Rebuilding health in Syria: from fragmentation to functional recovery

Syria’s health sector is emerging from a decade of conflict with a system marked by uneven damage, chronic under-investment, and fragmented governance. However, the picture is not totally bleak. A recent Health Systems Global (HSG) Thematic Working Group (TWG) Health Systems in Fragile and Conflict Affected Settings (FCAS) webinar - The Future of the Health Sector in Syria - brought together policymakers, practitioners, and researchers who described real momentum toward integration, a PHC-first model of care, and a pragmatic path to universal health coverage (UHC). This blog post reflects on the key messages, tensions, and practical priorities that surfaced across presentations and the discussion.

What is changing - and what is not
Several overarching themes emerged during our session.
• Uneven functionality: Public hospitals and primary health care (PHC) facilities remain only partially functional, with PHC the weakest link relative to UHC ambitions. Damage to utilities - electricity, water, roads, connectivity -compounds clinical challenges and varies widely by governorate.
• Returns reshape demand: Aleppo, Rural Damascus, and Damascus are experiencing significant returns of people who had fled the country. Recovery planning must anticipate localized surges in need and the knock-on effects across referral networks and supply chains.
• Workforce attrition and slow return: A large proportion of the health workforce left Syria during the conflict. Returns of these workers are gradual and depend on salaries and “enablers” (housing, utilities, schools). Maldistribution of the workforce is acute; urban hubs attract staff while rural and hard-to-reach areas lag behind.
• Fragmented information systems: Multiple parallel reporting lines and databases - humanitarian, development, local directorates, and private sector - mirror contested authority across the country. Without trust and alignment, country-wide planning remains guesswork.
• Financing gaps: Humanitarian appeals remain significantly underfunded. Meanwhile, system-wide costing for recovery and reform is only beginning to crystallize.
Amid these constraints, speakers highlighted signs of coordinated improvements: a two-year, seven-pillar national health sector strategy; a government-led UHC Compact process; active inter-ministerial cooperation, and a stronger emphasis on data-driven decision making.

Protect PHC and the referral spine
Before the conflict, Syria had a large PHC sector. Much of that network is now degraded, but the institutional memory remains alongside a successful example of integrated PHC network in Northwest Syria during the conflict . A practical recovery strategy should:
• Define and cost an Essential Package of Health Services (EPHS) centred on PHC but explicitly linked to secondary care and emergency/ambulance services.
• Standardize community health platforms introduced during the crisis (which filled critical gaps) and support them with standardised tools, supervision, and data flows.
• Reconstruct health facilities with utilities —bundling power, water, and connectivity into facility packages rather than addressing buildings alone.
• Strengthen referral and transport mechanisms so PHC can function as a point of entry, not a dead-end.
If PHC is not protected there is the very real risk of an expansion of unregulated, urban-centric private care, rising out-of-pocket spending, and widening inequities.

Stabilize the workforce where people live
Maldistribution of the health workforce, not just a shortage of staff, is a major challenge. The panel agreed on several priorities:
• Harmonize pay scales and incentives across donor programmes to reduce bidding issues and dual practice, with targeted incentives for underserved areas.
• Standardize scopes of practice and competency definitions (e.g. what “nurse” or “midwife” means in practice) to support safe task-sharing and mobility.
• Scale up existing programmes - training cohorts (e.g. MH-GAP , psychological first aid, emergency and non-communicable disease (NCD) care). Train trainers to quickly expand the reach of these programs.
• Enable local directorates - authority should be delegated, with clear lines of accountability, allowing staffing decisions to respond to local realities.

Finance the transition: predictable, phased, and pro-equity
We heard that there is a movement toward a UHC Compact led by the Ministry of Health and Ministry of Finance, with external partners supporting. The emerging logic is pragmatic sequencing:

1. Start with the most vulnerable to protect against catastrophic health expenditure.
2. Pilot with civil servants or defined groups to test purchasing and provider payment while building administrative capacity.
3. Pool and purchase - strategically-aligned public, NGO, and private providers should pool efforts to deliver the EPHS at defined quality and cost.
4. Grow predictably as fiscal space, systems, and trust expand.
   For donors and development banks, this implies shifting from short-cycle programming to multi-year, on-budget or para-fiscal support that ring-fences PHC, immunization, essential medicines (notably oncology and NCDs), and laboratory networks.

Coordination is not décor - it's the load-bearing wall
With more than a hundred active partners in the Syrian health system, coordination fatigue is real. However, the alternative is duplication of effort in cities and gaps in rural districts. The webinar generated several recommendations to achieve more effective coordination:
• Government-led, inclusive platforms that bring together line ministries, UN agencies, NGOs, private sector, and diaspora groups.
• Shared “rules of the road” for data, pay scales, procurement, and monitoring —light enough to implement, strong enough to matter.
• Trust-first tactics: build around what already functions locally. Publish decisions and data transparently, while changing slowly and predictably.
The Humanitarian-Development-Peace (HDP) nexus is not a slogan. It is the only way to sequence recovery amid persistent hazards, economic constraints, and political complexity.

Data governance is political governance
One clear thread emerged - information confers power. Who collects data, who can access it, and who benefits from it are political questions as much as technical ones. During the conflict and across many regions, competing authorities, cross-border influences, and donor reporting requirements produced multiple overlapping workforce and facility databases, each a locus of control. Attempts to centralize such information without trust tended to fail.

This suggests a need to start rebuilding with functional coordination rather than structural consolidation. A minimal common indicator set should be agreed, as should a shared facility and workforce registry. Privacy must be protected, and integration should be fostered amongst local actors who already perform reliably. The ongoing consolidation of Early Warning, Alert, and Response System (EWARS) and Early Warning, Alert, and Response Network (EWARN) toward IDSR (Integrated Disease Surveillance and Response) is an important objective.

Six priorities to act on now

1. Establish EPHS with costings and align partner purchasing and reporting. Protect community health and referral/ambulance services as critical enablers.
2. Stabilize the workforce through harmonized pay bands, rural incentives, standardized scopes of practice, and scaled bridging programs (MH-GAP, emergency, NCDs).
3. Bundle utilities with facility reconstruction (power, water, connectivity) and prioritize sites in return areas to match real demand.
4. Secure predictable multi-year financing tied to milestones (PHC functionality, coverage, and quality) rather than inputs alone.
5. Institutionalise inclusive coordination, ensuring it is government-led, evidence-driven, and transparent, and enable 120+ actors to move in one direction.
6. Adopt a national core indicator set and create a unified, versioned facility and HRH registry. Complete EWARS/EWARN integration into one platform (IDSR) and expand event-based surveillance.

A realistic optimism
The discussion did not minimize risk. Many hazards identified in recent risk assessments remain, e.g. returns will strain already weak systems, and financing gaps persist. Nevertheless, there is credible movement, with evidence of government ownership, inter-ministerial cooperation, a near-term health sector strategy, early recovery mechanisms, and a UHC Compact process.
The ultimate objective is clear enough to align action: a PHC-first, data-informed, and financially realistic health system that Syrians can access and trust. Getting there will not be a linear process - it rarely is - but with functional governance, predictable financing, and disciplined coordination, recovery can shift from aspiration to operating routine.

Where this conversation goes next
• We expect partners to share the forthcoming two-year national health sector plan and UHC Compact details widely and align partner portfolios accordingly.
• Convene a follow-up session with Ministry of Health participation to translate the priorities identified into phased implementation and monitoring.

Recovery is not only about rebuilding what was lost. It is about building what is needed now – a fair, resilient health system that is fit for the Syria that is re-emerging. Nevertheless, we are aware that health can only be improved if there is multi-system resilience, based on sustained peace and security all over the country.

Image: A doctor attends to a young patient in Tel Samen displacement camp in Northern Syria. © European Union, 2023 via Flickr