Health system governance cooperation with unrecognised health authorities: a political economy analysis in Afghanistan and Northwest Syria.

Background: The government is normally the leading actor in health system governance, yet in some conflict-affected contexts, government or equivalent health authorities are not formally recognised by the international partners who co-finance the health system. This study considers what has inhibited or facilitated cooperation between two types of non-recognised health authorities and international partners in Afghanistan from 2021 to 24 and Northwest Syria from 2013 to 19.

Methods: A literature review was combined with 14 semi-structured key informant interviews, mostly with representatives (often health advisers) of donors or UN agencies. A political economy analysis (PEA) analytical framework was used, focusing on the capacities, incentives, beliefs, institutional and structural factors that influenced the behaviour of the key health system actors.

Results: Although widely cited as a critical barrier, the lack of formal recognition was not the main constraint on cooperation. The in/stability of the conflict context, the likelihood of survival of de facto health authorities, the extent to which there were clashing norms between actors, and the incentives and 'ways of doing things' of both unrecognised authorities and international actors also played key roles. For example, in Afghanistan, the Taliban's approach to women's rights and education was identified as the major barrier to cooperation. In Northwest Syria, on the other hand, establishing health governance bodies that were strongly technical in focus and claimed functional independence from sanctioned ruling militias significantly boosted cooperation and protected the health system. Most interviewees felt there was more room for international actors to work with unrecognised health authorities within the "red lines" of international law and organisational mandates, using promising entry points such as supporting Human Resources for Health. There was significant agreement between authorities and international partners on the core health system strategies and priorities in these contexts. But health authorities wanted - and aid cuts suggested they should take - more control over financing and management, and they were naturally more focused than international actors on the holistic needs of the health system, beyond 'emergency' assistance.

Conclusions: International partners and de facto authorities can both take action to use more of the operational space for cooperation.