NIHR HPSR-CA: Research for Health System Strengthening in northern Syria (R4HSSS) 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.
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.
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). The main aim of Research for Health System Strengthening in northern Syria 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.