Rebuilding cancer care in post-conflict Syria: restoring continuity across the cancer care continuum

Introduction

Protracted conflicts are increasing globally causing extensive disruption to health systems. This has both immediate and long-term impacts on access to healthcare (1). Patients with complex needs may be deprioritized in resource-constrained, overstretched health systems where more acute, more visible conditions need to be priorities (2). As such, oncology care during conflict - from screening, through to diagnosis, treatment and end of life care (where needed) - may be comparatively neglected, particularly by international humanitarian organizations who often prioritize low-cost, high impact interventions which reach a wider population (3–5). However, over two billion people now live in fragile and conflict affected settings, meaning that how we address oncology care in humanitarian responses must shift. A 2025 study estimated that more than 50% of all pediatric cancer deaths globally occur in regions affected by armed conflict (6).

In pre-revolution Syria (before March 2011), there was a relatively robust framework for oncology care, positioning the country among the more advanced middle-income settings in the Eastern Mediterranean Region (7). However, the protracted conflict has had profound impacts on both the population and the health system. Over time, the conflict contributed to the emergence of fragmented subnational health systems shaped by shifting territorial control, geopolitical pressures, resource constraints, and humanitarian needs (8).

The conflict evolved through several phases. Between 2011 and 2014, Syria experienced rapid escalation of violence and changing geographical control. Between 2015 and 2019, the conflict became increasingly internationalized, particularly following Russia's military intervention in 2015. This period also coincided with large-scale attacks on healthcare infrastructure and major shifts in internal lines of control. Between 2020 and 2024, the conflict entered a relatively frozen phase, during which distinct subnational health systems became more consolidated (9). By this latter phase, the main health systems configurations had emerged: the northwest of Syria, serving approximately 5–6 million people including areas under Turkish control; the northeast of Syria, serving around 3–4 million people; and the remaining government-controlled areas, which accounted for around two-thirds of the population and all the major cities (7).

The fragmentation of Syria's health system had significant impacts on the availability of health services across the country. In particular, the historical centralization of oncology services in major cities, particularly Damascus, Aleppo and Latakia limited access across the cancer care continuum for populations living outside areas under former regime control (10). While oncology services in major cities under the control of the former regime operated under difficult conditions, the northwest and northeast regions suffered from a complete lack of these services, prompting efforts to develop basic cancer treatment centers. For northwest Syria, the most severe and complex cases were referred to neighboring countries, particularly Türkiye (10). The toppling of the Syrian regime in December 2024 has demonstrated the extent to which these subnational health systems had become disparate and, in the later stages of the conflict, increasingly isolated in their functioning with limited communication or cross-line referrals (11). For oncology services, the impacts have been profound with patients bearing the brunt of this fragmentation.

In this perspective, we argue that early oncology recovery in Syria should prioritize institutional coherence, clearly structured referral pathways, and a defined essential cancer service package in order to restore continuity across the cancer care continuum from early detection and diagnosis to referral, treatment, follow up, and supportive care before expanding specialized services. This perspective is informed by a combination of direct operational and policy engagement within the Syrian health system, including contributions from authors affiliated with the Syrian Ministry of Health and national oncology leadership, as well as expert consultation and narrative synthesis of available literature and national-level information. Understanding how fragmentation affects each stage of this continuum helps clarify key priorities for rebuilding oncology services during early recovery.

In this paper, institutional coherence refers to the alignment of governance, regulatory, financing, and service delivery structures under a unified national framework. Consolidation refers to the strategic coordination and rationalization of services and systems while an essential cancer service package refers to a defined set of prioritized, feasible, and cost-effective oncology interventions aligned with system capacity and financing constraints.

Burden of cancer in Syria and current state of services

Cancer has emerged as a major and steadily growing public health challenge in Syria, placing significant pressure on a health system still recovering from years of conflict and economic strain. The Global Cancer Observatory data on Syria from 2022, estimates almost 22,000 new cases of cancer reported and almost 14,000 deaths. However, this is modelled data that is not based on in-country reporting or statistics given the absence of a cancer registry within Syria during the conflict (11). These figures likely underestimate the true burden, given non-presentation, diagnostic gaps and access barriers, yet they clearly signal an epidemiological shift toward non-communicable diseases in a fragile setting. While a national oncology network comprising approximately 20 specialized centers operates across several governorates, service capacity remains uneven, with substantial concentration in Damascus and limited availability in peripheral regions. Importantly, the designation of “specialized” centers does not imply the provision of comprehensive, multi-modal cancer care. Services remain fragmented, with limited availability of complex oncological surgery, systemic anti-cancer therapy (SACT), and radiotherapy within single facilities, requiring patients to navigate multiple centers to complete treatment. See Figure 1.

Up-to-date peer-reviewed data on the availability of diagnostic and treatment capacity are limited. The figures presented below are based on available Ministry-level information, internal operational reports, expert consultations, and rapid service mapping and should therefore be interpreted as indicative rather than comprehensive national estimates. Nevertheless, these sources consistently point to severe shortages in cancer diagnostic and treatment services. Based on current operational reports and available national-level information, critical shortages affect advanced diagnostics and treatment modalities. Only six linear accelerators are available countrywide: four in Al-Bairuni (three functioning and one under repair,) and two in Lattakia (one working and one out of service.) According to available national information, radiotherapy waiting times of three to six months are adversely affecting an estimated 40% of urgent cases. Access to CT-PET imaging (required for diagnosis and staging) is not currently available in the public sector based on available system-level information, but is available in the private sector in Damascus (though costs are prohibitive for most,) immunotherapy and targeted therapies remain limited, and there are no operational bone marrow transplantation centers in the country. Interruptions in chemotherapy supply and variability in pathology and molecular diagnostic capacity further constrain optimal care. Even in areas formerly under regime control such as Damascus, Latakia and Aleppo, cancer care was fragile, often reliant on out-of-date treatment protocols, shortages of newer chemotherapeutic agents or immunotherapy and dependence on unbranded medicines from Iran or India (which had not undergone quality control.).

Yet, there are no systematic analyses of capacity or capability of oncology services in either the public or private sectors. These constraints reflect deeper structural fragmentation within Syria's health system, disrupting continuity across the cancer care continuum by delaying diagnosis, limiting referral coordination, constraining treatment access, and interrupting follow up care. The figures presented above are based on current operational reports, ministry-level information, expert consultations, and rapid service mapping, and should be interpreted as indicative rather than comprehensive national estimates.

Addressing fragmentation and improving access to oncology services

Restoring continuity across the cancer care continuum requires addressing the institutional fragmentation that has shaped oncology governance and service organization throughout the conflict. Given the widespread gaps in services and the current state of the health system during this early recovery phase, prioritizing institutional coherence rather than focusing only on reopening facilities or restoring isolated service components is required. Fragmentation of oncology services extends beyond referral gaps and reflects weak governance arrangements, inconsistent regulatory oversight, uneven workforce distribution, limited centralized procurement mechanisms, lacking data systems, and unclear accountability across levels of care (10). Disruption across screening and early detection, diagnostics, multi-modal care access and palliative care, combined with concentration of advanced services in Damascus and severe workforce shortages, further demonstrates the systemic nature of this fragmentation (12). In conflict-affected settings, restoring legitimacy with defining stewardship under a unified authority is central to rebuilding equitable service delivery (12). Addressing fragmentation therefore requires strategic consolidation of oncology governance under the oversight of the Syrian Ministry of Health.

From other contexts, examples of post-conflict reform suggest that expanding specialty services without stabilizing governance architecture risks reinforcing systemic disorganization and poor quality care (13). In Bosnia and Herzegovina, strengthening primary care governance and institutional accountability preceded tertiary expansion and helped restore system coherence before tertiary expansion (13). In Liberia, adoption of a nationally defined essential health service package implementing partners under shared national priorities and reduced fragmentation in service delivery (14). These reforms highlight that restoring services alone is not sufficient to consider a system functional. Continuity depends on how institutions are aligned, how referral pathways are structured, and whether there is sustained national stewardship to coordinate the system.

For oncology service reconstruction in Syria, consolidation must extend beyond identifying functional facilities. Capacity and capability mapping should capture all aspects of the care continuum from screening and diagnostics for early detection, pathology/imaging, through to a full assessment of surgical, radiotherapy and SACT including workforce distribution to inform strategic planning. Two critical vectors including time (to diagnose, and to complete treatment) and quality also need to be assessed. Governance reform should be accompanied by harmonized clinical and regulatory standards to reduce unwarranted variation across facilities. Epidemiological and audit surveillance and reporting systems are necessary to support equitable resource allocation and monitor regional disparities. Workforce planning must balance existing concentration of expertise with phased training strategies to prevent long-term geographic imbalance, while procurement governance should be centralized sufficiently to prevent parallel supply chains and inconsistent medicine allocation. Well governed regulatory, workforce, procurement, and data systems create the institutional foundation upon which referral reform and financial protection strategies can operate effectively. Fragmentation affects not only governance arrangements but also continuity of care experienced by patients across the cancer continuum.

Discussion

Within the cancer care continuum, referral systems play a critical role in linking early detection and diagnostic confirmation with timely access to treatment and specialist care. As depicted in Figure 2, strengthening referral pathways in Syria should be grounded in current system capacity and patient-level constraints, rather than focusing solely on revising protocols. Cancer care (early diagnosis) should be prioritized at the primary health care (PHC) level through standardized early detection protocols, clearly defined referral criteria distinguishing urgent from routine cases, provider training on early warning signs, and public awareness efforts that promote timely care-seeking behavior where feasible. In the absence of a functional PHC system gatekeeping role, patients often bypass these facilities and self-refer to tertiary centers, overwhelming specialized services and contributing to diagnostic delays (12), which distinguishes between current referral challenges and the proposed structured pathway.

Rebuilding referral pathways, therefore, requires first considering the actual locations where PHC services are provided and their linkage to hospital care. Many of these services are delivered in pharmacies, and, in some cases, community practices, including religious men, for some psychological diseases, outside the official standards of the Syrian health system. There are many reasons for this structure, including inequitable distribution of health services, with some governorates, such as Damascus, Tartus, and Latakia, having many more PHCs than others, such as Idlib and Al-Raqqa, according to pre-war data (13). This is a part of the inequitable structure of the health system in Syria, where the former regime used health services to reward or punish communities for political loyalty (14). For example, the average number of people per hospital bed was 573 and 672 in Latakia and Tartus (areas loyal to the former regime), compared to 2113 and 1,379 in Idlib and Al-Raqaa, respectively, before the uprising in 2011 (15). This is linked to a significant imbalance in workforce distribution with a report by the UNHCR and the World Bank suggests that the number of doctors per thousand increased in Tartous and Damascus and dropped most sharply in the governorates of Dera'a, Homs, Sweida, rural Damascus, Quneitra, and Deir-ez-Zor during the conflict (15).The significant destruction of PHCs during the war, killing and migration of healthcare professionals, and economic hardship also increased the lack of access to the official PHC structure, making health care services in pharmacies accessible and affordable for the majority of people. Therefore, restoring confidence in PHC as the entry point to oncology care requires addressing the historical unfair structure and considering practices outside the official PHCs (16). Additionally, it is necessary to ensure that referral criteria align with available downstream diagnostic and specialist capacity.

Referral systems and patient pathways in fragile and post-conflict settings rarely function solely through documentation. Evidence from health system recovery contexts shows that when adherence to formal procedures is inconsistent and public trust in institutions is affected, referral pathways require practical implementation mechanisms to translate policy into practice (17). In Liberia's early recovery period, referral compliance improved when defined focal persons were assigned at district hospitals and communication between referring clinics and receiving facilities was structured rather than left informal (18). Similarly, Rwanda's post-genocide reforms strengthened referral continuity through lines of responsibility between health centers and district hospitals, combined with supervisory follow-up rather than reliance on forms alone (19). For Syria, benefiting from tacit unwritten knowledge developed over the conflict period, streamlined communication between facilities, designated referral focal points within oncology centers, and confirmation mechanisms of referral receipt can strengthen continuity without requiring sophisticated digital systems.

Physical access constraints are equally influential. Studies from post-conflict West Africa demonstrate that distance, transport availability, and indirect costs significantly affect referral completion, particularly when advanced services are centralized (20). Evidence from conflict settings such as Ukraine also shows that war can reshape patterns of patient mobility, as individuals travel across regions or borders to access oncology services that are unavailable locally, often increasing the financial and logistical burden of care (21). Even if transport incentive programs are not feasible in Syria, better coordination of referrals and linking publicly funded oncology services to formal referral pathways can reduce unnecessary travel and financial strain on patients. Monitoring referral performance in early recovery settings has also been shown to be most effective when limited to simple, high-yield indicators rather than complex registry systems (19). Post-conflict reforms in Rwanda and Liberia began with basic tracking mechanisms, such as confirmation of arrival at referral facilities and time to service receipt, before expanding into more integrated data platforms (17). In Syria, simplified referral tracking could provide sufficient visibility to identify bottlenecks and guide incremental improvement.

Although centralization raises equity concerns, research on service consolidation in resource - constrained recovery contexts suggest that concentrating complex services during early recovery can preserve quality and specialist capacity while systems are being rebuilt (21). Such consolidation should be explicitly transitional and paired with a phased decentralization plan (where appropriate) that progressively strengthens diagnostic and treatment capacity in selected governorate hospitals as workforce availability, infrastructure reliability, and fiscal space improve. During the consolidation phase, strengthening basic system governance mechanisms will also be important, including the gradual digitalization of patient tracking systems that allow continuity of information across diagnosis, referral, treatment, and follow-up. Also, revising national oncology treatment protocols should be reviewed and revised to ensure they adhere to the national essential medicines list and essential health service package, where referral decisions and treatment pathways remain consistent with available resources and publicly financed services. In fragile systems, sequencing is not a retreat from equity but a strategy to protect it during reconstruction. However, improving referral coordination alone cannot ensure equitable access to oncology services if patients cannot afford to complete diagnostic and treatment pathways.

Defining and sequencing financial protection in oncology care

Financial protection is essential to ensuring that patients are able to complete each stage of the cancer care continuum, from diagnostic evaluation to treatment and follow up. Aligning financial protection mechanisms with governance reform and referral coordination ensures that service expansion translates into effective coverage rather than increased financial burden on patients. In fragile and conflict-affected settings, health financing reforms are most effective when aligned with governance strengthening and institutional stewardship rather than fragmented short-term interventions (15). Given Syria's severe fiscal constraints, universal coverage of oncology health benefits is not immediately feasible. During early recovery, financial protection could consider community-based initiatives, local networks, and international non-governmental organizations to help bridge gaps in access to oncology care.

Experience from post-conflict recovery demonstrates that well-defined essential health service packages enhance predictability, reduce fragmentation, and improve accountability before broader expansion. In Liberia, aligning limited resources within a structured essential health service package improved coordination and service availability under severe fiscal constraints

(20). Similarly, Rwanda's reforms demonstrate how sequencing financing mechanisms and clarifying entitlements can stabilize service delivery before scaling (22). For oncology in Syria, this supports defining an essential cancer care service package centered on first-line chemotherapy regimens aligned with national disease burden and expected survival benefit. The Disease Control Priorities framework emphasizes prioritizing cost-effective cancer interventions and high-impact treatments before expanding to more resource-intensive services (22). Targeted protection for pediatric cancers and curative-intent, multi-modal care would reduce mortality while preserving fiscal discipline.

Improving access to oncology services must be linked to patient-centered financial protection. In fragile and post-conflict health systems, referral completion is not only dictated by distance and transport barriers but also by patients’ and their families’ ability to absorb the direct and indirect costs associated with diagnosis and treatment (22). Cancer treatment often requires repeated travel, long treatment courses, and purchase of medicine or diagnostic tests that may not be consistently available within public facilities. As a result, referral pathways that appear functional from a clinical perspective may be inaccessible in practice when patients cannot afford to seek services to which they are referred. Aligning referral pathways with realistic financing arrangements is essential to ensuring that improvements in access translate into effective coverage rather than increased financial burden for patients. Fragmented procurement systems contribute to stock-outs, price variability, and geographic inequity in fragile settings (20). Centralizing procurement and strengthening forecasting of essential oncology medicines can reduce interruptions in treatment and improve price negotiation capacity. Standardized national oncology treatment protocols adapted to available medicines, medical technology and infrastructure further reduce unwarranted variation in prescribing, improve cost predictability, and support equitable allocation across facilities. Evidence from fragile health system recovery contexts underscore that institutional alignment in financing, procurement, and regulation is central to restoring continuity and accountability (12). As fiscal space expands and supply chains stabilize, coverage can be progressively broadened in a prioritized and evidence-informed manner. Phased expansion rather than pursuing immediate universalization reflects lessons from post-conflict health reforms, where gradual consolidation has proven more sustainable than rapid expansion under weak institutional capacity (20).

In this context, financial protection is not solely a budgetary decision but a governance instrument that shapes equity, predictability, and system legitimacy during recovery. Given the severe under-resourcing of Syria's health system during early recovery and the multiple competing needs for the population, approaching cancer care equitably across Syria is required (23). Rebuilding oncology services requires restoring continuity across the care continuum by addressing system fragmentation and prioritizing institutional coherence. Early recovery should prioritize mapping oncology capacity, defining an essential service package, reforming referral pathways, centralizing procurement and protocols, strengthening the workforce, and improving cancer data systems to enable equitable, integrated, and sustainable cancer care.

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Footnotes

Edited by: Zahi Abdul-Sater, Phoenicia University, Lebanon

Reviewed by: Joe El Khoury, Centre Hospitalier Public d'Hauteville, France

Yasar Ahmed, University College Dublin, Ireland