perspectives on rebuilding health system governance in opposition-controlled syria: a qualitative study

Background: 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. methods: 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. results: 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. conclusion: 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.