Local solutions, local governance: the municipal health committee initiative in Majdal Anjar, Lebanon.

Abstract

In fragile and shock-prone settings, where political instability, economic crises, and institutional fragmentation weaken central authorities, strengthening local health governance has become critical for health system resilience. Lebanon represents an example, having faced compounded shocks including economic collapse, the COVID-19 pandemic, and armed conflict, all of which have strained an already fragmented health system. Despite increasing recognition of the importance of sub-national governance, limited empirical evidence exists on how municipal-level health governance structures function in practice under such conditions. This article evaluates the establishment and functioning of a Municipal Health Committee (MHC) as a pilot model of local health governance, analysing factors influencing good governance practices. Using participatory action research and an implementation research design, qualitative data were collected through process documentation and field observations, six critical reflective meetings, and nine key informant interviews. Data were analysed using the TAPIC framework to examine transparency, accountability, participation, integrity, and capacity in the MHC's operations. Findings indicate that the MHC enhanced inclusive participation thereby strengthening local legitimacy and trust. The committee progressively embedded transparency and evidence-informed decision-making, including efforts to generate local health data. However, compliance by formulated ideal and institutional integrity was persistently challenged by political interference, patronage networks, weak enforceability of accountability mechanisms, and financial precarity. Sustained mentorship by the research team strengthened governance practices and enhanced the MHC's ability to implement its mandate effectively. Municipal committees can strengthen equity and resilience in settings through inclusive, evidence-informed processes; however, sustainability depends on local ownership, functional autonomy from political capture, and capacity development.