'This is not our mandate': a qualitative case study on the resilience of a humanitarian health programme in Lebanon

Decision-making in humanitarian crises is rarely based on evidence and often constrained by uncertainty. Humanitarian health organizations such as the International Committee of the Red Cross (ICRC) operate in conflict settings, characterized by multi-layered, complex crises. Understanding how their decision-making processes influence the continuity of humanitarian health operations can provide insight to inform the development of resilience-oriented interventions in these contexts. We conducted a qualitative case study on the ICRC health operations in Lebanon, with the objective of exploring the elements shaping decision-making and understanding how different organizational factors influenced absorptive, adaptive, and transformative capacities in response to disruptive events in a hospital programme. Twenty semi-structured interviews were conducted with ICRC decision makers. Data were analysed through qualitative content analysis. Three themes emerged, describing how decisions were shaped by people and the trust they were able to develop in internal and external relationships; political considerations often overriding public health priorities; and unresolved tensions around the institutional identity and mandate. Resilience capacities were sustained by different factors. Absorptive capacities were primarily sustained by the availability of material resources, as well as operational contingency plans allowing for flexibility in their allocation. Adaptive capacities were strengthened by cohesive social networks among committed team members. Transformative capacities were limited, promoted by the ability to innovate while at the same time constrained by a rigid organizational culture. Our findings suggest that health governance and local leadership need to be strengthened to enable transformative capacities within humanitarian organizations. Through this, accountability and legitimacy can be enhanced, especially amid growing critiques and dramatically contracting funding.