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.

BackgroundTeaching Evidence Based Medicine (EBM) is becoming a priority in the healthcare process. For undergraduates, it has been proved that integrating multiple strategies in teaching EBM yields better results than a single, short-duration strategy. However, there is a lack of evidence on applying EBM educational interventions in developing countries. In this study, we aim to evaluate the effectiveness of a multiple strategy peer-taught online course in improving EBM awareness and skills among medical students in two developing countries, Syria and Egypt.MethodsWe conducted a prospective study with pre- and post- course assessment of 84 medical students in three universities, using the Berlin questionnaire and a set of self-reported questions which studied the students’ EBM knowledge, attitude and competencies. The educational intervention was a peer-taught online course consisting of six sessions (90 min each) presented over six weeks, and integrated with assignments, group discussions, and two workshops.ResultsThe mean score of pre- and post-course Berlin tests was 3.5 (95% CI: 2.94–4.06) and 5.5 (95% CI: 4.74–6.26) respectively, increasing by 2 marks (95% CI: 1.112–2.888; p-value <0.001), which indicates a statistically significant increase in students’ EBM knowledge and skill, similar to a previous expert-taught face to face contact course. Self-reported confidences also increased significantly. However, our course did not have a major effect on students’ attitudes toward EBM (1.9–10.8%; p-value: 0.12–0.99).ConclusionIn developing countries, multiple strategy peer-taught online courses may be an effective alternative to face to face expert-taught courses, especially in the short term.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-017-0924-1) contains supplementary material, which is available to authorized users.

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ObjectivesTo provide an overview of the holistic impact of the armed conflict on medical education and health professionals’ training (MEHPT) in Syria.SettingSyria is a country which underwent an armed conflict for 10 years and suffered from the weaponisation of health.MethodsA mixed-methods systematic review including quantitative, qualitative, mixed-methods and textual literature between 2011 and 2021 including papers on the Syrian MEHPT undergraduate and postgraduate education and training personnel (including medicine, dentistry, pharmacy, nursing, midwifery and allied health professionals). The electronic search was conducted in October 2018 in Embase, Global Health, Medline, PsycINFO, Web of Science, PubMed, Scopus, CINAHL and grey literature. And an update to the search was conducted in August 2021 in PubMed, Google Scholar and Trip database.OutcomesThe impact of conflict on the MEHPT system, personnel, experiences, challenges and channels of support.ResultsOf the 5710 citations screened, 70 met the inclusion criteria (34 quantitative, 3 qualitative, 1 mixed-method, and 32 reports and opinion papers). The two major cross-cutting themes were attacks on MEHPT and innovations (present in 41% and 44% of the papers, respectively), followed by challenges facing the MEHPT sector and attitudes and knowledge of trainees and students, and lastly health system and policy issues, and narrating experiences.ConclusionConflict in Syria has politicised all aspects of MEHPT. Influenced by political control, the MEHPT system has been divided into two distinguished geopolitical contexts; government-controlled areas (GCAs) and non-GCAs (NGCAs), each having its characteristics and level of war impact. International and regional academic institutes collaboration and coordination efforts are needed to formulate educational platforms using innovative approaches (such as online/blended/store-and-forward/peer-training/online tutoring) to strengthen and build the capacity of the health workforce in conflict-affected areas.

Background The COVID-19 pandemic has escalated the use of telemedicine in both high and low resource settings however its use has preceded this, particularly in conflict-affected settings. Several countries in the WHO Eastern Mediterranean (EMR) region are affected by complex, protracted crises. Though telemedicine has been used in such settings, there has been no comprehensive assessment of what interventions are used, their efficacy, barriers, or current research gaps. Main body A systematic search of ten academic databases and 3 grey literature sources from January 1st 2000 to December 31st 2020 was completed, identifying telemedicine interventions in select EMR conflict-affected settings and relevant enablers and barriers to their implementation. Included articles reported on telemedicine use in six conflict-affected EMR countries (or territories) graded as WHO Health Emergencies: Afghanistan, Gaza, Iraq, Libya, Syria and Yemen. Data were extracted and narratively synthesised due to heterogeneity in study design and outcomes. Of 3419 articles identified, twenty-one peer-reviewed and three grey literature sources met the inclusion criteria. We analysed these by context, intervention, and evaluation. Context: eight related to Afghanistan, eight to Syria and seven to Iraq with one each in Yemen and Gaza. Most were implemented by humanitarian or academic organisations with projects mostly initiated in the United States or Europe and mostly by physicians. The in-country links were mostly health professionals rather than patients seeking specialist inputs for specialities not locally available. Interventions: these included both SAF (store and forward) and RT (real-time) with a range of specialities represented including radiology, histopathology, dermatology, mental health, and intensive care. Evaluation: most papers were observational or descriptive with few describing quality measures of interventions. Conclusions Telemedicine interventions are feasible in conflict-affected settings in EMR using low-cost, accessible technologies. However, few implemented interventions reported on evaluation strategies or had these built in. The ad hoc nature of some of the interventions, which relied on volunteers without sustained financial or academic investment, could pose challenges to quality and sustainability. There was little exploration of confidentiality, ethical standards, data storage or local healthcare worker and patient acceptability.

Purpose: A group of Arab-American physicians and researchers in the United States organized a blended online course in academic writing and publishing in medicine targeting medical students and physicians in war-torn Syria. This was an effort to address one of the reasons behind the poor quantity and quality of scientific research papers in Syria and the Arab region. In this paper, we report on the design, conduct, and outcome of this course and attempt to evaluate its effectiveness. Methods: The educational intervention was a 2-month blended online course. We administered a questionnaire to assess satisfaction and self-reported improvement in knowledge, confidence, and skills of academic writing and publishing. Results: The course succeeded in reaching more than 2588 physicians and medical students from the region; 159 of them completed most of the course. Eighty-three percent of the participants felt that they were confident enough to write an academic paper after the course and 95% felt the learning objectives were achieved with an average student satisfaction of 8.4 out of 10. Conclusion: Physicians in Syria and neighboring countries are in need of training to become an active part of the global scientific community and to document and communicate the crisis their countries are going through from a medical perspective. Low-cost online educational initiatives help respond, at least partially, to those needs.

Background Syria has witnessed more than a decade of armed conflict through which healthcare workers and facilities have not only been affected, but targeted. Amidst this targeting of healthcare workers, subsequent displacement, and ‘weaponization’ of healthcare, the medical education and health professional training (MEHPT) of those that remain has split into at least two distinctive contexts: government controlled, and non-government controlled. Efforts to rebuild MEHPT in light of this polarisation and fragmentation have led to a new MEHPT system in non-government controlled northwest Syria, that functions through what we describe as a ‘hybrid kinetic model’. This mixed-methods study provides an in-depth analysis of this MEHPT system as a case study to inform future policy planning and interventions in the context of future post-conflict health workforce development. Methods We used mixed methods to investigate the state of MEHPT in northwest Syria during September 2021 and May 2022. This included a) Stakeholder analysis, b) 15 preparatory experts consultations c) 8 Focus group discussions d) 13 Semi-structured interviews e) 2 Questionnaires and f) Validation workshops. Results We identified three main categories of key stakeholders working on MEHPT in northwest Syria: 12 newly established academic institutions, 7 local governance authorities involved in MEHPT, and 12 non-governmental organisations (NGOs). The MEHPT system operated through these stakeholders in a three-layer system to provide undergraduate and postgraduate MEHPT. In the first, top, layer, external NGOs and donors hold the strongest capacity at the expense of relatively under resourced internal governance in the second, middle, level. In the third, bottom, level, local academic bodies operate. We uncovered several levels of challenges facing these stakeholders including governance challenges, institutional challenges, individual challenges, and political challenges. Despite these challenges, participants in our study highlighted significant opportunities within the MEHPT system and that MEHPT can be a peace building pillar for the community. Discussion To our knowledge, this is the first paper that provides an in-depth situational analysis of the MEHPT system in a conflict setting while engaging the voice of local key stakeholders. We found that local actors in MEHPT in non-government controlled northwest Syria have made efforts towards (re)building a new, hybrid and kinetic MEHPT system, through a bottom-up approach. Despite these efforts, the MEHPT system remains fragile and polarised, suffering from several levels of challenges with limited involvement of internal governance. Building on our findings, to improve this approach and build bridges of trust among stakeholders and the MEHPT community, further studies are needed to determine feasible approaches to increasing the role of internal governance structures in the MEHPT system through: 1-Formalisation of efforts through establishing a MEPHT technical coordination unit. 2-Further shifting of power from external supporting NGOs and funders to internal governance structures. 3- Working towards achieving sustainable long-term partnerships.

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