Navigating turbulence: analyzing the resilience of Lebanon's healthcare system in a multi-crisis scenario.

Introduction: Lebanon's healthcare system, historically reliant on privatization and public-private partnerships, faces unprecedented challenges owing to a compounded crisis environment. Since 2019, economic collapse, the coronavirus disease 2019 (COVID-19) pandemic and the Beirut port explosion have placed immense strain on an already fragile system, highlighting the necessity to understand its resilience in sustaining service provision. This study aims to examine the capacities of the local health system to absorb, adapt and potentially transform in response to ongoing crises, in Majdal Anjar, a municipality located in the Zahle District.

Methods: This qualitative study employed key informant interviews (KIIs) with nine local healthcare stakeholders, including healthcare providers, officials from the Ministry of Public Health (MoPH) and representatives from the United Nations and non-state actors, and was conducted from May to June 2022. The interviews focused on stakeholders' insights into the actions taken to address challenges triggered by the crisis. Data were coded according to the Health System Resilience Framework, developed by the Rebuild Consortium, and analyzed through a deductive approach to classify identified responses according to the resilience capacities of absorption, adaptation and transformation.

Results: Within the adopted resilience framework, the capacities identified in the responses appear as follows: Absorption: International organizations and non-state actors provided crucial financial and operational support, compensating for the government's disengagement from funding and regulation. While this support sustained essential services, it had also introduced inequities and coordination challenges, as aid priorities sometimes diverge from local needs. Adaptation: The MoPH and municipal entities have implemented policy adaptations, including tolerating informal healthcare providers and allowing contracting of health institutions with humanitarian actors directly, while healthcare facilities innovated to manage medication shortages. The MoPH sought to bolster local pharmaceutical production and reform reimbursement policies. Transformation: Local stakeholders, particularly municipalities, demonstrated capacity to manage healthcare services independently during COVID-19 crisis cells, but this autonomy remained underutilized.

Conclusions: Lebanon's healthcare system has demonstrated resilience through absorptive and adaptive responses amidst multiple crises. However, these strategies have been insufficient to ensure equitable and sustainable access. Reliance on humanitarian funds and centralized, profit-driven governance has deepened structural weaknesses, hindering long-term resilience. Achieving genuine resilience requires governance reforms, strategic resource allocation, decentralization and a shift towards a needs-based health approach. Future strategies should prioritize equity, ensuring all populations access quality healthcare regardless of financial or geographic barriers.