Interactions among a wide range of humanitarian actors to deliver health services inside Syria from Turkey offer original insights into the politics and logistics of such partnerships. On the one hand, efforts have been made to integrate Syrian NGOs in the international response through the formalisation of coordination structures (humanitarian coordination meetings initially, and later a Humanitarian Liaison Group) and pooled funding mechanisms as well as the activation of UN-led clusters [20]. Syrian NGOs have also opted for a more formal structure by creating multiple coordination platforms over the years — such as the Syrian NGO alliance or the Syria Relief Network — to facilitate engagement between Syrian and international humanitarian actors. In addition, we will show that national NGOs also bring into these structures local medical staffs from inside Syria with whom they partner to deliver services to individuals and communities.
The “low-profile” and “close-ties” approach to humanitarian access in northern Syria
Beyond the narrow “humanitarian access” terminology (which may reduce humanitarian routes to logistic considerations), lies a key challenge in creating or developing effective inter-organisational and interpersonal relationships among non-state actors collaborating to deliver an intervention in areas where parties in the conflict directly target health providers. Humanitarian access in Syria has been constrained by several issues that have evolved over time, including conflict and attacks on access routes, restrictions imposed by the Syrian government and parties to the conflict and targeting of healthcare workers and facilities. Access challenges have created the essential conditions for IOs and INGOs to work in partnership with national NGOs and medical actors in Syria to reach the most vulnerable, using a low-profile approach: “the use of smaller tonnage and fewer vehicles at a time, with no branding, and the use of commercial carriers are common modalities employed” [21].
In addition to this low-profile approach, our interviews with Syrian doctors working in the Idlib province in Syria revealed the centrality of interpersonal trust to enable any collaboration with Syrian and non-Syrian actors offering support from outside the country in the early phases of the conflict; a phenomenon reminiscent of the literature citing the importance of social trust in improving cooperative relations [22, 23]. In the context we studied, trust was often present with networks previously forged, or when being introduced by a trusted intermediary. For example, while starting to establish networks with expatriate doctors from outside Syria, doctors from Idlib initiated limited communication with few focal points, using pseudonyms, relying on Virtual Private Networks (VPNs) to hide their internet access, using Subscriber Identity Modules (SIM cards) with unknown accounts, etc. Networks were also mobilised inside the country to channel medical supplies across military obstacles, e.g. through doctors sometimes relying on women from their family, as they were less likely to be searched at checkpoints. Within this context, “frontline health workers” become “undercover relief workers”, putting personal relationships at the centre of professional partnerships. Even though the humanitarian and medical work was institutionalised through local NGOs and INGOs over time, interpersonal relationships were key to facilitate the development of a coordinated health response. While interpersonal connections were crucial in such a context, it emerged from some accounts that they can also burden responders, as personal disagreements could sometimes affect professional relationships.
Funding landscape mechanisms
Funding sources for the humanitarian and medical cross-border response in North West Syria were diverse. Some of the main ones were institutional donors such as governments or the European Commission Humanitarian Fund (ECHO), which were largely covering the majority of the humanitarian cross-border operations in North-West Syria. The main channel for this type of funding was through IOs or INGOs, which were either carrying out the implementation themselves or subcontracting Syrian NGOs. Funding also came from philanthropists. This type of funding was channelled through either INGOs, Syrian NGOs or even grassroots organisations that had no registration in neither Damascus nor neighbouring countries. However, this funding was running short as the crisis prolonged. Diaspora networks, composed of Syrian expatriates who established networks in their countries of residence, also supported the humanitarian response in Syria. The early diaspora networks were mainly medical ones. Some of these networks were institutionalised and converted into NGOs such as the Syrian American Medical Society (SAMS) and the Syrian Expatriates Medical Association (SEMA). Since both NGOs had wide networks of members and supporters, they had flexible funding through membership fees and private donations. This made them more independent from donors’ money fluctuations and constraints. For example, their private fund (20–30% of the overall funding) was used in besieged areas where donors were reluctant to fund projects. In addition, this flexible fund allowed these NGOs to fill gaps caused by withdrawal of some INGOs after financial cuts by donors. For instance, SEMA’s flexible funds allowed it not to withdraw from any project it had started in the past and fill the gaps caused by the withdrawal of INGOs. At the time of our interviews, this latter phenomenon was happening - key international humanitarian actors were withdrawing from health facilities and SEMA was among the NGOs to cover these gaps alongside with SAMS and the Union for Medical and Relief Organisations (UOSSM).
Since 2014 and following United Nations Security Council Resolutions 2139 and 2165, Syrian NGOs have had direct access to international funds through the Humanitarian Pooled Fund (HPF), a multi-donor, earmarked fund managed by UNOCHA to fund the Humanitarian Response Plan. All international and national NGOs registered in UNOCHA coordination platforms were eligible to apply for this fund, but this required registration in Turkey (or another country) and UNOCHA validation of the organisation’s capacity to manage resources. Registered NGOs were then classified into three levels of liability, which determined not only their eligibility but also the funding ceiling. This adaptation of a global funding scheme to the localisation framework in Syria was key to facilitate direct funding from UNOCHA to avoid duplication of effort.
Our research identified several challenges for funding cross-border activities, including the logistics for cash flow inside Syria. The collapse of the banking system in opposition-controlled areas in North-West Syria, for example, and the absence of registered money transfer agencies left humanitarian actors with no option but to rely on local money transfer agencies (sometimes referred to as Hawalah). NGOs rely on these agencies to transfer funds from NGO offices and bank accounts in Turkey to NGO staff or partners in Syria. Another main challenge was related to the ambiguity of the Turkish government legislations in relation to the use of the above-mentioned system, as there was no previous legalisation in place in relation to such system for money transfer to cover cross-border activities. While the Turkish government was trying to develop a legalisation to balance between the urgent needs to transfer money for the operations inside Syria and the need to fully control the money movement across the border, most cases related to this issue were discussed through unofficial channels between NGOs and the Turkish government.
A bottom-up approach to coordination
Complex, bottom-up, personal relationship-driven channels of coordination emerged among responders implementing medical interventions in areas outside the control of the regime. These ultimately shaped global coordination mechanisms for health inside opposition-controlled areas. “Trust” and “intersubjectivity”, which also manifested themselves in the “low profile” and “close ties” approach to humanitarian access discussed above, were central to these coordination channels, and can only be captured outside a restrictive emergency framework.
“From the beginning, we were trying to organise ourselves (…). Sometimes Idlib had no needs so they send to Homs, trying to organise the response. We deal with the doctors from outside individually at the beginning and they know us with our fake names. Inside, there are two kinds of doctors: field doctors and management doctors who deal with logistics and coordination. Not everyone knows the structure of the group for security issues.” (Syrian clinician).
Inter-individual relations and social networks were key to develop connections between doctors outside and inside Syria as this was a context where health providers were imprisoned and where the long-term presence of secret intelligence in the country affected trust among citizens. Expatriate doctors divided responsibilities for different regions in Syria according to the access they had through professional and family networks and contacts. Technicians and experts in telecommunication from outside and inside the country were involved as well and provided VPN accounts for activities.
The role played by Syrian providers to coordinate health activities inside Syria has evolved throughout the conflict. Syrian health professionals started to organize inside Syria forming medical committees and health directorates. This progressively expanded outside the Syrian borders as Syrian NGOs began to have a more active stance in international coordination mechanisms and as coordination agencies began to recognize entities inside Syria (such as health directorates). The role of the multiple interim governments of opposition in the cross-border activities in North-West Syria was limited because of issues related to legitimacy, stability and resources. In general, it took until 2015 for the coordination to evolve on both sides of the border including both national and international actors:
“At the beginning we suffered (…) in 2013 when the health working group started in Antakya. The Syrian NGOs were seated in a corner without any contribution. It was not respectful. All the international staff would speak, and Syrians would stay quiet. One woman who worked with an international NGO supported us to be on the table with the other players…Now the health cluster speaks Arabic and there is a co-lead from a Syrian NGO. Coordination between Syrian NGOs improved, and we advocated that our priority be the priority of the health cluster.” (Syrian clinician, Turkey-based Syrian NGO staff member).
Such examples are key to understand the realities of building up coordination mechanisms in a transnational humanitarian context while working at the intersection between health networks that had never met before the crises. They show that coordination cannot always be channelled down through vertical processes. While reflecting on her/his practice during the interview, one of our informants, who was country director for an INGO, emphasized the value of coordination mechanisms initiated by Syrian doctors. Such value lay in the efficiency of those networks in maintaining communication between different areas and quickly mobilising resources and response to emergencies. Over the years, these mechanisms became integrated into more formal platforms of coordination such as the health cluster in Gaziantep. However, this bottom-up approach is still the backbone of the coordination mechanisms.
Cross-border monitoring and evaluation
In a context where organisations work remotely to deliver medical aid inside Syria, third party monitoring has been used by some organisations. [24] Monitoring and evaluation companies were established in Turkey with field staff and networks inside Syria. These companies are contracted by INGOs or Syrian NGOs to monitor and evaluate their projects inside Syria. Some donors and INGOs made this third party monitoring a reporting requirement for any project conducted remotely in Syria. However, some of these monitoring mechanisms have become challenging in light of reports of private monitoring firms disrupting relationships between NGOs and beneficiaries on the ground as well as relationships between NGOs and donors [24]. Humanitarian organisations thus developed creative ways to monitor the implementation of their intervention without physical access to the field and to report to their funders. For instance, following the Office of U.S. Foreign Disaster Assistance (OFDA) investigation that happened in Turkey in 2016 [25], some INGOs implemented new monitoring tools such as photographic evidence, GPS location evidence, and paper work (e.g. receipts).
International humanitarian staff who, before working on the Syrian crisis, used to work in coordination positions for their organisations, acknowledge that coordinating a mission always involved working remotely, typically being based in the capital, with monthly field visits. In contrast, humanitarian field logisticians felt that their role was redefined by the lack of access to the field, and part of their professional identity was challenged. In Turkey, one of the organisations we visited had lost its registration, making it impossible for staff based on each side of the border to cross for over a year. The absence of a direct relationship between IOs staff and beneficiaries restricted efforts to improve accountability to populations in need. In some cases, community health workers recruited by organisations we approached were considered as being the “voice of the community” inside Syria. The pathways by which community health workers can truly channel beneficiaries’ views and concerns need to be better understood. However, there were some innovative approaches to engage local communities in the process of remote monitoring through triangle agreements between INGOs, implementing Syrian NGOs and local councils or local committees. Threeway-communication channels were set up in these agreements to ensure quality and compliance. Still, other barriers were faced by humanitarian organisations to measure the performance of their cross-border programmes in the Syrian context. To start with, there was limited circulation of documents, either because that could put local partners and organisations at risk by rendering their action too visible or because there was lack of trust in the effectiveness and neutrality of some of the coordination mechanisms that were led either by UN agencies or INGOs that had presence in regime-controlled areas. This sometimes led to a lack of transparency in reporting mechanisms [24]. The lack of coordination and standardization processes on monitoring and evaluation mechanisms among funders was an additional constraint faced by local partners in Syria [24].
Localisation processes beyond emergency response
Partnerships developed over time to deliver or support the provision of health services inside Syria have made visible the dynamic character of medical humanitarianism. In this section, we will draw on some of our findings on the cross-border response to reflect on longer-term implications for the Syrian health system and for the humanitarian sector.
Any health interventions in a humanitarian context can lead to innovations in the health system, and in Syria, funding channelled through cross-border mechanisms shaped how health services were prioritised by the local health authorities formed in opposition-held areas. [26]. The implementation of an intervention to build capacity among midwives through training existing midwives and creating a 3-year programme for new recruits is a good example of such synergies between humanitarian interventions and local health programmes. According to one of our study participants involved in this initiative, the idea of this intervention was born from a simple observation: there were fewer gynaecologists in Syria, yet a large pool of trained midwives persisted; however, Syrian midwives were not working up to international guidelines. During the needs assessment phase of the intervention, discussions took place between the reproductive healthworking group in Gaziantep and providers in Syria to identify which resources were needed at each level of the health system, and what steps should be taken to have a more effective system. The Minimum Initial Service Package (MISP) was used as an evidence-based approach, and it was compared to the existing health system structure in Syria, with the aim of decentralising reproductive health services. Community health workers were tasked with providing advice and identifying women at risk of pregnancy complications so that they could be referred. The overall strategy took nine months of negotiations with local health workers: doctors, in particular, needed to be convinced that midwives could gain the required skills to work independently and provide good standards of care. Midwives were identified during trainings to act as trainers themselves in Syria. Schools of midwifery were opened, and agreements were made to issue diplomas that would be delivered by the organisation, health directorates and the opposition ministry of higher education.
Humanitarian principles in tension
Humanitarian principles (humanity, impartiality, neutrality and independence) were well known by all international and Syrian NGOs working on the cross-border response. However, the implementation and monitoring of these principles through cross-border health activities was challenging, especially in a context of remote training of health providers and remote monitoring of activities. Some relief workers we interviewed raised specific concerns around the implementation of neutrality. Local medical and humanitarian workers have their own political views, they argued, particularly after witnessing crimes committed by parties to the conflict and being threatened or persecuted by the same parties. Therefore, it might be challenging to be neutral. However, the same workers had no issues with being impartial. For example, one interviewee shared an incident where a soldier of the Syrian army was brought to a hospital supported by a Syrian NGO. He was provided with the required medical care before opposition groups took him. At the same time, this NGO and the hospital staff identified themselves as part of the revolution against the Syrian government. This account by no mean suggests that humanitarian actors’ neutrality and impartiality in a conflict — including local actors —can be taken for granted. However, such accounts question the problematic assumption that local actors are by essence less prone to be neutral and impartial.
In this study, it was important to reflect about values and principles emerging outside the centres of humanitarian action. In our interviews with Syrian doctors involved in the humanitarian response in Syria, for example, “localisation” emerged as a key principle that needs to be unpacked. Localisation was valued by local NGOs providing health services, given their understanding and proximity to the context and the people affected by the crisis: “We are the sons of this country”, stated one of the Syrian doctors we interviewed in Gaziantep to justify the focus his organisation puts on never interrupting the provision of health services. In our informants’ discourses, this was associated with a focus on continuity of health service provision, as opposed to international organisations.
Localisation was also perceived as a means to avoid “trends” in interventions that were not adapted to the field and that might not be sustainable:
“We don’t believe in mobile clinics as a long-term solution. Equipment, labs, privacy of the doctors. At a certain point in time, mobile clinics became like a fashion trend. The health system before the war did not have any mobile clinics. It is hard for doctors to go to the areas with the mobile clinics. It is exhausting. They already work in several facilities. In some areas, it was useful to detect malnutrition and refer them to hospitals. One organisation wants to implement 25 mobile clinics and wants to put all the resources in these clinics. We used to have mobile operation rooms, but it was dangerous for doctors. Everything regarding the health project is dangerous and mobile clinics are not the solution; even if the car is not visible, the crowd will be visible” (interview with Syrian doctor).
Although we cannot offer a comprehensive picture accounting for the pros and cons of facilities like mobile clinics, these field-based perspectives shed light on how humanitarian interventions were framed by Syrian humanitarian responders, as a reality check on innovation brought (and sometimes imposed) by international partners and funders.
Study limitations
The spectrum of informants we interviewed for this study is limited and does not reflect the full range of humanitarian actors involved in the cross-border assistance for health services from Turkey to North-West Syria. Notably we did not interview Turkish actors involved in the response. In addition, the statements of informants operating inside Syria were exclusively collected from Turkey as we did not conduct fieldwork in North-West Syria. A comprehensive political economy analysis is also lacking in our analysis, which could have played a key role in determining the attitude, motivations and some practices of local actors in North-West Syria. However, such analysis was beyond the scope of this study.