The international humanitarian framework in northwestern Syria has so far largely failed to cooperate with grassroots initiatives in their efforts to coordinate the aid response across sectors. The closest they’ve come is in the integration of local health directorates.

What began as informal networks of doctors, nurses and paramedics working to fill the gap left by the withdrawal of the government’s Ministry of Health from opposition-controlled areas have become health directorates. These de facto health ministries could act as models for other civil services, and serve as the foundation to rebuild northern Syria’s shattered healthcare system.

The humanitarian response in northwestern Syria was based on the experience of international actors in other crises, where local groups were less involved. As a result, very little attention was given to investing in local medical resources such as staff, the existing health infrastructure and most importantly, strengthening the health system and governance.

The Humanitarian Response in Syria

The healthcare system in northwestern Syria has gone from being one of the best in the region to what a report published by the Lancet Commission on Syria described as one of the most dangerous places on Earth for healthcare providers. The World Health Organization-led health humanitarian cluster in northwestern Syria documented more than 200 attacks on healthcare facilities in 2016 alone.

The humanitarian response in Syria is divided into two categories: a Damascus-based response that operates mainly in regime-held areas, with minor cross-line operations into opposition-controlled territory; and a cross-border response from neighboring countries, mainly Turkey and Jordan, which did not officially begin until the U.N. security council passed resolution 2165 in July 2014. However, even after the start of cross-border operations, local actors remained at the forefront of aid efforts, as many INGOs had limited access inside Syria.

This infrastructure is one of the main challenges preventing the humanitarian community from responding to the escalating healthcare needs in a country where more than 50 percent of health facilities have been damaged or destroyed and 27 percent of the population lives in areas without access to medical professionals.

The humanitarian response is generally coordinated either by the state itself or by the United Nations. In Syria, however, U.N. agencies have not been able to effectively lead the coordination. The Turkey-based hub for the U.N. Office for Coordination Humanitarian Affairs (UNOCHA), for example, has set up several platforms for aid groups to apply for cross-border humanitarian pooled funds, but only licensed organizations are eligible.

This system excludes many local actors, especially in opposition-controlled areas, that are not registered in Damascus and do not have the capacity to get licensed in Turkey. Local health directorates, for example, are neither registered NGOs nor an official government entity, which means that international agencies do not have the legal framework to deal with them in a formal capacity.

Transforming Healthcare in Idlib

The Idlib Health Directorate (IHD) is emblematic of the crucial role structured local coordination groups can play in the international humanitarian response. The IHD started out in 2013 as a loosely connected network of medics and nurses focusing on emergency trauma response and has since developed into a structured organization as a de facto health ministry in northwestern Syria. For example, when polio broke out in Syria later that year, the IHD was not only able to stretch its vaccination campaign beyond its original geographical boundaries to cover the whole governorate, but it also established a team structure in order to respond to any future or different outbreaks.

The IHD has also implemented a basic governing system for the directorate in its aim to act as the representative of all medical doctors in the governorate. In May 2015, it invited all medical doctors in the province to elect the board of trustees of the directorate, who then appointed a director general of the health directorate in Idlib Governorate.

Despite structural restrictions, some international aid agencies have partnered with the IHD and other local health directorates in an attempt to improve their response to the humanitarian crisis in the northwest. As early as January 2014, Save the Children International became one of the first international actors to deal directly with the IHD. During the polio response, Save the Children identified the IHD as the only health actor in the region with the capacity to carry out a door-to-door vaccination campaign that covered the whole governorate and established a partnership focused on supporting the IHD’s organizational development. The IHD’s success with the polio campaign, and in other leading roles, encouraged additional actors to cooperate with them, which eventually increased the number of health projects and the amount of support for health governance in Idlib.

In 2016, the WHO-led health cluster in Gaziantep included the IHD as a key member. Although this inclusion was quite late, the IHD’s involvement helped shape the health cluster’s strategies and operations to more accurately reflect the actual needs on the ground. It also ensured that cluster members were better informed about health priorities in the field, thereby helping them ensure maximum efficiency in dispersing available resources.

The inclusion of the IHD provides a model that could guide a revision of the humanitarian response system focused on integrating local actors who are often the best suited to address challenges on the ground.

What’s more, the international community and humanitarian actors can apply this model to other local networks that provide civil services and local leadership, as a way of bridging the humanitarian and the development responses to the conflict. Such initiatives have been on the rise throughout the conflict in opposition-controlled areas to fill the absence of the state.

By fostering the IHD model to span education directorates and other governance structures, local communities will be directed away from military engagement and toward building civil institutions that might be the first step toward a healthy recovery period in the country. Moreover, civil institutions would attract Syrians both inside Syria and in exile to take part in the rebuilding process.