Abstract
Introduction
Palliative care is often perceived as a secondary concern during times of crisis—a luxury to be deferred until systems recover. But what if we reimagined it as foundational? As a form of care that becomes even more essential when health systems are under siege?
Lebanon offers a powerful case study. Since 2019, the country has faced overlapping emergencies: an economic collapse, a global pandemic, a devastating explosion in its capital, and more recently, a renewed regional conflict. Each of these crises altered the health needs of the population and severely disrupted the health system. And yet, against the odds, palliative care did not only endure—but also expanded.
This commentary traces how one model of home-based palliative care, spearheaded by the Lebanese Center for Palliative Care—Balsam, responded and adapted through adversity. We highlight the national advocacy efforts that emerged in parallel, gradually shaping policy and expanding access. Together, they form a powerful illustration of how palliative care can become not just a service but also a sign of resilience and a form of resistance.
A blended model rooted in community
Palliative care in Lebanon was still considered in its infancy as late as 2007, with limited public awareness, underdeveloped legislation, and nascent training programs. 1 It was in this evolving environment that Balsam emerged. Founded in 2010 by a family physician who saw her patients’ needs go unmet as they approached the end of life, Balsam began as a modest initiative, as the very first palliative care service in Lebanon. 2 Operating from a small office with two part-time nurses, a volunteer pharmacist, and a volunteer psychologist, the team attended to just six patients in its first year. By year 3, the patient load had grown to 50. Today, Balsam provides care for over 300 patients annually. 3
Balsam is now staffed by a combination of full-time and part-time staff and its team has expanded into an interdisciplinary unit that includes physicians, nurses, advanced practice nurses, a social worker, and administrative personnel. 2 Services are offered free of charge and delivered at home.
While the Lebanese model draws inspiration from both the French Mobile Teams (EMSP) 4 and North American hospice systems,5,6 it offers distinct and often superior advantages in fragile settings. Unlike the French EMSP model, which is consultative, limited to weekday hours, and restricted to offering clinical recommendations rather than assuming care, Balsam provides direct, continuous, and comprehensive support, 24 h a day, 7 days a week. This includes a dedicated telephone line through which patients and families can reach their assigned nurse at any time, including an on-call nurse available during nights and weekends. The model also incorporates planned in-person visits tailored to acuity, scheduled follow-up phone calls, and the capacity for emergency home visits, including overnight or weekend interventions when needed. The team manages prescriptions, treatment modifications, and care coordination, ensuring medical and logistical continuity. Unlike the system in the United States, access is not conditioned on a prognosis of 6 months or less and a decision to forego curative treatment. There is no disruptive transition to a new team at the end of life: the same team follows the patient throughout, fostering consistency, trust, and continuity. This model integrates medical, emotional, and social care with remarkable flexibility, cultural sensitivity, and strong caregiver support and training. Crucially, it avoids the insurance-driven eligibility barriers of US hospice care. Functioning without public funding, it relies on community donations, charity events, and support from patients’ families—generating both financial vulnerability and extraordinary local ownership.
As Balsam is independent from any hospital, coordination is essential. 7 For patients not yet known to the team, Memorandums of Understanding with nearby facilities enable smooth transitions: upon discharge, the hospital’s palliative team shares a detailed report and remains available for follow-up. For patients already followed by Balsam, weekly updates are sent to their referring physicians, and any necessary hospitalizations occur under their care. This two-way communication ensures continuity and reduces the burden on patients and families.
These features make the Lebanese model not only viable in crisis contexts but also remarkably well suited to a wide range of settings beyond (Table 1).
Comparative overview of palliative care models in France, Lebanon, and North America.
Sentences
Crisis as catalyst: How the model adapted
From 2019 onward, Lebanon has faced a series of overlapping crises. Each crisis tested the system’s capacity to function. Each also triggered new forms of adaptation, gradually adding new layers to the model and making it more complete.
2019: Financial collapse
Lebanon’s banking system imploded, and with it, access to essential medical supplies. The national currency lost over 90% of its value. Pharmacies ran dry, and price inflation made even basic care unaffordable. Healthcare workers emigrated en masse. For home-based palliative care service providers, this meant caring for patients who were more vulnerable with less resources including limited medications and an overextended staff.
In response, practical, grassroots solutions were developed to ensure that care was maintained. Lebanese expats established an informal medication donation network to deliver medications to local NGOs. 8 Suitcases filled with essential medications began arriving from abroad and were distributed according to needs. At the same time, Balsam expanded a medication recycling system, allowing the team to collect unused medications from discharged or deceased patients and redistribute them to others in need. 9 These grassroots solutions preserved a minimal but meaningful level of care, particularly for symptom control.
Opioids shortages posed a major challenge. Even before the crisis, Lebanon’s opioid options were limited, with no methadone, hydromorphone, or immediate-release morphine in liquid, granule, or lollipop formulations. As the situation worsened, opioid access became a daily struggle. In response, Balsam took on a leading advocacy role, working with the Ministry of Public Health and a local pharmaceutical company to produce immediate-release morphine domestically and make it available at low cost, which marked a critical step in improving access to essential pain relief. 10
2020: COVID-19 pandemic
Just months later, the pandemic brought national lockdowns and travel bans. Home visits became nearly impossible. Hospitals were overwhelmed and inaccessible. Personal protective equipment was scarce. Family caregivers, often untrained, were left to manage alone.
Balsam rapidly scaled up its existing distance support program which had been originally developed to support patients living in rural areas and remote villages. 11 During the pandemic, this telephone-based program turned into a comprehensive telemedicine system. The team also prepared and distributed emergency medication kits containing essentials like morphine, midazolam, and antiseizure medications, allowing caregivers to manage symptoms at home. 12 Balsam provided caregiver training, as families received clear, accessible instructions—in-person or via video—on how to administer medications, monitor symptoms, and respond to clinical changes, with a return demonstration by video to ensure understanding. These interventions empowered family caregivers and enabled patients to remain in their homes, in familiar surroundings, even during peak lockdown periods. 13
August 2020: Beirut port explosion
The explosion devastated much of the capital’s medical infrastructure. More than 200 were killed, thousands injured, tens of thousands displaced, and several hospitals damaged or destroyed. Like many, Balsam’s operations were immediately affected. Medications were lost, team members were traumatized, some were displaced and coordination of care was nearly impossible.
This time, what was needed wasn’t just medication or protocols—it was support. The team needed logistical and emotional support to keep providing care at a time of extreme uncertainty and vulnerability.
In response, the Balsam International Support Initiative was launched.13,14 This virtual collaboration brought together clinicians from top tier institutions around the world to join the Balsam team in their weekly virtual interdisciplinary team meetings—offering clinical expertise, solidarity, and validation. During this period, the organization also expanded its international education program. Team members were supported to train abroad, gaining advanced expertise, and renewed perspective. In parallel, Balsam collaborated with international partners to develop training programs for other countries in need, sharing the lessons learned from delivering palliative care in times of crisis. 15
This approach not only allowed Balsam to share its model internationally but also to gain visibility, recognition, and a voice within the global palliative care community.
2024: Regional war and displacement
In late 2024, Lebanon was once again plunged into crisis—this time due to escalating regional conflict and widespread displacement. The healthcare system, already fragile, was further destabilized. Hospitals, ambulances, and emergency rescue workers were bombed. Those who were not bombed were overwhelmed. Access routes were blocked, and entire communities were uprooted. For many, immediate survival replaced access to medical care as the primary concern.
This was the ultimate test to the Lebanese model. Patients were suddenly dispersed, many without access to their medications, medical records, or usual caregivers. Road closures, power outages, and communication blackouts made even the most basic coordination extraordinarily difficult. Team members themselves were not spared: several faced direct threats to their safety, and some were forced to evacuate their own homes for extended periods of time. Amid these conditions, Balsam prioritized continuity of care for those who needed it most. When possible, the team visited patients in the areas where they had been displaced, including in temporary shelters. In addition, this time, the response did not rely on emergency improvisation. The team combined its telemedicine tools, emergency medication kits, caregiver training systems, and international supply channels to ensure continuity of care.
Despite the immense challenges to the national healthcare system, care continued. Not only because the system held—but because the model had been designed to function even in its absence.
Beyond survival: Signs of growth
Despite the challenges of major national and regional crises, Lebanon’s palliative care sector has continued to grow—marked by increased demand and utilization, improved patient access. During this same period, Lebanon witnessed the emergence of new programs and services including pediatric care delivery 3 and fees coverage thanks to a partnership with the Children’s Cancer Center of Lebanon, 15 the formation of national professional associations, and key policy advances in training, reimbursement, and medication access16,17 (Figure 1).
Timeline of palliative care development in Lebanon (2000–2025).
Each of these milestones represents a step toward sustainability.
The advocacy behind the model
In the absence of centralized leadership or dedicated funding, advancing palliative care in Lebanon required clinicians to become advocates, educators, and system designers.
Alongside the clinical care, a parallel movement at the policy level was unfolding. The same clinicians delivering home-based palliative care were also advocating with policy makers, drafting policies, training colleagues, and participating in national working groups.
These efforts led to critical national recognitions: official medical specialty status, integration into national health strategies, and reimbursement policy shifts.16,17 These changes were the result of a decade-long campaign to make palliative care not just available, but visible, legitimate, and embedded in Lebanon’s health framework.
Lessons from Lebanon
Lebanon’s palliative care journey, forged through crises, offers critical insights for other fragile health systems.
Several key lessons stand out:
Crisis accelerates innovation—when systems are flexible
Balsam’s rapid shift to telemedicine, medication recycling, and caregiver training was born out of necessity. In a disrupted environment, rigid systems fail; adaptable ones evolve.
Telehealth and emergency preparedness are essential—not optional
The ability to reach patients remotely and equip families with emergency kits became the foundation for maintaining care in the absence of physical access.
Community-based care can bridge the gap when healthcare systems collapse
By rooting care in homes, families, and local networks, the Lebanese model reduced dependence on centralized systems and kept services running when hospitals could not meet the needs of the population.
Caregiver empowerment multiplies capacity
When resources were limited and patient access was challenging, trained caregivers became frontline providers. Their role was not auxiliary—it was central. Providing caregivers with the support and skills to care for family members at home was both empowering and healing. This redistribution of responsibility and shifting of tasks made the model more resilient.
International solidarity sustains both care quality and morale
Strategic international partnership and collaboration proved vital. These connections offered more than expertise—they offered validation, presence, perspective, and hope.
Conclusion
Lebanon’s palliative care story is not one of perfect systems; it is a story of improvisation, and adaptation through commitment and conviction. The model did not survive despite the crises; it was shaped by them. In a region where trauma, crises, and instability have become a part of reality, this model has offered something remarkably rare: continuity, growth, and care.
For fragile health systems, Lebanon provides a roadmap for resilience. For stronger systems, it offers a chance to reflect on how flexibility, community, and moral clarity might be just as important as infrastructure.
This is not merely a story of survival—it is a demonstration of how care, when rooted in solidarity and built to bend, can not only persist, but lead.
Footnotes
Acknowledgements
The authors wish to acknowledge the remarkable contribution of Balsam’s team and donors over the past 15 years. Their sustained commitment has been instrumental in shaping palliative care in Lebanon and demonstrating what is possible through steady, community-rooted engagement.
Ethical considerations
This article does not contain any studies with human or animal participants; therefore, ethics approval is not required.
Author contributions
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.