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

尽管发生了七年的冲突，但尚未有关于叙利亚反对派控制区（OCAs）卫生系统适应和治理的发表研究。这在一定程度上是由于在叙利亚开展研究面临的明显挑战，也是由于卫生系统治理在卫生系统研究中是一个“被忽视的议程”，缺乏关于如何在国家和国家以下各级解释和评估它的证据。大多数卫生系统研究的重点是冲突后的重建，因为卫生系统在冲突等冲击和压力期间的适应和治理难以衡量和解释。然而，这种研究没有考虑冲突期间产生的重要基层反应，这些反应有可能被用来提高以后重建和加强工作的有效性。本研究将审查叙利亚反对派控制地区（如伊德利卜、哈马、阿勒颇、德拉）卫生主管部门正在采取的适应和治理应对措施，以总结经验教训，为该国以及可能受冲突影响的其他国家当前和未来加强卫生系统提供信息。调查结果可供叙利亚卫生主管部门、非政府卫生保健提供者以及有意支持叙利亚卫生系统的国际供资伙伴使用。我们将努力确定现在以及在叙利亚最终重建卫生系统期间可以改进治理和问责制的领域。本研究的参与性，将包括与服务使用者、卫生系统管理者和一线医疗保健提供者的访谈和讨论，支持那些直接受研究结果影响的人拥有所有权。从长期来看，研究可以促进政策变化，以改善所研究地区卫生系统的可及性、质量和物有所值。在投资于脆弱卫生系统的兴趣日益增加之际，通过对世卫组织若干基本要素（例如服务提供、治理、卫生人力）的贡献，研究可能有助于为重建叙利亚卫生系统提供证据基础。

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.