Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency UNRWA and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. ...We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. ...