Title: Research for Health System Strengthening in Syria (R4HSSS)
Funder: Department of Health and Social Care

Abstract: Background: The Syrian armed conflict which began in 2011 is the deadliest of recent wars and the worst humanitarian catastrophe this century. With approximately half a million deaths and more than 13 million people displaced, the conflict continues to have a devastating impact on the health system and health outcomes within Syria. Health systems in north west (NW) and north east (NE) Syria are facing enormous challenges relating a chronic shortage of financial resources, decreasing external influence, health workforce drain, and violence against healthcare. Most large scale health research relating to the Syrian conflict has been focusing mostly on Syrian refugees in neighbouring countries and in Europe. There has been with very little focus on health issues inside the country. Research for Health Systems Strengthening in northern Syria (R4HSSS) addresses these significant gaps through studying the experience of health systems in NW and NE Syria in relation to four interrelated elements of health system strengthening: provision of health services – by comparing different models of health service provision; health education and medical training; health governance and financing; and the use of digital solutions in health information systems. Conducting locally-driven, co-produced research on hybrid health systems and proposing evidence-based solutions on their scaling up, sustainability and integration for these two regions in Syria is crucial. _x000D_ Research Consortium: King’s College London (KCL) and the Union of Medical Care and Relief Organisations (UOSSM) are the key lead organisations for the research consortium. UOSSM has accumulated considerable experience in health systems strengthening and collecting health data in northern Syria and KCL has considerable experience in strengthening research capacity in conflict-affected regions. The KCL-UOSSM partnership creates a strong basis for collaborative research and capacity strengthening. _x000D_ Study aims and Objectives: The main aim of R4HSSS is to produce a model on health system strengthening in conflict settings which could be applied in other contexts affected by protracted and complex conflicts._x000D_ Study Methods: The research will use a mixed methods approach with qualitative and quantitative research methods to include systematic reviews, a case studies on NE and NW Syria (with key informant interviews, direct observations, focus-group discussions, questionnaires and surveys where several units of analysis representing different pillars of health system will be studied) and policy validation workshops. A separate methodology will be used to develop digital solutions for health data. The surveys will target communities, patients and service-users to capture information related to the effectiveness, responsiveness and quality of health interventions provided by the health system focusing on the modalities that are designed to strengthen the health system under conflict circumstances._x000D_ Capacity Strengthening Approach: We will use a context-specific, adapted DFID research capacity framework focusing on three levels of interventions; individual, organisational and institutional level.

Lay abstract: As the Syrian conflict enters its ninth year, 13.2 million Syrians are in need of health assistance. Displacement continues to be a major challenge for the country with 5.6 million refugees and 6.6 million internally displaced persons (IDPs) according to UNHCR as of April 2019. The conflict has caused a severe disruption in health services leading to a collapse of the health system in the most conflict-affected areas. Attacks on healthcare have been a major threat in Syria, in what has been described as a weaponisation of health care. The UN estimates that half of the health facilities in Syria are either only partially functional or destroyed. Physicians for Human Rights have documented 588 attacks on health facilities and 914 medical personnel killed between March 2011 and November 2019. Essential health services have been further disrupted by the increasing number of health professionals fleeing the country. This has left populations with limited access to healthcare leading to increased vulnerability to communicable and non-communicable diseases. _x000D_ Recently, there have been three distinctive territories in Syria corresponding to the different areas of control. About 60% of the Syrian territories, including the capital Damascus and most central and southern areas, are controlled by Assad regime. Kurdish armed groups, supported by the US, control around 25% of north east Syria, with a population of approximately 4 million. The remainder of opposition armed groups, supported by Turkey, control around 15% in the north west with a population of approximately 3.5 million. The health system in each territory developed different adaptation mechanisms to the conflict. For example, after the collapse of the health system in north west Syria, local medical networks - relying on limited local resources, the remanence of health infrastructure and equipment, and the humanitarian health resources - adopted a new bottom up approach to build a hybrid and kinetic health system that is currently functioning as an autonomous local health authority in the region. Whereas, the health system in north east Syria maintained a level of functionality throughout the conflict with a similar structure to the pre-conflict health system and some ties to the Damascus Ministry of Health._x000D_ Little is understood about how contemporary conflicts shape emergent health ‘systems’. It is important to study these different adaptation mechanisms and explore various strategies to strengthen these health systems and ways to integrate them into a national health system in what will now be the post conflict phase. Throughout the Syrian conflict, research has been focused largely on Syrian refugees in neighbouring countries and in Europe with very little focus on health issues within the country. Our project will study the experience of health systems in north west and north east Syria in relation to four elements of health system adaptation and strengthening; provision of health services – by comparing different models of health service provision, health education and medical training, health financing, and the use of digital solutions in health information system to inform future post conflict systems strengthening (SDG 3 and 6).

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: GENERIC HEALTH RELEVANCE