We delve into the complex issue of sustaining healthcare systems in regions that lack internationally recognised governmental structures. It draws upon the invaluable experiences and insights of practitioners who are actively working on the ground in Northwest Syria, Northeast Syria, and Myanmar.

The session brief aims to answer the fundamental question: How are healthcare systems maintained when there is no formal government to oversee them? Through a focused session with these practitioners, the brief illuminates the local solutions, innovative approaches, and inherent challenges faced in building resilient health systems in such challenging environments.

We present a comprehensive overview, outlining 5 key takeaways and 10 detailed findings. Collectively, these demonstrate the critical importance of supporting locally led, bottom-up initiatives for developing health system governance. The brief not only highlights existing innovative practices but also explores pathways for institutional development, emphasising that even in the absence of traditional government, effective and legitimate healthcare governance can emerge from the community level.

To discuss the topic, we were joined by:

• Abdulkarim Ekzayez: Senior Health Fellow, Syria Development Centre

• Safwan Alchalati: Head of the Syrian Board of Medical Specialties (SBOMS) in Northwest Syria

• Egbert Sondrop: Senior Advisor in Health Systems, Un Ponte Per (UPP)

• Mohammad Mansour Alatrash: Head of the Health Information System (HIS) Unit in Northwest Syria

• Rima Ismail: health governance coordinator at UPP

• Ali Ardalan: Regional Adviser and Head of the Health Systems in Emergencies Lab (HSEL), World Health Organisation, EMRO

• Cynthia Maung: Medical doctor and founder of Mae Tao Clinic