"We rely on the lecturer's skills and knowledge rather than set curricula. Some of our modules are taught based on translated textbooks that are 30 and 35 years old which are far from being related to the health needs of our people or even the research community."
             Senior faculty member of an academic institute
"We are not used to conducting research, we have a lot to tell, but we are not even trained on how to write a scientific paper. We need interventions for our cadres rather than on our facilities and infrastructure."
             Representative of a governance body
Political level. The unstable state of security, 'polarisation', and 'politicisation' of MEHPT were the major factors impacting support channels and reaching out to donors. Participants felt these issues were a real impediment to achieving a stable base for development work.
"It is time now to neutralise medical education work, as we were able to neutralise medical relief and humanitarian work when the situation and the context necessitated it, now it is time to do this for medical education because the situation and the context necessitates."
             Representative of a national NGO
Governance level. Participants expressed major challenges facing them on the governance level due to the weak internal decision-making capacity of local governance bodies. The reliance on external funding channels from donors and non-governmental organisations (NGOs) has caused a lack of autonomy and independence of these bodies. Furthermore, this has been the cause for complexities related to the requirements of donor-related reporting, red tape, and logistics. Participants also described this as the reason for a 'hesitance to initiate change':
"There is no unified governance structure that can coordinate efforts, set plans, achieve standardisation, achieve effective external partnerships, and approach funders. This creates negative competitiveness between the local bodies for funding opportunities which come and go, and projects are hugely dependent on the presence of external funding, as long as there is a donor organisation implementing the project and providing funds, the project will continue, as soon as it stops, the work ends. This is a waste of local efforts, and a source of disappointment."
             Representative of a governance body
Given the subsequent lack of holistic and systematic need assessment studies to inform the initiation and distribution of support programmes, there is a lack of effective coordination and communication towards standardisation of curricula, assessments, evaluations, and quality control procedures.
"Lack of local accreditation is a significant issue in northwest Syria, there is a focus on international recognition and external accreditation, at the expense of the local accreditation:I will only accredit your graduates if you accredit my graduates."
             Director of academic institute
Despite the multi-level challenges facing actors, participants perceived significant opportunities within the MEHPT sector. They said they believed the MEHPT has high levels of resilience. They also expressed a belief in a dominant culture of proactivity and creating positive changes which they felt would be the catalyst for future development work. They also professed a strong sense of loyalty to MEHPT and mutual hope in bettering the future of health and creating peace for the local population. These feelings stemmed from their joint experiences during the ten plus years of "sacrifice", "enduring extreme violence" and operating within limited or absent resource-settings:
"We work in a uniquely complex context, we have been able to establish institutions from scratch under shelling, what we need now is to look at medical education and training from a different lens, we need to go beyond short intermittent courses to the space of building systems and strengthening institutions. We need to re-think medical education and training as a peace building pillar for our community."
             Key individual
The extensive efforts of the Syrian diaspora were seen as a significant pillar of support which "broadened horizons" for local actors. Additionally, innovation and technology made it possible to coordinate remote training and capacity strengthening activities for local staff by experts from international institutions. This was perceived to have created the potential to network and establish more stable and sustainable partnerships with international academic institutions.
The participants suggested several recommendations for future work in the field of MEHPT in northwest Syria. Firstly, they perceived the political neutralization of MEHPT as the main pillar for future development. They explained that this may include lining up around "a core body" or "a core alliance" which is able to overcome the polarisation and political sensitivities within the context and hence guarantee representation, independence, and collective decision making in MEHPT towards achieving sustainable and effective external partnerships. Secondly, strengthening the local MEHPT governance bodies to enable improved leadership, ownership, coordination, accreditation, and decision making. They suggested this may be achieved by gradually shifting power from external support systems (including NGOs and donors) to local governance systems, together with holistic capacity strengthening approaches and programmes in leadership, conflict resolution, management, strategic planning, information technology, needs assessment, public health planning, research and quality improvement, communication, "common value-building", and English language skills. Thirdly, networking with neighbouring and international academic institutions and establishing sustainable academic partnerships and capacity building programmes with local academic bodies, including training senior leadership and teaching staff especially in areas such as assessments, teaching strategies, curriculum design, and English language.