Lebanon’s primary care centers were very good at reporting disease, yet no center reported a formal way to systematically address community concerns. That contrast is the central surprise of this preparedness study. The COVID-19 pandemic exposed critical gaps in health system preparedness worldwide, particularly within primary health care.

In Lebanon, disparities between rural and urban and INGO-supported and non-INGO-supported primary health care centers may affect the ability of centers to respond to future pandemics. The Health Emergency Preparedness, Response, and Resilience framework builds on five core pillars, commonly called the five Cs.

Collaborative surveillance focuses on timely identification and prompt action through an integrated approach with surveillance teams, laboratory networks, and event-based monitoring. Community protection emphasizes social and financial protection, risk communication, and community-based interventions for trust building and the ability to absorb shocks during crises.

Safe and scalable care includes planning, infection prevention and control, essential services, emergency services, case management, training, and infrastructure. Access to countermeasures includes equitable vaccine accessibility, diagnostics, treatment, and a robust supply chain, while emergency coordination establishes command, control, and accountability.

Reliable information on governance, capacity, material resources, and human resources in rural, urban, INGO-supported, and non-INGO-supported centers remained unavailable in Lebanon. The study goes beyond descriptions of pandemic response, hospital-based preparedness assessment, and country-level HEPR reviews to analyze preparedness capacity in primary health care centers.

Using the framework on all primary health care facilities provides concrete information about preparedness within different domains and demonstrates systemic trends missed at higher levels of analysis. The study therefore conducted a health facility survey in Lebanon’s primary health care centers to identify preparedness for a subsequent pandemic.

The research assesses preparedness of primary health care centers within Lebanon’s Ministry of Public Health network to respond to future pandemics and identify structural and non-structural gaps. It collects systematic information on pandemic preparedness at the primary health care level in both rural and urban areas using the five Cs domains in the HEPR framework.

The official Ministry of Public Health registry at the end of twenty twenty-three listed 209 primary health care centers, and 185 met the predefined eligibility criteria. The eligible centers had to have a Ministry of Public Health contract through the end of twenty twenty-three, provide five routine primary health care services for at least three years, and use PHENICS.

Out of the 185 eligible centers, 169 responses were received, for a response rate of 91.4 percent. An INGO-supported center was defined as receiving active support from one or more international non-governmental organizations during data collection in May twenty twenty-five.

Data collection took place in May twenty twenty-five, using an English and Arabic electronic Google Form survey sent to 185 eligible primary health care centers. The center director completed the survey, while other health care workers completed sections related to their areas of expertise, such as drugs or program management.

Potential contributors included center directors or managers, physicians, nurses, midwives, and pharmacists. The primary health care pandemic health facility assessment tool was developed and validated through two focus group discussions with primary health care stakeholders and one in-depth interview with the former Lebanese Minister of Public Health.

The process ensured contextualization to Lebanon and incorporated lessons learned from previous outbreaks and pandemics, while expert consultations and informal piloting assessed clarity, relevance, completeness, feasibility, and wording. The five HEPR domains were retained without modification to preserve conceptual alignment with the WHO framework.

Indicators were screened for relevance, measurability, and applicability to functions that primary health care centers could directly implement, influence, or report. The resulting tool represents a facility-level operationalization of HEPR rather than a modification of the underlying HEPR conceptual framework.

The survey tool was designed as a descriptive facility-level assessment instrument to capture preparedness capacities rather than generate a composite score. The indicators were organized according to five HEPR domains: collaborative surveillance, community protection, safe and scalable care, access to countermeasures, and emergency coordination.

Each domain included indicators used to assess preparedness at the facility level. Unadjusted bivariate analyses assessed associations between rural versus urban setting and INGO-supported versus non-INGO-supported status across preparedness indicators.

Pearson’s chi-square test was used for categorical variables, and Fisher’s exact test was used when chi-square assumptions were not met. For selected binary comparisons, unadjusted odds ratios with 95 percent confidence intervals were calculated as measures of effect size.

For continuous variables, the non-parametric Mann-Whitney test was used because the variables were not normally distributed. All statistical tests were two-tailed, with an alpha level of zero point zero five, and a p-value below zero point zero five was considered statistically significant.

Because the study was exploratory, no formal adjustment for multiple comparisons was applied. The p-values were therefore interpreted as exploratory, especially those close to the zero point zero five threshold, with emphasis on overall patterns rather than isolated statistically significant associations.

A total of 169 centers, or 91.4 percent, filled out the survey, and centers were distributed across rural and urban areas and between INGO-supported and non-INGO-supported groups. Most centers were owned by non-governmental organizations, at 79.3 percent, or 134 centers, while municipalities owned 14.8 percent, or 25 centers.

Looking down the governorate rows, the reported frequencies range from three centers in Keserwan-Jbeil to thirty-six in North, with Akkar and Mount Lebanon each at thirty-two. In the final section, the supported and unsupported groups are nearly balanced: the table shows a difference of three centers, corresponding to a one-point-eight percentage-point gap.

The findings show strong overall preparedness in core collaborative surveillance functions. Most centers reported participation in DHIS2, PHENICS, and MERA, timely reporting of priority diseases within required national timelines, established laboratory network access, and adequate knowledge of communicable diseases.

Gaps remained in decentralized detection capacity and local surveillance coordination. The main surveillance gaps concerned the availability of rapid diagnostic tests and linkage and communication with district epidemiology focal persons.

In the table’s rightmost n-percent column, the broader infrastructure indicators are more consistently reported: laboratory network availability is listed for 154 of 169 facilities, and staff knowledge for 166. By contrast, the system-specific entries range from 36 facilities reporting MERA to 127 reporting PHENICS, with DHIS2 at 104.

Community engagement and protection showed mixed levels of preparedness across the primary health care centers. Most centers reported conducting community engagement activities, indicating widespread interaction with local communities. Community health workers were present in 70.4 percent of facilities, but risk communication was less consistently implemented and a structured two-way feedback mechanism was absent across all centers.

Primary health care centers demonstrated foundational capacity to deliver safe and scalable care through core clinical services, essential workforce cadres, and basic infrastructure. Most centers reported essential services such as maternal and child health and chronic disease management, alongside infection prevention and control measures and access to WASH resources.

Isolation capacity, sterilization rooms, and backup electricity sources were present in many centers, though not uniformly. Emergency services case management showed vaccination access at 99.4 percent, triage implementation at 79.3 percent, and clinical protocols at 82.8 percent.

Workforce availability was generally high across core cadres, but only 55 percent of staff received emergency training. Primary health care centers reported broad availability of essential countermeasures needed for emergency preparedness and continuity of care.

Most centers reported stocks of vaccines, acute medications, and chronic disease medications, along with high availability of disinfectants and personal protective equipment. Most centers also reported access to diagnostic services through established laboratory networks.

Emergency coordination structures and processes were implemented inconsistently across primary health care centers. Emergency planning remained limited: 53.8 percent of centers reported having an emergency plan, and 52.1 percent reported that plans were reviewed regularly.

Approximately half of centers reported an emergency task force and an identified incident commander or emergency lead. Plans for mobilizing or recruiting additional staff to support surge capacity were reported by only a subset of centers. Most centers reported limited financial preparedness for emergency response, with fewer than one-quarter indicating adequate financial resources or access to a sustainable source of funding.

These patterns were consistent regardless of geographic setting or support status, with no statistically significant differences observed. In the n-percent column, the adequacy item shows thirty-four centers marked “Yes” and one hundred thirty-five marked “No.” The sustainable-funding item follows a similar split, with thirty-eight “Yes” responses and one hundred thirty-one “No” responses, making the two indicators closely aligned in the table.

The assessment reveals uneven and operationally driven preparedness across Lebanon’s primary health care network. Important strengths included widespread adoption of PHENICS and DHIS2 and sustained disease surveillance through laboratory networks, while persistent gaps remained across key preparedness domains.

The most pronounced gaps involved emergency coordination, risk communication and community engagement, and safe and scalable care. Although INGO-supported centers showed stronger workforce capacity and availability of essential services, those advantages did not translate into stronger preparedness planning, coordination mechanisms, or sustainable financing.

The preparedness profile reflects adaptive service delivery rather than institutionalized system preparedness, and the lack of strong rural-urban differences suggests system-wide constraints rather than geographic disparities. The policy priority is to strengthen connections across domains through interoperable surveillance-to-action linkages, institutionalized risk communication and community engagement with feedback loops, workforce models, standardized coordination mechanisms, and sustainable financing.

Lebanon must invest in domestic financing mechanisms and local governance capabilities that reduce reliance on external actors, because operational strengths do not necessarily translate into institutional preparedness. Future preparedness surveys would benefit from standardized indicators on data quality and health workforce wellbeing alongside facility-level service and infrastructure measures.

The online self-administered survey reduced the possibility of clarifying questions and restricted the depth of responses, although Field Coordinators were available for inquiries. Social desirability bias could not be eliminated because some respondents may have answered favorably, considering the researcher’s role in the Ministry of Public Health primary health care department.

The findings reflect primary health care facility-level preparedness rather than the entire health system, because the HEPR framework did not encompass broader system-level aspects such as cross-sectoral surveillance or national-level emergency coordination. Multiple bivariate comparisons without formal adjustment for multiple testing may increase type one error, so statistically significant findings close to zero point zero five should be interpreted cautiously and considered exploratory.

Because the analyses were unadjusted and bivariate, observed associations may be influenced by facility size, geographic location, ownership, and INGO support status, and the cross-sectional design cannot establish causality. Future studies should use multivariable analyses to assess these relationships while accounting for potential confounders.

Lebanon’s primary care network had operational strengths in surveillance and countermeasures, but preparedness was not fully institutionalized: emergency coordination, communication, training, and financing remained major gaps.