Background: Ongoing conflict and systematic targeting of health facilities and personnel by the Syrian regime in opposition-controlled areas have contributed to health system and governance mechanisms collapse. Health directorates (HDs) were established in opposition-held areas in 2014 by the interim (opposition) Ministry of Health (MoH), to meet emerging needs. As the local health authorities responsible for health system governance in opposition-controlled areas in Syria, they face many challenges. This study explores ongoing health system governance efforts in 5 oppositioncontrolled areas in Syria. Methods: A qualitative study design was selected, using in-depth key informant interviews with 20 participants purposely sampled from HDs, non-governmental organisations (NGOs), donors, and service-users. Data were analysed thematically. Results: Health system governance elements (ie, strategic vision, participation, transparency, responsiveness, equity, effectiveness, accountability, information) were considered important, but not interpreted or addressed equally in opposition-controlled areas. Participants identified HDs as primarily responsible for health system governance in opposition-controlled areas. Main health system governance challenges identified were security (eg, targeting of health facilities and personnel), funding, and capacity. Suggested solutions included supporting HDs, addressing health-worker loss, and improving coordination. Conclusion: Rebuilding health system governance in opposition-controlled areas in Syria is already progressing, despite ongoing conflict. Local health authorities need support to overcome identified challenges and build sustainable health system governance mechanisms.

ObjectivesTo explore health-worker perspectives on security, improving safety, managing constrained resources and handling mass casualties during besiegement in Syria.DesignA qualitative study using semi-structured key informant interviews, conducted remotely over WhatsApp and Skype, and analysed thematically using inductive coding.SettingSecondary and tertiary health facilities affected by besiegement in Aleppo (from July to December 2016) and Rural Damascus (from August 2013 to February 2018).ParticipantsTwenty-one male Syrian health-workers and service-users who had experienced besiegement and targeting of their health facilities.ResultsParticipants described four related challenges of: (i) conflict-related responses, particularly responding to mass casualties; (ii) targeted attack responses, particularly preventing/surviving facility bombings; (iii) besiegement responses, particularly mitigating severe resource constraints; and (iv) chronic risk responses, particularly maintaining emotional resilience. Mass casualty response involved triage and training to prioritise mortality reduction and available resources, for example those with greatest need and likelihood of survival. Targeting response was largely physical, including fortification, working underground, reducing visibility and services dispersal. Besiegement response required resource conservation, for example, controlling consumption, reusing consumables, low-technology equipment, finding alternative supply routes, stockpiling and strengthening available human resources through online trainings and establishing a medical school in Ghouta. Risk responses included managing safety worries, finding value in work and maintaining hope.ConclusionBesieged health-workers were most affected by severe resource constraints and safety concerns while responding to overwhelming mass casualty events. Lessons for targeting/besiegement planning include training staff and preparing for: (i) mass casualties, through local/online health-worker training in triage, emergency response and resource conservation; allowing task-shifting; and providing access to low-technology equipment; (ii) attacks, through strengthened facility security, for example, protection and deterrence through fortification, working underground and reducing visibility; and (iii) besiegement, through ensuring access to internet, electricity and low-technology/reusable equipment; securely stockpiling fuel, medicines and supplies; and establishing alternative supply routes.

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