health: Overwhelmed healthcare Facilities do not have the capacity to isolate
system and treat COVID-19 patients
“ [We are] completely helpless in the face of In November-December 2020, cases exceeded
the unprecedented magnitude of the disaster” most health centers’ capacity. In GoS-held
areas, bed occupancy rates of 100% were
Health Directorate Director in Homs (Enab reported in As-Sweida, Homs, and Dara’a
Baladi 26/11/2020). governorates and up to 80% in Idlib
The low availability of health equipment, governorate (OCHA & WHO 16/12/2020, Syria TV
personnel, functioning health facilities, and 20/12/2020, Enab Baladi 02/12/2020, Enab
testing capacity is further overstretching an Baladi 26/11/2020). Some health facilities had
already weak healthcare system. Coupled with to suspend surgeries as all health personnel
both greater challenges in accessing are mobilized to attend to COVID-19 patients
healthcare and reluctance to seek treatment, (Tishreen news 03/12/2020, Enab Baladi
this is leaving many without care. Major 13/11/2020). Health facilities in some areas are
hospitals have already exceeded their capacity turning away patients (Albaath Media
and are not able to cope with the influx of 03/12/2020). Overcrowding in health facilities
patients. As a result of limited supplies, sick has been reported as a barrier to healthcare
patients are being turned away when the access in close to half of the communities in
necessary resources are unavailable. the northwest and about a quarter in the
northeast (REACH Initiative Northwest
Overstretched healthcare system without the 21/12/2020, REACH Initiative Northeast
equipment it needs 21/12/2020). The loss of beds hin Dara’a is now
similar to2011, with only 15% remaining
The scarcity of functioning health centers, ICU undamaged in 2019 (Enab Baladi 02/01/2021),
beds, ventilators, medicine, and staff has and where all 250 beds in isolation centres
hampered the health response to the have been fully occupied over the past few
epidemic. Since 1 December 2019, over 80 weeks (SAMA TV 02/01/2021). In northeast Syria
health facilities have temporarily or and GoS-controlled areas, almost no sub-
permanently suspended services in northwest districts have quarantine and isolation spaces
Syria due to the armed conflict and out of 577 to monitor COVID-19 cases (HNAP 27/01/2021,
assessed facilities, 62% are fully functional HNAP 27/01/2021), and lack of such services
(WHO & Health Cluster 20/11/2020) with only 9 has also been reported in northwest Syria, with
dedicated COVID-19 hospitals, 212 ICU beds two-thirds of sub-districts also missing such
and 162 ventilators for a population of 4 million spaces (HNAP 27/01/2021). In GoS-controlled
(International Rescue Committee 27/01/2021). areas, most governorates have reportedly
An increasing number of reports highlight the insufficient spaces for COVID 19 cases in health
lack of availability of adequate equipment at facilities (HNAP 27/01/2021).
medical facilities such as swabs, test kits,
PPEs and oxygen tanks. PPEs availability
continued to be reported as insufficient across
the country (OCHA & WHO 23/12/2020).
Better Data Better Decisions Better Outcomes24 // 57
Figure 5. Number of hospital beds (including ICU) / 10,000 population in public hospitals,
December 2019 (WHO HeRAMS 2019)
20
18
15
15 14
13 13
Inter-Agency Standing Committee(IASC) Standards: 10 Hospital beds
10
7
6
5
5 4 4
3 3 3 3
0
Damascus
As-Sweida
Lattakia
Quneitra
Tartous
Hama
Rural Damascus
Al-Hasakeh
Aleppo
Homs
Deir-ez-Zor
Dar’a
Ar-Raqqa
Grand Total
Not enough qualified medical staff available healthcare for 14% of assessed communities in
A shortage of qualified medical staff continues the northwest (REACH Initiative 28/01/2021)
to be reported hampering the medical and 10% in the northeast (REACH Initiative
response to COVID-19 (Enab Baladi 28/01/2021), and has remained mostly
02/01/2021). In Salhad city, all departments consistent since October (REACH Initiative
were closed due to lack of medical staff in 28/01/2021).
December according to a hospital director (Al
Watan online 02/12/2020). In Dara’a
governorate, most doctors have been
displaced or dismissed by the local authorities
as they had been accused of working with the
opposition (Middle East Eye 10/12/2020) and
there are reports of detention of health care
workers by the Government of Syria who
accuse them of diagnosing patients’ without
liaising with the Ministry of Health (Daraa
Martyrs 16/12/2020). In the northeast, the need
for more staff and training has been made
evident by the deaths of 55 of the 58 intubated
patients who received invasive ventilation
(WHO & OCHA 12/01/2021). The shortage of
health workers was a barrier to access
Better Data Better Decisions Better Outcomes25 // 57
Figure 6. Number of health staff (doctors, nurses, and midwives) per 10,000 population in
public health centers, December 2019 (WHO HeRAMS 2019)
40
3.7 1.8
35
Health Staff /10,000 Population
25.1 30.1
3.6
30
20.9
25
Inter-Agency Standing Committee (IASC) Standards: health staff > 22
20
2.4
15 13.4 2.0
1.7
10 10.7 7.0 1.6 1.0
10.4 9.1 0.8 0.9 0.3 5.3
5.7 0.4
5 5.5 5.2 3.9 4.5
0.5
4.3 1.9 2.7 1.0 0.6 0.2
3.0 3.9 1.3 0.7 1.5 0.4 2.2 1.1 1.0 0.2 0.8 2.0
0
Deir-ez-Zor
Al-Hasakeh
Grand Total
As-Sweida
Damascus
Ar-Raqqa
Lattakia
Tartous
Aleppo
Homs
Hama
Dar'a
Idleb
Rural
Damascus
Quneitra
Doctors Nurses Midwives
High rates of infection among healthcare steady increase in affected healthcare workers
workers further disrupt a fragile healthcare across the country since July further disrupts
system the fragile healthcare system which is already
The toll on health workers continues, with 100 dealing with insufficient numbers of qualified
doctors in GoS-controlled areas reportedly healthcare personnel and preventive kits.
having died due to COVID-19 (Sham FM Taking precautionary measures remains
09/01/2021), and with 20 doctors having passed difficult even for healthcare workers due to an
away in the northwest (Syria Direct 14/01/2021). overall shortage of PPE as well as prohibitive
As of 1 February 2021, 459 cases, of which 28 costs (see c. Preventative measures).
deaths, have been reported officially among Precautionary measures in hospitals are still
healthcare workers in GoS-controlled areas, not yet fully adhered to in Dara’a governorate,
almost double since mid January (WHO & OCHA with reports of medical staff not wearing face
01/02/2021). As of 26 January, 1,513 cases have masks and lack of sterilisation of common
been reported among the health care workers areas undermining the healthcare response to
in the northwest, representing 7.4% of all the pandemic (Enab Baladi 02/01/2021).
cases, a slight decrease compared to
December, due to strengthened infection
prevention control training and equipment
(WHO & OCHA 26/01/2021). In the northeast, 774
cases among healthcare workers have been
reported as of 31 January, of which 37 had
been reported in the last month (NES COVID-19
Dashboard 31/1/2021). While this high ratio can
be explained by the targeting of tests for
healthcare workers, the effect on the
healthcare system remains devastating. The
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