Abstract for: Vaccination delivery system responses to compound shocks: multi-level pathways influencing system resilience in Lebanon
Current data show that many of the countries worldwide with the lowest coverage for childhood immunisations are those affected by humanitarian crisis. In this paper, we developed a causal loop diagram (CLD) to describe the multi-level effects of shocks on childhood vaccination uptake in Lebanon, in the face of a compound crisis featuring refugee arrivals from Syria, an economic crisis, and COVID-19. The CLD was developed using purposive text analysis of transcripts from interviews with 38 key informants from different levels in the public vaccination delivery system in Lebanon from February 2020-January 2022. This was used to generate a series of individual participant CLDs which were then merged using a stepwise process. The CLD was validated using a reserve set of interviews. Shock effects were seen at multiple levels although major effects of refugee arrivals were seen mainly in policy responses to increase service supply in anticipation of escalating demand, which the economic crisis contributed to significant changes in demand dynamics for childhood vaccination across refugee and host community populations alike. We identified delays affecting system responsiveness at all levels, especially for human resource, funding mobilisation and viable vaccine dose delivery to facility level.