Bridging the Humanitarian-Development Nexus in Prosthetics and Orthotics: Operational Frameworks and Scaling Challenges in Protracted Emergencies

Modern armed conflicts generate staggering numbers of life-altering injuries, yet humanitarian responses frequently default to short-term "biological survivalism," neglecting long-term physical rehabilitation and assistive technology (Balsari et al., 2020). This study evaluates the operational, digital, and surrogate governance framework deployed in northwest Syria (2022–2024) to coordinate prosthetics and orthotics (P&O) services amidst protracted displacement, institutional collapse, and NGO fragmentation (Goyaux et al., 2021). Drawing from cross-border coordination reports, technical working group documentation, and multi-agency field assessments (OCHA, 2024), we analyze the transition from uncoordinated NGO silos to a unified digital ecosystem powered by DHIS2. Key interventions included establishing a unique patient identifier system, consensus-driven minimum quality standards (WHO, 2017), data quality audits (DQAs), predictive supply chain forecasting based on device lifespans, and proactive lifecycle planning. Applying Proctor's Implementation Outcomes Framework, we demonstrate how this surrogate governance model successfully eliminated multi-center duplicate registrations, optimized resource allocation, and improved spatial equity across isolated facilities. We address critical implementation hurdles, including NGO data sovereignty resistance, fragile digital infrastructure, high staff turnover, and political fragmentation, while offering strategic recommendations for institutionalizing P&O governance across global conflict settings.