Perspectives on Rebuilding Health System Governance in Opposition-Controlled Syria: A Qualitative Study

Document Type : Original Article


Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK


Ongoing conflict and systematic targeting of health facilities and personnel by the Syrian regime in opposition-controlled areas have contributed to health system and governance mechanisms collapse. Health directorates (HDs) were established in opposition-held areas in 2014 by the interim (opposition) Ministry of Health (MoH), to meet emerging needs. As the local health authorities responsible for health system governance in opposition-controlled areas in Syria, they face many challenges. This study explores ongoing health system governance efforts in 5 opposition-controlled areas in Syria.
A qualitative study design was selected, using in-depth key informant interviews with 20 participants purposely sampled from HDs, non-governmental organisations (NGOs), donors, and service-users. Data were analysed thematically.
Health system governance elements (ie, strategic vision, participation, transparency, responsiveness, equity, effectiveness, accountability, information) were considered important, but not interpreted or addressed equally in opposition-controlled areas. Participants identified HDs as primarily responsible for health system governance in opposition-controlled areas. Main health system governance challenges identified were security (eg, targeting of health facilities and personnel), funding, and capacity. Suggested solutions included supporting HDs, addressing health-worker loss, and improving coordination.
Rebuilding health system governance in opposition-controlled areas in Syria is already progressing, despite ongoing conflict. Local health authorities need support to overcome identified challenges and build sustainable health system governance mechanisms.



Watch the Video Summary here.



Main Subjects



  1. Ziadeh R. Revolution in Syria. Turkish Review. 2014;4(2):186.
  2. Sterling J. Daraa: The spark that lit the Syrian flame. CNN. March 1, 2012.  
  3. United States Agency for International Development (USAID). Syria - Complex Emergency Fact sheet #3, Fiscal Year (FY) 2016.  Accessed May 5, 2016. Published 2016.
  4. Price M, Gohdes A, Ball P. Technical Memo for Amnesty International Report on Deaths in Detention. Human Rights Data Analysis Group; 2016.
  5. Solvang O, Neistat A. Torture Archipelago: Arbitrary Arrests, Torture and Enforced Disappearances in Syria’s Underground Prisons since March 2011. Human Rights Watch; 2012.
  6. Al-Saleh A, White L. Dissecting an evolving conflict: the Syrian uprising and the future of the country. Institute for Social Policy and Understanding; 2013.
  7. Flood DH. An Overview of Syria’s Armed Revolution. Combating Terrorism Center. 2012;5(4):1-20.
  8. Human Rights Watch (HRW). Syria.  Accessed August 28, 2016. Published 2016.
  9. Syria: Government Airstrikes Closing Down Hospitals, UN Should Build Case to Prosecute. Human Rights Watch (HRW) website.  Published August 11, 2016.
  10. Frenk J, Moon S. Governance challenges in global health. N Engl J Med. 2013;368(10):936-942. doi:10.1056/NEJMra1109339
  11. Baker E, Brown W. Doctors in the Crosshairs: Four Years of Attacks on Health Care in Syria. Physicians for Human Rights (PHR); 2015.
  12. Anatomy of a Crisis, A Map of Attacks on Health Care in Syria. Physicians for Human Rights; 2017.
  13. Baker E, Heisler M. Aleppo Abandoned: A Case Study on Health Care in Syria. Physicians for Human Rights; 2015.
  14. Fouad FM, Sparrow A, Tarakji A, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516-2526. doi:10.1016/s0140-6736(17)30741-9
  15. Cousins S. Syrian crisis: health experts say more can be done. Lancet. 2015;385(9972):931-934. doi:10.1016/s0140-6736(15)60515-3
  16. Nasser R. Syria Squandering Humanity Socioeconomic Monitoring Report on Syria Combined third and fourth quarter report (July–December 2013). United Nations Development Programme (UNDP); 2014.
  17. Heisler M, Baker E, McKay D. Attacks on Health Care in Syria--Normalizing Violations of Medical Neutrality? N Engl J Med. 2015;373(26):2489-2491. doi:10.1056/NEJMp1513512
  18. Sparrow A. Syria’s Assault on Doctors. NYR Blog; 2013.  
  19. Dewachi O, Skelton M, Nguyen VK, et al. Changing therapeutic geographies of the Iraqi and Syrian wars. Lancet. 2014;383(9915):449-457. doi:10.1016/s0140-6736(13)62299-0
  20. Bernard V. Violence against health care: Giving in is not an option. International Review of the Red Cross. 2013;95(889):5-12. doi:10.1017/S1816383114000125
  21. Singh M. In Syria, Health Care Workers Are The Heroes — And The Targets. NPR website.  Published December 1, 2015.
  22. Hathout L. The right to practice medicine without repercussions: ethical issues in times of political strife. Philos Ethics Humanit Med. 2012;7:11. doi:10.1186/1747-5341-7-11
  23. Alahdab F, Omar MH, Alsakka S, Al-Moujahed A, Atassi B. Syrians’ alternative to a health care system: “field hospitals.” Avicenna J Med. 2014;4(3):51-52. doi:10.4103/2231-0770.133329
  24. Ahsan S. Providing medical relief in Syria’s conflict. Lancet. 2013;381(9866):523-524.
  25. Diggle E, Welsch W, Sullivan R, et al. The role of public health information in assistance to populations living in opposition and contested areas of Syria, 2012-2014. Confl Health. 2017;11:33. doi:10.1186/s13031-017-0134-9
  26. Ben Taleb Z, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak W. Syria: health in a country undergoing tragic transition. Int J Public Health. 2015;60 Suppl 1:S63-72. doi:10.1007/s00038-014-0586-2
  27. Health system in Yemen close to collapse. Bull World Health Organ. 2015;93(10):670-671.  doi:10.2471/blt.15.021015
  28. Qirbi N, Ismail SA. Health system functionality in a low-income country in the midst of conflict: the case of Yemen. Health Policy Plan. 2017;32(6):911-922. doi:10.1093/heapol/czx031
  29. Monaghan C, Battaglia L, Berry B, Murray M. “Every Day Things are Getting Worse”: The impact on children of attacks on health care in Yemen. Save the Children; 2017.
  30. Syria: a health crisis too great to ignore. Lancet. 2016;388(10039):2. doi:10.1016/s0140-6736(16)30936-9
  31. Hill PS, Pavignani E, Michael M, Murru M, Beesley ME. The “empty void” is a crowded space: health service provision at the margins of fragile and conflict affected states. Confl Health. 2014;8:20. doi:10.1186/1752-1505-8-20
  32. Hellmuller SA. Governance mechanisms in opposition-held areas in Syria. NOW website.  Published 2016.
  33. Mampilly Z. Rebel Governance and the Syrian War. Vasser College: Project on Middle East Political Science; 2013.
  34. Aljundi G. Local Governance Inside Syria: Challenges, Opportunities and Recommendations. Institute for War & Peace Reporting; 2014.
  35. Khalaf R. Governance without Government in Syria: Civil society and state building during conflict. Syria Studies. 2015;7(3):37-72.
  36. Angelova I. Governance in rebel-held East Ghouta in the Damascus Province, Syria. Cambridge: University of Cambridge Centre of Governance and Human Rights; 2014.
  37. Sekkarie MA, Murad L, Sahloul Z. Revival of basic health services in Syria. Lancet Glob Health. 2015;3(10):e597. doi:10.1016/s2214-109x(15)00124-2
  38. Sen K, Faisal WA. Public health challenges in the political economy of conflict: the case of Syria. Int J Health Plann Manage. 2015;30(4):314-329. doi:10.1002/hpm.2312
  39. Kherallah M, Alahfez T, Sahloul Z, Eddin KD, Jamil G. Health care in Syria before and during the crisis. Avicenna J Med. 2012;2(3):51-53. doi:10.4103/2231-0770.102275
  40. National Coalition of Syrian Revolution and Opposition Forces. Interim Ministry of Health Establishes Eleven Directorates of Health in Syria.  Published July 25, 2014.
  41. Department for International Development (DFID). Making government work for poor people: building state capability. London: DFID; 2001.
  42. Dodgson R, Lee K, Drager N. Global health governance: a conceptual review. London/Geneva: London School of Hygiene & Tropical Medicine (LSHTM), Dept of Health & Development, World Health Organization; 2002.
  43. Siddiqi S, Masud TI, Nishtar S, et al. Framework for assessing governance of the health system in developing countries: gateway to good governance. Health Policy. 2009;90(1):13-25. doi:10.1016/j.healthpol.2008.08.005
  44. World Health Organization (WHO). The world health report: 2000: health systems: improving performance. Geneva: WHO; 2000.
  45. World Health Organization (WHO). Everybody’s business -- strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: WHO; 2007.
  46. World Health Organization (WHO). System thinking for health systems strengthening. Geneva: WHO; 2009.
  47. Travis P, Egger D, Davies P, Mechbal A. Towards better stewardship: concepts and critical issues. Geneva: World Health Organization; 2002.
  48. World Health Organization (WHO). Health 2020: a European policy framework supporting action across government and society for health and well-being. Geneva: WHO; 2012.
  49. Kickbusch I, Gleicher D. Governance for health in the 21st century. Geneva, Switzerland: World Health Organization; 2012.
  50. Brinkerhoff DW. Rebuilding governance in failed states and post-conflict societies: core concepts and cross-cutting themes. Public Adm Dev. 2005;25(1):3-14. doi:10.1002/pad.352
  51. Edwards LM. State-building in Afghanistan: a case showing the limits? International review of the Red Cross. 2010;92(880):967-991. doi:10.1017/S1816383111000099
  52. Roberts D. Liberal Peacebuilding and Global Governance: Beyond the Metropolis. Taylor & Francis; 2011.
  53. Lincoln YS, Guba EG. Naturalistic Inquiry. Thousand Oaks, CA: Sage; 1985.
  54. Lo Iacono V, Symonds P, Brown DHK. Skype as a tool for qualitative research interviews. Soc Res Online. 2016;21(2):1-15. doi:10.5153/sro.3952
  55. Fusch P, Ness L. Are We There Yet? Data Saturation in Qualitative Research. Qual Rep. 2015;20(9):1408-1416.
  56. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  57. Jones A, Howard N, Legido-Quigley H. Feasibility of health systems strengthening in South Sudan: a qualitative study of international practitioner perspectives. BMJ Open. 2015;5(12):e009296. doi:10.1136/bmjopen-2015-009296
  58. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042
  59. Berry C, Forder A, Sultan S, Moreno-Torres M. Approaches to improving the delivery of social services in difficult environments. Poverty Reduction in Difficult Environments (PRDE) Working Paper; 2004:3.
  60. Support to Health Service Delivery in Fragile States: Improving the Contribution of NGOs to Building Institutional Sustainability in Post-conflict/Transitional Settings. London School of Hygiene and Tropical Medicine; 2007.
  61. Barbazza E, Tello JE. A review of health governance: definitions, dimensions and tools to govern. Health Policy. 2014;116(1):1-11. doi:10.1016/j.healthpol.2014.01.007
  62. Kaufmann D, Kraay A, Zoido-Lobaton P. Governance matters. World Bank Policy Research Working Paper (2196); 1999.
  63. United Nations Development Programme (UNDP). Governance for Sustainable Human Development: A UNDP Policy Document. UNDP; 1997.
  64. London School of Hygiene and Tropical Medicine. Post-conflict health system reconstruction: a review of the literature. London: London School of Hygiene and Tropical Medicine; 2011.
  65. Eldon J, Waddington C, Hadi Y. Health system reconstruction: Can it contribute to state-building? London: Health and Fragile States Network; 2008.
  66. Haar RJ, Rubenstein LS. Health in postconflict and fragile states. US Institute of Peace; 2012.
  67. Rubenstein LS. Post-conflict health reconstruction: New foundations for US policy. US Institute of Peace; 2009.
  68. Vergeer P, Canavan A, Rothmann I. A rethink on the use of aid mechanisms in health sector early recovery. Royal Tropical Institute, Development Policy & Practice; 2009.
  69. Newbrander W, Waldman R, Shepherd-Banigan M. Rebuilding and strengthening health systems and providing basic health services in fragile states. Disasters. 2011;35(4):639-660. doi:10.1111/j.1467-7717.2010.01235.x
  70. Cometto G, Fritsche G, Sondorp E. Health sector recovery in early post-conflict environments: experience from southern Sudan. Disasters. 2010;34(4):885-909. doi:10.1111/j.1467-7717.2010.01174.x
  71. Speakman EM, Shafi A, Sondorp E, Atta N, Howard N. Development of the community midwifery education initiative and its influence on women’s health and empowerment in Afghanistan: a case study. BMC Womens Health. 2014;14:111. doi:10.1186/1472-6874-14-111
  72. Miyake S, Speakman EM, Currie S, Howard N. Community midwifery initiatives in fragile and conflict-affected countries: a scoping review of approaches from recruitment to retention. Health Policy Plan. 2017;32(1):21-33. doi:10.1093/heapol/czw093
Volume 8, Issue 4
April 2019
Pages 233-244
  • Receive Date: 19 May 2018
  • Revise Date: 17 December 2018
  • Accept Date: 17 December 2018
  • First Publish Date: 01 April 2019