Donors urged to relax strict guidelines that allow use of aid to replace bombed medical equipment but prevent funding for makeshift underground facilities

Doctors in Syria have had to resort to crowdfunding in a desperate attempt to keep makeshift hospitals running in caves and underground, where they are protected from targeted bombing raids.

Rules governing how aid budgets are spent have blocked funding, forcing medics to seek alternative means of building and reinforcing the facilities, according to a report by the Syria Campaign, an advocacy group.

Under donor guidelines, work to maintain the subterranean hospitals, which replace overground clinics lost to the airstrikes, is deemed “development” rather than “humanitarian” expenditure.

In Idlib province, an opposition-held area in northern Syria, 30 hospitals have no fortification at all. Just three underground hospitals are running in the region, putting workers and patients alike at risk.

Physicians for Human Rights (PHR), an NGO that has tracked attacks on medical workers during the conflict, said there have been 454 strikes on medical facilities during the Syrian war, killing 814 medics. Underground and cave hospitals offer much better protection for staff.

In April 2017 alone, there were 25 attacks on health facilities, equivalent to one every 29 hours; 91% were carried out by the Syrian government or its allies, including Russia.



The Health Cluster Working Group, a body of Syrian NGOs, said in the report that fortification of basement, cave and underground field hospitals – developed by Syrian engineers and medical staff in response to the crisis – is urgently needed.

The study found that while medics have adapted operations “to fit the unique horrors of the conflict” in Syria, donors have failed to adapt their funding accordingly.

Most donors will not finance any development project in opposition-held areas of Syria. They will, however, fund the replacement of medical equipment destroyed during aerial attacks – a routine risk for overground hospitals – as that fits into funding models.



Hama’s Central Cave hospital, which lies under 17m of rock, is the pinnacle of underground clinic construction. The facility, which opened in 2015 and has three operating theatres, took a year to build.

Speaking before his death in an ambulance airstrike last year, the hospital’s founder, Dr Hasan al-Araj, said: “The thing I would ask for is that the world acts in order to protect patients, like with underground hospitals. We need protection.”

Aleppo’s M10 hospital was reinforced underground during the siege and bombardment of the city last year, when a series of attacks struck the building.



The latest underground medical project seeking crowdfunding to complete building works is the Avicenna women and children’s hospital in Idlib City, championed by Khaled al-Milaji, head of the Sustainable International Medical Relief Organisation.

Al-Milaji is working to raise money with colleagues from Brown University in the US, where he studied until extreme security vetting – the Trump administration’s “Muslim ban” – prevented him re-entering the country after a holiday in Turkey.

He has instead turned his attention to building reinforced underground levels of the hospital, sourcing private donations to meet the shortfall between donor funding and actual costs.

Over the past six years, $1.7m (£1.3m) in pooled funds, the main UN-led humanitarian funding mechanism for Syria, has been devoted to the reinforcement of underground hospitals. The French government has contributed just under $0.5m, while roughly $2.5m in private funding and grants has been provided by Syrian NGOs. The pooled funding request for health alone in 2017 is just under $500m.

Crowdfunding was an essential part of building the children’s Hope hospital, near Jarabulus in northern Syria. The project is run by doctors from eastern Aleppo, who were evacuated from the city in December after it was besieged for nearly six months amid a heavy military campaign. Doctors worked with the People’s Convoy, which transported vital medical supplies from London to southern Turkey as well as raising funds to build the hospital, which opened in April. More than 4,800 single donations raised the building costs, with enough left over to run the hospital for six months.



Attacking hospitals and limiting access to medicines and healthcare has long been a tactic of Bashar al-Assad and his military. In March, a UN convoy to Wadi Barada in rural Damascus was stripped of almost all its medical supplies and equipment. Last year, the World Health Organization said that about 20% of its medical aid was removed from UN convoys during the first eight months of the year.