The Institute for Global Health and Development
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Item Understanding Resilience in UNRWA Health Response to the Syrian Crisis: Lessons from Causal Loop Analysis(MIT Press, 2025) Ager, Alastair; Diaconu, Karin; Jamal, Zeina; Alameddine, Mohamad; Fouad, Fouad M.; Witter, Sophie; Blanchet, Karl1. Group model building gathers key stakeholders together to develop causal loop analysis of health system responses to experienced shocks. 2. Causal loop analysis can identify important resources and strategies supporting health system resilience. 3. Evidence of absorptive, adaptive, and transformative resilience capacities was demonstrated in UNRWA health response to the Syria crisis across Jordan, Lebanon, and Syria. 4. Analysis highlights the importance of collateral pathways and redundancy; flexible governance and leadership practices; and an organizational culture that sees challenge as an opportunity for learning and innovation. 5. Such evidence has implications for other health systems seeking to integrate provision of services to refugee populations, as well as for UNRWA itself operating in a context of political instability.Item Identifying vulnerabilities in essential health services: Analysing the effects of system shocks on childhood vaccination delivery in Lebanon(Elsevier, 2024-08-28) Ismail, Sharif A.; Tomoaia-Cotisel, Andrada; Noubani, Aya; Fouad, Fouad M.; Trogrlić, Robert Šakić; Bell, Sadie; Blanchet, Karl; Borghi, JosephineShocks effects are under-theorised in the growing literature on health system resilience. Existing work has focused on the effects of single shocks on discrete elements within the health system, typically at national level. Using qualitative system dynamics, we explored how effects of multiple shocks interacted across system levels and combined with existing vulnerabilities to produce effects on essential health services delivery, through the prism of a case study on childhood vaccination in Lebanon. Lebanon has experienced a series of shocks in recent years, including large-scale refugee arrivals from neighbouring Syria, the COVID-19 pandemic and a political-economic crisis. We developed a causal loop diagram (CLD) to explore the effects of each shock individually, and in combination. The CLD was developed and validated using qualitative data from interviews with 38 stakeholders working in Lebanon's vaccination delivery system, in roles ranging from national level policy to facility-level service delivery, conducted between February 2020 and January 2022. We found that each of the shocks had different effects on service demand- and supply-side dynamics. These effects cascaded from national through to local levels. Both Syrian refugee movement and the COVID-19 pandemic primarily exposed vulnerabilities in service demand, mainly through slowly emerging knock-on effects on vaccination uptake behaviour among host communities, and fear of contracting infection in crowded health facilities respectively. The economic crisis exposed wider system vulnerabilities, including demand for vaccination as household income collapsed, and supply-side effects such as reduced clinic time for vaccination, declining workforce retention, and reduced availability of viable vaccine doses, among others. Finally, important pathways of interaction between shocks were identified, particularly affecting the balance between demand for vaccination through publicly supported facilities and private clinics. Future research should incorporate dynamic approaches to identifying within-system vulnerabilities and their potential impacts under different scenarios, as a precursor to improved resilience measurement, system preparedness, and intervention targeting.Item 10 years of the Syrian conflict: A time to act and not merely to remember [Comment](Elsevier, 2021-03-12) Jabbour, Samer; Leaning, Jennifer; Nuwayhid, Iman; Ager, Alastair; Cammett, Melani; Dewachi, Omar; Fouad, Fouad M.; Giacaman, Rita; Sapir, Debarati Guha; Hage, Ghassan; Majed, Ziad; Nasser, Rabie; Sparrow, Annie; Spiegel, Paul; Tarakji, Ahmad; Whitson, Sarah Leah; Yassin, NasserItem Health system resilience in the face of crisis: Analysing the challenges, strategies and capacities for UNRWA in Syria(Oxford University Press, 2019-10-18) Jamal, Zeina; Alameddine, Mohamad; Diaconu, Karin; Lough, Graham; Witter, Sophie; Ager, Alastair; Fouad, Fouad M.Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency (UNRWA) and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. The study is a retrospective qualitative case study utilizing diverse methods. We conducted 35 semi-structured interviews with UNRWA clinical and administrative professionals engaged in health service delivery over the period of the Syria conflict. Through a group model building session with a sub-group of eight of these participants, we then elicited a causal loop diagram of health system functioning over the course of the war, identifying pathways of threat and mitigating resilience strategies. We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. We distinguish absorptive, adaptive and transformative capacities of the system facilitating this resilience. Absorptive capacities enabled immediate crisis response, drawing on available human and organizational resources. Adaptive capacities sustained service delivery through revised logistical arrangements, enhanced collaborative mechanisms and organizational flexibility. Transformative capacity was evidenced by the creation of new services in response to changing community needs. Analysis suggests factors such as staff commitment, organizational flexibility and availability of collaboration mechanisms were important assets in maintaining service continuity and quality. This evidence regarding alternative strategies adopted to sustain service delivery in Syria is of clear relevance to other actors seeking organizational resilience in crisis contexts.Item Resilience capacities of health systems: Accommodating the needs of Palestinian refugees from Syria(Elsevier, 2018-10-21) Alameddine, Mohamad; Fouad, Fouad M.; Diaconu, Karin; Jamal, Zeina; Lough, Graham; Witter, Sophie; Ager, AlastairResilience is increasingly recognised as a key process mitigating the impact of shocks and stressors on functioning. The literature on individual and community resilience is being extended to address characteristics of resilient service delivery systems in contexts of adversity. The validity and utility of a capacity-oriented resilience framework (including absorption, adaptation and transformation) is examined with respect to the functioning of United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) health systems in Lebanon and Jordan in the context of the Syrian crisis. We completed 62 semi-structured interviews (30 in Lebanon in November - December, 2016, and 32 in Jordan in January 2017) with professionals at primary care, area, and country management levels. Participants reflected on changes in population health status and health service delivery during the Syrian crisis, notably with respect to the influx of refugees from Syria. Interviews were analysed through inductive thematic analysis and used to critically interrogate health systems resilience against a pro-capacities framework. We find that UNRWA systems in Lebanon and Jordan were broadly resilient, deploying diverse strategies to address health challenges and friction between host and refugee populations. Absorptive capacity was evidenced by successful accommodation of increased patient numbers across most service areas. Adaptive capacities were reflected in broadening of collaboration and reconfiguration of staff roles to enhance service delivery. Transformative capacities were demonstrated in the revision of the service packages provided. While manifest as technical capacities, these clearly drew upon solidarity and commitment linked to the political context of the Palestinian experience. The study adds to the limited literature on health system and organizational resilience and indicates that capacity-oriented framings of resilience are valuable in extracting generalizable lessons for health systems facing adversity. The proposed resilience framework promises to guide strategies for sustained care delivery in these contexts.