Research for stronger health systems during and after crisis

Health system resilience in the Middle East: the experience of UNRWA and regional stakeholders


Date: October 10th 2018


About the session

Conflicts, epidemics and natural disasters pose critical challenges for sustaining population health. In the midst of crises, health systems struggle to offer quality health care services: health workers and communities are injured or displaced, physical infrastructure is destroyed or inaccessible, critical supply chains (eg for medicines) are disrupted, and new health care needs (eg mental health) emerge. Prolonged crises – such as the conflict in the Middle East – pose additional difficulties: health systems here must operate in a complex humanitarian context and be mindful of long-term health system strengthening.

‘Resilience’ is central to such situations, and refers to the ability of a system to respond to extraordinary shocks, or operate under everyday stresses. Researchers are increasingly trying to identify what ‘resilience’ means in practice, however much research to date has been confined to single country case studies or particular health system blocks (eg health care workers).

The panel reflects on theoretical framings of resilience and contrasts these with examples from three comparative country studies - Syria, Lebanon and Jordan - to spark discussion on health system resilience and its role in enabling humanitarian response and health system strengthening.



Chair: Alastair Ager - NIHR Research Unit in Health in Fragility, Queen Margaret University, UK



Discussant: Sophie Witter - Institute for Global Health and Development, Queen Margaret University, UK





Chair will introduce the session and its objectives. and will provide initial reflections on the concept of resilience and its current framings in global health.

Presentations and panel

Presentation 1 - Sustaining and transforming service delivery during active conflict: the experience of UNRWA Syria

Drawing on qualitative, semi-structured, key-informant interviews and a group model building session with health care personnel from UNRWA Syria (United Nations Relief and Works Agency for Palestinian Refugees in the Near East), the presentation describes what strategies were deployed to sustain service delivery during the ongoing crisis. Presenters will describe and appraise strategies enabling health system function given available resources and structures (‘absorptive resilience’) and contrast this with innovative emergent strategies deployed as/when systems become overstretched (‘adaptive and transformative resilience’). A causal loop diagram highlights underlying dynamics sustaining health system function.

Presentation 2 - Delivering health care services to substantive displaced populations: reflections on resilience from UNRWA Lebanon and Jordan 

Drawing on key-informant interviews and group model building sessions with UNRWA staff in Lebanon and Jordan, this presentation outlines how these health care systems coped with, and responded to, the influx of Palestine Syrian refugees. The dynamics sustaining the health system in meeting increasing health care needs are presented via system-wide causal loop diagrams. Presenters will distinguish between absorptive, adaptive and transformative system strategies and offer critical reflections on the applicability of such strategies in other country contexts.

Presentation 3 - Appraising ‘resilience’: systems dynamics models of resilience strategy impact on population health

Using routine UNRWA health system data, augmented via evidence reviews, this presentation describes the impact of stressors (the Syria conflict and health system reform) and diverse resilience strategies outlined in the two previous presentations on population health outcomes. Two systems dynamics simulation models using a stock and flow structure will be presented: a) a population model focused on estimating arising health care needs and related health service utilisation, and b) a health system model estimating the ability of UNRWA systems to offer quality patient care. Base case analyses reflect routine UNRWA functions; we contrast base estimates against two scenarios: active conflict and conflict as mitigated by UNRWA initiated resilience strategies.  

Presentation 4

Reflections on resilience exhibited by other organisations and health systems in the Middle East.


The Chair will invite the Discussant to give first remarks on the role of health system resilience for humanitarian response and system strengthening before opening up the floor for questions.


Who is the session aimed at?

Health care managers, policy makers and researchers interested in health service delivery during times of adversity.