Inclusive online health governance and equity research during protracted multiparty conflict in Syria

Abstract

Our approach to inclusive health research collaboration and respectful engagement in identifying and developing effective health system interventions is grounded in decolonising health research methodologies and global health approaches. This includes employing early career researchers from affected communities in Syria who are trained and supported to lead in designing, implementing, and disseminating research. By opening academic career pathways through lead/co-authoring articles and book chapters, co-developing grant proposals, engaging with donors and media, and conducting bilingual English-Arabic training and dissemination events, we build research capacity in Syria and within the refugee diaspora. This strengthens our research by necessitating relevance for affected communities, significantly increasing access and engagement with participants, and ensuring sensitivities and nuances of lived experiences, language, and conflict dynamics are highlighted and preserved.

Introduction

SyRG was founded by London-based refugees Yazan Douedari and Mervat Alhaffar at the London School of Hygiene and Tropical Medicine (LSHTM). Both were born and educated in Syria and provided health services during the Syrian uprising and conflict. Natasha Howard, Associate Professor at LSHTM and National University of Singapore School of Public Health (SPH), provides guidance and mentoring. 

Both Yazan and Mervat lead SyRG research and advocacy alongside with A/Prof Howard and a diverse network of student and non-aligned volunteers. Limited funding has enabled considerable creativity in developing a diverse and flexible research network, transferring skills to researchers in Syria, co-producing research outputs, sustaining engagement with study communities, and ensuring ongoing development of innovative and respectful remote research methodologies.

Context

In 2011, an uprising in Syria met with violent government responses and morphed into a complex, multi-party conflict that has severely damaged the country, now categorized by the World Bank as a low-income economy. In 2021, estimates showed over 90% of the population lived under the poverty line due to economic fragility influenced by corruption, protracted conflict, sanctions, currency inflation, and deficiencies of primary commodities. Conflict has fragmented Syria’s health system across approximately three main territories, each with its own healthcare approaches and services. 

Despite considerable humanitarian and academic interest, most research efforts were led by non-Syrians with minimal understanding of the socio-political context, relying on 'experts' and key informants based outside the country. Research did not include women's perspectives or those within marginalized communities. To counteract this, we examined health system governance through WhatsApp-based discussions with primarily mid-level and frontline staff and service users in Syria who are directly affected by changes in health services delivery. 

Most previous health system research focused on rebuilding after conflict, increasingly including the concept of ‘resilience’. However, many different interpretations of ‘resilience’ and ‘post-conflict’ exist: while important, such approaches generally do not consider grassroots responses that arise during protracted conflicts or how these could be leveraged to improve the effectiveness of post-conflict rebuilding and strengthening efforts. 

During the 2020 COVID-19 pandemic, we founded SyRG and expanded to examining outbreak response governance and experiences among displaced communities and women in healthcare spaces, retaining our focus on the frontline voices other research groups did not generally include. We seek to implement and promote rigorous, primarily remote, research that engages Syrians, credits 'local' efforts, and works to mitigate the risks and traumas participants.

The Initiative

We created the Syria Research Group (SyRG) as a loosely networked team of primarily Syrian, early career health system researchers co-hosted by the London School of Hygiene & Tropical Medicine (LSHTM) in the UK and the National University of Singapore Saw Swee Hock School of Public Health (SPH) in Singapore. Founded in 2020 by Yazan Douedari, Mervat Alhaffar, and Natasha Howard, SyRG focuses on rigorous interdisciplinary health policy and systems research within Syria and its regional neighbours. We are expanding our research to related projects within the region and among Syrian refugee and diaspora communities. We rely on strong networks of Syrian researchers, health professionals, and volunteers inside and outside Syria, to whom we are indebted for their efforts and interest. We consider our team development and research methodology to be unique among health systems researchers in Syria and the region, focusing on non-exploitative and sustained engagement within the team and in our research. We benefit displaced and marginalized communities in Syria through engagement with health system practitioners in health system governance strengthening, providing a model approach for other researchers interested in conducting more equitable research in Syria or other conflict-affected countries and enabling healthcare providers and service-users to access relevant health information. 

Our approach was triggered by our frustration with 'parachute research' approaches. As Syrians and researchers, we observed too many nuances related to the nature of the Syrian context were dismissed or considered insufficiently important. Such research lacked depth and gave a misleading impression of Syrians' circumstances, experiences, and perspectives. Our small-scale, capacity-building, and sustainably engaged 'slow research' approach is considerably different to typical competitive research approaches, and while it is intrinsically rewarding, we have experienced challenges – primarily due to the limited funding opportunities currently available for this type of research. 

SyRG is not the first research group to attempt to reduce 'neocolonial' global health research exploitation - rather, we are adopting and adapting best-practice equitable and decolonial research methodologies in our ongoing aim to challenge exploitative 'parachute research' approaches that work 'on' rather than 'with' affected individuals, communities, and populations.

Engagement

Engagement with research participants in affected communities, health service users, frontline health service providers, and other traditionally overlooked stakeholders is a key focus of our approach. Every research project is informed and guided by an advisory committee of interested Syrian health professionals, researchers, NGO workers, and laypeople. We ensure findings from our studies are shared with study co-authors and disseminated to affected communities. In particular, we used funding from the UK Medical Research Foundation’s Changing Policy and Practice Award to translate our published research and recent updates into Arabic to make it accessible to both the Syrian public and decision-makers in the country, contributing to efforts to decolonize global health research. We post regular bilingual blogs on our website, in Arabic and English, targeting the general public in Syria with contextualized health advice, and national and international humanitarian decision-makers to advocate policy changes based on research findings. We regularly update our bilingual Twitter and Facebook pages to further disseminate research findings and advocate improvements based on research recommendations and conduct quarterly webinars with international decision-makers (e.g. donors, humanitarian agencies, non-governmental organizations) and influential local actors (e.g. local health authorities, community leaders) to advocate research recommendations and further findings related to supporting displaced, marginalized, and under-served communities.

Impact

We have increased awareness of the complexities of the Syrian conflict and the impact Syrians have experienced in their health services. Our aim is for patients and affected communities to benefit from a strengthened, more equitable, and reintegrated health system rather than the fragmented, under-resourced, and brutally targeted systems they currently rely upon. In the interim, we document the experiences of healthcare workers and service users within these systems, highlight 'street-level' governance initiatives, and contribute contextually embedded recommendations to help build equitable health systems. We are collecting metrics to evidence the impact of our formal engagement activities using attendee feedback and increased awareness. We hope to develop decolonial monitoring/evaluation tools, as proposed by members of affected communities, to measure the value of our work in terms of effectiveness, efficiency, ethics, and humanity principles. 

However, it is likely we will need to do considerably more to raise the profile of team and of our work. Our approach could be implemented more widely within our respective institutions or across others. We have already seen other researchers drawing on our remote interview methods, hiring researchers who speak the same language as study participants, including psychological support funding for traumatized research participants, and other elements of our approach. If done consistently, this could help improve the equity of global health research.