Vaccination Governance in Protracted Conflict Settings: The Case of Northwest Syria

"A hybrid governance model that combines top-down and bottom-up approaches effectively improves immunisation programs in conflict settings and promotes local ownership."

Armed conflicts often influence the availability, quality, accessibility, and uptake of vaccination services, which can lead to the emergence of outbreaks and epidemics. The Syrian conflict, which started in March 2011, has led to a decline in vaccine coverage that resulted in outbreaks of vaccine-preventable diseases (VPDs), including polio (2013, 2017) and measles (2017, 2018). Since 2016, vaccination efforts have been led by the Syria Immunisation Group (SIG), formed by local humanitarian actors and co-chaired by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). This study evaluates the governance of vaccination programmes 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 validation 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 SIG. The analysis revealed several key themes. In brief:
 

• 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 reaching 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 organisations such as the WHO. Workshop participants supported these findings, expressing trust in the SIG's strategic planning but also highlighting the lack of engagement from partners in the decision-making process. Limited partner participation 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 decentralised structure and reliance on diverse donors. The transition from emergency task forces to SIG was marked by power dynamics and challenges to local ownership, raising questions about sustainability and integration into national vaccination programmes.

Thus, "The SIG's role is pivotal, but its legitimacy, transparency, and inclusivity require improvement."

Based on this analysis, the paper "calls for a push towards more localised ownership and transparency, with a hybrid top-down and bottom-up approach that addresses the unique context of conflict settings. Engaging local partners in decision-making and capacity building can improve sustainability and address issues surrounding legitimacy. Moreover, the responsibility to protect public health goes beyond national sovereignty, and the role of international bodies like the WHO becomes crucial in conflict areas. Inaction or delayed action can have catastrophic consequences, as witnessed in Syria with the emergence of diseases like polio and measles. It is essential to implement a structured feedback mechanism and transparent monitoring and evaluation processes to address challenges and foster trust among stakeholders and the community."

In conclusion: "Ultimately, the findings of this study inform debates around health governance in conflict settings, highlighting the need for more inclusive, transparent, and context-sensitive approaches to ensure the success and sustainability of vaccination programs."