Capturing sources of health system legitimacy in fragmented conflict zones under different governance models. A case study of northwest Syria

doi:10.21203/rs.3.rs-3972661/v1

Introduction

Legitimacy and trust are crucial for resilient health systems in fragmented conflict zones. This study evaluates the legitimacy of public health authorities in northwest Syria under different governance models.

Methods

Using a deductive and inductive mixed-methods approach, the research team developed a framework with 4 indices and 18 indicators to assess the legitimacy of public health authorities that operate under different health governance models – top-down, bottom-up, and hybrid – in the context of the response to the earthquake that hit Syria in February 2023. The study includes surveys, workshops, stakeholder consultations, and an expert panel conducted in northwest Syria and online.

Results

The findings indicate that bottom-up health governance model is perceived as the most legitimate, followed by the mixed model, while top-down model is perceived as the least legitimate. This preference is measured across all legitimacy source indices, including legality, justification, consent and performance and across the overall Health Sector Legitimacy Index (HSLI). However, the hybrid governance approach showed limited superiority at the sub-source level regarding long-term health system response.

Conclusion

This study highlights the importance of considering the legitimacy of the health system in fragmented conflict zones. It helps explaining the effectiveness of the bottom-up approach and community-based governance in enhancing trust, cooperative behaviour, health interventions and achieving sustainability. Additionally, the study highlighted the role of legitimate public authorities in practising civic virtue and promoting social justice, thus contributing to peace-building efforts. These insights are crucial for policymakers and development donors to strengthen health systems in challenging contexts.

Health

governance

Legitimacy Index

top-down

bottom-up

legality

justification

consent

performance

What is already known on this topic– Health systems in fragmented conflict zones face significant challenges, including issues of governance, effectiveness and securing compliance. Studies have shown that health governance evaluations in these settings are often limited in scope, favouring simplified designs focusing on health governance principles and lacking comprehensive approaches. Studies focusing on health governance legitimacy are scarce, indicating a clear gap in existing research.

What this study adds– This study added a new dimension to health governance evaluation frameworks that goes beyond the principle dimensions to include legitimacy sources. In addition, the study created a framework to evaluate public health authorities' legitimacy and a Health Sector Legitimacy Index (HSLI) which is useful for fragmented conflict zones.

How this study might affect research, practice or policy–The research team develops a comprehensive framework for evaluating health governance in conflict areas that includes legitimacy as one of the key dimensions. This paper contributes directly to the building of that framework. Moreover, we argue that using our new approach to capture sources of trust and legitimacy reveals a more granular perspective that is required for optimising health interventions and reveals important variations between the different models of governance that could guide the design of the health systems in conflict zones so that they can generate the cooperative behaviour needed for their efficiency and sustainability. In addition, policymakers, including development donors, can use this study to enhance the ability of health systems in conflict areas to exercise civic virtue and enhance social justice and thus their ability to play a peace-generating role rather than being an instrument of war.

Legitimacy of healthcare systems has become an area of increasing attention in the last two decades and particularly in the aftermath of the Covid 19 pandemic and global economic crisis [1], [2], [3]. Generally speaking, increased legitimacy brings better voluntary compliance, which is key to effective service delivery, especially for institutions, such as health institutions, which do not tend to exercise coercive power and require cooperative behaviour [3], [4], [5]. The question of the legitimacy of health systems during time of crisis attracted particular attention during and after the COVID19 pandemic [6], [7]. Trust has been found to be vital for adherence to prevention measures [8]. Also, the legitimacy of governance institutions and actors is found to be mainly based on trust [9]. A literature review on the role of trust in vaccine acceptance found that institutional trust is key in addressing vaccine hesitancy [10]. Attacks on the World Health Organization by the Trump administration during the pandemic became focused on its legitimacy, leading to a loss of trust in the organisation [7]. Legitimacy and trust have also been identified as important factors in improving the resilience of health systems in low- and middle-income countries and in improving its efficiency [4], [11].

In the context of fragile and conflict-affected areas, especially in rebel-controlled areas, the legitimacy of the healthcare systems becomes even more important [12]. In the absence of state authority, voluntary compliance becomes the cornerstone for delivering health services both in time of crisis and stability. As the centrally coordinated system of governance disintegrates in such areas, new de-facto systems emerge out of the chaos within different zones within the wider area, which are perceived with varying degrees of legitimacy by those in charge with governance. Due to limited local capacity in such areas, there is a strong reliance on international health interventions and support [13]. Understanding the nuances of trust and legitimacy in such complex environments could have a strong impact in designing more effective health interventions.

Although the question of how to understand and measure trust of healthcare systems has attracted some attention (e.g. [3], [5] and [12]), the analysis of the wider legitimacy of healthcare systems has received considerably less attention. The only example we identified is a framework for assessing the legitimacy and practices of discursive (de)legitimation of global governance institutions (GGIs) developed by Hai Yang [7]. By assessing the legitimacy and discursive (de)legitimation of a GGI, Yang’s framework can capture the fine grains of the empirical sources of legitimacy of a GGI, such as purpose irreplaceability, legality, inclusiveness, transparency, accountability, integrity, impartiality, problem-solving effectiveness and executive leadership [7]. But the framework was developed to examine specifically the legitimacy of international health institutions and is short of capturing the nuances of the sources of legitimacy of national and local health institutions.

Our study seeks to make both conceptual and empirical contributions to the understanding of the sources of legitimacy of healthcare systems in fragmented conflict zones. By using deductive and inductive approaches, we build on a framework that was developed by Rim Turkmani to measure the perception of legitimacy in fragmented conflict zones [14] to design a new framework for measuring citizen’s perception of the multiple sources of legitimacy of health systems in fragmented conflict zones. We then operationalise this framework to design a questionnaire and conduct a survey to capture the sources of legitimacy of the health system in three different areas in northwest Syria. These areas are characterised with three different models of de factor health governance. These are the top down, hybrid and the bottom-up models (see Table 1 for definitions). The survey was carried out six months after the earthquake that hit Syria and Turkey on 6 February 2023. The health system played a pivotal role as a frontline responder immediately after the earthquake and also in addressing multiple health issues in the period after, both on the ground and through representing the local community in the media and in front of international organisations to communicate the needs and to coordinate appeals [15]. As such, the period after the earthquake was a real test to the efficiency and responsiveness of the health system and it was also a period where most people came in direct experience with the health system and thus formed a view of both its performance and its capacity to represent them. Table 1 outlines key concepts utilised in this paper.

Table 1: Definitions

Legitimacy of a public authority	The legitimacy of a public authority is the recognised and accepted right to exert influence and act, both by political elites and the general public, seen as lawful and justified in society and national politics [16], [17], [18], [19], [20].
Trust in public authorities	Trust in public authorities refers to the public's confidence and satisfaction in these institutions and their leaders to act in the best interests of society [8], [9], [21].
Public Authority	Any authority beyond the immediate family that asks for voluntary obedience from the people [22].
Conflict-zone	Areas experiencing armed conflict, post-conflict fragility, weak governance, poor security, and systematic violations of international law, including human rights [23].
Health sector	The healthcare sector includes businesses providing medical services, manufacturing medical equipment and drugs, insurance, and other healthcare facilitation for patients [24].
Top-down governance	Hierarchical governance involves the direct application of state authority to target populations. It is used to enforce rules or standards of behaviour on other actors, supported by incentives and penalties, to achieve collective objectives [25].
Bottom-up governance	An approach that enables local communities and stakeholders to express views and help determine the development direction for their area in line with their opinions, expectations and plans [26].
Hybrid governance	Refers to shared decision-making processes and responsibilities between higher-level governmental bodies and local or community-based organisations. It aims to balance standardisation and adaptability to ensure that health services are effective and meet local needs and expectations.

The Syrian conflict started in 2011 and resulted in more than 874,000 deaths and more than 13 million refugees and internally displaced people (IDPs) [27]. It led to the political fragmentation of the country with different areas of control. The northwest of Syria, (focus of this study), came under the military control of various armed actors since 2015 after the central government in Damascus lost control [28]. The withdrawal of the state led to a governance vacuum which led to the development of various de facto governance structures. By 2017 the northwest itself was split into two main areas under the control of two different de facto governments. These are Idilb, governed by the Syrian Salvation Government (SSG), which is linked to Hayat Tahrir al-Sham (HTS) [29], and northern Aleppo which is governed by the Syrian Interim Government (SIG), which is derived from the National Coalition for Revolutionary and Opposition Forces with strong influence from Turkey [30].

But despite the chaos of governance in the northwest and the affiliation of governance bodies with armed and political actors, the health sector in Idlib maintained relative independence from armed and political actors. This is primarily due to the way this sector emerged in this area as a bottom-up institution driven by local medical staff who were determined to keep the sector independent to protect it from the political and armed competition in the area [31]. To regulate the health sector, the leading figures in the health sector founded the Idlib Health Directorate (IHD). To maintain the independence of IHD from the controlling authorities, it was designed so that it derives its legitimacy from the grassroots community or bottom-up. IHD would have a general assembly, which includes representatives of all health facilities in the governorate [32]. The General Assembly elects a board of trustees, which in turn elects the head of IHD. Although the SSG formed its own Ministry of Health in Idlib, its role remained marginal compared with that of IHD and its allies. This meant that the health sector in Idleb remained mainly a bottom-up sector.

In northern Aleppo, the Aleppo Health Directorate (AHD) emerged in 2013 from local health staff and maintained independence until 2014, when it officially decided to work under the SIG umbrella, choosing a different governance approach than IHD; it did not establish an election process or have a board of trustees. The influence of the Ministry of Health (MOH) of the SIG became clear in 2014 when the SIG received a $68 million grant from Qatar [33]. However, its influence became marginal after that due to the lack of capacity, legitimacy and resources. Its role was almost limited to hiring the head of AHD and marginal health activities in northern Aleppo. This weak role of the SIG keeps a balance in power between AHD and MOH/SIG.

After the Turkish military intervention in northern Aleppo in 2016 [34], Turkey played a key role in the health sector in the area. It built many health facilities and managed them directly through health directorates in the south of Turkey. In parts of northern Aleppo, Turkey took control of the management of the health sector and even applied the Turkish health system in these areas (such as Afrin, Al-Bab, Ar-Ra'ee, A'zaz and Mare). This resulted in a top-down managed health sector.

In other parts of northern Aleppo, the Turkish authorities did not assume full control of the health sector and left it to be managed by AHD, NGOs and the ministry of health of the SIG. This arrangement resulted in a hybrid model that combines aspects of both bottom-up and top-down governance.

The strength and resilience of the health sector in northwest Syria were repeatedly tested during the multiple crises it faced, particularly during the coronavirus pandemic and the February 2023 earthquake. Over 51,000 people died in both countries, with around 4540 in northwest Syria [35], [36]. In addition to the health directorates in Aleppo and Idlib, other actors played a role in response to the earthquake, mainly the NGOs, INGOs and the Health Cluster in Gaziantep, which is led by the WHO.

Our mixed empirical methodology consists of four main activities, stakeholder consultations to identify the governance models, a series of workshops to develop a framework and a questionnaire and to discuss the results, a field survey and an expert panel to discuss the initial findings.

We started by holding two one-day workshops for the research team including an external governance expert at LSE in London between April and June 2023 to develop and adapt the conceptual framework and to design questions for the survey.

In preparation for the fieldwork activities, we organised two online training workshops for 12 field enumerators based in northwest Syria except one in Gaziantep/Turkey to elucidate the survey's objectives and provide detailed clarification for each question within the questionnaire. Additionally, we compiled a comprehensive local researcher guide that offers thorough explanations for each question, aiming to minimise subjectivity in question comprehension by both enumerators and surveyed individuals. The lead author maintained direct supervision over field activities regularly, as well as the data entry process. The fieldwork team utilised Excel for entering data and following a thorough data cleaning and verification process by the research team, the data was imported into Stata 17.0 for further analysis.

We then conducted the survey in 36 sub-districts in northwest Syria, 17 of which are located in the Aleppo governorate and the remaining in Idlib. Data collection started in mid-July and ended in mid-September 2023. A sample size of 1,067 respondents was randomly selected from a total population of around 2.2 million individuals aged 18 or older to have a representative sample with a 95% confidence level and a 3% margin of error. The sample shows a well-balanced gender and age distribution, with approximately 46% of the surveyed individuals being females and 36% falling within the age range of 18 to 33. The sample has an employment ratio of 44%, with 28% of the employed persons being females. Furthermore, nearly half of the employed persons are engaged in the service sector.

To verify what governance model each surveyed sub-district followed, we conducted four rounds of virtual stakeholder consultations involving representatives from quasi-government institutions and NGOs. The aim was to identify the governance models within each sub-districts based on the criteria outlined in Table 3. The results were the distribution of governance models within the sample indicated: 18% top-down, 12% hybrid, and 70% bottom-up model.

Finally, we held a workshop in October 2023 for the research team in London to discuss results and we followed by organising a virtual expert panel in December 2023 which included five local experts and medical staff to deliberate the preliminary results of this descriptive analysis, aiming to establish a robust narrative that complements the quantitative findings.

Developing the conceptual framework

Our starting point in developing a framework to capture the perception of the legitimacy of healthcare systems in fragmented conflict zones is a framework developed by Rim Turkmani to capture the empirical legitimacy in fragmented conflict zones [14]. Empirical legitimacy is concerned with the beliefs and attitudes of the governed regarding the normative status of institutions [37]. The aim is to assess the legitimacy as believed by citizens rather than as claimed by authorities. The Turkmani framework starts from the three subtypes of legitimacy identified by Gilly: views of legality, views of justification, and acts of consent [38] and adds a fourth sub-type, the view of performance: Instrumental legitimacy. The definition of these sub-types is outlined in Table 2. The view of legality is also divided into internal and external legality. And since in conflict zones under de facto controls the question of legality is not straightforward, the framework examines the procedures and performances that produce legality and social accountability.

To adapt the Turkmani framework to the health sector we used deductive and inductive approaches to come up with a set of indicators for each sub-type of legitimacy. We followed the methodology developed by Bollen and Lennox (1991) to derive specific ‘substitutive and constitutive indicators’ for each of the four sources [39]. Constitutive indicators are direct indicators that constitute the essence of what is being measured [39], [40], [41], and are used to measure people’s perception of procedure or input legitimacy sources. While substitutive indicators are used as substitutes for direct measurement when constitutive indicators are hard to quantify or observe. They do not directly measure the concept but are close enough to provide a useful proxy to measure people’s perception of performance or output legitimacy sources [39], [40], [41].

The resulting 18 indicators we derived are summarised in Table 2 together with the literature that we relied on to justify each indicator. Our main criterion in selecting these indicators is that the indicator should be significant and justifiably related to one of the legitimacy sources. We also ensured that each sub-type of legitimacy is covered by several indicators that are suitable to capture the specifics of this sub-type within a fragmented conflict setting. The indicators for the view of performance were also chosen to assess the performance of health system in particular. For the indicators of the act of consent, we chose to look not only for people’s willingness to voluntarily comply with the instructions of the health authority, but also to investigate people’s willingness to delegate the health authorities to represent them and convey their needs to international bodies, such as the donors and the WHO. This is particularly important in such setting because of the absence of central political authority that could play the representation role. In addition to relying on the literature review and the first author’s lived experience in the health sector in northwest Syria to derive the indicators, we also relied on two one day workshops organised include the research team and an external governance expert to validate these indicators.

We operationalised this framework to design a questionnaire with a question for each indicator where people are asked to rate their perception on a five-point scale, ranging from 1 (very poor) to 5 (very good) (appendix 1).

With the aim of developing an index for health system legitimacy, we constructed indices for the four legitimacy sources to construct the Health Sector Legitimacy Index (HSLI) using a simple weighted arithmetic average formula:

HSLI = , j=1,2,…n

Where represents the score of the indicator i for observation (individual) j, and denotes the weight assigned to i indicator. The weights satisfy = 1 and < 0. Based on Table 2, the value of d stands at six for the legality index, six for the justification index, two for the acts of consent index, and four for the performance index. In constructing the HSLI, these four indices are utilized, resulting in d being equal to four.

Following expert discussions and consultations with local practitioners, we assigned equal importance to each indicator within the four composite indices. This method also aligns with Bruce Gilley's 'unweighted score’ concept [39].

We applied the Cronbach's alpha coefficient (c-alpha) to assess the internal consistency of the indicators used in developing HSLI. This statistical measure is particularly relevant when creating a composite index as a scale [42], which aligns with our approach. The computed c-alpha for HSLI exceeds 0.70, indicating an acceptable level of internal consistency within this set of indicators [43].

Since we aimed to test our framework in areas that we identified as governed under three different models of governance, we identified from the literature the criteria required to classify health governance models. The results are summarised in Table 3.

Table 2: Framework for evaluating the legitimacy of public health authorities in fragmented conflict zones

Legitimacy Sources (variables)	Definitions	Questionnaire indicators	Constitutive or substitutive
Views of legality	Whether the authority gets and exercises political power in accordance with citizens' views on laws, rules, and norms [44].	1- Coordination and cooperation among responding agencies [45], [46]	Constitutive
		2- Cooperation of responding bodies with local authorities [47].	Constitutive
		3- Involvement of the local community in the decision-making process [48].	Constitutive
		4- Community accountability [49], [50].	Constitutive
		5- The legal foundation of the responding bodies [51].	Constitutive
		6- Ability to coordinate with international donors and to secure services and support from them [52].	Constitutive
views of justification	Agreement with shared principles, beliefs, values and ideas [44].	1- Transparency [49], [53], [54].	Constitutive
		2- Fairness [19], [55].	Constitutive
		3- Incorruptness [19], [56].	Constitutive
		4- Understanding people's needs [57].	Constitutive
		5- Neutrality [56].	Constitutive
		6- Respect for community customs and traditions [58].	Constitutive
acts of consent	When someone gives permission for something to be done or acknowledges the authority of someone or an entity [59].	1- People’s compliance with health advice and instructions issued by responding agencies [56].	Constitutive
acts of consent		2- delegation of the local community to the responding bodies to represent community health interests and provide services [60].	Constitutive
View of performance (Instrumental legitimacy)	Assessing an organisation's capability to achieve its objectives effectively and efficiently while considering aligning its actions with societal expectations [19], [54], [61], [62], [63].	1- Rapid response [64].	Substitutive
		2- Quality of health services [65].	Substitutive
		3- Availability of health services [66].	Substitutive
		4- Effective health services (reliability) [19], [65].	Substitutive

Table 3: Health governance model criteria

Criteria	Top-Down Approach	Bottom-Up Approach	Hybrid Control Approach
Hierarchical Structure	Clear, top-to-bottom reporting and control mechanisms [67].	Decentralised structure [68].	Elements of both hierarchical and decentralised control [69].
Centrality of decision making and level of participatory approach	Policies and decisions are made primarily by centralised authority with little or no participation of local community [70].	Policies and decision-making are heavily influenced by local communities or grassroots organisations [26], [71].	Shared Decision-making: Policies are made through collaboration between centralised and local entities [67].
Standardisation	Uniform health practices and services across all areas [68].	Adaptable health practices and services that are tailored to local needs and preferences [72].	Partial Standardization: Some uniformity in health practices, but also room for localised adjustments.

The interviews revealed three different approaches to health governance in NWS. As for Idlib governorate and Western Aleppo, the governance structure is the same and follows a bottom-up approach; this area (figure 1, green) contains 21 sub-districts. In northern Aleppo, two main approaches were identified: a top-down approach was recognised in 5 sub-districts (figure 1, blue) and a hybrid approach in 10 sub-districts (figure 1, orange). Nevertheless, the hybrid one is closer to the top-down than the bottom-up one as it still works under the strategic plan of the Turkish health authorities.

Figure 1: Different types of health governance approaches in northwest Syria

Figure 2 illustrates the percentage distribution of people’s perception on the four legitimacy sources indices and the HSLI^{^[1]} in addition to the average scale of these indices by governance models. The ‘bottom-up’ model exhibits the highest scores for average scale across all indices, with the ‘hybrid’ model following behind. In contrast, the ‘top-down’ model registers the lowest scores for all indices. The view of performance has the highest average scale in all models, and the ‘view of justification’ has the lowest.

The findings indicate that across all indices, the ‘top-down’ model exhibits the lowest percentages of ‘above average’ perceptions (figure 2, top-down, blue), ranging from 6.6% for the justification index to 57.9% for the performance index. Conversely, the ‘bottom-up’ model demonstrates the highest ‘above average’ perceptions (figure 2, bottom-up, blue), varying from 44.8% for the justification index to 78.1% for the performance index.

However, in terms of ‘below average’ perceptions, the ‘top-down’ model generally displays the highest percentages (figure 2, top-down, red), reaching 87.4% for the justification index. In contrast, the ‘bottom-up’ model tends to have the lowest ‘below average’ perceptions across most indices (figure 2, bottom-up, red). Interestingly, this trend shifts for the performance index, where the ‘bottom-up’ model records the highest ‘below average’ perceptions at 15%, followed by the ‘top-down’ model at 13.7%, and the ‘hybrid’ model at 10.7% (figure 2, performance, red).

The HSLI reveals a clear pattern in people’s perceptions regarding health sector legitimacy. The ‘bottom-up’ governance model, scored 3.18, reflects the most favourable perception, followed by the ‘hybrid’ model at 2.92, while the ‘top-down’ governance areas display relatively poorer perceptions at 2.69 (figure 2, HSLE).

Figure 2: Percentage distribution of people’s perception on legitimacy indices and the average scale of these indices by governance models

Table 4 displays the average scale of legitimacy indicators used to construct the four legitimacy sources indices and Table 5 explains the Perception of answers for the legitimacy indicators. In terms of the ‘views of justification’ indicators, the results reveal a notably low average scale concerning the transparency of health entities across all governance models. Approximately 73.5% of individuals in all areas perceived transparency as either ‘very bad’ or ‘bad’. In the top-down and hybrid governance model areas, the average scales regarding fairness and incorruptibility of these entities are notably low. Merely less than 4% of individuals in these regions perceive the fairness and incorruptibility level of health entities as ‘above average’. In contrast, approximately 30% of people in bottom-up governed health sector areas hold this view. In the top-down governed regions, the capacity of health entities to understand the local community’s needs post-earthquake is rated close to ‘poor’, with 63.7% perceiving this capacity ‘below average’. However, in ‘bottom-up’ governed areas, this perception decreases to 26.3%. Neutrality within the health sector in ‘bottom-up’ governed areas is viewed as ‘good’ or ‘very good’ by over 70% of individuals, significantly exceeding the perceptions in the other governance models, where this figure remains below 30%. The respect for traditions by health entities in all areas score relatively well. ‘Bottom-up’ governed areas stand out, with around 60% of people perceiving this aspect as ‘very good’, markedly higher than regions governed by the other models.

Regarding ‘acts of consent,’ approximately 40% of individuals across all regions perceive the compliance with health advice as ‘good’ or ‘very good’. This percentage shows consistency across the three governance models. However, the delegation of responsibilities to health entities by local communities is notably higher in ‘bottom-up’ governed areas, with around 50% perceiving this level as ‘good’ or ‘very good’, significantly surpassing the top-down areas where this figure is less than 12%. In ‘hybrid’ governed areas, the level of delegation falls between that of the top-down and bottom-up models.

In terms of 'views of performance,' there is a positive perception across all areas with varying governance models across the four indicators. The highest percentage of ‘good’ and ‘very good’ perception is seen in the bottom-up governed areas regarding the health sector’s speed of response to the earthquake, reaching 66.8%. Conversely, the lowest percentage, at 35.8%, is linked to the quality of health services provided during the earthquake in top-down governed areas. People’s perception of the availability of health services scores lower in the bottom-up governed areas compared to those under the other two governance models.

Within the legality dimension, the findings indicate that the level of accountability of health entities to the local community and the level of participation of the local community in the decision-making process of these entities are rated below average in all areas with more than 50% of people perceived these levels as ‘bad’ or ‘very bad’. However, they are relatively better in the bottom-up governed areas. Moreover, the level of coordination among responding agencies after the earthquake is significantly higher in bottom-up governed areas compared to those governed by the top-down model. The results also demonstrate that cooperation between health entities and local authorities to obtain licenses exceeds the average in all areas, with around 60% of people perceiving this cooperation as ‘good’ or ‘very good’ in bottom-up governed areas. The three governance models show a level above average and relatively similar regarding the ability of responding agencies to secure services and support from donors. Approximately 50% of people believe that these agencies’ ability is ‘good’ or ‘very good’ in both hybrid and bottom-up governed areas, compared to less than 35% in top-down governed areas.

Table 4: The average scale of legitimacy indicators and indices by governance models (*)

Sources of legitimacy		Governance models
Sources of legitimacy		Top down	Hybrid	Bottom up
View of justification	Transparency	1.62	1.68	1.94
	Fairness	1.65	1.74	2.76
	Incorruptness	1.55	1.75	2.59
	Understand needs	2.29	2.61	3.30
	Neutrality	2.77	2.94	4.07
	Respect traditions	3.47	3.76	4.22
Act of consent	Compliance	3.31	3.35	3.40
Act of consent	Delegation	2.41	2.74	3.30
View of performance	Responsiveness	3.43	3.65	3.97
	Quality	3.28	3.53	3.75
	Availability	3.38	3.60	3.31
	Reliability	3.36	3.57	3.54
Legality	Coordination	2.74	3.16	3.73
	Approvals	3.03	3.28	3.51
	Participation	2.31	2.47	2.64
	Accountability	2.01	2.23	2.34
	Formation	2.77	2.78	3.11
	Fundraising	3.38	3.61	3.51

(*): Scale from 1 to 5 where 1 is very poor, 2 is poor, 3 is average, 4 is good, and 5 is very good.

Table 5: Perception of legitimacy indicators

			V.Bad	Bad	Avg	Good	V.Good	Dw*	Dk*
View of Justification	*Transparency*	Top_Down	54.4	21.2	11.9	3.1	0.5	2.6	6.2
		Hybrid	50.4	29.9	15.0	0.0	1.6	0.8	2.4
		Bottom_up	38.1	33.8	14.0	6.1	2.1	0.3	5.6
	*Fariness*	Top_Down	53.9	21.2	14.0	3.1	0.5	2.6	4.7
		Hybrid	46.5	33.9	15.8	1.6	0.8	0.8	0.8
		Bottom_up	21.5	28.7	12.7	19.6	14.6	0.3	2.6
	*Incorruptness*	Top_Down	58.0	20.7	8.8	4.2	0.0	3.1	5.2
		Hybrid	44.9	32.3	15.0	3.2	0.0	2.4	2.4
		Bottom_up	19.4	28.7	17.2	16.1	7.5	0.3	10.8
	*Understand needs*	Top_Down	18.1	45.6	22.3	8.3	2.6	1.6	1.6
		Hybrid	13.4	37.0	23.6	19.7	3.2	0.0	3.2
		Bottom_up	6.2	20.0	27.2	30.2	16.1	0.1	0.1
	*Neutrality*	Top_Down	7.8	22.8	54.9	9.8	3.1	0.0	1.6
		Hybrid	7.1	31.5	29.9	22.8	8.7	0.0	0.0
		Bottom_up	3.0	11.1	14.3	18.1	52.3	0.3	1.0
	*Respect traditions*	Top_Down	1.0	5.7	50.8	29.5	12.4	0.0	0.5
		Hybrid	0.8	4.7	35.4	36.2	22.8	0.0	0.0
		Bottom_up	1.6	8.8	14.2	15.9	58.7	0.1	0.8
Act of Consent	*Compliance*	Top_Down	3.6	9.3	51.8	20.7	13.0	0.0	1.6
		Hybrid	3.9	13.4	43.3	21.3	17.3	0.0	0.8
		Bottom_up	3.4	13.5	36.5	31.1	14.7	0.3	0.5
	*Delegation*	Top_Down	11.9	45.1	21.8	8.8	3.1	2.1	7.3
		Hybrid	9.5	30.7	31.5	11.8	7.1	0.0	9.5
		Bottom_up	11.2	14.4	25.6	28.4	19.1	0.1	1.2
View of Performance	*Responsiveness*	Top_Down	1.6	8.8	43.5	35.2	9.8	0.0	1.0
		Hybrid	3.2	8.7	29.9	36.2	22.1	0.0	0.0
		Bottom_up	2.9	7.5	22.2	23.9	42.9	0.3	0.3
	*Quality*	Top_Down	1.0	10.4	51.8	31.6	4.2	1.0	0.0
		Hybrid	3.9	8.7	35.4	32.3	18.1	0.0	1.6
		Bottom_up	1.4	7.7	27.8	38.9	22.6	0.4	1.2
	*Availability*	Top_Down	1.6	5.2	48.7	42.0	2.1	0.5	0.0
		Hybrid	3.2	6.3	37.0	33.1	19.7	0.8	0.0
		Bottom_up	3.0	17.3	39.7	24.7	14.8	0.1	0.4
	*Reliability*	Top_Down	1.0	7.3	48.2	36.8	3.6	1.0	2.1
		Hybrid	1.6	8.7	38.6	29.9	18.9	0.0	2.4
		Bottom_up	2.0	10.0	33.9	34.9	15.6	0.1	3.5
Legality	*Coordination*	Top_Down	6.7	31.6	38.9	15.0	2.6	2.1	3.1
		Hybrid	6.3	22.8	30.7	18.9	15.8	0.8	4.7
		Bottom_up	2.7	12.0	22.4	30.6	28.2	0.1	4.0
	*Approvals*	Top_Down	5.2	15.5	44.6	20.2	4.2	4.2	6.2
		Hybrid	5.5	18.1	31.5	23.6	15.8	2.4	3.2
		Bottom_up	2.7	10.8	31.3	27.8	16.9	0.4	10.0
	*Participation*	Top_Down	15.0	45.1	22.8	5.7	3.1	3.1	5.2
		Hybrid	8.7	44.9	27.6	8.7	2.4	0.8	7.1
		Bottom_up	22.0	17.3	37.8	16.4	4.6	0.3	1.7
	*Accountability*	Top_Down	22.8	48.7	18.1	2.1	0.5	5.2	2.6
		Hybrid	16.5	47.2	25.2	3.9	1.6	2.4	3.2
		Bottom_up	33.3	22.2	24.1	15.0	4.4	0.1	0.9
	*Formation*	Top_Down	7.8	20.7	46.1	9.8	3.1	5.2	7.3
		Hybrid	7.9	26.0	32.3	13.4	4.7	2.4	13.4
		Bottom_up	5.7	22.1	32.5	20.6	11.6	1.2	6.4
	*External connectivity*	Top_Down	0.5	5.2	53.4	26.9	7.3	1.6	5.2
		Hybrid	1.6	6.3	40.2	28.4	19.7	0.8	3.2
		Bottom_up	6.0	11.6	27.1	33.9	20.0	0.3	1.2

(*): Dw: I do not want to answer, and Dk: I do not know.

Views of justification

The ‘bottom-up’ model scores are higher across all aspects of the ‘views of justifications’ compared to ‘top-down’ and ‘hybrid’ models. These results suggest that a community-based governance structure, as the ‘bottom-up’ model was described in the expert panel, is more attuned to the local context and specific needs and values.

Lack of transparency in all different models is expected in a conflict-affected area such as northwest Syria, according to the expert panel, for many reasons: 1) the income of medical staff supported by NGOs is much higher than most people. So, in an area where the health sector depends mainly on aid and 90% of the people are under the poverty line, organisations tend to keep their financial data discrete. A local term has recently spread to describe people who receive external support as ‘dollars’ receivers. 2) The Syrian regime has criminalised health care workers (HCWs) in the opposition-controlled areas and intentionally attacked health facilities. So, sharing information about health activities, funding sources, partnerships, locations, and HCWs is very risky. 3) In an area that lacks an officially recognised government with many militias, sharing financial information might be dangerous and could expose some of these institutions to armed robbery.

Fairness scored below average in all areas. According to participants in the expert panel, there are several reasons for that: Health services distribution tends to depends more on the security situation rather than on people’s needs. For example, since the military campaign by the Syrian and Russian armies against northwest Syria in 2019 [73], which led to displacing a million people and destroyed 72 health facilities, more than 200,000 people in Al-Zawya mountain had no health facilities. All the attempts by the local health authorities and NGOs to provide health services in this area have failed because of the routine targeting by bombardment of these facilities by the Syrian army just as they open up. Additionally, there is a lack of alignment in general between people’s needs and health and humanitarian aid [28].

Regarding corruption, one of the main challenges in the ‘bottom-up’ area is the weakness of the rule of law and the monopoly of law enforcement by the SSG’s courts. To avoid dealing with these courts and to comply with the red lines drawn by donors regarding dealing with SSG, health institutions tend to handle corruption issues internally. However, the incorruptness indicator in the ‘bottom-up’ area is much better than that of the ‘top-down’ and ‘hybrid’ areas controlled by the SIG and Turkish authorities. The system of courts that emerged in northern Aleppo has no authority over Turkish health facilities; on the other hand, it is unclear to the public if there is an active internal mechanism to combat corruption. According to the participants in the expert panel, the ‘bottom-up’ model has acceptable internal regulatory and customary mechanisms to control corruption, and community oversight is clearer than other models.

The neutrality score in the ‘bottom-up’ area (4.07) is significant; the Idlib population is 3 million, 65% of whom are IDPs. More than a million people live in camps. Many concerns were raised about the hostility of local communities and discrimination against IDPs in other sectors. There are several proposed reasons for this positive result: 1) Entire communities were forcibly displaced by the Syrian regime from several governorates, such as Daraa, Ghouta, Homs and Hama, including their HCWs, to northwest Syria. These HCWs integrated with the local health sector and became part of the service delivery process. 2) The nature of health system governance, which depends on the participation of all health facilities in the elections of the General Assembly and then the Board of Trustees of IHD, allows for the inclusion of various HCWs’ backgrounds in the decision-making process. 3) The majority of people have similar political positions regarding the ongoing war in Syria against the Syrian regime. And 4) there are no significant ethnic and religious differences, as most people are from the same ethnic and religious background. In the ‘top-down’ approach, although displaced HCWs are involved in providing health services, they are not part of the decision-making process, which is concentrated in the hands of Turkish health officials. In addition, there are allegations of discrimination against the Kurdish people in northern Aleppo by the Turkish authorities and the military groups that control the area.

Respect of traditions indicator scored higher in all models than other justification values because most CHWs are from the same community or able to understand its traditions and values.

Acts of consent

Compliance with HCWs’ orders and advice is above average, with no significant differences among governance approaches. This result demonstrates trust in HCWs who gain significant practical experience in dealing with ‘war medicine’, especially trauma cases. However, the expert panel stressed that the HCWs still need a higher level of professional training to handle such emergencies.

When the contribution of society, including the medical community, in selecting medical leaders increases, even if this is imperfect, people feel more confident in the ability of these leaders to express their interests and act on it, according to a participant in the expert panel. This is a possible explanation for the relatively high delegation score in the ‘bottom-up’ approach in Idlib compared to the ‘top-down’ approach in northern Aleppo. In the ‘top-down’ area, people do not have the right to delegate or remove authorisation by any known mechanism, so the score was below average. However, delegating Turkish health authorities is part of a big dilemma in which Turkish authorities play a role in political negotiation as a partner and sometimes a representative of the opposition.

Views of performance

In evaluating the performance of various health systems in northwest Syria in the aftermath of the earthquake, the overall scores of the different health systems were above average. Notably, the ‘bottom-up’ and ‘hybrid systems’ demonstrated similar scores, with 3.62 and 3.61, respectively.

During the immediate emergency response phase, particularly in the initial days following the earthquake, the ‘bottom-up’ approach exhibited an advantageous capability to swiftly mobilise resources and deliver urgent health services, outperforming other health systems in this aspect, with 3.97 and 3.75 in terms of the speed of the health response and the quality of health services. 66.8% of respondents in the areas where the ‘bottom-up’ approach is implemented found the level of effective responsiveness to be above average, with 42.9% indicating a very good response, compared to 58.3% and 45% in areas with a ‘hybrid’ and ‘top-down’ health governance, respectively. In contrast, the hybrid health system demonstrated a relatively better performance regarding the sustained provision of health services (3.60) and the reliability of accurate diagnoses, treatments, and surgical interventions (3.57) in the long-term, surpassing the initial emergency response phase. Almost 52% of respondents perceived the sustainability of health services provided by a ‘hybrid’ system to be ‘good’ or ‘very good’, comparing to 44% for the ‘top-down’ approach and 39.5% for the ‘bottom-up’.

Several factors contribute to these variations across different phases of the earthquake response. The relative flexibility of the ‘bottom-up’ system in being able to promptly assess immediate needs, allocate resources, delegate functions, and to establish direct engagement with local communities proved beneficial in the rapid deployment of humanitarian health assistance [15], circumventing delays associated with centralised decision-making mechanisms typically constraining emergency humanitarian responses in complex crisis contexts. However, our data shows that such flexibility in decision-making capacity may fall short of ensuring the durability and reliability of health services over the long run. Achieving sustained effectiveness necessitates a more comprehensive needs assessment and coordination among responders, including national and international NGOs, as well as adopting long-term policies and procedures that often require a more robust institutional capacity and harmony at the national and sub-national levels. Such requirements are often found in ‘hybrid’ health systems, where the sustainability of health services depends on more centralised management of resources and assessment of long-term needs at the macro level.

Compared to other systems, the ‘top-down’ approach, found in the health governance structures in Azaz, Afrin and al-Bab, for instance, has notably lower scores concerning both the quality of health services dispensed during the initial phase of the emergency response (3.28) and the reliability of such services throughout the subsequent phases of the earthquake response (3.36). According to the experts, the internal patient’s referral in the aftermath of the earthquake was clearly from the ‘top-down’ area to the ‘bottom-up’ area in Idlib, especially for advanced specialised services. This could be attributed to the overreliance of the ‘top-down’ structures on the Turkish health authorities, their main conduit of support, which were institutionally overburdened and overwhelmed by the profound impact of the earthquake on the southern provinces of Turkey, thus impeding the efficacy of the health services provided in the aforementioned regions.

The only indicator in the ‘top-down’ approach overtaking that in the ‘bottom-up’ is the ‘availability’ of health services. According to the expert panel, this is because of the significant hospitals built by Turkey in northern Aleppo. Additionally, transferring patients with complicated diseases, including cancers, for treatment in Turkey is also much easier compared to the ‘bottom-up’ area because the ‘top-down’ area applies the Turkish health system.

Views of legality

Most respondents indicate a level of coordination between health and humanitarian responders that surpasses the average in areas where the ‘bottom-up’ approach to health governance is implemented, with a score of 3.73, closely followed by the hybrid system, which attained a score of 3.16. This can also be linked to the responsive coordination role played by the Health Cluster in Gaziantep in the ‘bottom-up’ area compared to the Turkish health authorities’ role in both ‘top-down’ and ‘hybrid areas’. However, there is uncertainty about the future of the Gaziantep Health Cluster—the central coordination platform for humanitarian aid in northwest Syria. This is because the Syrian regime’s approval for the UN-governed cross-border aid expires on 13 July 2024 [74]. Additionally, ‘The consent model’, where the Syrian regime’s approval of cross-border aid operations is required, is largely unaccepted by the local humanitarian actors [75] and communities [76] due to its unsustainability and vulnerability to different types of aid politicisations.

The pattern is consistent with regard to the indicators of the collaboration between responding entities and local authorities concerning the acquisition of requisite licenses and approvals, with scores of 3.51 and 3.28 for the ‘bottom-up’ and ‘hybrid’ systems, respectively.

These perceptions underscore the pivotal role played by the adaptability of local health actors in mobilising resources and the high level of delegation they had at the onset of the earthquake response, allowing for a better engagement with local health authorities, such as the IHD and the Ministry of Health at SSG. Such engagement has been instrumental in achieving an acceptable level of coordination and collaboration during the emergency phase of responding to the earthquake.

Nevertheless, the consistently lower scores assigned to all health systems in terms of involving the local community in decision-making processes during the initial response phase, coupled with the deficiencies in community-based accountability of responding bodies, indicate persistent inadequacies in good governance capabilities and institutional capacity beyond the immediate provision of health services. Most respondents expressed dissatisfaction with the local health actors’ level of community-based consultations and their transparency in sharing progress and financial reports in an accessible manner. 71.5% of individuals living in areas with the ‘top-down’ health system perceived its accountability to be ‘below average’, 63.7% for the ‘hybrid’ system and 55.5% for the ‘bottom-up’ one, which has relatively more accountability due to the direct engagement with local communities and their representatives, albeit restricted, in the decision-making mechanisms.

Notably, the public perception of the health systems’ external connectivity of all studied areas, such as the abilities to coordinate with international bodies such as the WHO, and to liaise with and secure funding from external donors, both international donor agencies and the diaspora, surpassed the average, with the ‘hybrid’ system receiving the highest score (3.61), closely followed by the ‘bottom-up’ system (3.51), and the ‘top-down’ approach (3.38).

The slightly higher rating of the ‘hybrid’ health system regarding ‘external connectivity’ is due to the flexibility of donors in working with the SIG and its institutions, including the AHD, and coordination with Turkey. However, restrictions exist when working with the SSG, which is a crucial player in the ‘bottom-up’ area. There are no explicit limitations when working with the IHD, which is why 81% of respondents reported having an ‘average’ to ‘above-average’ level of external connectivity in the ‘bottom-up’ area.

Furthermore, the profound impact of the earthquake on particular localities within these areas, such as Genderes and its surroundings, prompted the Syrian diaspora to organise highly effective fundraising campaigns within the first week of the earthquake. According to our respondents, most of these funds were directed towards addressing the specific needs of these affected areas. Additionally, diaspora organisations played a significant role in bridging the gap between donors and local actors, understanding urgent local needs in the aftermath of the earthquake and the first response.

Overall legitimacy

To assess the overall legitimacy under different governance models, two key factors need to be considered: the scores of the HLSI and the perceptions percentage of ‘below average’, ‘average’ and ‘above average’ in each governance area. The ‘bottom-up’ model registered the lowest percentage of ‘below average’ and the highest percentage of ‘above average’ at 34.9 % and 63.6 %, respectively. In contrast, the ‘top-down’ model showed the highest percentage of ‘below average’ and the lowest percentage of ‘above average’ at 78.8 % and 20 %, respectively. The ‘hybrid’ model ranked in the middle, with 63% of perceptions falling under ‘below average’ and 35% under ‘above average’. These figures demonstrate the advantage of the ‘bottom-up’ model in conflict zones in being perceived as more legitimate model.

However, when looking at the HLSI scores, the ‘bottom-up’, ‘hybrid’, and ‘top-down’ models scored 3.18, 2.92, and 2.69, respectively. While the ‘bottom-up’ model outperformed the others, all models scored around the average. This means that perceptions regarding health system legitimacy were slightly ‘above average’ in areas where the ‘bottom-up’ model was implemented. This slight advantage of the ‘bottom-up’ model over others in a highly volatile and unstable region is considered a somewhat muddled advantage. Nonetheless, the health system's legitimacy in all studied areas requires additional efforts to improve it and sustain it. An expert in the expert panel stated that we must consider that the health system in northwest Syria emerged almost from scratch due to the fact that the area was neglected in terms of services even before the conflict. Additionally, the limited existing infrastructure was destroyed by the Syrian regime [77]. Considering this context, according to the expert, we can say that the health sector, especially in the ‘bottom-up’ area, is on the right path to building its legitimacy.

Another point was raised by the experts: legitimate and effective services sectors, notably health and education, can significantly contribute to track two (civil society track) in the political negotiations, peacebuilding activities, exercise of civic virtue, promote social justice, sustain services and play a critical role in the conflict-to-recovery transition.

Our findings emphasise the importance of factoring in legitimacy in the design and evaluation of the health system in fragmented conflict zones. The framework and index that we developed and presented in this paper are designed to capture the legitimacy sources of the health sector using 18 substitutive and constitutive indicators.

Health system design and development in conflict zones have important implications on its legitimacy and subsequently its ability to secure voluntary compliance. The study shows the advantage of the ‘bottom-up’ approach regarding all the legitimacy sources’ indices and the overall legitimacy, emphasising the importance of community-based governance. However, the ‘hybrid’ approach explains slightly supreme concerning long-term response indicators, while the ‘top-down’ approach ranked the lowest in all of the legitimacy indices and indicators.

The study also demonstrates how the role of the health system in conflict zones extends beyond its role in providing health services to becoming an actor representing the community and its needs for the rest of the world and emphasises the virtues of neutrality and fairness in a context that severely lacks them.

Building on these findings, we set out below two sets of recommendations for the design and support of health systems in conflict zones.

First, bottom-up health governance in conflict zones should be encouraged and supported with the resources and tools needed to build its capacity. Community-based governance, in general, should be enhanced since it plays a significant role in improving legitimacy in all governance models. This could include encouraging more democratic mechanisms to represent local communities’ interest in decision-making. Additionally, strengthening the role of diaspora organisations in aiding emerging health systems in conflict zones is another way to enhance community-based governance because of their commitment to local communities’ interests and their ability to understand donors and local community requirements. The Syrian example demonstrated very well this positive role that diaspora organisations could play.

The ‘bottom-up’ health governance however, especially in conflict-affected areas, must improve its capacity to deal with long-term responses to compound crises. This could be achieved through improving strategic vision and planning, improving international partnerships, and ensuring financial sustainability through a context-specific and context-sensitive approach. While it is difficult to guarantee financial sustainability in conflict settings, helping health systems to have a sustainable basic budget and to diversify their resources is essential to ensure the functionality of health governance.

In case of the absence of a legitimate government in place, such as in northwest Syria, emerging health authorities should be encouraged to maintain a neutral position and avoid affiliation with political and military forces. This is important to maintain their role as a key service provider for the entire community and to maintain their key role in coordinating with international organisations and donors.

The ‘top-down’ health systems, such as the Syrian areas under Turkish control, should work on transferring power to local health authorities to foster more localised and responsive health governance.

Since trust has emerged as a key issue that could improve the effectiveness of health systems, it is important to build the system's and its workers' capacity to generate and maintain people’s confidence and trust in the leadership and governance system. There are many ways to do that, including creating and supporting precise accountability mechanisms within the health sector. Additionally, with medical education systems being affected in conflict settings, supporting emerging educational initiatives such as SBOMS and medical colleges would enhance people’s confidence in the medical system.

Second, it is important to build on the role that health systems and health workers play in conflict zones beyond their role in providing health services. Most importantly, benefiting from their legitimacy and neutrality, the health system could play a pivotal role in the peacebuilding process, community dialogue, and the conflict-to-recovery transition.

It is also important to build the capacity of the health system and workers as important upholders of civic virtues such as neutrality and transparency. In that context, it is vital to train them on how to maintain the principle of fairness and participation by giving particular attention to women, children, people with disabilities, IDPs, and minorities, as they are usually the most marginalised groups during conflicts.

Our results however demonstrate how delicate is the issue of maintain transparency and fighting corruption in a conflict zone. So, while transparency and free flow of information should be encouraged, it is key to be mindful of its potential consequences in such context. Information-sharing should not endanger operations or put the safety of HCWs and beneficiaries at risk, which means adopting conflict-sensitive transparency[78]. In the absence of credible national mechanisms for ensuring the rule of law, it is important to develop internal anti-corruption mechanisms within health institutions in conflict zones, particularly in ‘top down’ and ‘hybrid’ models.

Finally, while our study shed light on the role of legitimacy as an important dimension of health governance, we believe that more research should be done to discover possible other dimensions that could improve the efficiency of health systems in conflict zones such as power dynamics. This is a significant dimension where there are multipolar health systems with different governance models, such as the situation in Syria.

- Giving the same weight to the indicators and indices of legitimacy is subjective. Although it is justified in terms of methodology, further studies with different weights depending on the context may be useful.

- In the ‘top-down’ health governance area, the top level is related to foreign authorities (Turkish health institutions), which has an unknown impact on the results and cannot be isolated.

GGIs	Global Governance Institutions
OECD	Organisation for Economic Co-operation and Development
HIS	Health Information System
SBOMS	Syrian Board of Medical Specialists
HDs	Health Directorates
IHD	Idlib Health Directorate
AHD	Aleppo Health Directorate
NGOs	Non-governmental organizations
WHO	World Health Organization
MoH	Ministry of Health
IDPs	Internally Displaced People
GoS	Government of Syria
SSG	Syrian Salvation Government
HTS	Hayat Tahrir al-Sham
LSE	London School of Economics and Political Science
KIIs	Key Informants Interviews
OHAs	Opposition-Held Areas
SIG	Syrian Interim Government
HCWs	Health Care Workforces

Ethical approval and consent to participate

Ethical approval to conduct the survey, stakeholder consultations, expert panels, and workshops was obtained from the Idlib Health Directorate (IHD) in northwest Syria (No: 652 – 25/06/2023). Ethical approval was also obtained from the London School of Economics and Political Science (LSE) (REC ref. 000892b – 03/06/2019). The study ensured that all interviewee quotes remained anonymous.

Consent for publication

Verbal consent was obtained from participants in the questionnaire, and written consent was obtained from participants in the workshops, expert panel and individual consultations. Participants were informed that the findings might be shared and published in academic journals, conferences, or other scientific platforms. Their personal information and identity remain confidential, and all necessary steps were taken to ensure anonymity and privacy. The results were presented in an aggregated and anonymised format to protect participant privacy. By providing consent, participants agreed to disseminate and publish study findings while ensuring confidentiality and privacy.

Availability of data and materials

The research team cannot currently share the dataset used in this study due to constraints imposed by the Health Directorate in Idleb, which facilitated the survey process. The Directorate has requested that the data remain confidential. Future data-sharing procedures will strictly adhere to ethical considerations and relevant data policies guidelines. For inquiries about accessing the dataset once it becomes available for sharing, interested parties can contact the corresponding author, Munzer Alkhalil, for further details.

Competing interest

The authors declare that they do not have any recognised competing financial interests or personal relationships that could have appeared to impact the work reported in this manuscript.

Funding statement

This publication is funded mainly through the Foreign, Commonwealth and Development Office (FCDO) (c-13546243), Peace and Conflict Resolution Evidence Platform (PeaceRep), using UK aid from the UK Government. Additionally, the data collection work is funded partially by the National Institute for Health Research (NIHR) (131207), Research for Health Systems Strengthening in Syria (R4HSSS), also using UK aid from the UK Government. The views expressed in this publication are those of the author(s) and do not necessarily reflect those of the FCDO, NIHR or the UK government.

Authors’ contributions

This study was a collaborative effort by multiple authors. MAK was responsible for the initial conceptual framing, literature review, organising training workshops, supervising the data collection process, coordinating the expert panel, initial drafting of the paper, multiple rounds of edits, and producing the final manuscript. RT contributed to the initial conceptual framing based on her Turkmani framework, overall structuring of the paper, literature review, editing, and producing the final draft. MG contributed to the overall development of the paper, profiling of the different areas, analysis, and producing the final draft. PP contributed to the reviewing, editing and producing the final draft. ZM contributed to developing the Health Sector Legitimacy Index, data collection, data analysis, and producing the final manuscript. All authors read, edited, and approved the manuscript.

Acknowledgement

We would like to acknowledge the Research for Health System Strengthening in Syria (R4HSSS) project, Idlib Health Directorate (IHD) and Health Information System Unit for their role in facilitating and collecting data from Syria. We acknowledge Dr Zedoun Alzoubi for participating in two workshops as a governance expert. We acknowledge Dr Abdulhakim Ramadan for his role in the consultancies. We also acknowledge the data-collecting team: Hasan Alderwish, Bashar Kattiea, Amnaa Alkhaled, Mohammad Almousa, Abdul Hadi Shabaan, Maram Rajab, Omar Habboush, Abdulhaseb Alkdro, Abdulhaseb Alkdro, Ahmad Alhamdo, Rana Dada and Buthaina Halak.

Authors' information

Many authors of this paper are Syrians who have been involved in the legitimacy and governance discussions at political and operational levels since the start of the conflict in 2011. The lead author, MAK, co-founded several quasi-hybrid health governmental institutions and hospitals in northwest Syria, including the Idlib Health Directorate (IHD), the Health Information System Unit, the Forensic Medicine Unit, the Drugs Control Unit, The Health Central Coordination Body, and Referral System. He headed the IHD between 2011 and 2020. Additionally, RT, ZM and MG have an active role in the ongoing political negotiations under the international community umbrella as representatives of the Syrian civil society. As such, Syrian authors bring direct experience and understanding of different health governance models in the area and their legitimacy sources. PP brings a critical external perspective and enhances the paper's academic rigour, drawing from her extensive experience in health systems and governance research.

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The five composite indices represent continuous variables ranging from 1 to 5, with 1 indicating very poor and 5 signifying very good. This differs from the ordinal categorical variables that represent the 18 indicators. Thus, we consider any indices value below 3 as ‘below average’, while values above 3 are classified as ‘above average’, and a value of 3 is assigned as ‘average’.

No competing interests reported.

Questionnairlegitimacyandhealth.docx

Capturing sources of health system legitimacy in fragmented conflict zones under different governance models. A case study of northwest Syria

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Abstract

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Key Messages

1. Introduction

2. Contextual background

3. Study methodology

4. Results

5. Discussion

6. Conclusion and Recommendations

7. Limitations

Abbreviations

Declarations

References

Footnotes

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1