What makes Syrian doctors stay or return as the country rebuilds its health system

Syria’s health system has been one of the quiet casualties of more than a decade of war, and a new study suggests that rebuilding it will depend less on buildings and equipment than on persuading the people who once staffed its hospitals and clinics to stay — or to come back. The research, published in BMC Health Services Research, combined a targeted literature review with qualitative analysis, including a facilitated workshop with 53 healthcare professionals held in July 2023 and 26 key informant interviews conducted between September 2024 and March 2025. That interview window straddled December 2024, when the Syrian regime collapsed, giving the researchers an unusual technical vantage point: they could compare what drove clinicians away before the political transition with what shaped their decisions afterward, across the same population and within a single study.

The technical premise of the work rests on a well-established framework in health workforce research: retention and return decisions are shaped by push factors, which drive professionals out of a setting, and pull factors, which attract them elsewhere or draw them back. In protracted conflict, these forces operate simultaneously and interact with the structural destruction of the health system itself. Syria’s workforce has been decimated by years of insecurity, financial instability, and deteriorating working conditions, compounded by the emigration of large numbers of doctors and nurses. The study’s authors — a team spanning Syrian institutions and UK universities including King’s College London and Imperial College — set out to identify which of these forces dominated in Syria specifically, and to convert that evidence into context-appropriate policy recommendations rather than generic post-conflict templates.

Before December 2024, the push factors were stark. Insecurity was the dominant force driving healthcare professionals out, followed closely by financial instability — salaries that had lost most of their real value — and poor working conditions in facilities that had been damaged, under-equipped, or overwhelmed. The pull factors drawing clinicians abroad were equally concrete: better remuneration, structured training opportunities, and the recognition of degrees and training obtained in other countries. For a surgeon or physician whose Syrian qualifications might not transfer easily, the prospect of a career abroad offered both economic security and professional continuity. These findings align with what workforce researchers have documented in other conflict settings, but the Syrian case adds a distinctive complication: the country’s health system had fragmented into several parallel systems, each with its own education and training arrangements.

That fragmentation is one of the study’s most technically significant findings. As different regions of Syria fell outside former regime control, separate education and training systems evolved in each, raising concerns about accreditation — particularly for qualifications obtained in areas that the former regime did not recognize. The northeast of Syria was described as particularly neglected, with unequal opportunities across regions. Across all areas, participants raised concerns about the quality of education and of graduates, a signal that the workforce pipeline itself had been compromised, not just the retention of those already in post. This matters for reconstruction planning because accreditation is not merely administrative: without a unified system for recognizing qualifications, the country cannot reliably assess who is qualified to do what, and clinicians trained in one region may find their expertise undervalued or unusable in another.

The December 2024 political transition changed the calculus in some ways but not others. After the regime’s fall, participants reported that insecurity had become less of a push factor — a meaningful shift after years in which physical danger was the primary driver of emigration. But the pull factors persisted: better pay, training opportunities, and degree recognition abroad continued to attract clinicians out of the country. Meanwhile, external migration itself became harder, as destination countries tightened or adjusted their pathways in response to the changed political situation. The net effect was a population of healthcare professionals caught between reduced danger at home and continued economic and professional incentives to leave, with persisting socioeconomic and governance challenges shaping decisions about whether to stay or return.

Return — the decision of those who left to come back — emerged as a distinct phenomenon from retention, and the study treats it separately. The same pull factors that drew clinicians abroad in the first place continue to operate in reverse: someone considering returning weighs the security situation, the state of the health system, the availability of training and career development, and whether their qualifications and experience will be recognized. The researchers found that the fragmented health system that existed before December 2024 contributed to limited and fragmented workforce data — there is no reliable total count of healthcare professionals in Syria, nor of their production, distribution, or specialisation. This absence of workforce information is itself a technical barrier to recovery: without knowing how many surgeons, nurses, or midwives exist and where they are, planners cannot target recruitment, training, or incentives effectively.

The study’s methodology is worth examining because it illustrates how qualitative evidence can be gathered across a political rupture. The workshop, conducted under the Chatham House rule in July 2023, allowed 53 healthcare professionals to discuss retention factors collectively, generating themes that the researchers could then probe in the key informant interviews. Those interviews, held with written informed consent and the option to withdraw at any time, spanned the fall of the regime, so some informants spoke before the transition and others after. The researchers supplemented this primary data with a targeted review of peer-reviewed and grey literature, then integrated all three sources to identify key themes and subthemes and to draw policy recommendations. Ethical approval was obtained from the Idlib Health Directorate and through King’s College London’s minimal risk process, and the work was funded by the David Nott Foundation and the National Institute for Health and Care Research as part of a project on health systems strengthening in northwest Syria.

The policy recommendations that emerge are technically specific rather than aspirational. The researchers call for integrated health governance — a unified system rather than the parallel structures that evolved during the conflict — and for strengthening workforce information systems so that the country can finally count and map its health professionals. They recommend better workforce planning, improved working conditions, and fair remuneration as the economic levers of retention. They also highlight the need to strengthen training and accreditation systems, which speaks directly to the fragmentation problem, and to expand career development opportunities so that clinicians have a professional future in Syria rather than only abroad. Each recommendation maps onto a specific finding: governance integration responds to the parallel systems, information systems respond to the data gap, and accreditation responds to the qualification recognition problem.

What makes the study technically notable in the broader field of health workforce research is its timing. Most post-conflict workforce studies are conducted after the fact, once a transition has settled and the push and pull factors have stabilized. This one captured the moment of change itself, with interviews spanning the regime’s fall, allowing the researchers to document which factors shifted — insecurity declining as a push factor — and which persisted — economic and professional incentives remaining intact. That before-and-after evidence within a single qualitative study is rare, and it offers a technical template for studying workforce dynamics in other countries undergoing political transition, from Sudan to Myanmar to Afghanistan.

For Syria, the implications are sobering. The political transition removed one barrier to retention but left the structural ones standing: a fragmented health system, no unified workforce data, contested accreditation, and economic conditions that continue to push clinicians toward better-paid opportunities abroad. The researchers’ recommendations — integrated governance, workforce information systems, better planning, improved conditions, fair pay, strengthened training and accreditation, and career development — are the technical prerequisites for reversing a decade of workforce loss. Whether Syria’s health system can recover depends on whether those prerequisites are met, and on whether the healthcare professionals who stayed through the war, and those who left, see a professional future worth staying for or returning to. The study’s authors thank the healthcare workers in Syria who continue to lead efforts to support the health system, often in very challenging circumstances — a reminder that behind the technical findings are people who kept working when the system around them was collapsing.

Subject of Research: Healthcare professional retention and return in Syria across conflict and political transition: a targeted literature review and qualitative analysis

Article Title: Healthcare professional retention and return in Syria across conflict and political transition: a targeted literature review and qualitative analysis

Article References: Alkhalil, M., Abbara, A., Doghim, O., Alchalati, S., Alkarrat, Z., Zakaria, W., Hariri, M., & Ekzayez, A. (2026). Healthcare professional retention and return in Syria across conflict and political transition: a targeted literature review and qualitative analysis. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15660-2

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15660-2

Keywords: Healthcare, professional, retention, return, Syria, across, conflict, political, transition, targeted, literature, review