Health system adaptation and governance in conflict: a case study of Syria

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Despite seven years of conflict, published research exploring health system adaptation and governance in opposition-controlled areas (OCAs) in Syria is non-existent. This is partly due to the obvious challenges of conducting research in Syria and also due to health system governance being a 'neglected agenda' in health system research, with evidence lacking on how it is interpreted and assessed at national and sub-national levels. Most health system research has focused on rebuilding after conflict, as health system adaptation and governance during shocks and stresses such as conflict, are difficult to measure and interpret. However, such research does not consider important grassroots responses arising during conflict that could potentially be leveraged to improve the effectiveness of later rebuilding and strengthening efforts. This study will examine ongoing adaptation and governance responses among health directorates in opposition-controlled areas of Syria (e.g. Idlib, Hama, Aleppo, Daraa), to generate lessons to inform current and future health system strengthening in the country and potentially other conflict-affected countries. Findings can be used by Syrian health directorates, non-governmental healthcare providers, and international funding partners interested in supporting Syria's health system. We will seek to identify areas in which governance and accountability can be improved now and during Syria's eventual health system reconstruction. The participatory nature of this study, which will include interviews and discussion with service-users, health system managers, and frontline healthcare providers supports ownership by those immediately affected by research findings. Over the longer term, research can contribute to policy changes to improve health system access, quality, and value-for-money in the areas studied. Research can potentially contribute to the evidence base for rebuilding the Syrian health system through contributions on several WHO building blocks (e.g. services delivery, governance, health workforce) at a time when interest in investing in fragile health systems is increasing.