Reframing spinal cord injury rehabilitation in fragile contexts: a multi-level systems framework for Lebanon

Background: Spinal cord injury (SCI) requires long-term, multidisciplinary rehabilitation to optimize functioning and participation. In fragile health systems, however, rehabilitation services are often fragmented, under-resourced, and inconsistently accessible. This Current Debate paper examines SCI rehabilitation in Lebanon as an example of how health system fragility constrains rehabilitation delivery and disability inclusion.Methods: Using an International Classification of Functioning, Disability and Health (ICF)-informed approach, we developed a multi-level conceptual framework through structured narrative synthesis of 35 studies, contextual analysis of 10 policy documents, and iterative expert interpretation by a multidisciplinary team. The framework integrates evidence from rehabilitation systems literature with contextual analysis of the Lebanese healthcare system; its structure and prioritization reflect the authors' interpretive synthesis and professional experience rather than a fully systematic or validated methodology.Results: The proposed framework is organized across three interconnected levels: macro-level governance and financing, meso-level health system organization and workforce capacity, and micro-level functioning, self-management, and community participation. Health system fragility is conceptualized as a cross-cutting determinant influencing rehabilitation access, continuity of care, implementation capacity, and long-term outcomes. We argue that rehabilitation in crisis-affected settings cannot rely solely on incremental service expansion. Instead, rehabilitation should be reframed as a systems-level, disability-inclusive intervention addressing structural and contextual determinants of functioning.Conclusion: The framework provides a context-sensitive starting point for strengthening rehabilitation systems in comparable low- and middle-income settings; its broader scalability and generalizability beyond Lebanon remain conceptual at this stage and require empirical and stakeholder validation.