A liminal health system: Exploring the resilience strategies of healthcare providers and communities along the Thailand-Myanmar border

The Thailand-Myanmar border region has experienced sustained population displacement due to decades of conflict and insecurity. The 2021 military coup in Myanmar and subsequent violence significantly intensified these movements, displacing nearly 4.1 million individuals. In response, a diverse network of non-state health actors has emerged on both sides of the border, supplementing - and, in many instances, substituting for - national health systems. This study employs a qualitative design to analyze the configuration of formal and informal health system arrangements operating along and across the border. Through a participatory process comprising a stakeholder workshop and 32 key informant interviews, the research uncovers the resilience strategies and capacities that underpin the system’s response to evolving challenges. Findings reveal the emergence of a dynamic health system characterized by fluid movement of patients, supplies, personnel and financing around the border. We conceptualize this as a ‘liminal health system’. This analysis explores how liminal characteristics have enabled absorptive, adaptive and transformative strategies that bolster resilience in service delivery, health governance, procurement, funding, and training and deployment of health workers. Community members exercise substantial agency in effectively navigating care, leveraging the liminal structure and multiplicity of providers available on both sides of the border, even amidst extremely challenging circumstances and complex barriers to access healthcare. Nevertheless, rising health needs, financial constraints and legal uncertainty increasingly jeopardize the sustainability and resilience of this health system.