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.