Health information management systems and practices in conflict-affected settings: the case of northwest Syria

Critical gaps in public health information in the NWS were found, especially in the areas of population size and composition, health risk factors (such as food security and livelihood), health service (such as coverage of services, and quality of services), and health outcomes (especially NCDs, mental health, and mortality). The following table summarizes the available information for the key health information domains in the NWS (Table 1):

Table 1 Available data on the main health information domains in the NWS

Scores from 0 to 4 for each set of health information of these four domains were given based on the quality and number of available databases for each domain. The following diagram summarizes the scoring of the main public health information domains in the NWS. The colour scheme gets darker for domains with the most available information (Fig. 5).

In the absence of a national central body to manage health information in the NWS, international NGOs (mainly WHO and HWG) have become the central mechanism for data management and dissemination. To improve the availability and quality of health information, WHO and the HWG require increased technical support to strengthen the central mechanisms for data management, analysis, presentation, and dissemination and should work on building local capacities to sustain this function, specially that most of current systems are top down. Critical gaps in health data that humanitarian actors can help to fill include population size data, mental health, non-communicable diseases, and service quality. This can be done through:

1.

Using programmatic data, from nutrition screening or HIS data form different facilities and NGOs, to estimate population size and composition.
2.

Deploying a central reporting mechanism for major NCDs and mental health using the RHIS systems of NGOs to estimate prevalence and risk factors.
3.

Developing a set of indicators for health service quality to standardize the level of services quality tracked by HWG and WHO.
4.

Supporting health facilities to report and issue reports and forms on causes of death to better understand and estimate mortality data, especially on facility-based deaths.
5.

Collaborating across sectors to complement health data on social determinants of health, food security, water, sanitation, and hygiene (WASH).

Table of Contents

Information sharing and a harmonized system

In general, NGOs provide information about services availability and coverage, with a number of them providing information on budgeting, resource allocation, procurement plans, and service beneficiaries [16]. INGOs and donor organizations provide public information through their websites on programs structures, available funds, decision making processes, and services distribution through their programs [16]. Information sharing and management is a real challenge in NWS and does not seem to be collected in an efficient way to support policy or intervention planning or implementation. NGOs collected data directly from the field or through other NGOs and local health facilities, while INGOs seemed to collect data through local projects they funded (project reports) and monitoring and evaluation reports.

In addition, in NWS, the local NGOs and INGOs do not have a harmonized system of health information collection, analysis, or sharing [9, 23,24,25,26, 34]. Data collection and processing is fragmented where each facility and institution has its own methodology of collecting and processing health data, with little information cross-sharing [9, 27, 30, 31, 35, 36]. Despite a poorly managed system of paper-based health information system in pre conflict Syria, there was available data on population denominators and concrete data that directed and guided policy planning and healthcare provision priorities and gaps [34, 37]. This was mainly attributed to the centralized role of the Syrian Ministry of Health that provided unified data collection forms across healthcare facilities (both public and private) and managed all of these data through a central team at the MoH [37]. However, in current NWS, data lives in silos and is mainly used in advocacy and funding efforts by both local and international NGOs. As such, there is little data sharing across different health actors in NWS.

At the initial stages of the Syrian conflict, reluctance in information sharing across institutions especially local and international was mainly due to security and authorization concerns. [26, 30, 31] Data on health facilities and programs was often used for targeting as one of the broad illustrated methods of healthcare weaponization in Syria, especially the NWS [26, 30]. As a result, strict information sharing protocols were implemented by INGOs which still pertain until today [26,27,28,29,30]. This lack of data sharing and data accessibility among the different healthcare actors in NWS is severely restricting coordination and strategic planning, which are essential especially in the recovery stage of healthcare system in NWS. Table 2 shows the available databases of health information on multiple domains at the ReliefWeb Response website, which is a specialized digital service of OCHA. There is a demonstrated difference between the amount of data ReliefWeb, HWG, and HIS have access to compared to accessible data of this study, which is a reflection on the overall landscape of health information sharing systems in NWS. There are a number of mutual databases that are shared between RW website and this paper findings, and a number of more concrete databases available for RW especially in relation to mortality and healthcare coverage. In a region that suffered over a decade of conflict, data on morbidity, mortality, healthcare provisions, and healthcare facilities are essential to support appropriate public health actions, identify the population healthcare needs, identify humanitarian interventions, and documenting conflict impacts on health and on civilians. [26,27,28,29,30, 38, 39] It is also essential for effective advocacy campaigns and funding campaigns to mitigate some of the conflict impacts on the health of civilians [25, 26, 40]. Most of the current data on war affected Syrians is on refugee populations in neighbouring countries in Jordan, Lebanon, and Turkey [9,10,11,12,13,14, 16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33, 36, 41, 42]. Substantives public health analysis for Syrian population in the NWS is lacking [9, 26, 28,29,30,31]. Health data on the conflict trapped population in NWS is essential and requires a collective effort and collaboration among the various local and international actors in NWS who have valuable data on population and health conditions of the NWS population.

Table 2 ReliefWeb health information data in NWS (including Whole of Syria – WoS)

E-Health and m-Health opportunities

The fragmented nature of the Syrian conflict poses an opportunity to develop and implement eHealth tools to overcome barriers of data collection and management [26, 30]. Investments in eHealth to facilitate automated transmission and exchange of health data has the potential to overcome HIS conflict barriers such as security and safety concerns and remote management [27, 30]. In Lebanon, for example, the Global Health Institute of the American University of Beirut, developed and implemented an eHealth project (E-Sahha) which delivers healthcare to underserved populations such as Palestinian and Syrian refugees in Lebanon [43]. The health tool and content were designed and developed in collaboration with experts at the Ministry of Public Health, as well as health workers and users of primary care centres [43,44,45,46,47]. Based on this collaboration, the tool targets health patients for information about their healthcare, health workers and providers for care follow-up, and the Ministry of Public Health for documentation and data management. The digital platform was launched in 2014, and to date it generated data on prevalence of non-communicable diseases and depression and forms the central house of refugee health and population data in Lebanon allowing for informed health policies and interventions [43,44,45,46,47].

The E-Sahha platform was developed through a community participatory approach, which was key for its success despite the complex environment it operates in (refuges in crisis affected Lebanon) [43, 46, 47]. The participatory approach is necessary for the success of any health information system tools and platforms in the Syrian case, to assure overcoming local barriers and to empower local actors who are key users of such platform [48]. The participatory approach is an ecological one and includes three key pillars: intervention, evaluation, and community participation as shown in Fig. 6 [48].

Such an approach could also be applied to data management platforms such as DHIS-2, which is currently used by local and international NGOs in NWS. DHIS-2 is an open-source information system with minimal hardware requirements. It aggregately stores routinely collected data across health facilities of a given country to facilitate analysis of health services and project health needs at a national level [49, 50]. DHIS-2 is strong in relation to data visualization and provides the option of carrying out certain operations offline, although Wi-Fi is needed for launching and for data transferring [49,50,51]. In addition, as it is an open source, it offers flexibility for users to modify the platform to meet their needs [49,50,51,52]. However, the use of DHIS-2 is challenging in the Syrian context due to concerns around data security, availability and quality of data, and the integrity of the health system [49,50,51]. As the DHIS-2 was developed on the premise of open data with granted access to all involved stakeholders which poses risks related to data security especially in the context of healthcare weaponization in the Syrian context [53, 54]. Furthermore, for sufficient reporting outcomes, data entered DHIS-2 needs to be in specific format and with a number of variables to comply with DHIS-2 modules [49,50,51,52]. Given the current fragmented and non-harmonized data collection in NWS, sufficient usage of DHIS-2 is challenging. The health information system in NWS developed in a fragmented manner during the conflict, resulting in lack of data sharing, data duplications, improper use of data and disruption in healthcare provision, which pose challenges to data entry and analysis in DHIS-2 [49,50,51,52]. Another key challenge is that launching and implementing DHIS-2 in most countries requires external consultants (from the University of Oslo or WHO) which is restricted especially in NWS where the political environment is instable and insecure [49,50,51,52]. Modifying the system to allow for independent launching and implementation is important in conflict settings, especially that in NWS. If such a modification is not possible, then allowing communication pathways between local actors and external consultants is essential.

However, it is important to consider the limitations of mHealth and eHealth applications as they rely on functional internet connection and infrastructure as well as available electricity and communication infrastructure, which are not always present in conflict and limited resource settings. While this study points out these limitations, it also recognizes some solutions such as satellite internet and solar powers, which could overcome significant infrastructure and connection challenges if applied and implemented in regions of interest.

Empowering local agency

In NWS, local NGOs and health facilities are mainly responsible for managing health services for the population including internally displaced ones and needed to adapt to complex and new organizational mechanisms including new bilateral and multilateral actors such as international and humanitarian NGOs and UN and donor agencies with varying missions, mandates and agendas. [9, 11, 14, 16, 28, 29] Such a landscape resulted in a poorly coordinated and fragmented healthcare response in NWS and undermined local strategic plans and exiting local structures, which also reflected in HIS as explained earlier. [14, 28, 29] In addition, this landscape resulted in a general confusion over roles, responsibilities, and accountability, especially that multiple systems of hierarchy are in place in NWS from local to international organizations and institutions [26, 27, 35]. Therefore, empowerment and capacity building of local NGOs and actors working in the field is important to overcome these challenges. Almost all of the health datasets explored in this study were developed in a top-down manner, with minimal power of local actors beyond data collection. Most of the health information regarding Syrians focuses on Syrian refugee populations, with a limited information on the paralyzed health sector and the remaining resident population including internal displaced persons in NWS [26,27,28,29]. There is a need to include, empower, and build capacity and engagement of local actors in the process of data collection, management, analysis, and publication. Collection and management of data systems in humanitarian response in conflict settings and post conflict is proven to be more effective when local NGOs and health actors are involved with a large level of authority and leadership [16, 31, 34, 39, 41, 55]. Examples from Lebanon (E-Sahha platform), Palestine (DHIS-2 platform), Afghanistan (Aga-Khan, and IPath) proves the efficacy of adopting an ecological local community approach towards HIS systems development and management. [16, 30, 34, 38, 39, 41, 49] A participatory approach to health information collection and management also aligns with the recent global momentum to move away from short hierarchal health projects in conflict towards long-term, development-oriented, and locally engaged health systems with coordination with external actors [33, 38].

Limitations

One of the main limitations is perhaps that the findings may not be generalizable outside the NWS context, although a follow-up comparative study focusing on other areas in Syria would enable broader interpretations towards harmonisation of health information system in all of Syria [56]. Another limitation is that the study took place before the February 2023 earthquake that has had drastic consequences on the health system in NWS with all development activities being halted in favour of humanitarian support. However, this does not jeopardise the key results and findings of the study but rather highlight the need for more attention towards robust and sustainable solutions for improved health information systems in conflict and fragile settings. [12, 15, 36, 40, 43,44,45,46,47,48, 50, 51, 53,54,55, 57, 58].

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