Background: In a growing number of humanitarian crises, "remote management" is negotiated across borders and implemented by humanitarian agencies through "local actors" to deliver assistance. However, the narrative describing the involvement of local actors in the delivery of humanitarian aid in armed conflict settings remains reductionist and unreflective of the complex and circular course of the "localisation of aid". This paper explores cross-border humanitarian assistance within the Syrian conflict. We document how humanitarian actors operate to deliver humanitarian health care in North-West Syria (Turkish border), explore their challenges and critique the language used within current debates on the localisation of aid.

Methods: We undertook key informant interviews with Turkey-based humanitarian aid professionals involved in the humanitarian health response inside Syria. We integrated data previously collected forThe Lancet-American University of Beirut Commission on Syria during field work in Gaziantep, Turkey, through meetings, conversations, discussions and expert consultations with Syrian health professionals, WHO-Turkey staff members and members of Syrian health directorates. We also drew from background desk reviews conducted by the Commission on health systems responses and timeline of events in Turkey during the Syrian conflict.

Results: This paper uncovers creative and effective bottom-up strategies that enhanced cross-border coordination of aid delivery into Syria. Our findings unravel the key role played by Syrian providers in accessing vulnerable populations and in reshaping coordination and funding mechanisms inside Syria, as well as the disproportionate risks local actors bear within the response. Our findings also reveal an iterative negotiation of decision-making dynamics, a "low-profile approach" promoted to gain access to populations of concerns, and an environment that is heavily shaped by close interpersonal relationships and social trust.

Conclusions: Our multifaceted narrative unpacks circular flows of interactions among actors and uncovers strategies developed by practitioners on the field, which are often left undocumented. We argue that there is an opportunity for the humanitarian sector to learn from these synergies to rethink how medical humanitarianism is framed (hopefully leading to a more collaborative framing that resists mainstreaming "local" actors within a "traditional" system). There is also an opportunity for the humanitarian and global health communities to reflect on how value attributed to human lives needs to be questioned in contexts where national staff face a disproportionate risk to deliver aid.