LSE IDEAS, Conflict and Civicness Research Group (CCRG), London School of Economics and Political Science, London, UK.
Research for Health System Strengthening in Northern Syria (R4HSSS), Union for Medical and Relief Organizations, Gaziantep, Turkey.
Global Health. 2024 Oct 3;20(1):71. doi: 10.1186/s12992-024-01074-4.
Legitimacy and trust are crucial for resilient health systems in fragmented conflict zones. This study evaluates the legitimacy of health systems in northwest Syria under different governance models.
Using a deductive and inductive mixed-methods approach, the research team developed a framework with an index, 4 sub-indices and 18 indicators to assess the legitimacy of health systems using different governance models - top-down, bottom-up, and hybrid - in the context of the response to the earthquake that hit Syria in February 2023. The study includes surveys, workshops, stakeholder consultations, and an expert panel conducted in northwest Syria and online.
The findings indicate that bottom-up health governance model is perceived as the most legitimate, followed by the mixed model, while top-down model is perceived as the least legitimate. This preference is measured across all legitimacy source sub-indices, including legality, justification, consent and performance and across the overall Health System Legitimacy Index (HSLI). However, the hybrid governance approach showed limited superiority at two indicator levels regarding long-term health system response.
This study highlights the importance of considering the legitimacy of the health system in fragmented conflict zones. It helps explain the effectiveness of the bottom-up approach and community-based governance in enhancing trust, cooperative behaviour, health interventions and achieving sustainability. Additionally, the study highlighted the role of legitimate health systems in practising civic virtue and promoting social justice, thus contributing to peace-building efforts. These insights are crucial for policymakers and development donors to strengthen health systems in challenging contexts.
在碎片化冲突地区，合法性和信任对于有弹性的卫生系统至关重要。本研究评估了叙利亚西北部在不同治理模式下卫生系统的合法性。
研究团队采用演绎和归纳相结合的混合方法，制定了一个框架，其中包括一个指数、4 个分指数和 18 个指标，用于评估在应对 2023 年 2 月袭击叙利亚的地震中不同治理模式（自上而下、自下而上和混合模式）下卫生系统的合法性。该研究包括在叙利亚西北部和在线进行的调查、研讨会、利益攸关方协商和专家小组。
研究结果表明，自下而上的卫生治理模式被认为是最合法的，其次是混合模式，而自上而下的模式被认为是最不合法的。这种偏好体现在所有合法性来源分指数上，包括合法性、正当性、同意和绩效，以及整个卫生系统合法性指数（HSLI）上。然而，混合治理方法在长期卫生系统应对的两个指标水平上显示出有限的优势。
本研究强调了在碎片化冲突地区考虑卫生系统合法性的重要性。它有助于解释自下而上的方法和基于社区的治理在增强信任、合作行为、卫生干预和实现可持续性方面的有效性。此外，该研究强调了合法卫生系统在实践公民美德和促进社会正义方面的作用，从而为建设和平努力做出了贡献。这些见解对于政策制定者和发展捐助者在具有挑战性的情况下加强卫生系统至关重要。
