Alliance of Syrian Health Directorates in Opposition-Controlled Areas with Civil Society Organizations within Framework of Lost National State

A testimony from Dr.Munzer Alkhalil who was the head of Idlib Health Directorate between 2013-2020

Dr. Munzer Alkhalil


This article sheds light on the philosophy and circumstances of the alliance of the eight health directorates in the opposition-controlled areas with civil society organizations (CSOs), which overshadowed local alliances of a tribal character on the one hand, and their work with the official umbrella of opposition institutions represented by the Syrian Interim Government on the other hand. The alliance of the eight health directorates in the opposition-controlled areas with CSOs resulted in the inception of the Coordination Body of the Syrian Health Directorates in 2017. This Coordination Body played a central technical role in unifying policies, procedures and logos as well as shaping the contours of the health sector project within an inclusive national framework that covers all opposition-controlled areas as a first step. Subsequent steps have not been completed. This article sheds light on the reasons for the confusion in understanding the meaning of the national state and national projects in the Syrian context during the pre- and post-revolution periods, which had negative impact on the existing fragmentation and led to the evolution of many projects of a tribal character.

Historical Introduction:

During five decades of the Assad family’s rule, Syria witnessed consolidation of all pre-national loyalties and entities, strengthening the authority of the security grip, a significant decline in the level of liberty, and absence of the concept of citizenship and national state.

In 2011, a peaceful protest movement began calling for freedom and democracy. This movement was met with gunfire on peaceful demonstrations by the security services. After that, the country entered the spiral of violence, and was divided militarily into areas under the control of the Syrian opposition, the Syrian regime, or the Kurdish parties, with continuous changes in the geographical borders of control. Later on, extremist forces such as ISIS appeared and clashed with everyone.

After the collapse or withdrawal of the state’s institutions from the areas beyond the control of the regime, local medical cadres and the Ministry of Health (MoH) in the Syrian Interim Government (SIG) made significant efforts to rebuild the health sector by forming health directorates in 2013. These directorates were an extension of the medical offices and bodies that had been formed by volunteer medical cadres in the various Syrian governorates between 2011 and 2013 to provide field medical services in opposition-controlled areas. Simultaneously, parallel roles were played by the Assistance Coordination Unit affiliated to the National Coalition of Revolutionary and Opposition Forces and civil society organizations (CSOs). These groups provided some medical services and organised governance through their offices inside Syria.

Stage of Negative Competition:

The proliferation of stakeholders, such as the MoH in the SIG, the health directorate, the Assistance Coordination Unit (ACU), non-governmental organizations (NGOs), medical offices within local councils and affiliated to the military factions, and the absence of a regulator for the relationships between them, led to competition and conflict between these entities. The most significant forms of this competition were:

  1. A competition between health directorates and the MoH in the SIG: the workers in the directorates considered themselves the real founders of the health sector in the opposition-controlled areas, they are the ones who made sacrifices and put their lives at risk, while the MoH was a foreign imposition on them. On the other hand, the government believed that it had international legitimacy and resources, after it obtained 50 million euros from the State of Qatar in 2014, to impose its vertical vision on all local bodies and felt it is its duty to reproduce a central authority to end the state of chaos existing within the service sectors.
  2. A competition among the executive arms of the National Coalition for Revolutionary and Opposition Forces; the Coalition established the SIG in 2013 and maintained the ACU. This conflict reached its apex over immunization, which the MoH considered its sovereign domain, while the ACU considered itself most able to manage this area.
  3. A competition between the health directorates and medical NGOs: the directorates considered themselves the legitimate local authorities and managed the health sector in the region and NGOs sought to implement their plans. The health directorates were also looking with concern at the agenda of the NGOs associated with donors. In contrast, the NGOs considered themselves the most capable of assessing needs and providing services by virtue of the financial, human, and knowledge resources they possess, which was available to the health directorates at that time.
  4. A competition between the MoH in the SIG and medical NGOs, as the MoH believes that organizations must pass through the official channels to provide services. In contrast, the medical NGOs see themselves as neutral bodies and cannot pass through political channels linked to the SIG. Thus, NGOs preferred to work with health facilities directly within the plans drawn up by each NGO.

Stage of Alliances:

  1. The SIG was welcomed as an alternative to the Syrian regime’s government and was expected to play the lead role to design a new national project. However, it was unable to convince the stakeholders that it had a clear vision for the health sector, and it was also unable to link with these institutions as an interest-basis relationship. Therefore, about two years after its launch, the SIG found itself largely isolated and outside the framework of the understandings and alliances that began to appear between the directorates and NGOs.
  2. The ACU was able largely to distance itself from conflicts and alliances after 2015. In this regard, it helped that ACU runs some successful central programs such as the Early Warning Alert and Response Network (EWARN), which included all areas under the control of the opposition and helped the ACU in opening communication channels with the directorates, and with health facilities directly. However, the ACU entered the circle of conflict after the formation of the Coordination Body for Health Directorates (see below) in 2017 and sided with the Syrian Interim Government.
  3. Many alliances among Syrian NGOs have emerged, perhaps the most prominent of which is the alliance of five major NGOs in 2015 under the title of “The Charter of Honor”, which included the Union of Medical and Relief Organizations (UOSSM), the Syrian American Medical Society (SAMS), Physicians Across Continents (PAC), Al-Sham Humanitarian Foundation (SHAM) and Syrian Expatriate Medical Association (SEMA). The Charter articles included “Joint strategic planning, cooperation and coordination in the implementation of projects” as well as “Working on full support for the alternative medical institutions and governance frameworks for the medical sector in the whole of Syria”.
  4. An alliance between health directorates and NGOs was formed in 2015. The most important reasons for this alliance were:
  5. The need to create a success story and a model as a building block for the long-sought national state that has never existed before or after the revolution, and neither at the level of reality nor at the level of concept and practice. The national state should guarantee everyone respect for privacy and acknowledge the rights of all its components and individuals.
  6. The need to create a real authority in opposition-controlled areas that fills the void created by the absence of state’s institutions and fulfils the roles of governance entrusted to it.
  7. The need to protect the health sector from the interventions of military factions, especially those factions that had a civilian project such as Islamic Movement of Ahrar al-Sham, Hayat Tahrir al-Sham (HTS) and Army of Islam.
  8. The need to create a convincing model for both the local community and international society on creating alternative institutions to those of the Syrian regime.
  9. Realizing that humanitarian NGOs, which were formed in the context of the Syrian humanitarian crisis, would not be able to act as non-governmental and governmental institutions at the same time.
  10. Health directorates’ awareness of their need for an alliance with NGOs due to the vital human, knowledge and financial resources they possess to implement strategic plans and the national added value of these NGOs.
  11. Establishing channels of communication between the administrative boards of NGOs located in Europe, USA and the Arab Gulf Region and the health directorates. This was achieved through the visits made by many members of these boards into Syria and the meetings held in Turkey, which contributed to building confidence between the two parties.
  12. The emergence of the Health Cluster as a crucial player in Gaziantep, after the issuance of the Security Council Resolution 2139 dated February 22, 2014, which authorized the entry of humanitarian aid across borders. The Cluster played a significant role in opening dialogue channels and exchanging information between health directorates and NGOs through periodic meetings. In addition, the Cluster strengthened the leadership role of health directorates.

Result of the Alliance:

The alliance and understanding between health directorates and medical NGOs resulted in the first visit to the European Union countries; with a joint delegation of directors of Idlib and Hama Health Directorates as well as the five directors of “The Charter of Honor” on January 29, 2016 to advocate for funding for the health directorates. This advocacy led to securing funding for the Idlib Health Directorate for eight months as a pilot step. This was followed by financing for all health directorates in Idlib, Aleppo, Hama, Lattakia, Homs, Rural Damascus, Daraa and Quneitra in October 2017.

Through this project, the directorates were able to obtain direct funds, and it was the first time a project transcended geographical lines and covered all areas outside the regime’s control. A Coordination Body was established among the health directorates to bring them together. The Coordination Body worked on unifying policies, procedures and logos. The name of the Coordination Body was changed to “the Technical Body of the Health Directorates” to address the concerns of stakeholders:

  • The MoH in the SIG saw this organization as performing the roles of the Ministry itself and therefore as a potential threat to the Ministry’s role.
  • The ACU considered that it might pose a threat to the EWARN project, which is the most crucial project for ACU.
  • The World Health Organization saw in this organization a threat to the coordinating role WHO plays through the Health Cluster in Gaziantep, so it did not welcome the idea or interact positively with the Technical Body.
  • The military factions saw in this organization a threat to their ability to interfere in the work of the health sector and their projects of a local tribal character because it transcends each faction’s geographical lines.

Stage of Project Collapse and Weak Alliances:

The project collapsed in stages. Collapse began with the regime’s control over rural Damascus in April 2018, and in July 2019 the project completely collapsed with the cessation of funds for all activities. The most significant reasons for the collapse were:

  1. The regime’s control over Homs, Rural Damascus, Daraa, and Quneitra provinces caused the loss of half of the health directorates involved in the project.
  2. The restrictions imposed on the project by the SIG. SIG believed that the continuation of direct financing to the health directorates without passing through its channel weakened the central role of the MoH.
  3. Pressures from the Syrian Salvation Government (SSG), which was formed in October 2017 in the areas controlled by HTS. SSG considered itself unable to play an essential role through the MoH unless the Idlib Health Directorate’s leadership role was weakened.
  4. Declining support from donors and lack of funds provided to health directorates directly under the pretext of the danger of continuing to promote projects of a developmental nature in areas controlled by HTS. Donors judged that such projects could strengthen HTS, while in fact, these projects were weakening its control over the civilian sectors.

Moreover, the existing alliances between the NGOs involved in the Charter of Honor changed due to differing perceptions of governance concepts a in addition to the negative perception by the rest of the Syrian medical NGOs of the Charter itself. To explain this, the other Syrian NGOs saw the Charter as taking credit for all the great effort and contributions that all the Syrian NGOs make in favor of the Charter’s NGOs. Therefore, the alliances disintegrated into bilateral and tripartite alliances between NGOs and the rest of the health directorates, and there was no longer a critical mass directing the heath sector.


Many interventions with political and service dimensions built the health sector in the opposition-controlled areas. Some of them had a top-down approach, which distinguished the project of the SIG and the ACU. In contrast, some other interventions had a down-top approach, which distinguished the joint project that resulted from the coalition between the Syrian Health Directorates and CSOs. The directorates moved away from investing in the opposition’s official structures after the first two years of the SIG. The health directorates, however, have sided with CSOs. On the other hand, sub-national projects were more closely linked with the military factions in different geographical areas.

The common denominator of all projects is the turmoil in understanding the concept of the national project and the national state. This turmoil was a result of the historical context in which the Ba’ath Party and the military consecrated tribal rule at the expense of the homeland and citizenship and due to the nine-year military conflict between the Syrian regime and its allies, and the revolution’s forces. However, I can claim that the project of health directorates – CSOs is the most appropriate for the Syrian context and other contexts in which the state is collapsed or absent and enters into military conflicts. This alliance is the closest to the concept of the national state.

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