Health system resilience: Lebanon and the Syrian refugee crisis.
BACKGROUND
Between 2011 and 2013, the Lebanese population increased by 30% due to the influx of Syrian refugees. While a sudden increase of such magnitude represents a shock to the health system, threatening the continuity of service delivery and destabilizing governance, it also offers a unique opportunity to study resilience of a health system amidst ongoing crisis.


METHODS
We conceptualized resilience as the capacity of a health system to absorb internal or external shocks (for example prevent or contain disease outbreaks and maintain functional health institutions) while sustaining achievements. We explored factors contributing to the resilience of the Lebanese health system, including networking with stakeholders, diversification of the health system, adequate infrastructure and health human resources, a comprehensive communicable disease response and the integration of the refugees within the health system.


RESULTS
In studying the case of Lebanon we used input-process-output-outcome approach to assess the resilience of the Lebanese health system. This approach provided us with a holistic view of the health system, as it captured not only the sustained and improved outcomes, but also the inputs and processes leading to them.


CONCLUSIONS
Our study indicates that the Lebanese health system was resilient as its institutions sustained their performance during the crisis and even improved.
Ministry of Public Health, Beirut, Lebanon; Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
Walid
W
Ammar
Ministry of Public Health, Beirut, Lebanon.
Ola
O
Kdouh
Ministry of Public Health, Beirut, Lebanon.
Rawan
R
Hammoud
Ministry of Public Health, Beirut, Lebanon.
Randa
R
Hamadeh
Ministry of Public Health, Beirut, Lebanon.
Hilda
H
Harb
Ministry of Public Health, Beirut, Lebanon.
Zeina
Z
Ammar
Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA.
Rifat
R
Atun
Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA.
David
D
Christiani
Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA; School of Medicine, Lebanese American University, Beirut, Lebanon.
Pierre A
PA
Zalloua
D003141:Communicable Diseases; D003695:Delivery of Health Care; D006282:Health Personnel; D006801:Humans; D017053:Infection Control; D007861:Lebanon; D012036:Refugees; D013593:Syria