The research explores the challenges and transformations in health governance in Syria's opposition-held areas (OHAs) since the conflict's onset in March 2011. The Syrian government's withdrawal from large territories led to the collapse of the health system, prompting the emergence of thousands of civil society organizations, local administration councils, and technical directorates to provide essential services.

The study reveals a fragmented governance landscape with varying approaches—top-down, bottom-up, and mixed models—with each interpreting governance differently. This fragmentation, exacerbated by donor funding methods and security challenges, negatively impacted the humanitarian sectors, especially health.

This research particularly focuses on health sector governance in OHAs, analyzing its evolution and assessing if the resilience of bottom-up service delivery can foster state-building, codify institutional structures, and ensure future accountability. It identifies three main phases of governance development: an initial phase without clear hierarchy, a second phase marked by top-down governance led by the Syrian Interim Government (SIG), and a third phase beginning around the end of 2015, with more resilient collaborative models emerging among Syrian NGOs, health directorates, and local and international actors.

The report indicates that bottom-up approaches were more successful than top-down ones. The latter suffered from a lack of consensus and understanding of social factors affecting governance, leading to skepticism and poor acceptability at the community level. On the other hand, bottom-up approaches focused on service provision and regulation, emerging out of necessity with limited resources and shifting needs from trauma response to long-term public health concerns.

However, the research highlights that this bottom-up governance, while successful in creating accountability within the health sector, failed to extend to other essential sectors like justice and police, revealing a gap in establishing a replicable normative framework. The inability to effectively engage private sector providers, who once delivered half of all services, further limited the potential of these governance models.

The study concludes that state-building projects during conflicts should prioritize bottom-up approaches, understanding the competing social orders and interests of all stakeholders. It emphasizes the need for coordinated donor funding across regions and sectors and highlights the interconnectedness of different sectors, underscoring that success in one does not guarantee success in others. The emphasis should be on the technical role of local authorities to protect sectors from conflict-related interventions and ensure service provision to those in need. The research also notes the absence of a system to include the private sector in governance, leaving a significant service provider outside the system.