ORIGINAL ARTICLE Health system challenges for the management of cardiovascular disease and diabetes: an empirical qualitative study from Syria Balsam Ahmad • Fouad M. Fouad • Madonna Elias • Shahaduz Zaman • Peter Phillimore • Wasim Maziak Received: 7 February 2014 / Revised: 16 July 2014 / Accepted: 29 July 2014 / Published online: 9 August 2014 Ó Swiss School of Public Health 2014 Abstract Objectives To explore through empirical qualitative data health system barriers to effective management of cardio- vascular disease and diabetes in Syria before the crisis, and how such analysis can inform the building of a post-crisis system. Methods Data were collected through document review, semi-structured key informant interviews, and fieldwork in clinics. Results Institutional commitment to address the increas- ing burden of CVD and diabetes in Syria was limited and uncoordinated. Challenges included an increasingly split healthcare system, with private provision for those who could afford it, and a residual state health sector for the majority. Public trust in the system had been declining. Conclusions We conclude that lack of effective man- agement of CVD and diabetes indicated weaknesses of the state and its retracting role in providing effective health- care. Such weaknesses that existed before the crisis are now compounded by new challenges resulting from wide destruction of the health system due to the ongoing war. The rebuilding of post-conflict heath care system may benefit from insights into the structural problems of the pre-crisis system. Keywords Health system Á Syria Á Aleppo Á Cardiovascular disease Á Diabetes Á Qualitative study Introduction Much has been written recently on the growing burden of the non-communicable diseases (NCDs) epidemic and its risk factors, as well as the lack of preparedness of health systems in the Arab World to prevent, manage and control them (World Health Organisation 2011; Ben Romdhane et al. (2012); Abdul Rahim et al. 2014; Alwan 2014; Mokdad et al. 2014). The limited epidemiological picture of NCDs in Syria, prior to the present conflict, conforms to the larger regional pattern. Most published empirical research on NCD epidemiol- ogy and risk factors in Syria comes from the work conducted by the Syrian Centre for Tobacco Studies (SCTS) in Aleppo (2nd largest city in Syria with a popu- lation of approximately 3 million in 2011). Its analyses indicate that cardiovascular disease (CVD) and Type II diabetes mellitus (DM) were main contributors to mor- bidity and mortality: CVD had become the second cause of morbidity and responsible for half of the overall mortality (Rastam et al. 2012), with half of all CVD deaths in Syria occurring before the age of 65 (Maziak et al. 2007). A recent modelling study predicted that diabetes prevalence This article is part of the supplement ‘‘The rising burden of noncommunicable diseases in four Mediterranean countries and potential solutions’’. B. Ahmad (&) Á S. Zaman Á P. Phillimore Institute of Health and Society, Newcastle University, Richardson Road, Newcastle upon Tyne NE2 4AX, UK e-mail: balsam.ahmad@ncl.ac.uk F. M. Fouad Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon F. M. Fouad Á M. Elias Á W. Maziak Syrian Centre for Tobacco Studies, Aleppo, Syria W. Maziak Robert Stempel College of Public Health and Social Work, Florida International University, MiamiFL, USA Int J Public Health (2015) 60 (Suppl 1):S55–S62 DOI 10.1007/s00038-014-0594-2 123