1) Severe constraints on health service delivery.

All participants emphasized that the quantity and quality of health service delivery was affected by attacks on healthcare in both the short- and the long-term. This was due to a combination of direct damage to healthcare facilities, as well as increased health needs and demand on facilities due to the direct and indirect impacts of the conflict. At times of an acute increase in violence leading to forced displacement, participants reported that there could be a sudden and significant population growth in some areas, leading to a spike in demand.

Irreparable damage to health facilities. One participant observed that “if this destroyed hospital was providing healthcare services to a particular area of half a million people, then that half a million people would be without healthcare for a month. They may also have to go to other areas and their diagnosis may be delayed, as well as having complications and many other problems” (Administrator) Participants noted disparities between urban and rural facilities; in rural areas, when attacks on health facilities occurred resulting in closures, those communities had more limited options for alternative healthcare.

Even when health facilities were re-opened, “all services were not always fully reinstated” stated a participant who highlighted this reality with an example of a pediatric unit that remained closed to prioritize the reopening of the trauma unit (Physician). Chronic and preventative care, as well as care requiring specialized or high-resource equipment, took longer to reinstate. Another participant noted that early discharges of admitted patients were frequent when the facility was felt to be at higher risk of being attacked or had been attacked recently. In many cases, attacks also impacted the quality of care. “If we want to give each patient five minutes, the patient does not [get what they need] but these are the available capabilities (Lab Technician).

Ripple effects on nearby facilities. The reduction in services had ripple effects on other health facilities in the patient catchment area and their ability to meet demand, often overburdening still-functioning or partially functioning facilities. Several participants described that patients were transferred to or advised to go to alternative facilities, especially those outside city centers when attacks occurred. One participant described the scale of redistribution of patient loads: “The hospital has recently become the one to serve the entire south of Idlib. If you know southern Idlib, all hospitals were bombed before us, then all hospitals were stopped, so [our] hospital received patients from Ariha, rural Ariha, and southern rural Idlib; even northern rural Hama and southern rural Aleppo…. The workload—it was intense” (Nurse).

Irretrievable loss of specialized services. Specialized services were particularly affected if provider facilities were damaged; this included services for chronic conditions, including cancer, kidney failure (dialysis) and mental health conditions. Mental health needs among the community increased significantly due to the conflict and were noted by participants to be unmet due to the lack of mental health specialists (which also pre-dated the conflict, but was exacerbated by attacks,) and the fear among patients of visiting hospitals. Cancer services were also noted to be a particularly scarce resource in these areas.

A participant described the difficult decisions that patients need to make, “For example, cancer patients now have two options: either to head towards Damascus or towards Turkey” (Lab Technician) which is not always an option for all patients. This is particularly due to social factors which, as one participant noted, particularly affected widows or people living with a disability because they could not travel as easily (Physician).

2) Challenges in health workforce retention and morale.

Attacks on healthcare were described to result in a precipitous drop in the availability of workers through forced displacement, and a lack of training opportunities, among other reasons.

The lack of trained health workers had catastrophic effects on some services. One participant illustrated this experience:

“We still did not have skilled general practitioners who knew how to use the triage system and how to treat 90% of the common diseases in the community… The number of gynecologists was also very, very few compared to the number of women in the community… That is why a lot of complications and mortality were occurring. This is what we have… there are not enough physicians… What can we do?!”

(Physician)

Displacement and unemployment. Many health workers experienced forced displacement, often more than once. The wide-ranging impacts of this were noted to affect the quality of care for patients as well as the work experiences of health workers. Several participants described disruption to their ability to develop long-term rapport with their patients and strong relationships with their colleagues. A participant also noted the critical importance of establishing a long-term relationship with patients, particularly in settings where clinical records are absent, poorly kept, or destroyed. Other participants described that being unable to continue working with well-established and familiar colleagues was challenging. Some also described a different culture in different cities in Syria or that they felt like outsiders. “In Idlib, the culture is different. They call us nazeheen (displaced)–but we did not leave by our own choice,” said one participant who had been displaced more than 15 times (Nurse).

An important but paradoxical workforce challenge was that in the wake of an attack, despite increased needs for services, health workers could become unemployed if funding to a facility was interrupted or redirected, which often occurred following attacks. One participant said, “Physician retention is difficult as the hospital is rebuilding and [health workers] need to find work in the meantime and then come back” (Medical Technician). This resulted in unstable and inconsistent work as a direct result of attacks that severely damaged health facilities. Another participant explained that “health workers live in an ambiguous future—[the] near future and far future are both not clear” (Physician).

Skills and training. Staff shortages resulting from the targeting and the exodus of health workers have led to an increase in task-shifting, a phenomenon which was uncommon before the conflict. Health workers were forced to take on roles that they were not prepared or trained for, causing undue stress among health workers and their colleagues, and potentially leading to suboptimal quality of care for patients. One participant highlighted this gap, particularly concerning maternal health as there were too few obstetricians, stating, “…and midwives have only basic training so [we] have far more home births and maternal mortality than before the war” (Physician).

Feelings of resistance and solidarity allowed health workers to carry on. Despite the challenges noted by participants, there were also many examples of coping, survival, resistance, and solidarity among health workers. Participants stayed in Syria despite the risk it posed to their lives and their well-being and continued to provide services, motivated by duty towards their respective communities and wanting to meet ongoing needs. However, many participants rejected narratives of “hero” or “victim,” rather than just feeling an obligation to help. One participant described this sentiment as “The feeling that dominates me most is that there is a wounded person in need of rescue. He’ll die if I don’t do my job, its possibility is 100%, whereas the probability of my death in targeting is 5%, the feeling of rescue always prevails over me” (Physician).

Health workers were motivated by a sense of solidarity felt among other health workers undergoing similar circumstances and fighting for the Syrian cause. Many health workers described that they communicate via groups on phone messaging applications to stay connected with colleagues, support patients, share stories, and find mutual strength. Some participants worked in Syria and visited their families weekly or monthly in Turkey, who lived there for safety reasons, to find a balance between work and family. Participants also described feelings of resistance against the Syrian regime that drove them to continue working. One participant described, “For me, I absolutely refuse to leave Syria. In my opinion we must do anything that can support the Syrian revolution, God willing” (Administrator).

3) Compounding loss of essential medicines and infrastructure.

Damaged infrastructure. Participants discussed the extensive destruction of infrastructure in Syria due to attacks, including hospitals, mobile clinics, ambulances, and supply trucks. Damaged facilities were assessed in the aftermath of attacks and health workers supported the repair efforts and continued to see patients. However, compounded damage from multiple attacks made reconstruction efforts more costly. One participant noted, “If it was minor damage, [we] can build back in 2–3 weeks. But with severe damage, especially cumulative—it would be hard to ever build back” (Physician) The perceived high risk of future attacks often made funders and organizations reluctant to rebuild health infrastructure.

Scarcity of medical resources. Participants reported that interrupted medical supplies and medications presented challenges for the health system. This was not only due to the direct effects of attacks on health on pharmacy stocks but also damage to transport infrastructure and relevant hospital infrastructure such as electricity, particularly affecting medications that required refrigeration. Even if classes of medications were available, specialist medications or specific dosages and formulations were scarce. As a result of severe shortages, the cost of medications rose sharply, leaving many medications out of reach for many people who may have needed them. While health workers described a range of strategies to fill the gaps in medication coverage, including free pharmacies within facilities and negotiated discounts on medications coordinated among pharmacists, many patients were still unable to access their medications regularly, also out of fear of visiting health facilities to do so. One participant explained the downstream impacts of attacks on healthcare on medication shortages: “Many people cannot buy medicine because it is so expensive…Many people are displaced and in need, have left their jobs, lands, and livelihoods, and yet they are compelled to buy this drug” (Physician).

4) Weakened health governance.

Hindered effectiveness. Participants shared some glimpses of their experience with health governance in northern Syria. Several of them described that the Syrian government’s violence against healthcare includes deliberately undermining the establishment and effectiveness of local health governance and leadership in northern Syria. Attacks on healthcare have thus left both local and international humanitarian organizations to fill this gap. However, given the enormous challenges of building a new health system in the setting of war as well as targeted violence and the lack of executive authority, health governance actors in northern Syria faced numerous challenges, some of which participants touched on in the interviews. Challenges included managing security, ensuring that health facilities stayed open, staffed, and equipped, equitable and efficient policy making and procedures for rebuilding, and prioritizing limited resources. One participant noted that “the main infection in society [is that] there is no direct health authority, there is no security authority … Unfortunately, things have become random, …there is no regulation, and there is no one to impose curfews, stabilize markets, and regulate the work” (Administrator).

Limited planning and coordination. Participants noted that one of the key challenges for local governance actors (which include health directorates and humanitarian organizations) in northern Syria is the rehabilitation of health facilities damaged by attacks on health. Participants noted that they, as health workers, were also required to make challenging decisions, for example, around fortifying hospital buildings, locations of health facilities to minimize the risk of attacks, and where to prioritize resources. Several noted that prioritizing protection from attacks had trade-offs: more secure locations could restrict access. Participants described that health facilities were increasingly fragmented or siloed in some parts of opposition-controlled Syria. While peacetime structures are often built in central and accessible areas of communities, new health facilities were built away from the centers of town to protect civilians in case they were targeted. One participant described why: “Hospitals cost a lot to build. And one bomb can destroy the whole thing, so it is better to build smaller ones. We deliberately increased the medical points to reduce the damage” (Physician). Fragmentation of the health system(s) often resulted in inequities in healthcare services for different communities. For instance, one participant stated that “physicians and health care workers were not distributed evenly—[there were] more in safer areas, and fewer in dangerous areas” (Physician).

When rebuilt, services were also divided into separate facilities to ensure that a strike on one facility would not affect too many people or services. While this was effective for keeping some services accessible, it made holistic and coordinated medical care for patients challenging.

5) Uncertainties in health financing.

Both the direct airstrikes on health facilities and the indirect impact on services were associated with a high cost of healthcare system(s) in northern Syria, as referenced above regarding the increasing cause of medications. According to participants, increasingly limited financial resources over the protracted conflict resulted in tensions around broader medical resource allocation among the different actors and communities, as well as significant dependency on unstable donor funds and international aid (often restricted because of anti-terrorism regulations), and frequent interruptions of funding streams to health service organizations, facilities and staff. In addition, participants perceived that funders were reportedly reluctant to fund health facilities or services at high risk of repeat attacks.

Several participants described challenges with resource allocation both at administrative and clinical levels. Administrators noted that with restricted funds and ongoing losses of infrastructure, rebuilding facilities was not a priority, especially when the risk of re-attack was high. One participant noted, “The cost of establishing … a hospital was more than two or three million dollars… It is too costly… And in the end, after you pay all these costs, the regime with just one missile can destroy the entire hospital” (Physician). One participant noted that the persistence of attacks over the years also limited healthcare actors and donors from investing in establishing more sophisticated specialized services for tertiary care, concerned that health facilities continued to be targeted.

Interrupted funding streams. Unstable donor funds, top-down decisions on funding priorities (without consideration of local needs), and political or technical restrictions on funding resulted in unreliable and frequently interrupted funding streams for the health system. Several participants highlighted that salary delays caused by shifts in donor priorities, coupled with the absence of health and life insurance for workers, demotivated healthcare professionals from staying in perilous conditions and prompted them to contemplate migration. When funding was reduced or interrupted, and health workers were unemployed, participants described how this negatively impacted their livelihoods: “Costs actually go up—distance to work from a secure area, diesel costs, rent since [they] can’t live in their own home, food prices are up… all while employment goes down” (Medical Technician).

Increasing unaffordability of care. Further downstream, the limited resources caused by physical attacks and defunding led to increasing costs of health services, which disincentivized patients from accessing preventative care. For example, major transportation issues due to long distances and transportation costs led to the inaccessibility of hospitals among civilians, exacerbating conditions that require follow-up (particularly for those living in mountainous or rural regions). Numerous private health enterprises emerged to fill this gap, but participants reported that they were not consistent, and the resulting financial pressure was then on patients themselves to pay directly for services, a grim challenge when the conflict disrupted so much employment in the area. Participants mentioned that patients frequently had to choose between two risky options: fear of being in a public hospital that is being bombed or significant financial risks from seeking care in a more expensive private facility. For example, one participant said, “Private hospitals were $50 per day which is a lot. Bombing of big or public hospitals drove people to private smaller facilities but the financial pressures drove them back to the public hospitals. …and they became afraid and began to suffer from phobia from the intense and focused bombing on the medical centers” (Pharmacist).

6) Compromised security and protection.

In response to attacks on health, administrators, professionals, and patients were required to make constant calculations of security risks and plans. Many participants noted that security risks deeply impacted patients’ choice to even seek healthcare, often resulting in a chilling effect on health-seeking behavior. “Even the threat of violence limits health services,” said one participant, suggesting that frequent attacks on healthcare services cause some sick people to avoid seeking health services (First Responder). Several participants spoke about the deconfliction mechanism in Syria, the decision to share coordinates of hospitals with UN Member States and armed actors in a (failed) attempt to ensure respect for IHL. One of these participants said, “We did everything we had to do, and we told them that those locations were medical centers, but we were regarded as enemies and then were attacked…. No one… no one stopped these attacks” (Physician). The deliberate targeting of medical facilities by the Syrian government and its allies despite consensus from health actors in northern Syria to participate in the deconfliction mechanism was particularly galling for most participants, causing deep mistrust of the UN and the international response in Syria.

Fortifications and contingency measures. At the facility level, insecurity resulted in adaptations and restructuring that did not always provide added protection. Fortifications of community hospitals, building hospitals outside of the community and in caves and underground, were novel adaptations to high-intensity aerial attacks. While there was hope among participants that these fortifications would better protect patients and providers, this was not always the case. One participant pointed out that several fortified facilities have since been targeted and destroyed with even stronger weaponry. Beyond infrastructure modification, facilities also took steps to invest in air raid alarm programs, removing the medical emblem from their frontage, and employing armed guards to monitor the entrances to mitigate attacks.

Despite these efforts, protections were fragile and limited by the broader conflict and violence in the region. One participant explained “We built this hospital underground, which made us feel very safe because the airstrikes that targeted the perimeter of the hospital and the hospital itself did not damage at all. However, it was not very safe because the road leading to the hospital was dangerous”(Nurse). Transportation to or between health centers was especially fraught, “There is no public transportation. Even private transportation is dangerous. When a person moves at night, he is afraid of being sniped by a gun plane. The gun plane as soon as it sees a light at night, snipers it, regardless of whether there are children, women, or injured people” (Administrator).

Health workers themselves also attempted to mitigate the risk to themselves and their patients. Several participants described that offices would shorten visits or send patients home quickly to mitigate risks. They also developed staggered schedules to spare staff and patients if attacks occurred.