Before the uprising in March 2011, Syria was one of the more advanced middle-income settings for cancer care in the Eastern Mediterranean Region. Oncology services were, however, heavily centralized in Damascus, Aleppo, and Latakia. As the conflict escalated between 2011 and 2014, and then internationalized following Russia’s military intervention in 2015, waves of attacks on health infrastructure and shifting lines of territorial control carved the system apart. By the relatively frozen phase between 2020 and 2024, three main configurations had consolidated: a northwest serving roughly five to six million people, a northeast serving around three to four million, and the former government-controlled areas containing about two-thirds of the population and every major city. The northwest and northeast lacked comprehensive cancer services almost entirely, forcing the most severe cases to be referred abroad, particularly to Türkiye, while even the major cities operated under strained conditions with outdated protocols and reliance on unbranded medicines from Iran and India that had not undergone quality control.

The scale of need is substantial and growing. According to Global Cancer Observatory data for 2022, Syria recorded an estimated 22,000 new cancer cases and nearly 14,000 deaths, though these are modelled figures rather than in-country counts, because no functioning national cancer registry existed during the conflict. The authors caution that the true burden is likely higher, given diagnostic gaps, access barriers, and patients who simply never present to care. Around 20 specialized oncology centers operate across several governorates, but the designation is misleading: few facilities offer the full range of surgical, systemic, and radiation treatment within one institution, so patients must piece together their care across multiple sites, often traveling enormous distances at considerable personal cost.

The technical shortfalls described in the article are severe. Only six linear accelerators are available countrywide for radiotherapy, four at Al-Bairuni, of which three are functioning, and two in Lattakia, one of which is out of service. Waiting times of three to six months for radiotherapy are reportedly affecting an estimated 40 percent of urgent cases. CT-PET imaging, essential for accurate diagnosis and staging, is unavailable in the public sector; it exists only in Damascus’s private clinics at prices prohibitive for most patients. There are no operational bone marrow transplantation centers in the country, chemotherapy supply chains are frequently interrupted, and pathology and molecular diagnostic capacity varies widely between facilities. These figures, drawn from ministry-level information, operational reports, and rapid service mapping, are indicative rather than definitive, but they consistently point to a system unable to deliver continuous, multimodal cancer care.

The authors’ central argument is counterintuitive in an emergency: rather than rushing to reopen facilities and expand services, Syria’s early recovery should prioritize governance, referral structure, and financial protection first. They define institutional coherence as the alignment of governance, regulatory, financing, and service delivery structures under a unified national framework, and consolidation as the strategic coordination of services while capacity is rebuilt. Experience from other post-conflict settings supports this sequencing. In Bosnia and Herzegovina, strengthening primary care governance and institutional accountability preceded tertiary expansion and helped restore system coherence. In Liberia, adopting a nationally defined essential health service package aligned implementing partners under shared priorities and reduced fragmentation. Expanding specialized services without stabilizing the institutional architecture, the authors warn, risks reinforcing systemic disorganization and inequity rather than repairing it.

Referral pathways emerge as a critical fault line in the cancer care continuum, the chain running from prevention and early detection through diagnosis, treatment, follow-up, and supportive care. In principle, primary health care should serve as the entry point, applying standardized early detection protocols and distinguishing urgent from routine referrals. In practice, Syria’s primary care system has lost its gatekeeping function. Patients bypass it and self-refer directly to overwhelmed tertiary centers, contributing to diagnostic delays. Many people instead obtain care from pharmacies, community practitioners, and informal providers outside official health system standards, a pattern driven by destroyed facilities, the killing and migration of health workers, and economic hardship.

That dysfunction has deep historical roots, and the article is unusually direct about them. The former regime used health services to reward political loyalty and punish dissent. Before 2011, Latakia and Tartus, areas loyal to the government, had one hospital bed for every 573 and 672 people respectively, compared with 2,113 per bed in Idlib and 1,379 in Al-Raqqa. Workforce data from UNHCR and the World Bank show that doctor density rose in Tartus and Damascus during the war while falling most sharply in Dera’a, Homs, Sweida, rural Damascus, Quneitra, and Deir-ez-Zor. Restoring public confidence in primary care as the gateway to oncology services, the authors argue, therefore requires confronting this inherited inequity head-on, not merely drafting new referral protocols.

Lessons from Liberia and Rwanda suggest that referrals work when they rest on practical mechanisms rather than paperwork alone. In Liberia’s early recovery, compliance improved when district hospitals designated focal persons and communication between referring clinics and receiving facilities was structured rather than informal. Rwanda strengthened referral continuity through clear lines of responsibility between health centers and district hospitals, combined with supervisory follow-up. For Syria, the authors recommend building on the tacit, unwritten knowledge that accumulated across the conflict years: designated referral focal points within oncology centers, streamlined inter-facility communication, and simple confirmation that referred patients actually arrived. Monitoring, they suggest, should start with high-yield indicators such as confirmation of arrival and time to service receipt, before expanding into integrated data platforms. Distance and transport costs compound the problem, as evidence from post-conflict West Africa and from Ukraine, where patients cross regions and borders for unavailable oncology services, both demonstrate.

Financial protection is the third pillar of the proposed strategy, and the authors treat it as a governance instrument rather than a budgetary afterthought. Given Syria’s severe fiscal constraints, universal coverage of oncology benefits is not immediately feasible. Instead, they propose defining a phased essential cancer service package centered on first-line chemotherapy regimens matched to national disease burden and expected survival benefit, in line with the Disease Control Priorities framework, which prioritizes cost-effective, high-impact interventions. Targeted protection for pediatric cancers and curative-intent multimodal care would deliver the greatest mortality reduction while preserving fiscal discipline. Centralizing procurement of essential oncology medicines would reduce stock-outs, price variability, and geographic inequity, while standardized national treatment protocols adapted to available medicines would curb unwarranted variation in prescribing. As fiscal space grows, coverage could broaden progressively.

Perhaps the article’s most important message is that in fragile systems, sequencing is not a retreat from equity but a strategy to protect it. Concentrating complex services temporarily can preserve quality and specialist capacity while the system is rebuilt, provided consolidation is explicitly transitional and paired with a phased decentralization plan as workforce, infrastructure, and financing improve in governorate hospitals. The alternative, rapid expansion on top of fragmented governance, would lock in the very disparities that the war created, leaving patients in peripheral regions traveling vast distances and paying catastrophic costs for incomplete care. Syria’s cancer patients, the authors conclude, need continuity restored across the entire care continuum before capacity can credibly grow, and that continuity depends on aligning governance, service delivery, and financing into a single, accountable national framework.

Subject of Research: Post-conflict reconstruction of cancer care services and health system governance in Syria

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

Article References: Rebuilding cancer care in post-conflict Syria: restoring continuity across the cancer care continuum. (n.d.). https://doi.org/10.3389/fcacs.2026.1843120

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1843120

Keywords: Syria, cancer care, oncology, health system fragmentation, post-conflict recovery, referral pathways, radiotherapy, health financing, cancer registry, health governance, primary health care, financial protection