From ground realities to policy: a framework for assessing multipolar health system governance in conflict-affected and high-risk areas

Introduction: Understanding and evaluating health system governance is essential for resilient health systems. This study develops a framework to analyse health system governance in conflict-affected and high-risk areas, including fragmented systems. Methods: The methodology adopts a qualitative multi-faceted approach, encompassing five methods: consultations with experts, thematic analysis of existing health system governance frameworks, focus group discussions, interviews with key informants, and reflections from primary authors during fieldwork. The discussion centred on examples primarily drawn from northwest Syria throughout the conflict (2011–2024). Findings: Existing health system governance frameworks are less relevant in conflict-affected and high-risk areas. The authors developed a new institutional framework by adding more dimensions to well-known principle-based frameworks, such as Siddiqi et al., to address the complexities imposed by conflicts. The framework has a descriptive part that includes power dynamics (types and dimensions) and stakeholders’ traditional and non-traditional roles and responsibilities. Additionally, it has an evaluative part that includes eleven principles: strategic vision; participation and consensus orientation; rule of law and ethics; intelligence and conflict-sensitive transparency; responsiveness; equity and inclusiveness; effectiveness and efficiency; complex accountability; complementarity; localisation; and legitimacy. Conclusion: The proposed framework can deal with fragmented health systems characterised by multipolar health systems. It is typically applicable in conflict-affected and high-risk areas. It provides policymakers with a structured approach to describing and evaluating health system governance.