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This study provides a detailed overview of Syria’s health system from 2000 to 2024 by synthesizing existing literature and data. Its goal is to inform the health sector recovery plan following recent political changes in Syria, detailing the health system’s characteristics and evolution on the basis of the WHO’s conceptual framework. A scoping review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Data sources included PubMed, MEDLINE, Scopus, Google Scholar, grey literature and government reports. The analysis identified service delivery, financing, and governance as the most frequently discussed aspects of the health system. It revealed a distorted health system that retained aspects of the Semashko model whilst also incorporating elements of liberalization from the 2003 modernization program. The study underscores major challenges, including the politicization of healthcare, workforce shortages, fragmented financing, and disparities in access to healthcare services. The findings indicate that the Syrian health system has been characterized by centralized governance, inconsistent financing strategies, a fragmented health information system, and a growing dependence on the private sector. The post-conflict recovery phase offers a chance to rebuild a more equitable and resilient health system. Policymakers are urged to consider necessary reforms to the health system recovery plan in Syria.

Introduction The COVID-19 outbreak devastated the fragmented health system in Syria, a war-torn country, and exaggerated the demands for humanitarian assistance. COVID-19 vaccination was rolled out in Northwest Syria, an area out of government control, in May 2021. However, vaccine acceptance rates are still minimal, which is reflected in the meager percentage of vaccinated people. The study aims to investigate the effectiveness of the humanitarian actors’ plans to address the COVID-19 vaccine hesitancy and conclude practical strategies for boosting vaccine uptake in Northwest Syria. Methods and materials Two questionnaires were developed to collect data from humanitarian organizations involved in the COVID-19 vaccination campaign and people from northwest Syria. Data analysis was performed using SPSS 22 data analysis program. Results According to the findings, 55.5% of people refused the COVID-19 vaccine. The results showed a knowledge gap and lack of evidence regarding humanitarian actors’ strategies to address the vaccine’s low uptake. Besides, it was found that doctors and medical workers were reliable sources of information about the vaccine. However, they were not systematically engaged in community mobilization and risk communication to promote people’s perspectives on the vaccine. Conclusion Risk communication and community engagement programs were not significantly associated with increasing the COVID-19 acceptance rate. Humanitarian actors must reconsider their strategies to address vaccine hesitancy in Northwest Syria. These strategies should engage medical professionals through dialogue sessions on the realities of the pandemic and vaccine development mechanism based on a compelling and evidence-based approach.

Cholera is an ancient disease that persists as an issue of public health in many conflict-affected countries worldwide. Cholera is a diarrheal infection caused by ingested water or food contaminated with the bacterium Vibrio cholerae. On 10 September 2022, the Ministry of Health in Syria declared a cholera outbreak. Poor water and sanitation systems, disease surveillance breakdown, the collapse of the health system, and deteriorated socioeconomic conditions are potential risk factors for the outbreak's spread. Identifying the context-related factors associated with the spread of disease is a core to developing practical response mechanisms. In this study, we suggested a multisectoral approach that addresses context-specific elements contributing to the cholera outbreak spread in Syria; public health determinants, geopolitics, risk factors, and pandemic fatigue.

Background The 11 years of the devastating conflict in Syria resulted in more than 874,000 deaths, and in more than thirteen million refugees and internally displaced people (UNHCR, Syrian refugee crisis: aid, statistics and news, USA for UNHCR, Washington, 2020; Alhiraki et al. in BMJ Glob Health 7:e008624, 2022). The health system was severely affected and has become aid dependent. This study examines aid alignment over a decade of the Syrian crisis from 2011 to 2019. Methods Aid alignment involves donors using national systems and institutional structures to manage their aid to recipient governments and aligning their aid policies with development priorities and strategies defined by the partner countries (ROSA Newsletter, Moving towards increased aid alignment in the food and nutrition security sector, 2013. Available from: http://oxfamilibrary.openrepository.com/oxfam/bitstream/10546/141974/1/ ). Aid alignment was explored as part of the 2005 Paris Declaration Framework on aid effectiveness. Based on OECD’s survey on monitoring the Paris Declaration (OECD, Harmonisation, alignment, results: report on progress, challenges and opportunities, OECD, Paris, 2005; OECD, Survey on harmonisation and alignment of donor practices, OECD, 2006. Available from: https://www.oecd-ilibrary.org/development/survey-on-harmonisation-and-alignment-of-donor-practices_journal_dev-v6-sup1-en ) and based on a proposed methodology to assess aid effectiveness by Burall and Roodman (Developing a methodology for assessing aid effectiveness: an options paper, Overseas Development Institute, 2007. Available from: www.odi.org.ukhttp://www.cgdev.org ), we designed a sequential mixed methodology to address two main indicators: alignment with national strategies and local procedures, and aid delivery through local systems. The quantitative part investigated the financial alignment of aid using financial data trackers, such as creditor reporting system and the UN-OCHA financial tracking system, and the relevant humanitarian needs estimations by the humanitarian assistance response plans, humanitarian response plans, and humanitarian needs overviews. The qualitative part relied on four focus groups discussions and four key informants interviews with key policy makers, experts and practitioners involved in the humanitarian and health response in Syria, with the aim of interpreting the quantitative findings. Results While the study found an improvement in aid budget alignment with local procedures in Syria from 34% in 2012 to 86% in 2019, we found limited alignment with local strategies. Our qualitative findings pose doubts in the ability of the various data sources of humanitarian needs in Syria to reflect the actual realities, especially before 2014, due to lack of comprehensive local engagement and data systems by then. Therefore, even if the humanitarian budgets seemed to be aligned with the national procedures, the national plans did not seem to align with the actual realities, let alone the increase in the financing deficit over the years of the conflict. The reliance of humanitarian and health aid on governmental structures, as a main recipient, in Syria was much lower than other developing and fragile countries. This is mainly due to the nature of the Syrian conflict where the government is a party to the conflict. Donors were found to have invested poorly in advancing national and sub-national planning in Syria due to donors’ over reliance on the UN-led humanitarian system which struggles in armed conflict settings. As a result, we found a disconnection between field realities, national planning, and humanitarian aid. Conclusion In light of the dreadful humanitarian crisis in Syria, there has been an adverse aid alignment. Considering the chronicity of the conflict, there is an urgent need to improve aid alignment through more investment in local planning at district or governorate levels. This is especially important to navigate through conflict sensitivities while responding to local needs and initiating local developments. These approaches, combined with adopting health sector-wide approach, could contribute to the humanitarian-development-peace nexus in Syria, which in turn can contribute to a better aid alignment and aid effectiveness.

Introduction The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions. Materials and methods This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts. Results A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress. Conclusion The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

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.

Background Syria has been in continuous conflict since 2011, resulting in more than 874,000 deaths and 13.7 million internally displaced people (IDPs) and refugees. The health and humanitarian sectors have been severely affected by the protracted, complex conflict and have relied heavily on donor aid in the last decade. This study examines the extent and implications of health aid displacement in Syria during acute humanitarian health crises from 2011 to 2019. Methods We conducted a trend analysis on data related to humanitarian and health aid for Syria between 2011 and 2019 from the OECD’s Creditor Reporting System. We linked the data obtained for health aid displacement to four key dimensions of the Syrian conflict. The data were compared with other fragile states. We conducted a workshop in Turkey and key informants with experts, policy makers and aid practitioners involved in the humanitarian and health response in Syria between August and October 2021 to corroborate the quantitative data obtained by analysing aid repository data. Results The findings suggest that there was health aid displacement in Syria during key periods of crisis by a few key donors, such as the EU, Germany, Norway and Canada supporting responses to certain humanitarian crises. However, considering that the value of humanitarian aid is 50 times that of health aid, this displacement cannot be considered as critical. Also, there was insufficient evidence of health displacement across all donors. The results also showed that the value of health aid as a proportion of aggregate health and humanitarian aid is only 2% in Syria, compared to 22% for the combined average of fragile states, which further indicates the predominance of humanitarian aid over health aid in the Syrian crisis context. Conclusion This study highlights that in very complex conflict-affected contexts such as Syria, it is difficult to suggest the use of health aid displacement as an effective tool for aid-effectiveness for donors as it does not reflect domestic needs and priorities. Yet there seems to be evidence of slight displacement for individual donors. However, we can suggest that donors vastly prefer to focus their investment in the humanitarian sector rather than the health sector in conflict-affected areas. There is an urgent need to increase donors’ focus on Syria’s health development aid and adopt the humanitarian-development-peace nexus to improve aid effectiveness that aligns with the increasing health needs of local communities, including IDPs, in this protracted conflict. Key messages • Health aid displacement is not an effective tool for aid-effectiveness used by donors in Syria. • Some health aid displacement is evident for some leading donors such as the EU, Germany, Norway and Canada. • Donors prefer to fund humanitarian activities with humanitarian aid being 50 fold more than development health aid; this is largely because humanitarian projects are easier to implement with sanctions and highly dynamic borders. • There is an urgent need to adopt the humanitarian-development-peace nexus, considering the localization agenda. This approach can bridge the gap between the humanitarian and development phases, thereby increasing aid effectiveness.

The demonstrations in Syria in 2011 became an uncompromising conflict that divided the country into three main areas of control: governmental areas, northeast Syria, and Northwest Syria. A series of United Nations resolutions adopted in 2014 authorizing official cross-border humanitarian aid in opposition-held areas to allow humanitarian agencies and organizations to use routes across the border from neighborhood countries like Turkey to deliver humanitarian assistance to people in need in Syria. The resolution was extended annually until 2021 when it was adapted to involve a cross-line humanitarian response from governmental areas besides cross-border operations. The last adaptation of the cross-border resolution, whose original form was interpreted as a politicized action by Russia and China, implicates an unframed and unplanned transition from an emergency to an Early Recovery status. Without an appropriate framework for the current geopolitical complexity in Syria, Early Recovery programs are doomed to fail, resulting in further complications in the political and humanitarian scenes. Moreover, the effectiveness of the cross-line mechanism is questionable, considering the lack of accessibility and acceptability for Damascus-based humanitarian operations in areas out of government control. The article reviews studies about Early Recovery guidelines and operational frameworks of health systems recovery in post-conflict settings to derive a practical and hybrid framework for operationalizing health system recovery in Northwest Syria, considering current geopolitical and humanitarian circumstances. This article draws upon the six building blocks of the health system, the essential package of public health services, Early Recovery integration criteria, health system resilience dimensions in the literature, and public health determinants to identify context-specific health system recovery challenges and priorities. As a result, we introduce a new health system recovery framework, which is operationalized for the context of Northwest Syria.

IntroductionAid harmonisation is a key component of donor efforts to make aid more effective by improving coordination and simplifying and sharing information to avoid duplication. This study evaluates the harmonisation of health and humanitarian aid in Syria during acute humanitarian and health crises from 2011 to 2019.MethodsData on humanitarian and health aid for Syria between 2011 and 2019 was collected from the Organisation for Economic Cooperation and Development’s Creditor Reporting System to assess the harmonisation of aid. The data was linked to four key indicators of the conflict: the number of internally displaced persons; the number of people in need of humanitarian assistance; the number or frequency of internal movements (displacements) by individuals; and the decline in Syria’s population between 2011 and 2019. This was compared with data from highly fragile states and developing countries. Four focus group discussions, four key informants’ interviews and three consultations with humanitarian practitioners were also conducted.ResultsThe findings suggest that overall aid harmonisation did not occur and importantly did not correlate with increased humanitarian needs. During the first 5 years, humanitarian and health pooled funds (which endorse aid harmonisation) in Syria were nearly entirely absent, far less than those in developing countries and highly fragile states. However, from 2016 to 2019, a visible surge in humanitarian pooled funds indicated an increase in the harmonisation of donors’ efforts largely influenced by adopting the Whole of Syria approach in 2015 as a positive result of the cross-border United Nation (UN) Security Council resolution in 2014.ConclusionHarmonisation of aid within the Syrian crisis was found to have little correlation with the crisis parameters and population needs, instead aligning more with donor policies. Assessing fragmentation solely at the donor level is also insufficient. Aid effectiveness should be assessed with the inclusion of community engagement and aid beneficiary perspectives. Harmonisation mechanisms must be disentangled from international politics to improve aid effectiveness. In Syria, this study calls for finding and supporting alternative humanitarian coordination and funding mechanisms that are not dependent on the persistent limitations of the UN Security Council.