Millions of innocent civilians continued to bear the brunt of the Syrian conflict. In 2018, approximately 1.5 million people were newly displaced by hostilities in many areas including eastern Ghouta, the south and north-west, northern rural Homs and eastern Deirez-Zor. Overall, more than 13 million people in Syria need humanitarian assistance, 5.2 million acutely so. At least 6.2 million people have been displaced, many of them more than once. Two thirds of Syrians are living under the poverty line.
Political instability persisted. By the end of June, the Syrian government had ended its longstanding sieges and regained control of several areas formerly controlled by non-state armed groups. Conversely, Syrian non-state armed groups and Turkish military forces took control of most of Afrin district in Aleppo governorate, resulting in the collapse of the local health system and the displacement of 167 000 people.
Changes in political control led to further waves of displacement to and within north-west Syria. Tens of thousands of internally displaced people (IDPs) from eastern Ghouta, northern rural Homs and southern Hama were forcibly evacuated to Idleb governorate. The population of Idleb has doubled since 2011 and most IDPs there have very limited access to health care and other services.
There were outbreaks of measles, leishmaniasis and acute bloody diarrhoea, fuelled by displacement, hostilities and poor living conditions. Vaccination coverage rates remained low despite mass immunization campaigns and routine vaccination activities to curb the spread of diseases such as vaccine-derived polio and measles. Shortages of safe drinking water, due in part to the deliberate targeting of water networks, left up to 35% of the population relying on alternative and often unsafe water sources.
The operating environment in Syria continued to be demanding. WHO and other humanitarian agencies faced significant challenges to delivering assistance because of heavy fighting, the widespread presence of improvised explosive devices, and delays in obtaining authorization to enter many areas. In December 2018, the United Nations Security Council reiterated its grave concern over hindrances to the delivery of humanitarian assistance. It called on all parties to allow the safe, unimpeded and sustained passage of humanitarian convoys to all parts of Syria and renewed its earlier resolution (2165) authorizing the delivery of humanitarian aid from the neighbouring countries of Iraq, Jordan and Turkey.
In 2018, WHO and the United Nations shifted from a response by geographical location to one based on a detailed assessment of the severity of needs in all 270 sub-districts in Syria3 . While this has allowed for a more targeted delivery of assistance, it cannot be used as the only measure for determining health interventions. WHO has continued to work in areas with relatively low severity of need4 in order to vaccinate children and raise vaccination coverage rates across the country. It also continues to support referral hospitals located in areas of low severity because they provide essential services to people from nearby areas still caught up in the conflict.