Health system governance assessment in protracted crisis settings: Northwest Syria.

BACKGROUND: Since the withdrawal of government forces from Northwest Syria due to the conflict, several national initiatives have aimed to create alternative governance approaches to replace the central governmental system. One of the recent initiatives was the formulation of so-called 'Central Bodies' as institutional governance structures responsible for thematic planning and service provision; for example, the referral unit is responsible for planning and delivering medical referral services. However, the governance and administrative rules of procedures of these bodies could be immature or unsystematic. Assessing the governance of this approach cannot be condoned, especially with the urgent need for a methodical approach to strategic planning, achieving strategic humanitarian objectives, and efficiently utilizing available resources. Multiple governance assessment frameworks have been developed. However, none were created to be applied in protracted humanitarian settings. This research aims to assess the extent to which the existing health governance structure (central bodies) was capable of performing the governance functions in the absence of a legitimate government in Northwest Syria. METHODS AND MATERIALS: A governance assessment framework was adopted after an extensive literature review and group discussions. Four principles for the governance assessment framework were identified; legitimacy, accountability and transparency, effectiveness and efficiency, and strategic vision. Focus Group Discussions were held to assess the levels of the selected principles on the governance thermometer scale. Qualitative and quantitative data were analyzed using NVivo 12 and SPSS 22 software programs, respectively. RESULTS: The level of the four principles on the governance thermometer scale was between the lowest and middle quintiles; 'very poor or inactive' and 'fair and requires improvement', respectively. The results indicate that the governance approach of Central Bodies in NWS is underdeveloped and summons comprehensive systematic development. The poor internal mechanisms, poor planning and coordination, and the absence of strategic vision were among the most frequent challenges to developing the approach. CONCLUSION: Humanitarian actors and donors should pay more attention to health governance approaches and tools in protracted crises. The central bodies must improve coordination with the stakeholders and, most importantly, strategic planning. Establishing or utilizing an independent planning committee, with financial and administrative independence, is crucial to maintain and improving contextual governance mechanisms in Northwest Syria.

Medical education system (re)building in a fragile setting: Northwest Syria as a case study.

BACKGROUND: Syria has witnessed more than a decade of armed conflict through which healthcare workers and facilities have not only been affected, but targeted. Amidst this targeting of healthcare workers, subsequent displacement, and 'weaponization' of healthcare, the medical education and health professional training (MEHPT) of those that remain has split into at least two distinctive contexts: government controlled, and non-government controlled. Efforts to rebuild MEHPT in light of this polarisation and fragmentation have led to a new MEHPT system in non-government controlled northwest Syria, that functions through what we describe as a 'hybrid kinetic model'. This mixed-methods study provides an in-depth analysis of this MEHPT system as a case study to inform future policy planning and interventions in the context of future post-conflict health workforce development. METHODS: We used mixed methods to investigate the state of MEHPT in northwest Syria during September 2021 and May 2022. This included a) Stakeholder analysis, b) 15 preparatory experts consultations c) 8 Focus group discussions d) 13 Semi-structured interviews e) 2 Questionnaires and f) Validation workshops. RESULTS: We identified three main categories of key stakeholders working on MEHPT in northwest Syria: 12 newly established academic institutions, 7 local governance authorities involved in MEHPT, and 12 non-governmental organisations (NGOs). The MEHPT system operated through these stakeholders in a three-layer system to provide undergraduate and postgraduate MEHPT. In the first, top, layer, external NGOs and donors hold the strongest capacity at the expense of relatively under resourced internal governance in the second, middle, level. In the third, bottom, level, local academic bodies operate. We uncovered several levels of challenges facing these stakeholders including governance challenges, institutional challenges, individual challenges, and political challenges. Despite these challenges, participants in our study highlighted significant opportunities within the MEHPT system and that MEHPT can be a peace building pillar for the community. DISCUSSION: To our knowledge, this is the first paper that provides an in-depth situational analysis of the MEHPT system in a conflict setting while engaging the voice of local key stakeholders. We found that local actors in MEHPT in non-government controlled northwest Syria have made efforts towards (re)building a new, hybrid and kinetic MEHPT system, through a bottom-up approach. Despite these efforts, the MEHPT system remains fragile and polarised, suffering from several levels of challenges with limited involvement of internal governance. Building on our findings, to improve this approach and build bridges of trust among stakeholders and the MEHPT community, further studies are needed to determine feasible approaches to increasing the role of internal governance structures in the MEHPT system through: 1-Formalisation of efforts through establishing a MEPHT technical coordination unit. 2-Further shifting of power from external supporting NGOs and funders to internal governance structures. 3- Working towards achieving sustainable long-term partnerships.

COVID-19 response in northwest Syria: innovation and community engagement in a complex conflict.

Despite lacking capacity and resources, the health system in the northwest Syria is using innovative approaches for the containment of COVID-19. Lessons drawn from previous outbreaks in the region, such as the polio outbreak in 2013 and the annual seasonal influenza, have enabled the Early Warning and Response Network, a surveillance system to develop mechanisms of predicting risk and strengthening surveillance for the new pandemic. Social media tools such as WhatsApp are effectively collecting health information and communicating health messaging about COVID-19. Community engagement has also been scaled up, mobilizing local resources and encouraging thousands of volunteers to join the 'Volunteers against Corona' campaign. Bottom-up local governance technical entities, such as Idleb Health Directorate and the White Helmets, have played key leadership role in the response. These efforts need to be scaled up to prevent the transmission of COVID-19 in a region chronically affected by a complex armed conflict.

Coronavirus 2019 and health systems affected by protracted conflict: The case of Syria.

INTRODUCTION: Two thirds of countries globally are unprepared to respond to a health emergency as per the International Health Regulations (2005), with conflict-affected countries like Syria being particularly vulnerable. Political influences on outbreak preparedness, response and reporting may also adversely affect control of SARS-CoV-2 in Syria. Syria reported its first case on 22 March 2020; however, concerns were raised that this was delayed and that underreporting continues. DISCUSSION: Syria's conflict has displaced more than half of its pre-war population, leaving 6.7 million people internally displaced. The consequent overcrowding - with insufficient water, sanitation and healthcare (including laboratory capacity) - could lead to conditions that are ideal for spread of SARS-CoV-2 in Syria. Political changes have led to the formation of at least three health systems within Syria's borders, each with its own governance, capacity and planning. This fragmentation, with little interaction between them, could lead to poor resource allocation and adversely affect control. As such, COVID-19 could overwhelm the health systems (particularly intensive care capacity), leading to high deaths across the population, particularly for the most vulnerable such as detainees. CONCLUSIONS: Locally implementable interventions that rapidly build WASH and health system capacity are required across Syria to ensure early detection and management of COVID-19 cases.