Localisation and cross-border assistance to deliver humanitarian health services in North-West Syria: a qualitative inquiry for The Lancet-AUB Commission on Syria

Abstract

Background In a growing number of humanitarian crises, “remote management” is negotiated across borders and implemented by humanitarian agencies through “local actors” to deliver assistance. However, the narrative describing the involvement of local actors in the delivery of humanitarian aid in armed conflict settings remains reductionist and unreflective of the complex and circular course of the “localisation of aid”. This paper explores cross-border humanitarian assistance within the Syrian conflict. We document how humanitarian actors operate to deliver humanitarian health care in North-West Syria (Turkish border), explore their challenges and critique the language used within current debates on the localisation of aid. Methods We undertook key informant interviews with Turkey-based humanitarian aid professionals involved in the humanitarian health response inside Syria. We integrated data previously collected for The Lancet -American University of Beirut Commission on Syria during field work in Gaziantep, Turkey, through meetings, conversations, discussions and expert consultations with Syrian health professionals, WHO-Turkey staff members and members of Syrian health directorates. We also drew from background desk reviews conducted by the Commission on health systems responses and timeline of events in Turkey during the Syrian conflict. Results This paper uncovers creative and effective bottom-up strategies that enhanced cross-border coordination of aid delivery into Syria. Our findings unravel the key role played by Syrian providers in accessing vulnerable populations and in reshaping coordination and funding mechanisms inside Syria, as well as the disproportionate risks local actors bear within the response. Our findings also reveal an iterative negotiation of decision-making dynamics, a “low-profile approach” promoted to gain access to populations of concerns, and an environment that is heavily shaped by close interpersonal relationships and social trust. Conclusions Our multifaceted narrative unpacks circular flows of interactions among actors and uncovers strategies developed by practitioners on the field, which are often left undocumented. We argue that there is an opportunity for the humanitarian sector to learn from these synergies to rethink how medical humanitarianism is framed (hopefully leading to a more collaborative framing that resists mainstreaming “local” actors within a “traditional” system). There is also an opportunity for the humanitarian and global health communities to reflect on how value attributed to human lives needs to be questioned in contexts where national staff face a disproportionate risk to deliver aid.

Lessons from humanitarian clusters to strengthen health system responses to mass displacement in low and middle-income countries: A scoping review

“…Duclos and colleagues emphasised that increasing the capacity of local health-workers to assist populations with maternal and neonatal health interventions in places where international staff are unable or unwilling to work can reinforce existing structures, as shown in Syria ( Duclos et al . , 2019 ).…”

Partnerships with local organisations are vital for conducting health research in Syria—personal reflections

“…Local actors, who played a leading role in the health response in Syria (Duclos et al 2019), should be at the core of these efforts for these partnerships to be effective. And, considering the extreme insecurity in most conflict-affected areas in Syria, proposed partnerships would rely mostly on remote support and collaborations similar to the partnerships that emerged between international and local NGOs in the cross-border response in Syria (Diggle et al 2017).…”

“…To navigate this challenging environment, humanitarian actors adopted different modalities to deliver aid such as remote management and partnerships between local, regional and international humanitarian actors (Duclos et al 2019). However, the protraction and rapid changes of this conflict impose newer humanitarian dilemmas that require better understanding on the effectiveness of these humanitarian modalities.…”

Challenges of providing healthcare worker education and training in protracted conflict: a focus on non-government controlled areas in north west Syria

“…During the course of the conflict, this area has developed a complex healthcare system where Syrian-led initiatives, Syrian nongovernmental organisations (NGOs,) international NGOs and international organisations (e.g. WHO, UN) have provided cross-border health and humanitarian care; this has been mostly coordinated through the WHO-led Health Cluster in Gaziantep, Turkey [17]. Some of these organisations have also provided education or training to support the healthcare workforce on whom they draw on for staffing projects and healthcare facilities in north west Syria [17].…”

“…WHO, UN) have provided cross-border health and humanitarian care; this has been mostly coordinated through the WHO-led Health Cluster in Gaziantep, Turkey [17]. Some of these organisations have also provided education or training to support the healthcare workforce on whom they draw on for staffing projects and healthcare facilities in north west Syria [17]. As of May 2020, it describes an area which includes Idlib, north west Hama, northern Aleppo and north eastern Lattakia governorates [18].…”