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.

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.

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.

Peace-through-health has emerged as a promising concept but with variable evidence of success. Cooptation of health initiatives in conflict is believed to be a major challenge undermining peacebuilding potential. We examine the role that existing power structures and health initiative characteristics play at various levels of a conflict in peacebuilding outcomes. Using the Syrian conflict as a case study, we assess healthcare initiatives’ characteristics and their peacebuilding tendencies accounting for power dynamics at the (1) state citizen, (2) interbelligerents and (3) intercommunity conflict levels, drawing on the WHO’s framework for health and peace initiatives. Healthcare interventions at state citizen and interbelligerent levels generally addressed combat-related and material-dependent health needs, relied on large-scale international funding and centralised governance structures, and bestowed credit to specific agencies with political implications. These characteristics made such initiatives prone to cooptation in conflict with limited peacebuilding capacity. Healthcare initiatives at the community level addressed more basic, service-dependent needs, had smaller budgets, relied on local organisations and distributed credit across stakeholders, making them less amenable to cooptation in the conflict with more propeace potential. A pilot peacebuilding health initiative designed to leverage these propeace attributes navigated the political environment, minimised cooptation and fostered community collaboration, resulting in peacebuilding potential. In summary, peacebuilding health initiatives are more likely to materialise at the community as compared with higher political levels. Further studies, accounting for conflict power structures, are needed to examine the effectiveness of such initiatives and identify methods that maximise their peacebuilding outcomes.

BackgroundThe 11 years of the devastating conflict in Syria resulted in more than 874,000 deaths, and in thirteen million refugees and internally displaced people.1,2 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. MethodsAid alignment was explored as a part of the 2005 Paris Declaration Framework on aid effectiveness. Based on OECD’s survey on monitoring the Paris Declaration,3,4 and based on a proposed methodology to assess aid effectiveness by Burall and Roodman in 2007,5 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 (CRS) and the UN-OCHA financial tracking system (FTS), and the relevant humanitarian needs estimations by the Humanitarian Assistance Response Plans (HARPs), Humanitarian Response Plans (HRPs), and Humanitarian Needs Overviews (HNOs). The qualitative part relied on four Focus Groups Discussions (FGDs) and four expert interviews with key policy makers and practitioners involved in the health response in northwest Syria, with the aim to interpret the quantitative findings.ResultsWhile 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 to reflect the actual realities, especially before 2014, due to lack of comprehensive local engagement and data systems by then. Therefore, even if humanitarian budget 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, as a result of donors’ over reliance on the UN-led humanitarian system which struggles in armed conflict settings such as Syria. As a result, we found a disconnection between field realities, national planning, and humanitarian aid. ConclusionIn light of the dreadful humanitarian crisis in Syria, there has been an adverse aid alignment. There is an urgent need to improve aid alignment through more investment in local planning even at district or governorate level. 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 (SWAp), could contribute to a better initiating of the humanitarian-development-peace nexus in Syria, which in turn can contribute to a better aid alignment and aid effectiveness.