The impact of humanitarian aid on financial toxicity among cancer patients in Northwest Syria.

INTRODUCTION: The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions. MATERIALS AND METHODS: This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts. RESULTS: A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress. CONCLUSION: The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

Individual and social determinants of COVID-19 vaccine hesitancy and uptake in Northwest Syria.

INTRODUCTION: The COVID-19 outbreak devastated the fragmented health system in Syria, a war-torn country, and exaggerated the demands for humanitarian assistance. COVID-19 vaccination was rolled out in Northwest Syria, an area out of government control, in May 2021. However, vaccine acceptance rates are still minimal, which is reflected in the meager percentage of vaccinated people. The study aims to investigate the effectiveness of the humanitarian actors' plans to address the COVID-19 vaccine hesitancy and conclude practical strategies for boosting vaccine uptake in Northwest Syria. METHODS AND MATERIALS: Two questionnaires were developed to collect data from humanitarian organizations involved in the COVID-19 vaccination campaign and people from northwest Syria. Data analysis was performed using SPSS 22 data analysis program. RESULTS: According to the findings, 55.5% of people refused the COVID-19 vaccine. The results showed a knowledge gap and lack of evidence regarding humanitarian actors' strategies to address the vaccine's low uptake. Besides, it was found that doctors and medical workers were reliable sources of information about the vaccine. However, they were not systematically engaged in community mobilization and risk communication to promote people's perspectives on the vaccine. CONCLUSION: Risk communication and community engagement programs were not significantly associated with increasing the COVID-19 acceptance rate. Humanitarian actors must reconsider their strategies to address vaccine hesitancy in Northwest Syria. These strategies should engage medical professionals through dialogue sessions on the realities of the pandemic and vaccine development mechanism based on a compelling and evidence-based approach.

Health system governance assessment in protracted crisis settings: Northwest Syria.

BACKGROUND: Since the withdrawal of government forces from Northwest Syria due to the conflict, several national initiatives have aimed to create alternative governance approaches to replace the central governmental system. One of the recent initiatives was the formulation of so-called 'Central Bodies' as institutional governance structures responsible for thematic planning and service provision; for example, the referral unit is responsible for planning and delivering medical referral services. However, the governance and administrative rules of procedures of these bodies could be immature or unsystematic. Assessing the governance of this approach cannot be condoned, especially with the urgent need for a methodical approach to strategic planning, achieving strategic humanitarian objectives, and efficiently utilizing available resources. Multiple governance assessment frameworks have been developed. However, none were created to be applied in protracted humanitarian settings. This research aims to assess the extent to which the existing health governance structure (central bodies) was capable of performing the governance functions in the absence of a legitimate government in Northwest Syria. METHODS AND MATERIALS: A governance assessment framework was adopted after an extensive literature review and group discussions. Four principles for the governance assessment framework were identified; legitimacy, accountability and transparency, effectiveness and efficiency, and strategic vision. Focus Group Discussions were held to assess the levels of the selected principles on the governance thermometer scale. Qualitative and quantitative data were analyzed using NVivo 12 and SPSS 22 software programs, respectively. RESULTS: The level of the four principles on the governance thermometer scale was between the lowest and middle quintiles; 'very poor or inactive' and 'fair and requires improvement', respectively. The results indicate that the governance approach of Central Bodies in NWS is underdeveloped and summons comprehensive systematic development. The poor internal mechanisms, poor planning and coordination, and the absence of strategic vision were among the most frequent challenges to developing the approach. CONCLUSION: Humanitarian actors and donors should pay more attention to health governance approaches and tools in protracted crises. The central bodies must improve coordination with the stakeholders and, most importantly, strategic planning. Establishing or utilizing an independent planning committee, with financial and administrative independence, is crucial to maintain and improving contextual governance mechanisms in Northwest Syria.

Health aid displacement during a decade of conflict (2011-19) in Syria: an exploratory analysis.

BACKGROUND: Syria has been in continuous conflict since 2011, resulting in more than 874,000 deaths and 13.7 million internally displaced people (IDPs) and refugees. The health and humanitarian sectors have been severely affected by the protracted, complex conflict and have relied heavily on donor aid in the last decade. This study examines the extent and implications of health aid displacement in Syria during acute humanitarian health crises from 2011 to 2019. METHODS: We conducted a trend analysis on data related to humanitarian and health aid for Syria between 2011 and 2019 from the OECD's Creditor Reporting System. We linked the data obtained for health aid displacement to four key dimensions of the Syrian conflict. The data were compared with other fragile states. We conducted a workshop in Turkey and key informants with experts, policy makers and aid practitioners involved in the humanitarian and health response in Syria between August and October 2021 to corroborate the quantitative data obtained by analysing aid repository data. RESULTS: The findings suggest that there was health aid displacement in Syria during key periods of crisis by a few key donors, such as the EU, Germany, Norway and Canada supporting responses to certain humanitarian crises. However, considering that the value of humanitarian aid is 50 times that of health aid, this displacement cannot be considered as critical. Also, there was insufficient evidence of health displacement across all donors. The results also showed that the value of health aid as a proportion of aggregate health and humanitarian aid is only 2% in Syria, compared to 22% for the combined average of fragile states, which further indicates the predominance of humanitarian aid over health aid in the Syrian crisis context. CONCLUSION: This study highlights that in very complex conflict-affected contexts such as Syria, it is difficult to suggest the use of health aid displacement as an effective tool for aid-effectiveness for donors as it does not reflect domestic needs and priorities. Yet there seems to be evidence of slight displacement for individual donors. However, we can suggest that donors vastly prefer to focus their investment in the humanitarian sector rather than the health sector in conflict-affected areas. There is an urgent need to increase donors' focus on Syria's health development aid and adopt the humanitarian-development-peace nexus to improve aid effectiveness that aligns with the increasing health needs of local communities, including IDPs, in this protracted conflict.

The forgotten threat of cholera in Syria.

Cholera is an ancient disease that persists as an issue of public health in many conflict-affected countries worldwide. Cholera is a diarrheal infection caused by ingested water or food contaminated with the bacterium Vibrio cholerae. On 10 September 2022, the Ministry of Health in Syria declared a cholera outbreak. Poor water and sanitation systems, disease surveillance breakdown, the collapse of the health system, and deteriorated socioeconomic conditions are potential risk factors for the outbreak's spread. Identifying the context-related factors associated with the spread of disease is a core to developing practical response mechanisms. In this study, we suggested a multisectoral approach that addresses context-specific elements contributing to the cholera outbreak spread in Syria; public health determinants, geopolitics, risk factors, and pandemic fatigue.

An analysis of humanitarian and health aid alignment over a decade (2011-2019) of the Syrian conflict.

BACKGROUND: The 11 years of the devastating conflict in Syria resulted in more than 874,000 deaths, and in more than thirteen million refugees and internally displaced people (UNHCR, Syrian refugee crisis: aid, statistics and news, USA for UNHCR, Washington, 2020; Alhiraki et al. in BMJ Glob Health 7:e008624, 2022). The health system was severely affected and has become aid dependent. This study examines aid alignment over a decade of the Syrian crisis from 2011 to 2019. METHODS: Aid alignment involves donors using national systems and institutional structures to manage their aid to recipient governments and aligning their aid policies with development priorities and strategies defined by the partner countries (ROSA Newsletter, Moving towards increased aid alignment in the food and nutrition security sector, 2013. Available from: http://oxfamilibrary.openrepository.com/oxfam/bitstream/10546/141974/1/ ). Aid alignment was explored as part of the 2005 Paris Declaration Framework on aid effectiveness. Based on OECD's survey on monitoring the Paris Declaration (OECD, Harmonisation, alignment, results: report on progress, challenges and opportunities, OECD, Paris, 2005; OECD, Survey on harmonisation and alignment of donor practices, OECD, 2006. Available from: https://www.oecd-ilibrary.org/development/survey-on-harmonisation-and-alignment-of-donor-practices_journal_dev-v6-sup1-en ) and based on a proposed methodology to assess aid effectiveness by Burall and Roodman (Developing a methodology for assessing aid effectiveness: an options paper, Overseas Development Institute, 2007. Available from: www.odi.org.ukhttp://www.cgdev.org ), we designed a sequential mixed methodology to address two main indicators: alignment with national strategies and local procedures, and aid delivery through local systems. The quantitative part investigated the financial alignment of aid using financial data trackers, such as creditor reporting system and the UN-OCHA financial tracking system, and the relevant humanitarian needs estimations by the humanitarian assistance response plans, humanitarian response plans, and humanitarian needs overviews. The qualitative part relied on four focus groups discussions and four key informants interviews with key policy makers, experts and practitioners involved in the humanitarian and health response in Syria, with the aim of interpreting the quantitative findings. RESULTS: While the study found an improvement in aid budget alignment with local procedures in Syria from 34% in 2012 to 86% in 2019, we found limited alignment with local strategies. Our qualitative findings pose doubts in the ability of the various data sources of humanitarian needs in Syria to reflect the actual realities, especially before 2014, due to lack of comprehensive local engagement and data systems by then. Therefore, even if the humanitarian budgets seemed to be aligned with the national procedures, the national plans did not seem to align with the actual realities, let alone the increase in the financing deficit over the years of the conflict. The reliance of humanitarian and health aid on governmental structures, as a main recipient, in Syria was much lower than other developing and fragile countries. This is mainly due to the nature of the Syrian conflict where the government is a party to the conflict. Donors were found to have invested poorly in advancing national and sub-national planning in Syria due to donors' over reliance on the UN-led humanitarian system which struggles in armed conflict settings. As a result, we found a disconnection between field realities, national planning, and humanitarian aid. CONCLUSION: In light of the dreadful humanitarian crisis in Syria, there has been an adverse aid alignment. Considering the chronicity of the conflict, there is an urgent need to improve aid alignment through more investment in local planning at district or governorate levels. This is especially important to navigate through conflict sensitivities while responding to local needs and initiating local developments. These approaches, combined with adopting health sector-wide approach, could contribute to the humanitarian-development-peace nexus in Syria, which in turn can contribute to a better aid alignment and aid effectiveness.