Vaccination governance in protracted conflict settings: the case of northwest Syria.
Conflict setting
Health governance
Immunisation
Localisation
Syria
Vaccination
Journal
BMC health services research
ISSN: 1472-6963
Titre abrégé: BMC Health Serv Res
Pays: England
ID NLM: 101088677
Informations de publication
Date de publication:
12 Sep 2024
12 Sep 2024
Historique:
received:
16
01
2024
accepted:
07
08
2024
medline:
13
9
2024
pubmed:
13
9
2024
entrez:
12
9
2024
Statut:
epublish
Résumé
Effective vaccination governance in conflict-affected regions poses unique challenges. This study evaluates the governance of vaccination programs in northwest Syria, focusing on effectiveness, efficiency, inclusiveness, data availability, vision, transparency, accountability, and sustainability. Using a mixed-methods approach, and adapting Siddiqi's framework for health governance, data were collected through 14 key informant interviews (KIIs), a validating workshop, and ethnographic observations. Findings were triangulated to provide a comprehensive understanding of vaccination governance. The study highlights innovative approaches used to navigate the complex health governance landscape to deliver vaccination interventions, which strengthened sub-national vaccination structures such as The Syria Immunisation Group (SIG). The analysis revealed several key themes. Effectiveness and efficiency were demonstrated through cold-chain reliability and extensive outreach activities, though formal reports lacked detailed analysis of vaccine losses and linkage between disease outbreak data and coverage statistics. Key informants and workshop participants rated the vaccination strategy positively but identified inefficiencies due to irregular funding and bureaucracy. Inclusiveness and data availability were prioritised, with outreach activities targeting vulnerable groups. However, significant gaps in demographic data and reliance on paper-based systems hindered comprehensive coverage analysis. Digitalisation efforts were noted but require further support. The SIG demonstrated a clear strategic vision supported by international organizations such as the World Health Organization, yet limited partner participation in strategic planning raised concerns about broader ownership and engagement. While the SIG was perceived as approachable, the lack of public documentation and financial disclosure limited transparency. Internal information sharing was prevalent, but public communication strategies were insufficient. Accountability and sustainability faced challenges due to a decentralized structure and reliance on diverse donors. Despite stabilizing factors such as decentralization and financial continuity, fragmented oversight and reliance on donor funding remained significant concerns. The study highlights the complexities of vaccination governance in conflict-affected areas. Comparisons with other conflict zones underscore the importance of local organisations and international support. The SIG's role is pivotal, but its legitimacy, transparency, and inclusivity require improvement. The potential transition to early recovery in Syria poses additional challenges to SIG's sustainability and integration into national programs. The governance of vaccination in northwest Syria is multifaceted, involving multiple stakeholders and lacking a legitimate government. Enhancing transparency, local ownership, and participatory decision-making are crucial for improving governance. The role of international bodies is essential, emphasising the need for structured feedback mechanisms and transparent monitoring processes to ensure the program's success and sustainability.
Sections du résumé
BACKGROUND
BACKGROUND
Effective vaccination governance in conflict-affected regions poses unique challenges. This study evaluates the governance of vaccination programs in northwest Syria, focusing on effectiveness, efficiency, inclusiveness, data availability, vision, transparency, accountability, and sustainability.
METHODS
METHODS
Using a mixed-methods approach, and adapting Siddiqi's framework for health governance, data were collected through 14 key informant interviews (KIIs), a validating workshop, and ethnographic observations. Findings were triangulated to provide a comprehensive understanding of vaccination governance.
RESULTS
RESULTS
The study highlights innovative approaches used to navigate the complex health governance landscape to deliver vaccination interventions, which strengthened sub-national vaccination structures such as The Syria Immunisation Group (SIG). The analysis revealed several key themes. Effectiveness and efficiency were demonstrated through cold-chain reliability and extensive outreach activities, though formal reports lacked detailed analysis of vaccine losses and linkage between disease outbreak data and coverage statistics. Key informants and workshop participants rated the vaccination strategy positively but identified inefficiencies due to irregular funding and bureaucracy. Inclusiveness and data availability were prioritised, with outreach activities targeting vulnerable groups. However, significant gaps in demographic data and reliance on paper-based systems hindered comprehensive coverage analysis. Digitalisation efforts were noted but require further support. The SIG demonstrated a clear strategic vision supported by international organizations such as the World Health Organization, yet limited partner participation in strategic planning raised concerns about broader ownership and engagement. While the SIG was perceived as approachable, the lack of public documentation and financial disclosure limited transparency. Internal information sharing was prevalent, but public communication strategies were insufficient. Accountability and sustainability faced challenges due to a decentralized structure and reliance on diverse donors. Despite stabilizing factors such as decentralization and financial continuity, fragmented oversight and reliance on donor funding remained significant concerns.
DISCUSSION
CONCLUSIONS
The study highlights the complexities of vaccination governance in conflict-affected areas. Comparisons with other conflict zones underscore the importance of local organisations and international support. The SIG's role is pivotal, but its legitimacy, transparency, and inclusivity require improvement. The potential transition to early recovery in Syria poses additional challenges to SIG's sustainability and integration into national programs.
CONCLUSION
CONCLUSIONS
The governance of vaccination in northwest Syria is multifaceted, involving multiple stakeholders and lacking a legitimate government. Enhancing transparency, local ownership, and participatory decision-making are crucial for improving governance. The role of international bodies is essential, emphasising the need for structured feedback mechanisms and transparent monitoring processes to ensure the program's success and sustainability.
Identifiants
pubmed: 39267075
doi: 10.1186/s12913-024-11413-1
pii: 10.1186/s12913-024-11413-1
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1056Subventions
Organisme : National Institute for Health and Care Research
ID : 131207
Organisme : National Institute for Health and Care Research
ID : 131207
Organisme : National Institute for Health and Care Research
ID : 131207
Organisme : National Institute for Health and Care Research
ID : 131207
Informations de copyright
© 2024. The Author(s).
Références
Sato R. Effect of armed conflict on vaccination: evidence from the Boko Haram insurgency in northeastern Nigeria. Confl Health. 2019;13(1):1–10.
doi: 10.1186/s13031-019-0235-8
Ngo NV, Pemunta NV, Muluh NE, Adedze M, Basil N, Agwale S. Armed conflict, a neglected determinant of childhood vaccination: some children are left behind. 2019;16(6):1454–63. https://doi.org/10.1080/2164551520191688043
Lam E, McCarthy A, Brennan M. Vaccine-preventable diseases in humanitarian emergencies among refugee and internally-displaced populations. Hum Vaccin Immunother. 2015;11(11):2627–36.
doi: 10.1080/21645515.2015.1096457
pubmed: 26406333
pmcid: 4685677
Kennedy J, Michailidou D. Civil war, contested sovereignty and the limits of global health partnerships: a case study of the Syrian polio outbreak in 2013. Health Policy Plan. 2017;32(5):690–8.
doi: 10.1093/heapol/czw148
pubmed: 28453719
Pereira A, de Southgate L, Ahmed R, O’Connor H, Cramond P, Lenglet V. A. Infectious Disease Risk and Vaccination in Northern Syria after 5 years of Civil War: the MSF experience. PLoS Curr. 2018;10.
Tajaldin B, Almilaji K, Langton P, Sparrow A. Defining polio: closing the gap in global surveillance. Ann Glob Health. 2015;81(3):386–95.
doi: 10.1016/j.aogh.2015.06.007
pubmed: 26615073
Ahmad B, Bhattacharya S. Polio eradication in Syria. Lancet Infect Dis. 2014;14(7):547–8.
doi: 10.1016/S1473-3099(14)70803-5
pubmed: 24964936
Meiqari L, Hoetjes M, Baxter L, Lenglet A. Impact of war on child health in northern Syria: the experience of Médecins sans Frontières. Eur J Pediatr. 2018;177(3):371–80.
doi: 10.1007/s00431-017-3057-y
pubmed: 29255951
Initiative GPE. In. Syrian Arab Republic. 2021. p. 191–191.
Alkhalil M, Alaref M, Mkhallalati H, Alzoubi Z, Ekzayez A. An analysis of humanitarian and health aid alignment over a decade (2011–2019) of the Syrian conflict. Confl Health. 2022.
Alkhalil M, Ekzayez A, Rayes D, Abbara A. Inequitable access to aid after the devastating earthquake in Syria. Lancet Glob Health. 2023;0(0).
OCHA. Northwest Syria Humanitarian Readiness and Response Plan. 2020.
Zulfiqar ABBC, Reality C. 2020 [cited 2020 May 2]. Syria: Who’s in control of Idlib? - BBC News. https://www.bbc.co.uk/news/world-45401474
EUAA. 1.3. Anti-government armed groups | European Union Agency for Asylum [Internet]. 2020 [cited 2023 Sep 10]. https://euaa.europa.eu/country-guidance-syria/13-anti-government-armed-groups
Alkhalil M, Alaref M, Ekzayez A, Mkhallalati H, El Achi N, Alzoubi Z, et al. Health aid displacement during a decade of conflict (2011–19) in Syria: an exploratory analysis. BMC Public Health. 2023;23(1):1–16.
doi: 10.1186/s12889-023-16428-7
Security Council Report. In. Hindsight: the demise of the Syria cross-border aid mechanism, August 2023 Monthly Forecast. Security Council Report; 2023.
WHO, Unicef. Immunization Summary: A statistical reference containing data through 2010. Vol. 2011. 2011.
Ekzayez A, Alkhalil M, Patel P, Bowsher G. Pandemic governance and community mobilization in conflict: a case study of Idlib, Syria. Inoculating cities: Case studies of the Urban response to the COVID-19 pandemic. 2024;61–80.
OECD. Creditor Reporting System (CRS) [Internet]. 2023 [cited 2023 Dec 1]. https://stats.oecd.org/Index.aspx?DataSetCode=CRS1
Kaddar M, Saxenian H, Senouci K, Mohsni E, Sadr-Azodi N. Vaccine procurement in the Middle East and North Africa region: challenges and ways of improving program efficiency and fiscal space. Vaccine. 2019;37(27):3520–8.
doi: 10.1016/j.vaccine.2019.04.029
pubmed: 31130259
World Health Organization. World Health Organization Syrian Arab Republic [Internet]. 2020 [cited 2023 Sep 10]. http://apps.who.int/bookorders
ACU. Annual report 2019. Vol. 5, AIMS Mathematics. 2019.
Siddiqi S, Masud TI, Nishtar S, Peters DH, Sabri B, Bile KM, et al. Framework for assessing governance of the health system in developing countries: gateway to good governance. Health Policy. 2009;90(1):13–25.
doi: 10.1016/j.healthpol.2008.08.005
pubmed: 18838188
Hugh Guan T, Htut HN, Davison CM, Sebastian S, Bartels SA, Aung SM, et al. Implementation of a neonatal hepatitis B immunization program in rural Karenni State, Myanmar: a mixed-methods study. PLoS ONE. 2021;16(12 December):e0261470.
doi: 10.1371/journal.pone.0261470
pubmed: 34928996
Hugh Guan T, Htut HN, Davison CM, Sebastian S, Bartels SA, Aung SM et al. Implementation of a neonatal hepatitis B immunization program in rural Karenni State, Myanmar: A mixed-methods study. PLoS One [Internet]. 2021 Dec 1 [cited 2023 May 9];16(12 December):e0261470. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0261470
Alaref M, Al-Abdulla O, Al Zoubi Z, Al Khalil M, Ekzayez A. Health system governance assessment in protracted crisis settings: Northwest Syria. Health Res Policy Syst. 2023;21(1):1–13.
doi: 10.1186/s12961-023-01042-1