Paterson Anna, Palmer Jennifer, Sondorp Egbert
, London, UK.
London School of Hygiene and Tropical Medicine, London, England, UK.
Confl Health. 2025 May 26;19(1):30. doi: 10.1186/s13031-025-00669-x.
The government is normally the leading actor in health system governance, yet in some conflict-affected contexts, government or equivalent health authorities are not formally recognised by the international partners who co-finance the health system. This study considers what has inhibited or facilitated cooperation between two types of non-recognised health authorities and international partners in Afghanistan from 2021 to 24 and Northwest Syria from 2013 to 19.
A literature review was combined with 14 semi-structured key informant interviews, mostly with representatives (often health advisers) of donors or UN agencies. A political economy analysis (PEA) analytical framework was used, focusing on the capacities, incentives, beliefs, institutional and structural factors that influenced the behaviour of the key health system actors.
Although widely cited as a critical barrier, the lack of formal recognition was not the main constraint on cooperation. The in/stability of the conflict context, the likelihood of survival of de facto health authorities, the extent to which there were clashing norms between actors, and the incentives and 'ways of doing things' of both unrecognised authorities and international actors also played key roles. For example, in Afghanistan, the Taliban's approach to women's rights and education was identified as the major barrier to cooperation. In Northwest Syria, on the other hand, establishing health governance bodies that were strongly technical in focus and claimed functional independence from sanctioned ruling militias significantly boosted cooperation and protected the health system. Most interviewees felt there was more room for international actors to work with unrecognised health authorities within the "red lines" of international law and organisational mandates, using promising entry points such as supporting Human Resources for Health. There was significant agreement between authorities and international partners on the core health system strategies and priorities in these contexts. But health authorities wanted - and aid cuts suggested they should take - more control over financing and management, and they were naturally more focused than international actors on the holistic needs of the health system, beyond 'emergency' assistance.
International partners and de facto authorities can both take action to use more of the operational space for cooperation.
政府通常是卫生系统治理的主导者，但在一些受冲突影响的情况下，共同资助卫生系统的国际伙伴并不正式承认政府或同等的卫生当局。本研究探讨了2021年至2024年在阿富汗以及2013年至2019年在叙利亚西北部，两类未被承认的卫生当局与国际伙伴之间的合作受到了哪些抑制或促进因素。
文献综述与14次半结构化关键 informant 访谈相结合，访谈对象主要是捐助者或联合国机构的代表（通常是卫生顾问）。采用了政治经济分析（PEA）分析框架，重点关注影响关键卫生系统行为体行为的能力、激励措施、信念、制度和结构因素。
尽管缺乏正式承认被广泛认为是一个关键障碍，但它并非合作的主要制约因素。冲突背景的不稳定/稳定、事实上的卫生当局生存的可能性、行为体之间规范冲突的程度，以及未被承认的当局和国际行为体的激励措施和“行事方式”也发挥了关键作用。例如，在阿富汗，塔利班对妇女权利和教育的态度被确定为合作的主要障碍。另一方面，在叙利亚西北部，建立高度注重技术且声称在功能上独立于受制裁的统治民兵的卫生治理机构，显著促进了合作并保护了卫生系统。大多数受访者认为，国际行为体在国际法和组织任务规定的“红线”内，利用诸如支持卫生人力资源等有前景的切入点，与未被承认的卫生当局合作的空间更大。在这些情况下，当局和国际伙伴在核心卫生系统战略和优先事项上达成了重大共识。但卫生当局希望——援助削减也表明它们应该——对融资和管理有更多控制权，而且它们自然比国际行为体更关注卫生系统的整体需求，而不仅仅是“紧急”援助。
国际伙伴和事实上的当局都可以采取行动，更多地利用合作的操作空间。
