Background Syria has been in continuous conflict since 2011, resulting in more than 874000 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 analysed data on 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 with a panel of experts 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 unclear 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.

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.

Background: The conflict in Syria affected severely the health sector; health infrastructure was damaged, the Damascus ministry of health withdrew from opposition held areas, health workers fled the country, and there has been always a shortage of funding and medical supplies. To address these needs, Syrian NGOs, INGOs, donors, and UN Agencies have been providing health interventions through humanitarian channels. However, many of these interventions were short termed, and there was no governance framework to guide the newly introduced parallel system, leaving it subject to individual organizations’ strategies and approaches. To counter these challenges, local communities and Syrian NGOs established new platforms to govern and coordinate certain aspects of the health sector. These platforms are called “central desks”, which are perceived to be independent and neutral structures and can coordinate services between all actors. Examples of these structures are Syrian Immunization Group (SIG), Health Information System (HIS), the Infection Protection and Control initiative (IPC), and the Referral System network. Methods: The research was based on an institutional approach to governance as presented by (Abimbola et. Al, 2017) and (Baez-Carmago and Jacobs, 2011) of health governance. We have investigated the central desks across the main themes; governance inputs of these central desks, such as strategic vision and legitimacy; governance processes, such as accountability and transparency, and governance outcomes, such as effectiveness and efficiency. Further to intensive literature review, eight focus group discussion were conducted, average pf 12 participants. Key themes then were deducted and coded. The qualitative analysis was done using NVIVO 12 software. Conclusion: Central desks, that are not part of national ministries of health, are new innovative approaches that can increase the efficiency of health interventions in conflict settings. The detailed features of such desks should be context specific and locally informed and led.

Background: The conflict in Syria affected severely the health sector; health infrastructure was damaged, the Damascus ministry of health withdrew from opposition held areas, health workers fled the country, and there has been always a shortage of funding and medical supplies. To address these needs, Syrian NGOs, INGOs, donors, and UN Agencies have been providing health interventions through humanitarian channels. However, many of these interventions were short termed, and there was no governance framework to guide the newly introduced parallel system, leaving it subject to individual organizations’ strategies and approaches. To counter these challenges, local communities and Syrian NGOs established new platforms to govern and coordinate certain aspects of the health sector. These platforms are called “central desks”, which are perceived to be independent and neutral structures and can coordinate services between all actors. Examples of these structures are Syrian Immunization Group (SIG), Health Information System (HIS), the Infection Protection and Control initiative (IPC), and the Referral System network. Methods: The research was based on an institutional approach to governance as presented by (Abimbola et. Al, 2017) and (Baez-Carmago and Jacobs, 2011) of health governance. We have investigated the central desks across the main themes; governance inputs of these central desks, such as strategic vision and legitimacy; governance processes, such as accountability and transparency, and governance outcomes, such as effectiveness and efficiency. Further to intensive literature review, eight focus group discussion were conducted, average pf 12 participants. Key themes then were deducted and coded. The qualitative analysis was done using NVIVO 12 software. Conclusion: Central desks, that are not part of national ministries of health, are new innovative approaches that can increase the efficiency of health interventions in conflict settings. The detailed features of such desks should be context specific and locally informed and led.

Background: The Syrian conflict has resulted in significant displacement and increase in humanitarian needs within the last decade. Reports of increased prevalence of substance misuse and deliberate self-harm among internally-displaced Syrians are concerning, particularly given barriers to care for these conditions due to cultural stigma and legal repercussions for those reporting them. The aim of this study is to provide an overview of prevalence, risk factors and health services available for substance misuse and deliberate self-harm in Syria as well as share findings from a workshop with Syrian mental health stakeholders exploring current challenges with regards to these conditions. Methods: A scoping review was conducted using key search terms regarding substance misuse and suicide and/or self-harm inside Syria. These findings were supplemented by a discussion among 25 Syrian mental health stakeholders, including psychologists, psychiatrists, public health, and policy professionals to highlight key challenges and identify locally appropriate solutions. Results: Data regarding the prevalence of substance misuse and self-harm inside Syria among internally displaced populations varies greatly quality and accuracy. Substance misuse and deliberate self-harm, including suicide, are considered stigmatised and at times, criminalized, in Syria, leading to massive underreporting of prevalence, as well as underutilization of available treatment, which is also limited. The health system response in Syria, which has been compromised by a decade of conflict, is not prepared to cope with increasing rates of mental health disorders and particularly, substance misuse (i.e. Captagon) and instances of self-harm. Key suggestions from the workshop include the following: a) use of telepsychiatry and telepsychology interventions b) adaptation of WHO interventions c) multi-year investment and prioritisation of MHPSS programs and d) utilizing family skills interventions as a key tool in the prevention for substance abuse and self-harm, while embedding social and cultural sensitivities into interventions. Conclusions: Though current evidence gaps around substance misuse and deliberate self-harm in Syria remain, with the current socio-political climate in Syria, alongside significant shortfalls in funding for health, there is a present, urgent need to address these neglected MHPSS concerns. Emphasis must be placed on the needs of vulnerable populations including IDPs, war injured, children and teenagers.