Lebanon, as described in the source, is a fragile and shock-prone setting that has faced multiple, overlapping shocks including an economic collapse, the COVID-19 pandemic, and episodes of armed conflict. These shocks compounded pre-existing fragmentation in the health system and weakened central authority, drawing attention to the need for stronger sub-national health governance. The pilot Municipal Health Committee (MHC) in Majdal Anjar was established to test a model of local governance intended to enhance health system resilience through municipal-level structures.
The initiative was evaluated using a participatory action research approach combined with an implementation research design. Qualitative data collection comprised process documentation, field observations, six critical reflective meetings, and nine key informant interviews. Analysis applied the TAPIC framework to examine governance across five domains: transparency, accountability, participation, integrity, and capacity. The research team also provided sustained mentorship to the MHC during implementation, which was part of the programme design and implementation support.
The TAPIC framework guided structured analysis of the MHC's functioning. Each domain—transparency, accountability, participation, integrity, and capacity—was used as a lens to interpret qualitative data from observations, meeting records and interviews. This allowed the researchers to identify practices that supported good governance as well as persistent barriers rooted in the local political economy and institutional context.
A key finding was that the MHC enhanced inclusive participation at the municipal level. By involving a broader set of stakeholders in decision-making, the committee helped build local legitimacy for health-related actions and strengthened trust between citizens, municipal authorities, and health actors. Increased participation was reported as a central mechanism through which the MHC contributed to more accountable and accepted local health governance.
The committee progressively embedded transparency into its operations and moved toward evidence-informed decision-making. This included efforts to generate and use local health data to guide priorities and interventions. Embedding data use and transparent processes helped align decisions with local needs and improved the perceived credibility of the MHC among stakeholders.
Despite advances in participation and transparency, the MHC faced persistent challenges in the domains of accountability and integrity. The research identified political interference and patronage networks as ongoing threats to institutional integrity and to compliance with formulated ideals and procedures. Accountability mechanisms were weakly enforceable within the local context, which undermined the committee's ability to ensure consistent adherence to governance norms. Financial precarity at the municipal level further constrained the enforceability and sustainability of accountability systems.
Sustained mentorship provided by the research team strengthened governance practices and improved the MHC's capacity to implement its mandate. Capacity development—both technical and procedural—was necessary for the committee to operationalize transparency and evidence-based decision-making. The evaluation highlighted mentorship and ongoing support as important enablers of functional local governance in a fragile context.
The study concluded that municipal committees such as the MHC can strengthen equity and health system resilience in fragile settings by creating inclusive, evidence-informed processes that improve local legitimacy and trust. However, sustainability of these committees depends on several interrelated conditions: genuine local ownership, protection of committee functions from political capture, adequate and stable financing, enforceable accountability mechanisms, and continued capacity development. Without attention to these factors, the gains in participation and transparency remain vulnerable to reversal.
The evaluation of the Majdal Anjar MHC demonstrates that municipal-level governance structures can play a constructive role in fragile and shock-prone settings by enhancing participation, embedding transparency, and promoting evidence-informed decisions. At the same time, entrenched political dynamics, patronage, weak accountability enforcement, and financial precarity limit institutional integrity and sustainability. The research underlines the importance of mentorship and capacity building and emphasizes that long-term success requires local ownership and functional autonomy from political interference.
(Conflict of interest: None declared in the source.)