Resilience in Fragility: Community and Health System Responses to COVID-19 in Sierra Leone, Liberia, Lebanon, and Gaza

Read this Social Science & Medicine – Health Systems paper here [opens new tab]

This paper examines the experiences and coping strategies of health systems and communities in response to the COVID-19 pandemic across four fragile and shock-prone settings: Liberia, Sierra Leone, Lebanon, and Gaza. While much existing literature focuses on high-income countries, there is limited comparative research on low- and middle-income countries, particularly in the context of previous health crises like Ebola, or in settings affected by conflict and displacement. Using a cross-country approach, the paper aims to document stressors, coping mechanisms, and response strategies during the COVID-19 pandemic, highlighting the interplay between health systems and communities.

This study highlights that while government responses often followed global norms, their effectiveness was shaped by structural constraints, inequities in access, and the realities of daily life in fragile settings. Communities frequently encountered a dissonance between official directives and what was feasible in practice — whether due to lack of water, crowded living conditions, or the absence of livelihood support. At the same time, community health workers, local organisations, and informal coping strategies provided critical bridges of trust and resilience. The findings suggest that future preparedness must go beyond technical interventions, embedding equity, transparency, and community engagement as central pillars of response in order to align measures with lived realities and strengthen resilience in contexts of overlapping crises.

Suggested citation

Horncastle M, Dakessian A, Zaizay Z, Kollie K, Wurie H, Loffreda G, Noubani A, Saleh S, Jamal Z, Albaik S, Elkhatib Z, Dean L, Theobald S, Witter S, Diaconu K, Resilience in Fragility: Community and Health System Responses to COVID-19 in Sierra Leone, Liberia, Lebanon, and Gaza, SSM – Health Systems (2026) doi.org/10.1016/j.ssmhs.2026.100198.

Further information

This paper is part of a Social Science and Medicine – Health Systems special edition Developing health systems resilience in fragile and shock-prone settings: Findings from the ReBUILD for Resilience Consortium [opens new tab]

Image: COVID-19 immunisations in Sierra Leone. WHO/Saffea Gborie – view here [opens new tab]