Socio-demographic characteristics
The socio-demographic characteristics of survey participants are presented in this section and in Table 1.
A total of 1,919 participants responded to the survey: 1,111 in Northwest Syria (NWS) and 808 in Northeast Syria (NES). The mean age of participants across the two settings was 38 years, and they were predominantly men (74.6%). Across the two regions, the plurality (26.3%) of participants (i.e., heads of household) had attained a high school (or equivalent) level of education; and the majority were married (1607, 83.7%). Of the total sample of first respondents, 1,208, (62.9%) participants were employed, with the first source of income coming from self-employment (38%), followed by a job salary (28.3%). Most respondents (60.9%) reported having an annual income of between 500 USD and 2500 USD.
Across the two regions, 1,153 (60.1%) of participants identified themselves as members of host communities, while the remaining 766 (39.9%) identified themselves as Internally Displaced Populations (IDPs); however, in NWS, the majority of respondents identified themselves as IDPs (56.3%). Additionally, in NWS, 18.5% of our respondents reported living in camps or tents, a residence type that is almost non-existent in NES. Across the two settings, participants’ households had an average crowding index of 3.6 persons per room (SD=3.3).
The mean age of the second household member requiring healthcare support in the 6 months preceding the survey was 18 years, with 54% of them being women.
Health needs and service utilization
Health needs and service utilization patters among NES and NWS residents are presented in Table 2, including for the respondent and the second household (HH) member who had a recent health need.
About 90% of the respondents (i.e., first HH members) and 72% of the second HH members across the two regions reported needing healthcare in the last six months, with the most common healthcare need being an infectious disease (34.9% among the respondents), followed by a chronic non-communicable disease (27.3%). Almost all first and second HH members (>98%) confirmed that they sought health services when needed.
About 33% of respondents reported that they went to a private clinic as their first source of healthcare, followed by about 32% going to an NGO-run PHC centre or a dispensary. As for the second HH member, 41.3% reported going to an NGO-run PHC centre, and 25.7% to private clinics. It is worth noting that the second HH members had a different distribution of needs as shown in table 2 below (higher percentage of infections and lower percentage of chronic NCDs), and a lower mean age of 18 years – as reported in the previous section.
About a third of households had a birth in the last year with most women in both settings having a vaginal delivery (64.7%), mainly in public hospitals (56.2%). However, while most women in NWS chose public hospitals for delivery (about 82%) followed by private hospitals (10%), higher percentages of women in NES attended private hospitals for delivery (26.4%) or had a home delivery with a traditional birth attendant (28.1%). The p-value for this geographical difference was <0.001, showing statistical significance.
In both settings, the primary reason for selecting a specific health provider (e.g. NGO-run PHC centre or a private clinic) is the relevance and appropriateness of the provider for the health need (58.4%), followed by the affordability of care costs (9.5%), and the rapidity of obtaining an appointment (8%). The second main reason for selecting a provider included a recommendation by the social network of respondents (27.1%), followed by affordability of care costs (18.4%) and drugs (16%). Across all responses, affordability of care costs was reported as a driving reason behind selecting a provider, by almost half of our sample. The detailed findings are presented in appendix 2.
We also investigated the three overall main sources of healthcare for the whole household, and findings are presented in appendix 3. PHC centres are the primary source of healthcare in Northern Syria(66.1%), followed by public hospitals (58.3%), and then private pharmacies (38.9%). Other sources include, in order, private specialists (37%), private hospitals (13%) and other doctors such as gynaecologist, paediatrician and private GP.
Availability of providers in Northern Syria
We also present the results for the availability of providers and the distance to reach them (appendix 4). NWS respondents reported being closer to PHC centres (64.7% needing less than 10-min drive), compared to NES respondents, where only 22.2% reported a PHC centre being within the same distance. Private pharmacies were also reported to be within 10-min drive distance by most NWS respondents (73.4%), while NES respondents reported that private pharmacies are either within 10-min or 10-30 min-drive distance (42.6% for each answer).
Private GPs were reported to be within 10-30 min drive distance by the highest proportion of respondents in both settings (54.2% overall). The same trend was also reported for other private doctors (e.g., paediatricians, gynaecologists) and specialists. Overall, public hospitals were reported to be close to communities in both settings: 74% and 70% being within 30-minute drive distance in NWS and NES respectively. Private hospitals were reported to be closer in NES: 70% being within 30-minute drive distance compared to 47% in NWS.
Affordability of providers in Northern Syria
Table 3 presents the results of the level of household affordability of services across different providers, from not at all affordable to always affordable (or indicating that services are available for free).
For private clinics, 29.8% of NWS respondents consider them mostly or always affordable, compared to 48% of NES respondents. About 71% of respondents from both settings reported that consultations from private pharmacies are provided for free, but drugs purchased from private pharmacies are reported to be mostly or always affordable by 52% of NWS respondents and 58% of NES respondents. Private hospitals are reported as unaffordable by about 75% of respondents in NWS and 56% of NES respondents, while services in public hospitals are reported as provided for free by most respondents. PHC services were reported to be free of charge by almost all participants in both areas.
Community preferences in health providers for selected common health conditions
To further assess the perceptions of respondents regarding the best available source of care across sectors for selected common conditions, we asked them to provide a recommendation for the best provider for selected clinical scenarios.
In both NWS and NES, about 34% of respondents would recommend a PHC centre for a child with fever or diarrhoea followed by public hospitals and private pharmacists, and about 62% would recommend a PHC centre for child immunization (followed by dispensaries). As for a child injury, most respondents in NWS (73%) would recommend public hospitals, whereas only 36.6% of NES respondents would recommend a public hospital. For antenatal care, majority of NWS respondents would consider PHC as the best provider (46.9%), while most NES respondents would select private doctors (47.5%). With regards to family planning, both NES and NWS respondents would recommend PHC centres as the best health providers (50.2%).
Regarding seeking recommendations on healthy behaviours related to chronic diseases (diet counselling; smoking cessation), participants from NWS considered PHC centres to be the best health provider for these services (36.3%), while NES respondents considered private doctors as their first choice (34.9%). For surgeries, such as cardiac and cardiac catheterization, NWS participants would recommend the public hospital based on the quality of services, while NES would recommend private hospitals. For orthopaedic surgery, both NWS and NES respondents considered the hospital as being the best provider, with predominantly private hospitals in NES. The detailed results are presented in appendix 5.
Trust in the private sector
The results for trust in the private sector can be found in Table 4. About 57% of respondents across NWS and NES either agreed or strongly agreed that communication with the provider is better in the private sector compared to other facilities, with 19% being neutral about the statement. Yet only 52% of the sample agreed that private health providers do not deceive or mislead patients, and about 24% expressed a neutral opinion. In NWS, participants were more in disagreement or neutral about private health providers being more qualified and competent than in the public or NGO sector (74%) – compared to 60% in NES.
Participants from both settings agreed that the quality of health services in the private sector (including doctors’ clinics and hospitals) is better than in public or NGO-supported facilities. About 60% of respondents in our study agreed that the private health care system in Northern Syria can be trusted (as an overall statement) with higher percentage in NWS (68%) compared to NES (47%) (p-value <0.001). However, most participants across both settings agreed that private providers are still mainly interested in self-gain and vulnerable people might not be treated as fairly as other people in the private sector.
Factors affecting the first source of healthcare: a bivariate analysis
We present below the results of the bivariate analysis of socio-demographic and other characteristics of respondents affecting the main study outcome which is the first source of healthcare for the recent health need (Tables 5a and 5b).
With regards to the socio-demographic characteristics of community members living in Northern Syria and their association with the first source of healthcare, the analysis showed that women are more likely to use private clinics (40%) compared to men (30.1%), and a higher proportion of men reported to use NGO-run PHC centres (33%) compared to women (28.7%), as well as private hospitals (5.2% vs 2.9%).
In terms of education level, people who attained middle institute (42.1%) are more likely to use NGO-run PHC centres, while respondents with a university degree (44.8%) are more likely to use private clinics. Public hospitals represent the first source of healthcare for people with a primary school education (31.4%). Unemployed respondents (but seeking a job) are less likely to resort to private clinics (24.9%) and private hospitals (0.4%) compared to employed participants (34.1% and 5.7% respectively). Following the same trend, respondents who receive cash/in-kind assistance considered NGO-run PHC centres (42.7%) and public hospitals (37.3%) as their first source of healthcare, while people with a salaried job reported higher use of private clinics (38.4%) compared to the overall sample. Having an annual salary higher than 2500 USD is associated with higher use of private clinics (53.3%) and private hospitals (16.7%), with a clear trend in the association between income and use of private services.
Regarding the use of healthcare in different governorates, statistical differences were identified. For instance, participants from Alhasakah reported using more NGO-run PHC centres (42.7%) than the sample average for this source of healthcare. In general, participants from NES stated that they use more private clinics (37.3%) compared to other services, while in NWS they would use more NGO-run PHC centres (30.8%); private pharmacies are the least utilised in Alhasakah governorate (1.3%). In comparison with host communities, IDP community members are more likely to seek healthcare from NGO-run PHC centres (33.6%) and public hospitals (both 29.5%), with lower use of private services. In line with these findings, homeowners reported seeking healthcare more at private clinics (36.7%), while people who are renting their home or live in a tent would go more to NGO-run PHC centres or public hospitals. The lowest crowding index is associated with higher use of private pharmacies (2.88%) and private clinics (2.96%).
In terms of health needs, for infectious diseases, participants would seek care predominantly at NGO-run PHC centre (52.5%), and at private clinics for antenatal care (40.6%) and gynaecological consultations (47.9%). For injuries, orthopaedic and other surgical consultations, public hospitals (53.0%) are utilised more than other services, and private clinics (11.3%) are the most used among other health needs. The number of visits is not associated with the sources of healthcare. With regards to the reasons for provider selection, affordability of transportation (55.3%), care costs (38.2%) and drugs (48.3%) were associated with seeking care at NGO-run PHC centres. The same is true for public hospitals. On the other side, the main reasons for choosing private clinics included being the right providers (44.8%). Additionally, the proximity of private GPs and other specialists within 10-minute drive and between 10-30-minute drive is associated with respondents considering private clinics as their first source of healthcare. The affordability of private providers and drugs in private pharmacies is also associated with both the use of private clinics (mean 3.63, SD 0.98) and private hospitals (mean 4.39, SD 0.92). Finally, trust in the private sector followed the same direction in the association with the outcome: higher trust is associated with higher use of private services (Table 5b).