Resilience amid conflict: A qualitative study of perspectives on the provision of and experience with Sexual and Reproductive health services during war

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Kabakian-Khasholian, L. Abi Jaoude, D. El Chaar, G. E. Saad, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8559503/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2026 Read the published version in BMC Health Services Research → Version 1 posted 12 You are reading this latest preprint version Abstract Background: War has far-reaching impacts on health, through direct injury and death as well as indirect causes such as disruptions to health care service delivery. Sexual and reproductive health is among the most affected, due to reduced access to services, limited resources, and its frequent de-prioritization in emergency response. Lebanon, already burdened by multiple crises, was severely affected by the 2024 war, which displaced internally over one million people, mostly women and girls. To date, there has been little in-depth research exploring how Primary Health Care Centers (PHCC) have adapted to sustain services during the war. This paper draws on perspectives from key informants and service users to examine the challenges in delivering and accessing SRH services during the 2024 war on Lebanon and the efforts employed to respond to community needs. Methods: This qualitative study used grounded theory to explore key informants’ and service users’ perspectives on SRH service provision and use in Lebanese PHCCs, focusing on barriers and facilitators to contraception, family planning, and sexuality education. We conducted 20 key informant interviews with health staff and 20 focus groups with community members across 10 PHCCs in Lebanon to explore SRH service provision and user experiences. The interviews were audio-recorded and transcribed verbatim. The authors used thematic analysis to analyze the data. Results: Two main themes emerged: (1) The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs (2) The adaptive efforts employed by PHCCs to respond to community needs. The 2024 war on Lebanon exposed major systemic vulnerabilities in PHC, including reduced access, staff shortages, and eroded trust in governance. Despite these challenges, PHCCs demonstrated adaptability through mobile outreach, workforce mobilization, and community needs assessment. Central to this resilience was the civic commitment of healthcare providers who sustained SRH services amid severe strain. However, persistent service disruptions highlight the limits of individual dedication without broader system support. Conclusion: The study underscores the need to institutionalize PHCC’s adaptive responses and support healthcare providers’ resilience and civic engagement during wartime. Expanding workforce capacity, mobile services, and community assessment are key to a more resilient health system. Sexual and Reproductive Health Primary Health Care Centers War Conflict Lebanon Health System Resilience Healthcare workforce Civic commitment Background War and armed conflict have multifaceted and far-reaching consequences for the health and wellbeing of affected communities. These consequences range from direct war-related morbidities and mortalities to indirect impacts due to interruptions of the delivery, availability, and accessibility of health services (1). Sexual and reproductive health (SRH) is among the most affected sectors during conflict, due to service disruptions, reduced access to SRH including Gender-Based Violence (GBV) services, limited resources, and its frequent de-prioritization during emergencies (2). Even when services are available, women’s ability to access them may be limited by movement restrictions, fear, or political control (3). One major contributor to reduced access to care during conflicts is the attacks on health facilities, which may extend during a protracted healthcare crisis, with long-term impacts on public health (4). This has been documented in Syria with over half of health facilities shut down or partially operational, pointing to around 133,000 pregnant women, breastfeeding mothers, and menstruating girls lacking adequate access to essential healthcare and facing poor quality of care in 2024 (5). The challenges reported by women in Syria included restricted access to facilities due to roadblocks, bombing, and shortages in medical supplies, with the WHO reporting a rise in Maternal Mortality Ratio, due to lack of essential resources, family planning services and prenatal check-ups (6). Similarly, in Gaza, the war has limited access to public facilities and emergency obstetric care, with reports of increased preterm labor and drastically shortened postnatal hospital stays due to overcrowding and security concerns. (7). Similar to its neighboring countries, Lebanon has faced significant challenges, including political instability, economic collapse, and the most recent 2024 war, all of which have strained its already fragile health system. The most recent war began in October 2023, and escalated dramatically by September 2024, as armed attacks intensified in South Lebanon extending further into the eastern region, and the North of the country reaching daily bombings of the southern suburbs of Beirut as well as the capital Beirut itself. This led to the massive internal displacement of 1.2 million individuals within a few weeks, over half of whom were women and children. More than 250,000 internally displaced persons (IDPs) stayed in around 1,200 crowded shelters, mainly schools, religious places, abandoned houses, and NGO spaces in cities and towns (8). Many of these shelters lacked proper construction and maintenance, such as water, sanitation, and privacy (8). The conflict lasted for about a year, with a 60-day ceasefire brokered in November 2024. Lebanese sources reported at least a total of 3,768 deaths and 15,699 injuries (9;10). Based on a UNFPA report, 11,600 pregnant women were negatively affected by the conflict, with 3,900 women expected to give birth within the next 3 months following their displacement. Tens of thousands of women and girls have sought refuge in collective sites in Lebanon, exacerbating vulnerabilities to gender-based violence (GBV) (5). In terms of health care facilities, many have been forced to close, particularly in conflict-affected regions, leading to significant healthcare worker shortages. The crisis also highlighted the need to integrate mental health into emergency services, recommending expanded inpatient care and training in psychosocial support (11). The Lebanese Ministry of Public Health (MoPH) established a PHCC network in 1996 which currently comprises of 326 centers. These PHCCs are in their majority owned and operated by nongovernmental organizations and municipalities (12). PHCCs play a vital role in delivering SRH services, such as family planning, antenatal and postnatal care, and GBV support (13). The comprehensive nature of PHC makes it responsible not only for responding to major incidence or emergencies, but also for preparing and responding to communities’ needs and supporting them during and after such events (14). This makes the PHCCs well-suited to play a vital role in responding to acute events during armed conflicts and war. Recent research finds that Lebanon’s primary healthcare system has demonstrated resilience despite overlapping crises, continuing to provide essential services to a large number of users (15). In response to the war in Lebanon, the MOPH and the WHO country office, organized healthcare delivery for IDPs through functioning PHCCs in neighborhoods hosting the displaced as well as through mobile units. These services included maternal health care, SRH care, childhood vaccination, GBV, Clinical Management of Rape (CMR), and care of chronic disease. Although 56 PHCCs closed due to security issues, 241 remained active, supported by mobile units and outreach teams. In specific, 968 collective shelters were linked to active PHCCs to ensure continuation of health services to IDPs. A total of 239 PHCCs and 260 PHC satellite units visited 734 shelters (11; 13). While empirical evidence on how PHCCs maintain SRH service delivery during war remains limited, few studies from Syria suggest that PHCCs continued to provide care, but suffered challenges such as lack of funding, limited resources, and staff shortages (4). To date, there has been little in-depth research exploring how PHCCs, especially in the realm of SRH, have adapted to sustain services under such prolonged and compounding pressures. Such understanding is crucial for informing strategies to strengthen health system resilience and ensure continuity of care for vulnerable populations, particularly women and girls. This paper reports on key informant and service users’ perspectives aiming to identify the challenges faced in the delivery and use of SRH services at the PHC level during the 2024 war on Lebanon and to explore the strategies and efforts employed by PHCCs to adapt to the conflict and respond to community needs. Methodology Study design and setting This study is part of a multiphase study on Development of Gender and Person-informed Multi-component Wellness Intervention for Comprehensive Family Planning, Contraceptive Services, and Sexuality Education in Lebanon (GEMSELF). The study used a qualitative research approach and a grounded theory design, allowing for a thorough understanding of the emic perspectives of key informants and service users pertaining to the provision and use of SRH services within PHCCs in Lebanon and the experienced barriers and facilitators for quality contraception, family planning services, and sexuality education through a gender sensitive and person-centered approach. Study participants We conducted 20 key informant interviews (KIIs) with administrative staff at the MoPH, at non-governmental and humanitarian organizations (n = 6), with directors (n = 2) and healthcare providers (HCP) (5 physicians; 2 nurses; 5 midwives) working in PHCCs. Interviews addressed perspectives on the organization’s background and provision of SRH services, within the primary health care system in Lebanon. Additionally, we conducted 20 focus group discussions (FGDs) with community members (adults and adolescents of different genders) seeking SRH care from across 10 PHCCs throughout Lebanon. This provided valuable perspectives on the user experience and their relationship with HCPs. Participant recruitment and data collection Key informant interviews A purposive sample of key informants was selected based on a stakeholder mapping exercise conducted by the study team in consultation with the Lebanese MoPH staff. The sampling strategy ensured variation in the participants between program managers and service providers, geographical region, and public vs private sector practice. Semi-structured interviews were used as a data generation tool. The interview questions were developed through a gender lens, and were piloted and adapted to the context of PHCCs in Lebanon. Participants were scheduled for online KIIs, with consent forms signed electronically. A trained research assistant conducted all KIIs which lasted between 30 and 50 minutes and were audio-recorded after participants’ consent. Interviews were conducted using a semi-structured interview guide developed for this study (Supplementary file 1). Data saturation was reached by completion of 20 interviews. Data collection was done during the period of October 2024 to January 2025. Service users seeking PHCC services A purposive sample of 10 PHCCs was obtained with the aim of ensuring variability in affiliation with the MoPH PHCCs network, size of the health care facility and number of users, geographical representation, and range of SRH services offered. FGDs were used as a data generation tool. The service users (women, men, adolescent girls and boys) in each selected PHCC were considered eligible to be invited to participate in FGDs. The consent of the legal guardian was secured in addition to the ascent of adolescents under the age of 18 years. The FGDs aimed to uncover experiences with care and existing services, identify barriers, including power dynamics, and facilitators to inform future interventions. Over the period extending from January 2025 to June 2025, twenty FGDs were conducted by a trained research assistant, 10 with adults and 10 with adolescents, before reaching data saturation. Each FGD consisted of 7–8 participants, lasted 50–80 minutes and was audio-recorded after consent. Separate semi-structured focus group discussion guides were developed for women and girls, and for men and boys. All interview guides were developed specifically for this study (see Supplementary File 1). Due to the ongoing war, fieldwork was postponed and experienced delays, adapting continuously to evolving security conditions. Data collection through FGDs resumed at the beginning of 2025 with relatively fewer security concerns to ensure safety of participants and field workers. Data was collected while the war was ongoing and directly following the ceasefire, allowing the participants to provide insights into both the acute disruptions of war and the early recovery phase. Data analysis All audio recordings of KIIs and FGDs were transcribed verbatim in Arabic, the language of the interviews. Data collection, transcription, and preliminary analysis were conducted simultaneously. Thematic analysis was applied using Braun and Clarke’s six-stage framework, which involved familiarizing ourselves with the data, coding, and identifying patterns (16). Codes were manually recorded and validated by another researcher. They were used to build categories and develop a qualitative matrix to generate emerging themes. Reflexivity The researchers upheld cultural sensitivity and reflexivity during data collection and analysis, especially recognizing the challenging personal situations of participants during the on-going war. Equitable participant recruitment, in terms of sociodemographic and regional diversity ensured multiple perspectives among key informants and service users. Results Recruited key informants presented diverse socio-demographic backgrounds and different types of job positions, varying from administrative positions at the MoPH, at non-governmental and humanitarian organizations (n = 6), to PHCC directors (n = 2), and HCPs that included family medicine and obstetrician/gynecologists (n = 5), nurses (n = 2), and midwives (n = 5) (Table 1 ). Table 1 Key Informant characteristics Key informants Number of key informants Number of regions Site Administrative staff 6 4 regions Ministry of Public Health, local NGOs, humanitarian NGOs, and iNGOs PHCC directors 2 2 regions PHCCs Physicians 5 3 regions PHCCs Midwives 5 3 regions PHCCs Nurses 2 1 region PHCCs Similarly, service users, both adults and adolescents, had varied socio-demographic backgrounds, and were recruited from PHCCs across regions in Lebanon. Ten FGDs were conducted with adults, from which 6 were done with women and 4 with men distributed across different regions in Lebanon. Similarly, 10 FGDs were conducted with adolescents from which 6 were done with girls and 4 with boys across different regions (Table 2 ). Table 2 Focus Group Discussion Participant Characteristics FGD Number of FGD Number of Region Women 6 6 regions Men 4 4 regions Adolescent boys 4 3 regions Adolescent girls 6 6 regions Two main themes related to the Lebanese 2024 war and its consequences on SRH service delivery and care in PHCCs emerged. The first is about the multifaceted impacts of the war on geographical and logistical factors and accessibility to PHCCs, infrastructure of PHCCs, human resources, mental health concerns, and shifting priorities within PHCCs focus of care. The second theme talks about the efforts employed by PHCCs to respond to community needs, coupled with the civic responsibility and moral commitment of HCPs. The themes are presented in Table 3 and described in detail in the next section. Illustrative quotes supporting each theme and sub-themes are presented in Table 4 at the end of the results section, and referenced in the text using superscript numbers. Table 3 Key themes and sub-themes of the Lebanese 2024 war, its consequences, and PHCCs’ efforts to adapt and address community SRH needs across affected and non-affected regions. Themes Sub-themes Description The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs 1- Restricted accessibility 2- Infrastructure & staff shortages 3- War’s psychological and physiological toll 4- Shift in Health Priorities 5- Mistrust in the healthcare system 1- Challenges in reaching health facilities due to unsafe roads and transportation barriers. 2- PHCC closures and reduced availability of skilled health professionals. 3- Increased mental health needs and struggles among communities, especially displaced ones. 4- Diverting resources and attention away from SRH services towards emergency response needs, especially communicable diseases. 5- Erosion of trust towards government provided services following long years of prioritizing refugee populations over the local host communities. The adaptive efforts employed by PHCCs to respond to community needs 1- Efforts employed by PHCCs to respond to community needs 2- Civic responsibility and moral commitment of HCPs 1- PHCCs mobilized their care beyond the health facility setting, either through mobile clinics or outreach activities in shelters, often combined with informational sessions. 2- HCPs demonstrated a strong sense of duty, emotional connection to affected communities, including internally displaced in shelters. They showed personal commitment to responding to specific needs of individuals and alleviating suffering amid the ongoing crisis and uncertainty. The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs Restricted Accessibility The security situation and the 2024 war in Lebanon have significantly impacted accessibility to PHCCs for SRH including family planning services. Key informants highlighted how the war has made it difficult for people, particularly those in highly affected areas, to access PHCCs and seek essential SRH services. In particular, transportation was a critical barrier for displaced individuals residing in collective shelters or in remote areas. Unsafe roads and being near affected regions further limited mobility and created substantial geographical inaccessibility. 1,2 This was also stated across different FGDs describing their inability to reach healthcare services, not only due to limited transportation, but also because of uncertainties about road closures. 3 Infrastructure and staffing shortages Key informants noted physical destruction and other forms of damage in the infrastructure of some PHCCs as an influential factor disrupting provision of essential SRH services. 4 PHCCs also experienced a reduction in available specialized medical staff such as gynecologists, and pediatricians, limiting the capacity to deliver SRH care to beneficiaries and restricting service scope to general health care only. Centers also reported being unable to carry out routine community needs assessments due to disruptions in service delivery and support systems. 5,6 Staffing shortages resulted from healthcare workers being unable to reach facilities, while those who could access the center to deliver care were overwhelmed by the volume of patients, particularly those requiring urgent care. The surge in demand, combined with reduced personnel, placed high strain on PHCC’s ability to provide timely and quality SRH services. This was particularly significant in terms of shortage in mental health experts, whose support was considered very critical in shelters. 7,8,9 War’s Psychological and Physiological Toll Key informants highlighted how conflict-related stress and trauma had particularly impacted pregnant and postpartum women, many of whom were internally displaced. One key informant referenced a recent study in light of the war, which showed the significant mental health challenges, such as depression faced among this group, which impacted their ability to carry out daily activities, caregiving, and access to essential SRH services. 10 Another key informant reported the deep psychological toll of bereavement and displacement explaining how the war left a detrimental impact on mental health of individuals who experienced family loss, further reducing their motivation to access SRH services due to psychological distress. 11 The struggles with mental health were echoed by service users themselves across FGDs. Both men and women, described the war’s impact on their psychological well-being and how it interfered with different aspects of SRH. Women described how war negatively impacted their mental health, menstrual cycles and heightened menstrual pain. Men spoke about how war decreased their sexual desire and willingness to have more children due to chronic stress and persistent fear. 12,13,14 Shift in Health Priorities The 2024 war on Lebanon led to a significant shift in healthcare priorities, diverting resources and attention away from SRH services towards emergency response needs. As PHCCs and supporting organizations scrambled to address urgent needs, such as treating injuries, managing displacement, and controlling communicable disease outbreaks, SRH services were deprioritized. This shift contributed to both a reduction in service provision and a noticeable decline in demand for SRH care at PHCCs. 15 Mistrust in the healthcare system Key informants described the eroding trust of the public in government-provided healthcare services, including those delivered through PHCCs. They explained that the war intensified lack of resources which highlighted feelings of neglect among Lebanese. They considered this a significant consequence of long years prior to this war where resources were allocated to refugee populations in Lebanon with disregard to the needs of the host communities. The existing mistrust in government services was expected to grow with the lack of resources to meet the population needs during and following the war. 16 The adaptive efforts employed by PHCCs to respond to community needs Efforts employed by PHCCs to respond to community needs The majority of key informants highlighted that PHCCs in Lebanon adapt to community needs through various strategies, such as conducting regular community assessments to identify healthcare needs and inform yearly plans. This approach enabled PHCCs to properly respond to the growing needs of individuals during the war, including challenges with transportation, a main identified need among communities. Some PHCCs used mobile clinics to provide services such as vaccinations and mental health assessments. 17,18 Additionally, many informants reported how community outreach activities which were originally part of PHCCs nature of work, have intensified during the war, with PHCCs offering SRH services in shelters for displaced people, conducting information sessions in shelters and in schools about period poverty, STIs, vaginal and urinary tract infections, and menstrual hygiene, and involving communities in decision-making processes. 19 Additionally, key informants have noted that recent community assessments have specifically shown an increased need for mental health support and education on period poverty and STIs, prompting PHCCs to prioritize these services in response. 20,21 Similarly, users across several FGDs, particularly men, reported several positive outcomes resulting from the PHCCs efforts during the war, including outreach and shelter visits to provide SRH services to internally displaced Lebanese population. FGD participants noted the efforts of the PHCCs and the MoPH in the implementation and activation of mobile clinics during war, which offered flexible services in areas where communities had limited access to care. They noted these coordinated efforts of redistributing staff and health services from better-resourced and non-affected areas to those experiencing shortages, especially in locations hosting internally displaced communities or severely-affected by the war. 22,23,24 Civic responsibility and moral commitment of HCPs Apart from structural and logistical efforts PHCCs made to sustain care during war, it was the dedication of HCPs that often made the difference. Their strong sense of civic responsibility and moral commitment was described as a key driver behind sustained care delivery during the conflict. According to key informants who were administrative staff working in NGOs and the MoPH, they reported significant investments within the workforce that showed, not only the adaptations done in light of the war, but the strong commitment and discipline HCPs had throughout this phase. For instance, even in the absence of specialized mental health professionals, PHCCs in collaboration with the National Mental Health Programme (NMHP) took proactive actions to train general practitioners and family physicians to fill this gap and serve the vulnerable population, especially displaced individuals in shelters. This demonstrated the strong sense of moral commitment that those physicians had to dedicate their time and efforts in learning new skills in order to respond to the needs of a larger portion of affected communities. These physicians made sure to actively collaborate with psychiatrists remotely whenever they were conducting assessments in shelters, ensuring professional and credible care and committing to not leaving people without support. 25 Midwives were also key HCPs included in these efforts, specifically trained to support the mental health of pregnant and postpartum displaced individuals. This reflects how midwives extended their care beyond the core components of their role in PHCCs to address broader community needs. 26 In addition to the expanded roles to cover mental health needs, HCPs also adapted their daily clinical routines to include HIV and tuberculosis screening. This shift in practice not only showcases their clinical responsiveness but also their deep involvement and connection to meet the evolving needs of the communities. HCPs embraced a more personal, human-centered, and community-based approach, as the integration of HIV and TB screening was driven by urgent needs identified by the needs assessments initiatives, which included treating injuries, managing displacement, and controlling communicable disease outbreaks. 27 Key informants who were HCPs themselves confirmed the prominence of this dedication and civic commitment to human-care amid the crisis. Midwives reported being present and engaged daily, even with a shelter full of displaced people located just steps away from the PHCC, a situation that likely added pressure to their routine work. One midwife mentioned the term “interaction” as an aspect that was present between them and the people in shelters. There was also a sense of compassionate care that went beyond their routine professional duty. 28 A midwife described how she took initiative in visiting shelters and transporting women to the PHCC to offer family planning related information and services. Midwives underscored the provision of context-specific and culturally sensitive services as they understood the consequences of unplanned pregnancies during war and displacement and prioritized family planning accordingly. 29 Obstetricians/gynecologists also emphasized their daily commitment to providing not just clinical care, but also emotional comfort and reassurance, especially for people living in shelters, ensuring they were safe, supported, and that support was provided to unmet needs. They would also guide them to seek the PHCC for wider scope of care according to the demand and the individual case. 30 The reports of adults from FGDs noted the devotion described by HCPs in their approach during war. They felt proud about how the PHCC staff handled the situation during war, labeling them as “strong leaders”. They discussed how HCPs were ‘mobilized’ and left their own centers to fill gaps elsewhere. Their commitment went beyond serving their own communities and they stepped in to different regions around Lebanon where help was most needed. 31,32 Table 4 Illustrative quotes from KIIs and FGDs, organized by theme and sub-themes. Theme Sub-theme Quote The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs Restricted Accessibility 1 “ …We’re now back in a state of war, so it’s only natural that women have ended up in a dire situation to reach anywhere. That’s why very few of them go to PHCC anymore to receive care” – OBGYN at PHCC 13 2 “We want people to go to the centers. We want the health seeking behavior of the people to change, to go to the center and to have everything they need. So even though this is our steer and this is our aim and this is what we built throughout the years…. we found ourselves this year in front of a situation where people cannot or might not be able to go to the PHCCs at all. They got displaced from one area to another. The roads are unsafe or damaged…maybe they don't know where the centers are. Also, their presence at the center might create a huge pressure. The center cannot bear this pressure” Admin staff at humanitarian NGO 3 “During the war, there was difficulty accessing health services, whether related to sexual and reproductive health or other services… Or for example, here, this road was closed, or was it not closed?” – FGD 14, men Infrastructure and staffing shortages 4 “Well, of course. I mean, we haven’t really started yet in the PHCC, it was destroyed, you could say we’re just starting to get back to work”- OBGYN at PHCC 5 5 “The services we provide are medical, related to illness, and awareness-based. Currently, I only have one general practitioner. I used to have a gynecologist, a pediatrician, and a dentist. But after the war we’re in, I’m left with only general health service provider. The dentist stopped coming because (the PHCC) is in a mountainous area, about 20 kilometers from (name of city).”- Director at PHCC 4 6 “How am I supposed to go to these people and tell them that I have nothing to offer them, neither medical nor material support? How can I go to someone and ask, 'What do you need?' when I have nothing to give due to the war that strained my PHCC” – Director at PHCC 4 7 “Of course, the war affected us. The team did its best to respond, but part of it had to go down to the shelters, so we felt there was a shortage of personnel, we could no longer keep up” – Midwife at PHCC 8 8 “There was a need for more personnel…because the psychologist who was with us, she would still have about 4 or 5 (cases) left. We couldn’t say anything to her (asking for more attention); we just let her continue” – FGD 14, men 9 “The people… they were in urgent need because the psychological factor had a huge impact, especially on the displaced people who were living outside their home areas and going through these situations. Some of them were not treated or reached even” – FGD 14, men War’s Psychological and Physiological Toll 10 “For example, we did a study about IDPs, and it showed that they are experiencing depression, whether pregnant women, they are dealing with depression. She doesn’t want to feed, doesn’t want to eat, doesn’t want to do anything. And postpartum as well, she doesn’t want to breastfeed the baby” – Administrative staff at NGO 1 11 “I mean, if we notice, there are, there might be, a lot of families who have lost people, from their family. And even those who lost their homes… you could say they’re in a state of confusion, a kind of disorientation. They don’t know what to do, where to go, or how to move forward. Some have also lost their livelihoods. All of this affects mental health and access to SRH” – OBGYN at PHCC 5 12 "For example, after the war, I’m a woman, I didn’t get my period for a month, a month and a bit. It stopped because of the stress and fear” – FGD 7, women 13 “As a result of ev,1erything we’ve been through, like war now… there has been an impact on mental health. If there is fear, there is no sexual desire at all. If there’s no psychological stability, there’s no sexual relationship, it just doesn’t happen. Mental and physical well-being are both necessary to reach that desire” – FGD 1, men 14 “After the war, who still has the desire to have children, ma’am?” – FGD 14, men Shift in Health Priorities 15 “SRH used to be the main topic, in every club, they had to be talking with beneficiaries about SRH; it was the main focus. But unfortunately, now due to the escalation and the crisis, we are in emergency response mode. Yes, they’re still providing a bit of education, but not like before, because now we’re focusing mostly on communicable diseases.” - Deputy manager at iNGO Mistrust in the healthcare system 16 “I'm telling you, and with the war now, people have lost a lot of trust in the Ministry of Social Affairs because we always go and do statistics, ask what they need, and so on, but in the end, nothing comes out of it. Maybe for every 200 families, only one family gets something. The Lebanese community has become, for the most part, in need. And when people come to me at the health center and I have nothing to give them, if I have no medicine, what are they supposed to do? Initially, the focus was on the Syrian community, neglecting the Lebanese. Raising awareness on mental health and sexual health, especially for Lebanese women, is crucial.” – Director at PHCC 4 The adaptive efforts employed by PHCCs to respond to community needs Efforts employed by PHCCs to respond to community needs 17 “…and especially with the current crisis and with the displacement crisis, like in the last two months, this comprehensive package of care, including sexual and reproductive health, went from the PHCCs to what we are calling now primary health care satellite units or mobile medical units as we used to know them before” - Administrative staff at humanitarian NGO 18 “Yes, they had a mobile clinic, it’s basically a big bus that has an ultrasound machine inside, medications, a bed… We used to go around schools and shelters where families were located, and anyone who had a problem could come in the morning and we’d help them”- OBGYN at PHCC 14 19 “We had a school [shelter] here…we used to go down to the school every few days to see what people needed. The most common issues we faced were genital infections and urinary tract infections among women. We started referring them to our center and provided them with treatment” - Midwife at PHCC 7 20 “Period poverty and sexually transmitted diseases…. they were interested in learning more about these topics” - Admin staff at NGO 2 21 “So, people are still, you know, a bit busy with their homes and the destruction that happened. But overall, the focus of the services will be more on mental health, especially after the war that took place”- OBGYN at PHCC 5 22 “They used to come with mobile clinics, like for example, in our village… They used to come to the schools [shelter] also” – FGD 14, men 23 “Primary healthcare services during the war were stronger because people were mobilized for these matters. For example, if we say in the southern suburbs, there are between 30 and 35 primary healthcare centers. These centers, once mobilized, directed their efforts outside the suburbs, going to the areas where displaced people were hosted. They went to schools and buildings where displaced people were located. In certain areas like Ain el-Rummaneh, Qamatia, and Bourj Hammoud, there was a shortage of centers. The staff from those centers moved to these areas to cover the gap” - FGD 14, men 24 “The Ministry of Health card, along with all the centers in the southern suburbs, was following up with each one individually. The schools [shelters] were being divided. The schools were assigned to the active centers that were not working in the southern suburbs during the war, coordinating with them” – FGD 14, men Civic responsibility and moral commitment of HCPs 25 “….now, with displacement, we have mobile clinics that go to shelters, and we have approximately 20 primary healthcare satellite units (PSUs) now. We have trained the work team in them so that they know how to provide mental health services, because in the heart of this PSU, we do not have mental health specialists, but we have family medicine or general practitioners. These 20 were trained by the National Mental Health Program so that they can help people in shelters if they are taking medications specific to mental health, so that they can give it to them…if they need someone to follow up on them…to help them and support them because people are in need, this doctor who was trained can communicate remotely with the psychiatrist on call, and they can identify this case in the shelter so that they can help them and provide them with the best care and support” – Admin staff at MOPH 26 “….the identified women struggling with mental health….they are already being referred to and gaining the skills of the midwives we have that have been trained to support the women in need, it’s their duty” – Admin staff at NGO 1 27 “We had to adapt our interventions. For example, we intensified screening for tuberculosis and HIV awareness. In these places, doctors intensified talking about them more during the crisis or during the war because you know the overcrowding that was happening in the shelters. You see over 100 people sitting on top of each other. So you are risking the transmission of TB. I mean, if someone has TB and they infect you, see how contagious they are. So, doctors are also doing screening for TB, and people who were coming out as TB cases or confirmed TB cases. They also were doing contact tracing, and this was done a lot during the war. We tailored our interventions in one way or another to meet the new needs” – Admi staff in NGO 3 28 “Regarding the circumstances we're currently in, we had a shelter center directly across from the center, with everyone sitting right in the center. We were building strong centers, and the people would come to us and we would go a lot to check on them everyday. There was a lot of interconnections between us, as displaced people, and staff in PHCCs, we would not leave anyone without care, at all” – Midwife at PHCC 6 29 “Of course, family planning services, in the midst of war, we had a lot of them. You know, as displaced people in schools [shelters], this was a problem. So we focused a lot on these topics, we explained everyday so much. There were also days when we would bring people to the center and explain to them and show them the methods. I would go bring them myself. We would have a lot of displaced people, so I would teach them. The most important thing is family planning in this regard, because it would be difficult to get pregnant and they wouldn't be properly followed up and the cost would be a little... so there were a lot of patients to whom we would give family planning services like pills, sterile lotion. We also tackled a big issue with personal hygiene and a lot of infections like genital and urinary infections. We had a school here for boys and we use to go to the school everyday and see what was happening. We would help and treat as much as we could, we did not want to leave anyone behind and without care” – Midwife at PHCC 7 30 “I mean, we would go to schools, and if anyone had a problem, we would help, and every morning they would also come to the center and we would help them with it…we made sure everyone was ok” – OBGYN at PHCC 14 31 “Primary healthcare services during the war were so strong. They mobilized their staff, they went outside the suburbs and went out to the areas in need. They started going to schools and the buildings that were used for the displaced. They were going to these areas. There was a shortage in other centers in a specific location, like [name of regions]. These areas where there was a shortage, what was present in the active centers was moved to them” – FGD male, Mount Lebanon 32 “Yes, they (the HCPs) used to drop by and check in on us in the shelters…. there was also an active PHCC in the village, people knew about it. It felt easy, accessible... there were no real obstacles. Things just flowed”- FGD male, Mount Lebanon Discussion The 2024 war on Lebanon exposed deep systemic vulnerabilities in PHC, while also revealing remarkable resilience within the overall health system and the frontline workforce which are at the core of this health system. Analysis of the qualitative data revealed two overarching themes: The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs, which included security threats, staff shortages, infrastructure damage, shifting priorities, and growing mistrust in the healthcare system. Yet, amidst these challenges, adaptive efforts were employed by PHCCs to sustain SRH services. These were characterized by workforce mobilization from non-affected to affected areas across the country, deploying mobile clinics to delivering care in shelters, and outreach activities coupled with community needs assessments conducted regularly. All these efforts were driven by a profound sense of civic duty and moral responsibility among the HCP workforce across PHCCs in Lebanon. When looking at the war’s multifaced impacts, one can deduce how it disrupted not only access to SRH services, but the entire continuum of care within PHCCs. Rather than affecting SRH services in isolation, the war placed tension on every component of the health system, ranging from accessibility through unsafe roads, infrastructure, and human resources being strained to overall service delivery shifts and governance. According to the World Health Organization’s six building blocks of health systems (17), war can critically undermine these pillars, and the 2024 war in Lebanon was no exception. Based on our findings, the most significant disruptions were observed at the level of service delivery, health workforce, and leadership governance. In terms of service delivery , unsafe roads and restricted transportation limited access to PHCCs, especially for displaced individuals in shelters, and strained fragile outreach mechanisms, which is a key feature of good service delivery. Additionally, the service lacked proper coverage of all population in Lebanon, service provision became uneven, with vulnerable population often excluded from care due to logistical barriers such as infrastructure damage and staffing shortages. PHCCs also experienced a shift in health priorities, with SRH services deprioritized and in favor of communicable disease response. These challenges echo patterns observed in other conflict-affected contexts. In Ukraine, widespread infrastructure damage and electricity outages coupled with restricted funding led to disruptions in PHCC operations and reduced service delivery (18). Similarly, in Gaza, extensive attacks on healthcare facilities, unsafe transport routes compromised service delivery (19). The health workforce was severely affected, the shortage in staff within PHCCs, limited medical specialties, and caused burnout among overstretched personnel. These challenges mirror the experiences of health system in other conflict-affected contexts such as Ukraine and Afghanistan. In Ukraine, prolonged insecurity led to departure of trained staff, reducing both the availability and quality of services. Similarly, in Afghanistan, health workforce suffered from fatigue and high turnover rates due to burnout (20). Leadership and governance were another point of fragility. Community trust in government was notably diminished, with many perceiving a lack of adequate support and feelings of neglect. This reflects a broader governance challenge in crisis settings, where slow or fragmented responses further erode public confidence. A similar pattern was observed in Afghanistan, where poor governance and security challenges jointly undermined maternal and child health services (20). Another example is in Ukraine where individuals living near conflict-affected areas reduced trust in government institutions, not only the ones who were displaced or remained within heavily impacted regions. At the same time, the study found that proximity to combat zones increased social solidarity, while further undermining confidence in government bodies (21). Despite these immense challenges, the response of PHCCs revealed a surprising level of resilience and adaptability, offering critical lessons on how decentralized and fragmented health structures can still sustain care and respond effectively to community needs during times of crisis. PHCCs ensured some level of care and support to those affected by war, demonstrating that conflict settings can also mobilize resources and foster a sense of community-based engagement. The 2024 war on Lebanon has pushed PHCCs to innovate, from mobile clinics to increased community outreach activities, efforts to sustain ongoing needs assessments were put in place, showcasing how the war catalyzed community-based health delivery and revealed areas of system flexibility and social cohesion. This mirrors the broader resilience documented in Lebanon’s primary care system. In fact, a 2024 scoping review done in Lebanon, showed that despite the multiple crisis the country has been facing for years, including the COVID-19, the Beirut port explosion, the economic collapse and the recent 2024 war, there have been remarkable achievements, showing resilience and readiness in service delivery and community engagement (15). Similar efforts to maintain equitable service delivery have been documented in other conflict-affected settings such as Syria (22). Central to those resilient efforts was the civic responsibility and ethical commitment of HCPs, who are the cornerstone of any health system and whose role can’t be overlooked. When we speak of a resilient and competent health system that continued to deliver efficiently even under stress, as seen in Lebanon, we are, in essence, speaking of resilient and ethically committed workforce, which was clearly evident in our data. Civic responsibility of HCPs refers to their ethical and professional duty to individuals, the community, and society (23). It goes beyond personal or institutional gain, to serve the health and dignity of “all” people, especially the vulnerable, which during war was confined to displaced individuals living in shelters. The findings in this paper align strongly with this concept, as it showed HCPs embracing emotional attachment to the mission and services, regardless of their specialties, and focusing more on the human-side of the care. GPs, FM physicians, midwives, mental health experts, and the broader health workforce went beyond their usual responsibilities, demonstrating sustained presence and commitment to serving the public. They addressed significant gaps, such as transportation barriers, resource shortages, and personal deficits, through outreach visits to shelters, extended working hours, mobilization of resources across regions, dedication of their time and efforts, and continuous informational sessions on SRH. These actions were visible to the public affected by the war, and these efforts to deliver care equitably were appreciated by the affected communities. Qualitative evidence from other conflict-affected areas aligns with our data, indicating that frontline workers view their service as a moral obligation and ethical duty and part of humanitarian principles to their communities, which drove their sustained efforts and motivation despite overwhelming conditions (24). It is particularly interesting to observe these expressions of civic responsibility among HCPs in Lebanon, especially given the ongoing ethical dilemmas and debates surrounding the roles of HCPs in conflict settings, knowing the high level of inequity in health care that can take place in such settings and the limited efforts to address everyone’s needs. In the past years, scholars and researchers have increasingly discussed the difference between civic professionals, those who integrate social and ethical duty within their practice, and knowledge workers, whose roles are often limited to clinical delivery within institutional walls (25). Till now, this issue still remains an aspect of confusion among many academic institutions, and its implementation remains limited and hard to distinguish, especially with the overmedicalization that dominated many aspects of care in medicine. This is why recent studies have begun evaluating concepts of civic responsibility and encouraging academic leaders and medical educators to emphasize its importance in medical practice, and to hold HCPs and institutions accountable for fulfilling this essential professional and moral duty (26). Our findings highlight a striking unique example: Despite Lebanon being a resource-limited country and facing persistent systemic gaps, particularly at the level of PHCCs, HCPs and the overall health system demonstrated remarkable civic responsibility and resilience even under the extreme stressors of the war. Their actions during the war showcased their prioritization of community duty over narrowly defined clinical tasks. Findings from this study serve as a timely reminder that, even in times of crisis and war and despite the constraints of settings in a lower to middle income country, the health system and the workforce led with their dedication to meet community needs in SRH, going beyond provision of technical care, with listening to, assessing, and addressing the needs of their communities. However, it is also important to acknowledge that, even with such dedication, PHCCs faced significant strain, and service disruptions and unmet needs persisted, pointing to the limits of workforce commitments and health systems resilience amid conflict and underscoring the necessity of broader system support to fully address community health needs. The findings of this study highlight the urgent need to strengthen Lebanon’s health system by not only improving all six WHO health system building blocks, but also by building on and institutionalizing the adaptive efforts PHCCs demonstrated and the civic responsibility and moral commitment HCPs embraced during the 2024 war. The unwavering devotion of HCPs to remain involved and available, even beyond their standard clinical care is worth building upon and informing future emergency responses. Also, investing in capacity building of the healthcare workforce in PHCCs, with a specific focus on strengthening civic responsibility and community-based responses, especially in times of conflict is crucial. In parallel, it is essential to continue conducting large-scale community needs assessments as part of emergency preparedness efforts to ensure that service delivery is grounded in the evolving needs of the population and can be rapidly adapted in times of crisis. Additionally, investing in mobile units to improve geographical coverage and reach underserved or hard-to-access regions and populations, especially during times of conflict displacement is necessary. Strength and limitations A major strength of this qualitative study is its ability to capture the dual impact of war on Lebanon’s PHCCs, both the multifaced impacts that disrupted SRH service delivery and the remarkable resilience demonstrated by a committed, though fragmented health system and workforce. Nonetheless, this study presents findings drawn from a broader implementation research project “GEMSELF”, of which the impact of the 2024 Lebanese war on SRH service delivery was only one of several emerging themes. Hence, the interview guides used for both KIIs and FGDs were not originally designed to comprehensively explore this specific theme. A more focused, primary study on that topic may have yielded deeper and more targeted insights. Another limitation is the timing and mode of data collection that may have influenced the quality of participant responses. KIIs were conducted in the midst of the active phase of conflict in October 2024, while FGDs were held shortly after the ceasefire. Conclusions Lebanon’s experience offers valuable lessons for conflict-affected countries seeking to build more adaptable, community rooted, and equitable health systems, especially for SRH service delivery during emergencies. A unified health-system response that embeds civic responsibility within it is essential not only for meeting immediate needs of communities but also for strengthening long-term health equity, especially in ensuring SRH services remain accessible and equitable during crisis. Abbreviations COVID-19: Coronavirus Disease 2019 FGD: Focus Group Discussion FM: Family Medicine GP: General Practitioner HCP: Health Care Provider KII: Key Informant Interview NMHP: National Mental Health Programme PHC: Primary Health Care PHCC: Primary Health Care Centers SRH: Sexual and Reproductive Health WHO: World Health Organization Declarations Ethics approval and consent to participate The research was conducted upon attaining ethical approval from the American University of Beirut – Institutional Review Board (AUB-IRB) (reference number: SBS-2024-0057) and while maintaining ethical research conduct throughout the process. A consent form detailing the study’s aim, potential risks and benefits, participants rights, and confidentiality measures were shared and explained to potential participants. Ascents and guardian consents were shared with youths below 18 years old. The researcher provided time for questions and sought voluntary informed consent from participants to participate in the study. Participants were assured of their confidentiality and anonymity, and reminded that they could withdraw from the study at any time without consequences. Consent to record was always sought from participants. Transcripts were anonymized using pseudonyms to protect confidentiality. The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication Not applicable Availability of data and materials The qualitative datasets generated and analyzed during the current study are not publicly available due to confidentiality and privacy concerns but are available from the corresponding author on reasonable request. Competing interests The author declare that they have no competing interest Funding This study was funded by the International Development Research Centre (IDRC) through the GEMSELF project (Development of Gender and Person-informed Multi-component Wellness Intervention for Comprehensive Family Planning, Contraceptive Services, and Sexuality Education in Lebanon) and under grant number 104438. The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions TK provided overall leadership across all stages of the study, from concept development through data analysis and manuscript preparation. LAJ and DEC managed the field work. LAJ supervised data collection, conducted interviews and data analysis, and drafted the manuscript. LAJ is the corresponding author of this manuscript. FEK, SJM, GES, SEF, and DEC contributed to revisions and provided critical feedback. All authors read and approved of the final manuscript. Acknowledgements We are deeply grateful to all the key informants and service users who participated in this study for sharing their insights. References Arage MW, Kumsa H, Asfaw MS, Kassaw AT, Dagnew EM, Tunta A, et al. Exploring the health consequences of armed conflict: the perspective of Northeast Ethiopia, 2022: a qualitative study. BMC Public Health. 2023;23(1). Tunçalp Ö, Fall IS, Phillips SJ, Williams I, Sacko M, Touré OB, et al. Conflict, displacement and sexual and reproductive health services in Mali: analysis of 2013 HERAMS survey. Confl Health. 2015;9(1). Hedström J, Herder T. Women’s sexual and reproductive health in war and conflict: are we seeing the full picture? Glob Health Action. 2023;16(1). Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for the Lancet–American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516–26. UNFPA Arab States. Syria: women and girls’ rights are a casualty of 12 years of grinding conflict. 2024. UNFPA Arab States. Syria: women and girls’ rights are a casualty of 12 years of grinding conflict. 2024. UNFPA. Humanitarian crisis in Palestine. 2025. El Kak F. Women’s health and rights in conflict: the impact of renewed violence in Lebanon. Sex Reprod Health Matters. 2025;33(1). OCHA. Lebanon: Flash update #35 – escalation of hostilities in Lebanon. 2024. Anera. Lebanon Situation Report. 2024 World Health Organization. Health Emergency Response – Lebanon. 2024. Hemadeh R, Kdouh O, Hammoud R, Jaber T, Khalek LA. The Primary Healthcare Network in Lebanon: a national facility assessment. East Mediterr Health J. 2020;26(6):700–7. Ministry of Public Health. Emerging from crisis: health sector response and lessons learned from the 2024 war on Lebanon. 2025. Al-Jazairi AFH. Role of primary health care system in response to a major incident: challenges and actions. IntechOpen. 2020. Aoun N, Tajvar M. Healthcare delivery in Lebanon: a critical scoping review of strengths, weaknesses, opportunities, and threats. BMC Health Serv Res. 2024;24(1). Fouad FM, Hashoush M, Diab JL, Nabulsi D, Bahr S, Ibrahim S, et al. Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon. Womens Health. 2023;19. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. World Health Organization. Monitoring the building blocks of health systems. 2010. ReliefWeb. Refining primary health care financing in Ukraine. 2024. Mohammed F, Elgailani US, Ali SYI, Mohamed RF, Su Yin ET, Bravo-Vasquez ML. Defending the right to health in Gaza: a call to action by health workers. Confl Health. 2024;18(1). Mirzazada S, Padhani ZA, Jabeen S, Fatima M, Rizvi A, Ansari U, et al. Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan. Confl Health. 2020;14(1). Hoch G, Pondorfer A, Shkola V. Conflict and social capital: evidence from the Russian war against Ukraine. J Comp Econ. 2025;53(2):461–71. Fardousi N, Douedari Y, Howard N. Healthcare under siege: a qualitative study of health-worker responses to targeting and besiegement in Syria. BMJ Open. 2019;9(9). Gross M. Bioethics and war. Camb Q Healthc Ethics. 2006. Kallström A, Al-Abdulla O, Parkki J, Häkkinen M, Juusola H, Kauhanen J. I don’t leave my people; they need me: qualitative research of local health care professionals’ motivations in Syria. Confl Health. 2022;16:1–16. Larson EB. Physicians should be civic professionals, not just knowledge workers. Am J Med. 2007;120(11):1005–9. McCullough LB, Coverdale J, Chervenak FA. Professional virtue of civility and the responsibilities of medical educators and academic leaders. J Med Ethics. 2023;49(10):674–8. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1Warpaper.docx Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2026 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 13 Mar, 2026 Reviews received at journal 15 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviewers agreed at journal 11 Feb, 2026 Reviewers agreed at journal 10 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 06 Feb, 2026 Editor invited by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 19 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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These consequences range from direct war-related morbidities and mortalities to indirect impacts due to interruptions of the delivery, availability, and accessibility of health services (1). Sexual and reproductive health (SRH) is among the most affected sectors during conflict, due to service disruptions, reduced access to SRH including Gender-Based Violence (GBV) services, limited resources, and its frequent de-prioritization during emergencies (2). Even when services are available, women\u0026rsquo;s ability to access them may be limited by movement restrictions, fear, or political control (3).\u003c/p\u003e \u003cp\u003eOne major contributor to reduced access to care during conflicts is the attacks on health facilities, which may extend during a protracted healthcare crisis, with long-term impacts on public health (4). This has been documented in Syria with over half of health facilities shut down or partially operational, pointing to around 133,000 pregnant women, breastfeeding mothers, and menstruating girls lacking adequate access to essential healthcare and facing poor quality of care in 2024 (5). The challenges reported by women in Syria included restricted access to facilities due to roadblocks, bombing, and shortages in medical supplies, with the WHO reporting a rise in Maternal Mortality Ratio, due to lack of essential resources, family planning services and prenatal check-ups (6). Similarly, in Gaza, the war has limited access to public facilities and emergency obstetric care, with reports of increased preterm labor and drastically shortened postnatal hospital stays due to overcrowding and security concerns. (7).\u003c/p\u003e \u003cp\u003eSimilar to its neighboring countries, Lebanon has faced significant challenges, including political instability, economic collapse, and the most recent 2024 war, all of which have strained its already fragile health system. The most recent war began in October 2023, and escalated dramatically by September 2024, as armed attacks intensified in South Lebanon extending further into the eastern region, and the North of the country reaching daily bombings of the southern suburbs of Beirut as well as the capital Beirut itself. This led to the massive internal displacement of 1.2\u0026nbsp;million individuals within a few weeks, over half of whom were women and children. More than 250,000 internally displaced persons (IDPs) stayed in around 1,200 crowded shelters, mainly schools, religious places, abandoned houses, and NGO spaces in cities and towns (8). Many of these shelters lacked proper construction and maintenance, such as water, sanitation, and privacy (8). The conflict lasted for about a year, with a 60-day ceasefire brokered in November 2024. Lebanese sources reported at least a total of 3,768 deaths and 15,699 injuries (9;10). Based on a UNFPA report, 11,600 pregnant women were negatively affected by the conflict, with 3,900 women expected to give birth within the next 3 months following their displacement. Tens of thousands of women and girls have sought refuge in collective sites in Lebanon, exacerbating vulnerabilities to gender-based violence (GBV) (5). In terms of health care facilities, many have been forced to close, particularly in conflict-affected regions, leading to significant healthcare worker shortages. The crisis also highlighted the need to integrate mental health into emergency services, recommending expanded inpatient care and training in psychosocial support (11).\u003c/p\u003e \u003cp\u003eThe Lebanese Ministry of Public Health (MoPH) established a PHCC network in 1996 which currently comprises of 326 centers. These PHCCs are in their majority owned and operated by nongovernmental organizations and municipalities (12). PHCCs play a vital role in delivering SRH services, such as family planning, antenatal and postnatal care, and GBV support (13). The comprehensive nature of PHC makes it responsible not only for responding to major incidence or emergencies, but also for preparing and responding to communities\u0026rsquo; needs and supporting them during and after such events (14). This makes the PHCCs well-suited to play a vital role in responding to acute events during armed conflicts and war. Recent research finds that Lebanon\u0026rsquo;s primary healthcare system has demonstrated resilience despite overlapping crises, continuing to provide essential services to a large number of users (15). In response to the war in Lebanon, the MOPH and the WHO country office, organized healthcare delivery for IDPs through functioning PHCCs in neighborhoods hosting the displaced as well as through mobile units. These services included maternal health care, SRH care, childhood vaccination, GBV, Clinical Management of Rape (CMR), and care of chronic disease. Although 56 PHCCs closed due to security issues, 241 remained active, supported by mobile units and outreach teams. In specific, 968 collective shelters were linked to active PHCCs to ensure continuation of health services to IDPs. A total of 239 PHCCs and 260 PHC satellite units visited 734 shelters (11; 13).\u003c/p\u003e \u003cp\u003eWhile empirical evidence on how PHCCs maintain SRH service delivery during war remains limited, few studies from Syria suggest that PHCCs continued to provide care, but suffered challenges such as lack of funding, limited resources, and staff shortages (4). To date, there has been little in-depth research exploring how PHCCs, especially in the realm of SRH, have adapted to sustain services under such prolonged and compounding pressures. Such understanding is crucial for informing strategies to strengthen health system resilience and ensure continuity of care for vulnerable populations, particularly women and girls.\u003c/p\u003e \u003cp\u003eThis paper reports on key informant and service users\u0026rsquo; perspectives aiming to identify the challenges faced in the delivery and use of SRH services at the PHC level during the 2024 war on Lebanon and to explore the strategies and efforts employed by PHCCs to adapt to the conflict and respond to community needs.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis study is part of a multiphase study on Development of Gender and Person-informed Multi-component Wellness Intervention for Comprehensive Family Planning, Contraceptive Services, and Sexuality Education in Lebanon (GEMSELF). The study used a qualitative research approach and a grounded theory design, allowing for a thorough understanding of the emic perspectives of key informants and service users pertaining to the provision and use of SRH services within PHCCs in Lebanon and the experienced barriers and facilitators for quality contraception, family planning services, and sexuality education through a gender sensitive and person-centered approach.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy participants\u003c/h3\u003e\n\u003cp\u003eWe conducted 20 key informant interviews (KIIs) with administrative staff at the MoPH, at non-governmental and humanitarian organizations (n\u0026thinsp;=\u0026thinsp;6), with directors (n\u0026thinsp;=\u0026thinsp;2) and healthcare providers (HCP) (5 physicians; 2 nurses; 5 midwives) working in PHCCs. Interviews addressed perspectives on the organization\u0026rsquo;s background and provision of SRH services, within the primary health care system in Lebanon. Additionally, we conducted 20 focus group discussions (FGDs) with community members (adults and adolescents of different genders) seeking SRH care from across 10 PHCCs throughout Lebanon. This provided valuable perspectives on the user experience and their relationship with HCPs.\u003c/p\u003e\n\u003ch3\u003eParticipant recruitment and data collection\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eKey informant interviews\u003c/h2\u003e \u003cp\u003eA purposive sample of key informants was selected based on a stakeholder mapping exercise conducted by the study team in consultation with the Lebanese MoPH staff. The sampling strategy ensured variation in the participants between program managers and service providers, geographical region, and public vs private sector practice. Semi-structured interviews were used as a data generation tool. The interview questions were developed through a gender lens, and were piloted and adapted to the context of PHCCs in Lebanon. Participants were scheduled for online KIIs, with consent forms signed electronically. A trained research assistant conducted all KIIs which lasted between 30 and 50 minutes and were audio-recorded after participants\u0026rsquo; consent. Interviews were conducted using a semi-structured interview guide developed for this study (Supplementary file 1). Data saturation was reached by completion of 20 interviews. Data collection was done during the period of October 2024 to January 2025.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eService users seeking PHCC services\u003c/h3\u003e\n\u003cp\u003eA purposive sample of 10 PHCCs was obtained with the aim of ensuring variability in affiliation with the MoPH PHCCs network, size of the health care facility and number of users, geographical representation, and range of SRH services offered. FGDs were used as a data generation tool. The service users (women, men, adolescent girls and boys) in each selected PHCC were considered eligible to be invited to participate in FGDs. The consent of the legal guardian was secured in addition to the ascent of adolescents under the age of 18 years. The FGDs aimed to uncover experiences with care and existing services, identify barriers, including power dynamics, and facilitators to inform future interventions. Over the period extending from January 2025 to June 2025, twenty FGDs were conducted by a trained research assistant, 10 with adults and 10 with adolescents, before reaching data saturation. Each FGD consisted of 7\u0026ndash;8 participants, lasted 50\u0026ndash;80 minutes and was audio-recorded after consent. Separate semi-structured focus group discussion guides were developed for women and girls, and for men and boys. All interview guides were developed specifically for this study (see Supplementary File 1).\u003c/p\u003e \u003cp\u003eDue to the ongoing war, fieldwork was postponed and experienced delays, adapting continuously to evolving security conditions. Data collection through FGDs resumed at the beginning of 2025 with relatively fewer security concerns to ensure safety of participants and field workers.\u003c/p\u003e \u003cp\u003eData was collected while the war was ongoing and directly following the ceasefire, allowing the participants to provide insights into both the acute disruptions of war and the early recovery phase.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll audio recordings of KIIs and FGDs were transcribed verbatim in Arabic, the language of the interviews. Data collection, transcription, and preliminary analysis were conducted simultaneously. Thematic analysis was applied using Braun and Clarke\u0026rsquo;s six-stage framework, which involved familiarizing ourselves with the data, coding, and identifying patterns (16). Codes were manually recorded and validated by another researcher. They were used to build categories and develop a qualitative matrix to generate emerging themes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eThe researchers upheld cultural sensitivity and reflexivity during data collection and analysis, especially recognizing the challenging personal situations of participants during the on-going war. Equitable participant recruitment, in terms of sociodemographic and regional diversity ensured multiple perspectives among key informants and service users.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eRecruited key informants presented diverse socio-demographic backgrounds and different types of job positions, varying from administrative positions at the MoPH, at non-governmental and humanitarian organizations (n\u0026thinsp;=\u0026thinsp;6), to PHCC directors (n\u0026thinsp;=\u0026thinsp;2), and HCPs that included family medicine and obstetrician/gynecologists (n\u0026thinsp;=\u0026thinsp;5), nurses (n\u0026thinsp;=\u0026thinsp;2), and midwives (n\u0026thinsp;=\u0026thinsp;5) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey Informant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey informants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of key informants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of regions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSite\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministrative staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 regions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinistry of Public Health, local NGOs, humanitarian NGOs, and iNGOs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHCC directors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 regions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePHCCs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 regions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePHCCs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 regions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePHCCs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePHCCs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSimilarly, service users, both adults and adolescents, had varied socio-demographic backgrounds, and were recruited from PHCCs across regions in Lebanon. Ten FGDs were conducted with adults, from which 6 were done with women and 4 with men distributed across different regions in Lebanon. Similarly, 10 FGDs were conducted with adolescents from which 6 were done with girls and 4 with boys across different regions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus Group Discussion Participant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of FGD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Region\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 regions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 regions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdolescent boys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 regions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdolescent girls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 regions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwo main themes related to the Lebanese 2024 war and its consequences on SRH service delivery and care in PHCCs emerged. The first is about the multifaceted impacts of the war on geographical and logistical factors and accessibility to PHCCs, infrastructure of PHCCs, human resources, mental health concerns, and shifting priorities within PHCCs focus of care. The second theme talks about the efforts employed by PHCCs to respond to community needs, coupled with the civic responsibility and moral commitment of HCPs. The themes are presented in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and described in detail in the next section. Illustrative quotes supporting each theme and sub-themes are presented in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e at the end of the results section, and referenced in the text using superscript numbers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey themes and sub-themes of the Lebanese 2024 war, its consequences, and PHCCs\u0026rsquo; efforts to adapt and address community SRH needs across affected and non-affected regions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Restricted accessibility\u003c/p\u003e \u003cp\u003e2- Infrastructure \u0026amp; staff shortages\u003c/p\u003e \u003cp\u003e3- War\u0026rsquo;s psychological and physiological toll\u003c/p\u003e \u003cp\u003e4- Shift in Health Priorities\u003c/p\u003e \u003cp\u003e5- Mistrust in the healthcare system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- Challenges in reaching health facilities due to unsafe roads and transportation barriers.\u003c/p\u003e \u003cp\u003e2- PHCC closures and reduced availability of skilled health professionals.\u003c/p\u003e \u003cp\u003e3- Increased mental health needs and struggles among communities, especially displaced ones.\u003c/p\u003e \u003cp\u003e4- Diverting resources and attention away from SRH services towards emergency response needs, especially communicable diseases.\u003c/p\u003e \u003cp\u003e5- Erosion of trust towards government provided services following long years of prioritizing refugee populations over the local host communities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe adaptive efforts employed by PHCCs to respond to community needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1- Efforts employed by PHCCs to respond to community needs\u003c/p\u003e \u003cp\u003e2- Civic responsibility and moral commitment of HCPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1- PHCCs mobilized their care beyond the health facility setting, either through mobile clinics or outreach activities in shelters, often combined with informational sessions.\u003c/p\u003e \u003cp\u003e2- HCPs demonstrated a strong sense of duty, emotional connection to affected communities, including internally displaced in shelters. They showed personal commitment to responding to specific needs of individuals and alleviating suffering amid the ongoing crisis and uncertainty.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThe multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eRestricted Accessibility\u003c/h2\u003e \u003cp\u003eThe security situation and the 2024 war in Lebanon have significantly impacted accessibility to PHCCs for SRH including family planning services. Key informants highlighted how the war has made it difficult for people, particularly those in highly affected areas, to access PHCCs and seek essential SRH services. In particular, transportation was a critical barrier for displaced individuals residing in collective shelters or in remote areas. Unsafe roads and being near affected regions further limited mobility and created substantial geographical inaccessibility. \u003csup\u003e1,2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis was also stated across different FGDs describing their inability to reach healthcare services, not only due to limited transportation, but also because of uncertainties about road closures. \u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInfrastructure and staffing shortages\u003c/h2\u003e \u003cp\u003eKey informants noted physical destruction and other forms of damage in the infrastructure of some PHCCs as an influential factor disrupting provision of essential SRH services. \u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePHCCs also experienced a reduction in available specialized medical staff such as gynecologists, and pediatricians, limiting the capacity to deliver SRH care to beneficiaries and restricting service scope to general health care only. Centers also reported being unable to carry out routine community needs assessments due to disruptions in service delivery and support systems. \u003csup\u003e5,6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStaffing shortages resulted from healthcare workers being unable to reach facilities, while those who could access the center to deliver care were overwhelmed by the volume of patients, particularly those requiring urgent care. The surge in demand, combined with reduced personnel, placed high strain on PHCC\u0026rsquo;s ability to provide timely and quality SRH services. This was particularly significant in terms of shortage in mental health experts, whose support was considered very critical in shelters. \u003csup\u003e7,8,9\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eWar\u0026rsquo;s Psychological and Physiological Toll\u003c/h2\u003e \u003cp\u003eKey informants highlighted how conflict-related stress and trauma had particularly impacted pregnant and postpartum women, many of whom were internally displaced. One key informant referenced a recent study in light of the war, which showed the significant mental health challenges, such as depression faced among this group, which impacted their ability to carry out daily activities, caregiving, and access to essential SRH services. \u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAnother key informant reported the deep psychological toll of bereavement and displacement explaining how the war left a detrimental impact on mental health of individuals who experienced family loss, further reducing their motivation to access SRH services due to psychological distress.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe struggles with mental health were echoed by service users themselves across FGDs. Both men and women, described the war\u0026rsquo;s impact on their psychological well-being and how it interfered with different aspects of SRH. Women described how war negatively impacted their mental health, menstrual cycles and heightened menstrual pain. Men spoke about how war decreased their sexual desire and willingness to have more children due to chronic stress and persistent fear. \u003csup\u003e12,13,14\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eShift in Health Priorities\u003c/h2\u003e \u003cp\u003eThe 2024 war on Lebanon led to a significant shift in healthcare priorities, diverting resources and attention away from SRH services towards emergency response needs. As PHCCs and supporting organizations scrambled to address urgent needs, such as treating injuries, managing displacement, and controlling communicable disease outbreaks, SRH services were deprioritized. This shift contributed to both a reduction in service provision and a noticeable decline in demand for SRH care at PHCCs. \u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMistrust in the healthcare system\u003c/h2\u003e \u003cp\u003eKey informants described the eroding trust of the public in government-provided healthcare services, including those delivered through PHCCs. They explained that the war intensified lack of resources which highlighted feelings of neglect among Lebanese. They considered this a significant consequence of long years prior to this war where resources were allocated to refugee populations in Lebanon with disregard to the needs of the host communities. The existing mistrust in government services was expected to grow with the lack of resources to meet the population needs during and following the war. \u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe adaptive efforts employed by PHCCs to respond to community needs\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eEfforts employed by PHCCs to respond to community needs\u003c/h2\u003e \u003cp\u003eThe majority of key informants highlighted that PHCCs in Lebanon adapt to community needs through various strategies, such as conducting regular community assessments to identify healthcare needs and inform yearly plans. This approach enabled PHCCs to properly respond to the growing needs of individuals during the war, including challenges with transportation, a main identified need among communities. Some PHCCs used mobile clinics to provide services such as vaccinations and mental health assessments. \u003csup\u003e17,18\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdditionally, many informants reported how community outreach activities which were originally part of PHCCs nature of work, have intensified during the war, with PHCCs offering SRH services in shelters for displaced people, conducting information sessions in shelters and in schools about period poverty, STIs, vaginal and urinary tract infections, and menstrual hygiene, and involving communities in decision-making processes. \u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdditionally, key informants have noted that recent community assessments have specifically shown an increased need for mental health support and education on period poverty and STIs, prompting PHCCs to prioritize these services in response. \u003csup\u003e20,21\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSimilarly, users across several FGDs, particularly men, reported several positive outcomes resulting from the PHCCs efforts during the war, including outreach and shelter visits to provide SRH services to internally displaced Lebanese population. FGD participants noted the efforts of the PHCCs and the MoPH in the implementation and activation of mobile clinics during war, which offered flexible services in areas where communities had limited access to care. They noted these coordinated efforts of redistributing staff and health services from better-resourced and non-affected areas to those experiencing shortages, especially in locations hosting internally displaced communities or severely-affected by the war. \u003csup\u003e22,23,24\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCivic responsibility and moral commitment of HCPs\u003c/h2\u003e \u003cp\u003eApart from structural and logistical efforts PHCCs made to sustain care during war, it was the dedication of HCPs that often made the difference. Their strong sense of civic responsibility and moral commitment was described as a key driver behind sustained care delivery during the conflict. According to key informants who were administrative staff working in NGOs and the MoPH, they reported significant investments within the workforce that showed, not only the adaptations done in light of the war, but the strong commitment and discipline HCPs had throughout this phase. For instance, even in the absence of specialized mental health professionals, PHCCs in collaboration with the National Mental Health Programme (NMHP) took proactive actions to train general practitioners and family physicians to fill this gap and serve the vulnerable population, especially displaced individuals in shelters. This demonstrated the strong sense of moral commitment that those physicians had to dedicate their time and efforts in learning new skills in order to respond to the needs of a larger portion of affected communities. These physicians made sure to actively collaborate with psychiatrists remotely whenever they were conducting assessments in shelters, ensuring professional and credible care and committing to not leaving people without support. \u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMidwives were also key HCPs included in these efforts, specifically trained to support the mental health of pregnant and postpartum displaced individuals. This reflects how midwives extended their care beyond the core components of their role in PHCCs to address broader community needs. \u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn addition to the expanded roles to cover mental health needs, HCPs also adapted their daily clinical routines to include HIV and tuberculosis screening. This shift in practice not only showcases their clinical responsiveness but also their deep involvement and connection to meet the evolving needs of the communities. HCPs embraced a more personal, human-centered, and community-based approach, as the integration of HIV and TB screening was driven by urgent needs identified by the needs assessments initiatives, which included treating injuries, managing displacement, and controlling communicable disease outbreaks. \u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eKey informants who were HCPs themselves confirmed the prominence of this dedication and civic commitment to human-care amid the crisis. Midwives reported being present and engaged daily, even with a shelter full of displaced people located just steps away from the PHCC, a situation that likely added pressure to their routine work. One midwife mentioned the term \u0026ldquo;interaction\u0026rdquo; as an aspect that was present between them and the people in shelters. There was also a sense of compassionate care that went beyond their routine professional duty. \u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA midwife described how she took initiative in visiting shelters and transporting women to the PHCC to offer family planning related information and services. Midwives underscored the provision of context-specific and culturally sensitive services as they understood the consequences of unplanned pregnancies during war and displacement and prioritized family planning accordingly.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eObstetricians/gynecologists also emphasized their daily commitment to providing not just clinical care, but also emotional comfort and reassurance, especially for people living in shelters, ensuring they were safe, supported, and that support was provided to unmet needs. They would also guide them to seek the PHCC for wider scope of care according to the demand and the individual case. \u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe reports of adults from FGDs noted the devotion described by HCPs in their approach during war. They felt proud about how the PHCC staff handled the situation during war, labeling them as \u0026ldquo;strong leaders\u0026rdquo;. They discussed how HCPs were \u0026lsquo;mobilized\u0026rsquo; and left their own centers to fill gaps elsewhere. Their commitment went beyond serving their own communities and they stepped in to different regions around Lebanon where help was most needed. \u003csup\u003e31,32\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIllustrative quotes from KIIs and FGDs, organized by theme and sub-themes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRestricted Accessibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e1\u003c/b\u003e \u0026ldquo;\u003c/sup\u003e\u003cem\u003e\u0026hellip;We\u0026rsquo;re now back in a state of war, so it\u0026rsquo;s only natural that women have ended up in a dire situation to reach anywhere. That\u0026rsquo;s why very few of them go to PHCC anymore to receive care\u0026rdquo; \u0026ndash; OBGYN at PHCC 13\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e\u0026ldquo;We want people to go to the centers. We want the health seeking behavior of the people to change, to go to the center and to have everything they need. So even though this is our steer and this is our aim and this is what we built throughout the years\u0026hellip;. we found ourselves this year in front of a situation where people cannot or might not be able to go to the PHCCs at all. They got displaced from one area to another. The roads are unsafe or damaged\u0026hellip;maybe they don't know where the centers are. Also, their presence at the center might create a huge pressure. The center cannot bear this pressure\u0026rdquo; Admin staff at humanitarian NGO\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003e \u003cem\u003e\u0026ldquo;During the war, there was difficulty accessing health services, whether related to sexual and reproductive health or other services\u0026hellip; Or for example, here, this road was closed, or was it not closed?\u0026rdquo; \u0026ndash; FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInfrastructure and staffing shortages\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e4\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Well, of course. I mean, we haven\u0026rsquo;t really started yet in the PHCC, it was destroyed, you could say we\u0026rsquo;re just starting to get back to work\u0026rdquo;- OBGYN at PHCC 5\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e5\u003c/sup\u003e \u003cem\u003e\u0026ldquo;The services we provide are medical, related to illness, and awareness-based. Currently, I only have one general practitioner. I used to have a gynecologist, a pediatrician, and a dentist. But after the war we\u0026rsquo;re in, I\u0026rsquo;m left with only general health service provider. The dentist stopped coming because (the PHCC) is in a mountainous area, about 20 kilometers from (name of city).\u0026rdquo;- Director at PHCC 4\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e6\u003c/sup\u003e \u003cem\u003e\u0026ldquo;How am I supposed to go to these people and tell them that I have nothing to offer them, neither medical nor material support? How can I go to someone and ask, 'What do you need?' when I have nothing to give due to the war that strained my PHCC\u0026rdquo; \u0026ndash; Director at PHCC 4\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e7\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Of course, the war affected us. The team did its best to respond, but part of it had to go down to the shelters, so we felt there was a shortage of personnel, we could no longer keep up\u0026rdquo; \u0026ndash; Midwife at PHCC 8\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e8\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;There was a need for more personnel\u0026hellip;because the psychologist who was with us, she would still have about 4 or 5 (cases) left. We couldn\u0026rsquo;t say anything to her (asking for more attention); we just let her continue\u0026rdquo; \u0026ndash; FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e9\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;The people\u0026hellip; they were in urgent need because the psychological factor had a huge impact, especially on the displaced people who were living outside their home areas and going through these situations. Some of them were not treated or reached even\u0026rdquo; \u0026ndash; FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWar\u0026rsquo;s Psychological and Physiological Toll\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e10\u003c/sup\u003e \u003cem\u003e\u0026ldquo;For example, we did a study about IDPs, and it showed that they are experiencing depression, whether pregnant women, they are dealing with depression. She doesn\u0026rsquo;t want to feed, doesn\u0026rsquo;t want to eat, doesn\u0026rsquo;t want to do anything. And postpartum as well, she doesn\u0026rsquo;t want to breastfeed the baby\u0026rdquo; \u0026ndash; Administrative staff at NGO 1\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e11\u003c/sup\u003e \u003cem\u003e\u0026ldquo;I mean, if we notice, there are, there might be, a lot of families who have lost people, from their family. And even those who lost their homes\u0026hellip; you could say they\u0026rsquo;re in a state of confusion, a kind of disorientation. They don\u0026rsquo;t know what to do, where to go, or how to move forward. Some have also lost their livelihoods. All of this affects mental health and access to SRH\u0026rdquo; \u0026ndash; OBGYN at PHCC 5\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e12\u003c/sup\u003e \u003cem\u003e\"For example, after the war, I\u0026rsquo;m a woman, I didn\u0026rsquo;t get my period for a month, a month and a bit. It stopped because of the stress and fear\u0026rdquo; \u0026ndash; FGD 7, women\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e13\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e\u0026ldquo;As a result of ev,1erything we\u0026rsquo;ve been through, like war now\u0026hellip; there has been an impact on mental health. If there is fear, there is no sexual desire at all. If there\u0026rsquo;s no psychological stability, there\u0026rsquo;s no sexual relationship, it just doesn\u0026rsquo;t happen. Mental and physical well-being are both necessary to reach that desire\u0026rdquo; \u0026ndash; FGD 1, men\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e14\u003c/sup\u003e \u003cem\u003e\u0026ldquo;After the war, who still has the desire to have children, ma\u0026rsquo;am?\u0026rdquo; \u0026ndash; FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eShift in Health Priorities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e15\u003c/sup\u003e \u003cem\u003e\u0026ldquo;SRH used to be the main topic, in every club, they had to be talking with beneficiaries about SRH; it was the main focus. But unfortunately, now due to the escalation and the crisis, we are in emergency response mode. Yes, they\u0026rsquo;re still providing a bit of education, but not like before, because now we\u0026rsquo;re focusing mostly on communicable diseases.\u0026rdquo; - Deputy manager at iNGO\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMistrust in the healthcare system\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e16\u003c/sup\u003e \u003cem\u003e\u0026ldquo;I'm telling you, and with the war now, people have lost a lot of trust in the Ministry of Social Affairs because we always go and do statistics, ask what they need, and so on, but in the end, nothing comes out of it. Maybe for every 200 families, only one family gets something. The Lebanese community has become, for the most part, in need. And when people come to me at the health center and I have nothing to give them, if I have no medicine, what are they supposed to do? Initially, the focus was on the Syrian community, neglecting the Lebanese. Raising awareness on mental health and sexual health, especially for Lebanese women, is crucial.\u0026rdquo; \u0026ndash; Director at PHCC 4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe adaptive efforts employed by PHCCs to respond to community needs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eEfforts employed by PHCCs to respond to community needs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e17\u003c/sup\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;and especially with the current crisis and with the displacement crisis, like in the last two months, this comprehensive package of care, including sexual and reproductive health, went from the PHCCs to what we are calling now primary health care satellite units or mobile medical units as we used to know them before\u0026rdquo; - Administrative staff at humanitarian NGO\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e18\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Yes, they had a mobile clinic, it\u0026rsquo;s basically a big bus that has an ultrasound machine inside, medications, a bed\u0026hellip; We used to go around schools and shelters where families were located, and anyone who had a problem could come in the morning and we\u0026rsquo;d help them\u0026rdquo;- OBGYN at PHCC 14\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e19\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;We had a school [shelter] here\u0026hellip;we used to go down to the school every few days to see what people needed. The most common issues we faced were genital infections and urinary tract infections among women. We started referring them to our center and provided them with treatment\u0026rdquo; - Midwife at PHCC 7\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e20\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Period poverty and sexually transmitted diseases\u0026hellip;. they were interested in learning more about these topics\u0026rdquo; - Admin staff at NGO 2\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e21\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;So, people are still, you know, a bit busy with their homes and the destruction that happened. But overall, the focus of the services will be more on mental health, especially after the war that took place\u0026rdquo;- OBGYN at PHCC 5\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e22\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;They used to come with mobile clinics, like for example, in our village\u0026hellip; They used to come to the schools [shelter] also\u0026rdquo; \u0026ndash; FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e23\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Primary healthcare services during the war were stronger because people were mobilized for these matters. For example, if we say in the southern suburbs, there are between 30 and 35 primary healthcare centers. These centers, once mobilized, directed their efforts outside the suburbs, going to the areas where displaced people were hosted. They went to schools and buildings where displaced people were located. In certain areas like Ain el-Rummaneh, Qamatia, and Bourj Hammoud, there was a shortage of centers. The staff from those centers moved to these areas to cover the gap\u0026rdquo; - FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e24\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;The Ministry of Health card, along with all the centers in the southern suburbs, was following up with each one individually. The schools [shelters] were being divided. The schools were assigned to the active centers that were not working in the southern suburbs during the war, coordinating with them\u0026rdquo; \u0026ndash; FGD 14, men\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCivic responsibility and moral commitment of HCPs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003csup\u003e25\u003c/sup\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;.now, with displacement, we have mobile clinics that go to shelters, and we have approximately 20 primary healthcare satellite units (PSUs) now. We have trained the work team in them so that they know how to provide mental health services, because in the heart of this PSU, we do not have mental health specialists, but we have family medicine or general practitioners. These 20 were trained by the National Mental Health Program so that they can help people in shelters if they are taking medications specific to mental health, so that they can give it to them\u0026hellip;if they need someone to follow up on them\u0026hellip;to help them and support them because people are in need, this doctor who was trained can communicate remotely with the psychiatrist on call, and they can identify this case in the shelter so that they can help them and provide them with the best care and support\u0026rdquo; \u0026ndash; Admin staff at MOPH\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e26\u003c/sup\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;.the identified women struggling with mental health\u0026hellip;.they are already being referred to and gaining the skills of the midwives we have that have been trained to support the women in need, it\u0026rsquo;s their duty\u0026rdquo; \u0026ndash; Admin staff at NGO 1\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e27\u003c/sup\u003e \u003cem\u003e\u0026ldquo;We had to adapt our interventions. For example, we intensified screening for tuberculosis and HIV awareness. In these places, doctors intensified talking about them more during the crisis or during the war because you know the overcrowding that was happening in the shelters. You see over 100 people sitting on top of each other. So you are risking the transmission of TB. I mean, if someone has TB and they infect you, see how contagious they are. So, doctors are also doing screening for TB, and people who were coming out as TB cases or confirmed TB cases. They also were doing contact tracing, and this was done a lot during the war. We tailored our interventions in one way or another to meet the new needs\u0026rdquo; \u0026ndash; Admi staff in NGO 3\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e28\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Regarding the circumstances we're currently in, we had a shelter center directly across from the center, with everyone sitting right in the center. We were building strong centers, and the people would come to us and we would go a lot to check on them everyday. There was a lot of interconnections between us, as displaced people, and staff in PHCCs, we would not leave anyone without care, at all\u0026rdquo; \u0026ndash; Midwife at PHCC 6\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e29\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Of course, family planning services, in the midst of war, we had a lot of them. You know, as displaced people in schools [shelters], this was a problem. So we focused a lot on these topics, we explained everyday so much. There were also days when we would bring people to the center and explain to them and show them the methods. I would go bring them myself. We would have a lot of displaced people, so I would teach them. The most important thing is family planning in this regard, because it would be difficult to get pregnant and they wouldn't be properly followed up and the cost would be a little... so there were a lot of patients to whom we would give family planning services like pills, sterile lotion. We also tackled a big issue with personal hygiene and a lot of infections like genital and urinary infections. We had a school here for boys and we use to go to the school everyday and see what was happening. We would help and treat as much as we could, we did not want to leave anyone behind and without care\u0026rdquo; \u0026ndash; Midwife at PHCC 7\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cem\u003e30\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e\u0026ldquo;I mean, we would go to schools, and if anyone had a problem, we would help, and every morning they would also come to the center and we would help them with it\u0026hellip;we made sure everyone was ok\u0026rdquo; \u0026ndash; OBGYN at PHCC 14\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e31\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Primary healthcare services during the war were so strong. They mobilized their staff, they went outside the suburbs and went out to the areas in need. They started going to schools and the buildings that were used for the displaced. They were going to these areas. There was a shortage in other centers in a specific location, like [name of regions]. These areas where there was a shortage, what was present in the active centers was moved to them\u0026rdquo; \u0026ndash; FGD male, Mount Lebanon\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e32\u003c/sup\u003e \u003cem\u003e\u0026ldquo;Yes, they (the HCPs) used to drop by and check in on us in the shelters\u0026hellip;. there was also an active PHCC in the village, people knew about it. It felt easy, accessible... there were no real obstacles. Things just flowed\u0026rdquo;- FGD male, Mount Lebanon\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe 2024 war on Lebanon exposed deep systemic vulnerabilities in PHC, while also revealing remarkable resilience within the overall health system and the frontline workforce which are at the core of this health system. Analysis of the qualitative data revealed two overarching themes: The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs, which included security threats, staff shortages, infrastructure damage, shifting priorities, and growing mistrust in the healthcare system. Yet, amidst these challenges, adaptive efforts were employed by PHCCs to sustain SRH services. These were characterized by workforce mobilization from non-affected to affected areas across the country, deploying mobile clinics to delivering care in shelters, and outreach activities coupled with community needs assessments conducted regularly. All these efforts were driven by a profound sense of civic duty and moral responsibility among the HCP workforce across PHCCs in Lebanon.\u003c/p\u003e \u003cp\u003eWhen looking at the war\u0026rsquo;s multifaced impacts, one can deduce how it disrupted not only access to SRH services, but the entire continuum of care within PHCCs. Rather than affecting SRH services in isolation, the war placed tension on every component of the health system, ranging from accessibility through unsafe roads, infrastructure, and human resources being strained to overall service delivery shifts and governance. According to the World Health Organization\u0026rsquo;s six building blocks of health systems (17), war can critically undermine these pillars, and the 2024 war in Lebanon was no exception. Based on our findings, the most significant disruptions were observed at the level of service delivery, health workforce, and leadership governance.\u003c/p\u003e \u003cp\u003eIn terms of \u003cb\u003eservice delivery\u003c/b\u003e, unsafe roads and restricted transportation limited access to PHCCs, especially for displaced individuals in shelters, and strained fragile outreach mechanisms, which is a key feature of good service delivery. Additionally, the service lacked proper coverage of all population in Lebanon, service provision became uneven, with vulnerable population often excluded from care due to logistical barriers such as infrastructure damage and staffing shortages. PHCCs also experienced a shift in health priorities, with SRH services deprioritized and in favor of communicable disease response. These challenges echo patterns observed in other conflict-affected contexts. In Ukraine, widespread infrastructure damage and electricity outages coupled with restricted funding led to disruptions in PHCC operations and reduced service delivery (18). Similarly, in Gaza, extensive attacks on healthcare facilities, unsafe transport routes compromised service delivery (19).\u003c/p\u003e \u003cp\u003eThe \u003cb\u003ehealth workforce\u003c/b\u003e was severely affected, the shortage in staff within PHCCs, limited medical specialties, and caused burnout among overstretched personnel. These challenges mirror the experiences of health system in other conflict-affected contexts such as Ukraine and Afghanistan. In Ukraine, prolonged insecurity led to departure of trained staff, reducing both the availability and quality of services. Similarly, in Afghanistan, health workforce suffered from fatigue and high turnover rates due to burnout (20).\u003c/p\u003e \u003cp\u003e \u003cb\u003eLeadership and governance\u003c/b\u003e were another point of fragility. Community trust in government was notably diminished, with many perceiving a lack of adequate support and feelings of neglect. This reflects a broader governance challenge in crisis settings, where slow or fragmented responses further erode public confidence. A similar pattern was observed in Afghanistan, where poor governance and security challenges jointly undermined maternal and child health services (20). Another example is in Ukraine where individuals living near conflict-affected areas reduced trust in government institutions, not only the ones who were displaced or remained within heavily impacted regions. At the same time, the study found that proximity to combat zones increased social solidarity, while further undermining confidence in government bodies (21).\u003c/p\u003e \u003cp\u003e Despite these immense challenges, the response of PHCCs revealed a surprising level of resilience and adaptability, offering critical lessons on how decentralized and fragmented health structures can still sustain care and respond effectively to community needs during times of crisis. PHCCs ensured some level of care and support to those affected by war, demonstrating that conflict settings can also mobilize resources and foster a sense of community-based engagement. The 2024 war on Lebanon has pushed PHCCs to innovate, from mobile clinics to increased community outreach activities, efforts to sustain ongoing needs assessments were put in place, showcasing how the war catalyzed community-based health delivery and revealed areas of system flexibility and social cohesion. This mirrors the broader resilience documented in Lebanon\u0026rsquo;s primary care system. In fact, a 2024 scoping review done in Lebanon, showed that despite the multiple crisis the country has been facing for years, including the COVID-19, the Beirut port explosion, the economic collapse and the recent 2024 war, there have been remarkable achievements, showing resilience and readiness in service delivery and community engagement (15). Similar efforts to maintain equitable service delivery have been documented in other conflict-affected settings such as Syria (22).\u003c/p\u003e \u003cp\u003e Central to those resilient efforts was the civic responsibility and ethical commitment of HCPs, who are the cornerstone of any health system and whose role can\u0026rsquo;t be overlooked. When we speak of a resilient and competent health system that continued to deliver efficiently even under stress, as seen in Lebanon, we are, in essence, speaking of resilient and ethically committed workforce, which was clearly evident in our data. Civic responsibility of HCPs refers to their ethical and professional duty to individuals, the community, and society (23). It goes beyond personal or institutional gain, to serve the health and dignity of \u0026ldquo;all\u0026rdquo; people, especially the vulnerable, which during war was confined to displaced individuals living in shelters. The findings in this paper align strongly with this concept, as it showed HCPs embracing emotional attachment to the mission and services, regardless of their specialties, and focusing more on the human-side of the care. GPs, FM physicians, midwives, mental health experts, and the broader health workforce went beyond their usual responsibilities, demonstrating sustained presence and commitment to serving the public. They addressed significant gaps, such as transportation barriers, resource shortages, and personal deficits, through outreach visits to shelters, extended working hours, mobilization of resources across regions, dedication of their time and efforts, and continuous informational sessions on SRH. These actions were visible to the public affected by the war, and these efforts to deliver care equitably were appreciated by the affected communities. Qualitative evidence from other conflict-affected areas aligns with our data, indicating that frontline workers view their service as a moral obligation and ethical duty and part of humanitarian principles to their communities, which drove their sustained efforts and motivation despite overwhelming conditions (24).\u003c/p\u003e \u003cp\u003eIt is particularly interesting to observe these expressions of civic responsibility among HCPs in Lebanon, especially given the ongoing ethical dilemmas and debates surrounding the roles of HCPs in conflict settings, knowing the high level of inequity in health care that can take place in such settings and the limited efforts to address everyone\u0026rsquo;s needs. In the past years, scholars and researchers have increasingly discussed the difference between civic professionals, those who integrate social and ethical duty within their practice, and knowledge workers, whose roles are often limited to clinical delivery within institutional walls (25). Till now, this issue still remains an aspect of confusion among many academic institutions, and its implementation remains limited and hard to distinguish, especially with the overmedicalization that dominated many aspects of care in medicine. This is why recent studies have begun evaluating concepts of civic responsibility and encouraging academic leaders and medical educators to emphasize its importance in medical practice, and to hold HCPs and institutions accountable for fulfilling this essential professional and moral duty (26).\u003c/p\u003e \u003cp\u003eOur findings highlight a striking unique example: Despite Lebanon being a resource-limited country and facing persistent systemic gaps, particularly at the level of PHCCs, HCPs and the overall health system demonstrated remarkable civic responsibility and resilience even under the extreme stressors of the war. Their actions during the war showcased their prioritization of community duty over narrowly defined clinical tasks. Findings from this study serve as a timely reminder that, even in times of crisis and war and despite the constraints of settings in a lower to middle income country, the health system and the workforce led with their dedication to meet community needs in SRH, going beyond provision of technical care, with listening to, assessing, and addressing the needs of their communities. However, it is also important to acknowledge that, even with such dedication, PHCCs faced significant strain, and service disruptions and unmet needs persisted, pointing to the limits of workforce commitments and health systems resilience amid conflict and underscoring the necessity of broader system support to fully address community health needs.\u003c/p\u003e \u003cp\u003eThe findings of this study highlight the urgent need to strengthen Lebanon\u0026rsquo;s health system by not only improving all six WHO health system building blocks, but also by building on and institutionalizing the adaptive efforts PHCCs demonstrated and the civic responsibility and moral commitment HCPs embraced during the 2024 war. The unwavering devotion of HCPs to remain involved and available, even beyond their standard clinical care is worth building upon and informing future emergency responses. Also, investing in capacity building of the healthcare workforce in PHCCs, with a specific focus on strengthening civic responsibility and community-based responses, especially in times of conflict is crucial. In parallel, it is essential to continue conducting large-scale community needs assessments as part of emergency preparedness efforts to ensure that service delivery is grounded in the evolving needs of the population and can be rapidly adapted in times of crisis. Additionally, investing in mobile units to improve geographical coverage and reach underserved or hard-to-access regions and populations, especially during times of conflict displacement is necessary.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations\u003c/h2\u003e \u003cp\u003eA major strength of this qualitative study is its ability to capture the dual impact of war on Lebanon\u0026rsquo;s PHCCs, both the multifaced impacts that disrupted SRH service delivery and the remarkable resilience demonstrated by a committed, though fragmented health system and workforce. Nonetheless, this study presents findings drawn from a broader implementation research project \u0026ldquo;GEMSELF\u0026rdquo;, of which the impact of the 2024 Lebanese war on SRH service delivery was only one of several emerging themes. Hence, the interview guides used for both KIIs and FGDs were not originally designed to comprehensively explore this specific theme. A more focused, primary study on that topic may have yielded deeper and more targeted insights. Another limitation is the timing and mode of data collection that may have influenced the quality of participant responses. KIIs were conducted in the midst of the active phase of conflict in October 2024, while FGDs were held shortly after the ceasefire.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eLebanon\u0026rsquo;s experience offers valuable lessons for conflict-affected countries seeking to build more adaptable, community rooted, and equitable health systems, especially for SRH service delivery during emergencies. A unified health-system response that embeds civic responsibility within it is essential not only for meeting immediate needs of communities but also for strengthening long-term health equity, especially in ensuring SRH services remain accessible and equitable during crisis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOVID-19: Coronavirus Disease 2019\u003c/p\u003e\n\u003cp\u003eFGD: Focus Group Discussion\u003c/p\u003e\n\u003cp\u003eFM: Family Medicine\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGP: General Practitioner\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCP: Health Care Provider\u003c/p\u003e\n\u003cp\u003eKII: Key Informant Interview\u003c/p\u003e\n\u003cp\u003eNMHP: National Mental Health Programme\u003c/p\u003e\n\u003cp\u003ePHC: Primary Health Care\u003c/p\u003e\n\u003cp\u003ePHCC: Primary Health Care Centers\u003c/p\u003e\n\u003cp\u003eSRH: Sexual and Reproductive Health\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was conducted upon attaining ethical approval from the American University of Beirut – Institutional Review Board (AUB-IRB) (reference number: SBS-2024-0057) and while maintaining ethical research conduct throughout the process. A consent form detailing the study’s aim, potential risks and benefits, participants rights, and confidentiality measures were shared and explained to potential participants. Ascents and guardian consents were shared with youths below 18 years old. The researcher provided time for questions and sought voluntary informed consent from participants to participate in the study. Participants were assured of their confidentiality and anonymity, and reminded that they could withdraw from the study at any time without consequences. Consent to record was always sought from participants. Transcripts were anonymized using pseudonyms to protect confidentiality. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative datasets generated and analyzed during the current study are not publicly available due to confidentiality and privacy concerns but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declare that they have no competing interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the International Development Research Centre (IDRC) through the GEMSELF project (Development of Gender and Person-informed Multi-component Wellness Intervention for Comprehensive Family Planning, Contraceptive Services, and Sexuality Education in Lebanon) and under grant number 104438.\u0026nbsp;The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTK provided overall leadership across all stages of the study, from concept development through data analysis and manuscript preparation. LAJ and DEC managed the field work. LAJ supervised data collection, conducted interviews and data analysis, and drafted the manuscript. LAJ is the corresponding author of this manuscript. FEK, SJM, GES, SEF, and DEC contributed to revisions and provided critical feedback. All authors read and approved of the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are deeply grateful to all the key informants and service users who participated in this study for sharing their insights.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArage MW, Kumsa H, Asfaw MS, Kassaw AT, Dagnew EM, Tunta A, et al. Exploring the health consequences of armed conflict: the perspective of Northeast Ethiopia, 2022: a qualitative study. BMC Public Health. 2023;23(1).\u003c/li\u003e\n\u003cli\u003eTun\u0026ccedil;alp \u0026Ouml;, Fall IS, Phillips SJ, Williams I, Sacko M, Tour\u0026eacute; OB, et al. Conflict, displacement and sexual and reproductive health services in Mali: analysis of 2013 HERAMS survey. Confl Health. 2015;9(1).\u003c/li\u003e\n\u003cli\u003eHedstr\u0026ouml;m J, Herder T. Women\u0026rsquo;s sexual and reproductive health in war and conflict: are we seeing the full picture? Glob Health Action. 2023;16(1).\u003c/li\u003e\n\u003cli\u003eFouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for the Lancet\u0026ndash;American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eUNFPA Arab States. Syria: women and girls\u0026rsquo; rights are a casualty of 12 years of grinding conflict. 2024.\u003c/li\u003e\n\u003cli\u003eUNFPA Arab States. Syria: women and girls\u0026rsquo; rights are a casualty of 12 years of grinding conflict. 2024.\u003c/li\u003e\n\u003cli\u003eUNFPA. Humanitarian crisis in Palestine. 2025.\u003c/li\u003e\n\u003cli\u003eEl Kak F. Women\u0026rsquo;s health and rights in conflict: the impact of renewed violence in Lebanon. Sex Reprod Health Matters. 2025;33(1).\u003c/li\u003e\n\u003cli\u003eOCHA. Lebanon: Flash update #35 \u0026ndash; escalation of hostilities in Lebanon. 2024.\u003c/li\u003e\n\u003cli\u003eAnera. Lebanon Situation Report. 2024\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Health Emergency Response \u0026ndash; Lebanon. 2024.\u003c/li\u003e\n\u003cli\u003eHemadeh R, Kdouh O, Hammoud R, Jaber T, Khalek LA. The Primary Healthcare Network in Lebanon: a national facility assessment. East Mediterr Health J. 2020;26(6):700\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMinistry of Public Health. Emerging from crisis: health sector response and lessons learned from the 2024 war on Lebanon. 2025.\u003c/li\u003e\n\u003cli\u003eAl-Jazairi AFH. Role of primary health care system in response to a major incident: challenges and actions. IntechOpen. 2020.\u003c/li\u003e\n\u003cli\u003eAoun N, Tajvar M. Healthcare delivery in Lebanon: a critical scoping review of strengths, weaknesses, opportunities, and threats. BMC Health Serv Res. 2024;24(1).\u003c/li\u003e\n\u003cli\u003eFouad FM, Hashoush M, Diab JL, Nabulsi D, Bahr S, Ibrahim S, et al. Perceived facilitators and barriers to the provision of sexual and reproductive health services in response to the Syrian refugee crisis in Lebanon. Womens Health. 2023;19.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Monitoring the building blocks of health systems. 2010.\u003c/li\u003e\n\u003cli\u003eReliefWeb. Refining primary health care financing in Ukraine. 2024.\u003c/li\u003e\n\u003cli\u003eMohammed F, Elgailani US, Ali SYI, Mohamed RF, Su Yin ET, Bravo-Vasquez ML. Defending the right to health in Gaza: a call to action by health workers. Confl Health. 2024;18(1).\u003c/li\u003e\n\u003cli\u003eMirzazada S, Padhani ZA, Jabeen S, Fatima M, Rizvi A, Ansari U, et al. Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan. Confl Health. 2020;14(1).\u003c/li\u003e\n\u003cli\u003eHoch G, Pondorfer A, Shkola V. Conflict and social capital: evidence from the Russian war against Ukraine. J Comp Econ. 2025;53(2):461\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eFardousi N, Douedari Y, Howard N. Healthcare under siege: a qualitative study of health-worker responses to targeting and besiegement in Syria. BMJ Open. 2019;9(9).\u003c/li\u003e\n\u003cli\u003eGross M. Bioethics and war. Camb Q Healthc Ethics. 2006.\u003c/li\u003e\n\u003cli\u003eKallstr\u0026ouml;m A, Al-Abdulla O, Parkki J, H\u0026auml;kkinen M, Juusola H, Kauhanen J. I don\u0026rsquo;t leave my people; they need me: qualitative research of local health care professionals\u0026rsquo; motivations in Syria. Confl Health. 2022;16:1\u0026ndash;16.\u003c/li\u003e\n\u003cli\u003eLarson EB. Physicians should be civic professionals, not just knowledge workers. Am J Med. 2007;120(11):1005\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eMcCullough LB, Coverdale J, Chervenak FA. Professional virtue of civility and the responsibilities of medical educators and academic leaders. J Med Ethics. 2023;49(10):674\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sexual and Reproductive Health, Primary Health Care Centers, War, Conflict, Lebanon, Health System Resilience, Healthcare workforce, Civic commitment","lastPublishedDoi":"10.21203/rs.3.rs-8559503/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8559503/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eWar has far-reaching impacts on health, through direct injury and death as well as indirect causes such as disruptions to health care service delivery. Sexual and reproductive health is among the most affected, due to reduced access to services, limited resources, and its frequent de-prioritization in emergency response. Lebanon, already burdened by multiple crises, was severely affected by the 2024 war, which displaced internally over one million people, mostly women and girls. To date, there has been little in-depth research exploring how Primary Health Care Centers (PHCC) have adapted to sustain services during the war. This paper draws on perspectives from key informants and service users to examine the challenges in delivering and accessing SRH services during the 2024 war on Lebanon and the efforts employed to respond to community needs.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis qualitative study used grounded theory to explore key informants\u0026rsquo; and service users\u0026rsquo; perspectives on SRH service provision and use in Lebanese PHCCs, focusing on barriers and facilitators to contraception, family planning, and sexuality education. We conducted 20 key informant interviews with health staff and 20 focus groups with community members across 10 PHCCs in Lebanon to explore SRH service provision and user experiences. The interviews were audio-recorded and transcribed verbatim. The authors used thematic analysis to analyze the data.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eTwo main themes emerged: (1) The multifaced impacts of the 2024 war in Lebanon on SRH service delivery in PHCCs (2) The adaptive efforts employed by PHCCs to respond to community needs. The 2024 war on Lebanon exposed major systemic vulnerabilities in PHC, including reduced access, staff shortages, and eroded trust in governance. Despite these challenges, PHCCs demonstrated adaptability through mobile outreach, workforce mobilization, and community needs assessment. Central to this resilience was the civic commitment of healthcare providers who sustained SRH services amid severe strain. However, persistent service disruptions highlight the limits of individual dedication without broader system support.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe study underscores the need to institutionalize PHCC\u0026rsquo;s adaptive responses and support healthcare providers\u0026rsquo; resilience and civic engagement during wartime. Expanding workforce capacity, mobile services, and community assessment are key to a more resilient health system.\u003c/p\u003e","manuscriptTitle":"Resilience amid conflict: A qualitative study of perspectives on the provision of and experience with Sexual and Reproductive health services during war","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 14:41:38","doi":"10.21203/rs.3.rs-8559503/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-13T16:38:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T19:09:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T02:47:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T14:05:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187780514224464975970191821381261195496","date":"2026-02-11T13:11:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223354078457739055186698861571762431990","date":"2026-02-10T09:27:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83540912594573077548620490230142390053","date":"2026-02-09T17:08:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T10:55:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-06T07:31:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-19T10:32:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T09:47:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-19T09:31:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"017ccbae-6dfe-4abc-8c69-4807bcc07fc1","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:01:23+00:00","versionOfRecord":{"articleIdentity":"rs-8559503","link":"https://doi.org/10.1186/s12913-026-14541-y","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-04-21 15:57:56","publishedOnDateReadable":"April 21st, 2026"},"versionCreatedAt":"2026-02-12 14:41:38","video":"","vorDoi":"10.1186/s12913-026-14541-y","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14541-y","workflowStages":[]},"version":"v1","identity":"rs-8559503","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8559503","identity":"rs-8559503","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}