Conducting health research in conflict-affected areas and other complex environments is difficult, yet vital. However, the capacity to undertake such research is often limited and with little translation into practice, particularly in poorer countries. There is therefore a need to strengthen health research capacity in conflict-affected countries and regions.In this narrative review, we draw together evidence from low and middle-income countries to highlight challenges to research capacity strengthening in conflict, as well as examples of good practice. We find that authorship trends in health research indicate global imbalances in research capacity, with implications for the type and priorities of research produced, equity within epistemic communities and the development of sustainable research capacity in low and middle-income countries. Yet, there is little evidence on what constitutes effective health research capacity strengthening in conflict-affected areas. There is more evidence on health research capacity strengthening in general, from which several key enablers emerge: adequate and sustained financing; effective stewardship and equitable research partnerships; mentorship of researchers of all levels; and effective linkages of research to policy and practice.Strengthening health research capacity in conflict-affected areas needs to occur at multiple levels to ensure sustainability and equity. Capacity strengthening interventions need to take into consideration the dynamics of conflict, power dynamics within research collaborations, the potential impact of technology, and the wider political environment in which they take place.

Despite lacking capacity and resources, the health system in the northwest Syria is using innovative approaches for the containment of COVID-19. Lessons drawn from previous outbreaks in the region, such as the polio outbreak in 2013 and the annual seasonal influenza, have enabled the Early Warning and Response Network, a surveillance system to develop mechanisms of predicting risk and strengthening surveillance for the new pandemic. Social media tools such as WhatsApp are effectively collecting health information and communicating health messaging about COVID-19. Community engagement has also been scaled up, mobilizing local resources and encouraging thousands of volunteers to join the ‘Volunteers against Corona’ campaign. Bottom-up local governance technical entities, such as Idleb Health Directorate and the White Helmets, have played key leadership role in the response. These efforts need to be scaled up to prevent the transmission of COVID-19 in a region chronically affected by a complex armed conflict.

Without healthcare workers (HCWs), health and humanitarian provision in Syria cannot be sustained either now or in the post-conflict phase. The protracted conflict has led to the exodus of more than 70% of the healthcare workforce. Those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. For many HCWs, particularly those in non-government-controlled areas (NGCAs) of Syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. In this manuscript, we explore initiatives present in north west Syria at both undergraduate and postgraduate level for physician and non-physician HCWs. Conclusion: Challenges to HCW education in north west Syria can be broadly divided into 1. Organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. Programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. Healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) Locally implementable strategies including dedicated funding are key to supporting retention of HCWs and return during post-conflict reconstruction.

Background In a growing number of humanitarian crises, “remote management” is negotiated across borders and implemented by humanitarian agencies through “local actors” to deliver assistance. However, the narrative describing the involvement of local actors in the delivery of humanitarian aid in armed conflict settings remains reductionist and unreflective of the complex and circular course of the “localisation of aid”. This paper explores cross-border humanitarian assistance within the Syrian conflict. We document how humanitarian actors operate to deliver humanitarian health care in North-West Syria (Turkish border), explore their challenges and critique the language used within current debates on the localisation of aid. Methods We undertook key informant interviews with Turkey-based humanitarian aid professionals involved in the humanitarian health response inside Syria. We integrated data previously collected for The Lancet -American University of Beirut Commission on Syria during field work in Gaziantep, Turkey, through meetings, conversations, discussions and expert consultations with Syrian health professionals, WHO-Turkey staff members and members of Syrian health directorates. We also drew from background desk reviews conducted by the Commission on health systems responses and timeline of events in Turkey during the Syrian conflict. Results This paper uncovers creative and effective bottom-up strategies that enhanced cross-border coordination of aid delivery into Syria. Our findings unravel the key role played by Syrian providers in accessing vulnerable populations and in reshaping coordination and funding mechanisms inside Syria, as well as the disproportionate risks local actors bear within the response. Our findings also reveal an iterative negotiation of decision-making dynamics, a “low-profile approach” promoted to gain access to populations of concerns, and an environment that is heavily shaped by close interpersonal relationships and social trust. Conclusions Our multifaceted narrative unpacks circular flows of interactions among actors and uncovers strategies developed by practitioners on the field, which are often left undocumented. We argue that there is an opportunity for the humanitarian sector to learn from these synergies to rethink how medical humanitarianism is framed (hopefully leading to a more collaborative framing that resists mainstreaming “local” actors within a “traditional” system). There is also an opportunity for the humanitarian and global health communities to reflect on how value attributed to human lives needs to be questioned in contexts where national staff face a disproportionate risk to deliver aid.

Background Armed conflicts are known to have detrimental impact on availability and accessibility of health services. However, little is known on potential impact on utilisation of these services and health seeking behaviour. This study examines whether exposure to different types of war incidents affected utilisation of key health services—outpatient consultations, antenatal care, deliveries, and C-sections, in conflict affected areas of north west Syria between 1 October 2014 and 30 June 2017. Methods The study is an observational study using routinely collected data of 597,675 medical consultations and a database on conflict incidents that has 11,396 events. Longitudinal panel data analysis was used with fixed effect negative binomial regression for the monthly analysis and distributed lag model with a lag period of 30 days for the daily analysis. Results The study found strong evidence for a negative association between bombardments and both consultations and antenatal care visits. The monthly Risk Ratio was 0.95 (95% CI 0.94–0.97) and 0.95 (95% CI 0.93–0.98); and the cumulative daily RR at 30 days was 0.19 (95% CI 0.15–0.25) and 0.42 (95% CI 0.25–0.69) for consultations and antenatal care respectively. Explosions were found to be positively associated with deliveries and C-sections. Each one unit increase in explosions in a given month in a given village was associated with about 20% increase in deliveries and C-sections; RR was 1.22 (95% CI 1.05–1.42) and 1.96 (95% CI 1.03–3.74) respectively. Conclusion The study found that access to healthcare in affected areas in Syria during the study period has been limited. The study provides evidence that conflict incidents were associated negatively with the utilisation of routine health services, such as outpatient consultations and antenatal care. Whereas conflict incidents were found to be positively associated with emergency type maternity services—deliveries, and C-sections.