Postoperative care in conflict-affected northwest Syria: a mixed-methods study assessing the perspectives of patients, health workers, and non-governmental organizations

INTRODUCTION: Thirteen years of conflict have profoundly disrupted Syria's health system. In northwest Syria, constraints such as deliberate attacks on healthcare, chronic underfunding, and a fragmented health system have created a fragile surgical ecosystem in which health workers operate under extreme resource constraints, patients struggle to access care, and postoperative complications are increasingly likely. In this study, we aim to assess the burden of postoperative complications by examining patient-reported outcomes and barriers to care while integrating this data with insights from health workers and non-governmental organization (NGO) stakeholders. METHODS: This mixed-methods study uses secondary data from a cross-sectional survey of 261 adult patients who underwent surgery in hospitals in northwest Syria. Firth's logistic regression was used to estimate adjusted odds of complications by surgery type. To contextualize these findings, a workshop engaged 31 surgeons, hospital administrators, and surgeons to identify perceived drivers of complications and prioritize interventions across the WHO health system building blocks. RESULTS: Barriers to seeking postoperative follow-up care were reported by 57.5% of participants, with transportation, cost, appointment availability, and proximity among the most prevalent barriers. Trauma and orthopedic surgeries demonstrated notably higher odds of adverse outcomes. Workshop participants identified workforce shortages, surgeon rotation across hospitals, fragmented health information systems, and underfunded systems as factors perceived to be associated with these challenges. Workshop participants proposed interventions focused on expanding clinical training, strengthening infection prevention and control, improving provider-patient communication, and establishing governance mechanisms that incentivize quality care. CONCLUSIONS: Our findings illustrate how systemic vulnerabilities shaped outcomes for surgical patients and the surgical ecosystem in northwest Syria. Although data collection occurred during the Assad regime, the findings provide relevant insights for Syria's health system reconstruction, as addressing the identified challenges will be critical not only for strengthening the surgical ecosystem but also for supporting long-term recovery and resilience efforts.