Twelve female and eight male interviewees participated. The majority of the participants were either managing directors or project managers of Swiss NGOs having operations in low- and middle- income countries. Two of the interviewees were based in the partner country as project managers, and the remaining participants were based in Switzerland having close and regular contact with their respective in-country partners. Most organisations have ongoing project engagements in Africa, whilst a few of them oversee projects in Asia, Middle East, Eastern Europe, and South America. The primary target groups of the key informants’ organisations are summarised in Table 1.
Overview of key informants’ organisational primary target group(s)
Primary target group(s) of the NGO*
Women and pregnant mothers (4)
Health workers, veterinarians, midwives (12)
Youth and children (5)
People living with HIV/AIDS and LGBTQ (4)
Persons with disabilities (2)
Total priority target groups
|*multiple responses were possible
The results section presents key findings elucidating the practical experience and perspectives of Swiss-based NGOs supporting health systems in low- and middle- income countries. The results are categorised into the role of the governments, the role of the NGOs, and practical future steps for building health system resilience.
Governments: Governance And Responsibility
Health systems with strong ‘foundations of resilience’ may unleash greater attributes of resilience
The participants overall had a solid understanding of health system resilience based on their experience managing programmes and projects in low- and middle- income countries. When asked of the most critical component of resilience, the responses fit into one of the foundations of resilience that serve as inputs into the health system that would activate resilience attributes described in Grimm et al’s framework (15). As depicted in figure 1, among the five foundations, four were considered dominant for unleashing resilience attributes. ‘Change management,’ however, did not emerge as a key foundation from the interviews.
The first foundational element is ‘realigned relationships,’ which was seen to provide a strong basis of resilience at the system level. Establishing trust and collaborations across differences appeared in particular to offer a source of strength against all kinds of external shocks.
"But, these (external shocks) are not the biggest headaches as long as you have a good team and partnerships that are build on trust." (I03)
A participant stressed the importance of investing in the initial networking and building of connections as they form the foundation of solid working relationships that can overcome and counteract future shocks. These good working relationships on the ground were what enabled projects to proceed with minimal interference albeit wider contextual disruptions. The answer lies not in a hypothetical system, but in the people that own and carry out the vision of the projects.
"If you are really engaged with the technocrats on the ground who are still working in the health system, you can still achieve lots of your goals. So, I think the investments especially in the beginning, the investments into the networking and the building of the relationships are key to overcoming and counteracting those shocks which anyway you cannot influence. If a president dies, he dies, and of course there is a state of emergency and so on, but as long as you have good relationships on the ground, people are still willing to continue with the project because they believe in it, having a strong ownership." (I06)
Building trust, however, does not spring up organically; rather, it entails longstanding collaboration, a cadre of trained staff, an established organisational structure and most importantly a shared vision that stems from a collective sense of ownership.
"In order to establish the trust, you also need some structure, trained staff, you need a mindset to be able to go there and do that." (I15)
The second foundational element ‘foresight’ helps to see the importance of investing in long-term functional infrastructure, prioritising in human resource readiness, and focusing on overall health system strengthening. One participant pointed out that a functioning health system, which is not guaranteed in all countries, should take precedence over resilience building.
More important than having a specific disaster preparedness plan is obviously to strengthen the overall health system. Several participants underscored that a preventive approach to resilience is especially necessary in low- and middle- income settings, as the building of infrastructure, equipment, well-trained health workers and responsive communities take intentional investments to cultivate.
"to make it more resilient, I think it is less important to have a specific disaster preparedness, but rather to strengthen the health system as such.. It's not about once you have a crisis, then you need to react. You need to really strengthen the system before. Indeed a system with a sufficient number of infrastructure, equipment, medication, well-trained health workers, and community which is interacting well, is quite resilient." (I08)
The third foundational element ‘motivation’ when instilled at the community level builds community-based preparedness and resilience, a precondition for enabling health system resilience. One respondent explicitly depicted communities as the “drivers of the health system,” an indispensable gateway to project sustainability.
“Not only the perception of integration, of participation, on feedback mechanisms, but also as the driver of the health system. Communities are part of our common approaches and most of our projects acknowledge sustainability through communities." (I04)
In the context of failed or fragile states, strong community structures may serve as the sole source of continuous development and fill vacuums created by the lack of state governance. This was apparent in the case of one of the respondents working in Afghanistan where the solidarity from the communities abridged decision-making structures and facilitated resilience.
“Sometimes you could not work with the government, in the case of Taliban. Then, the development agency tries to build up the community structures and then strengthening them. They are still there and always there. Especially in times of crises they can easily be activated and there is a lot of solidarity and short decision-making structures and agile. This is a big factor when it comes to resilience of a community and of supporting the health system." (I06)
The fourth foundational element ‘emergency preparedness’ was best exhibited through financial investments and resource preparedness, vital prerequisites to activating resilience. Many highlighted that resources are the bedrock of any development work including that of resilience building. The consequence of financial gaps in fragile states that resulted in shortages of all basic needs were proven detrimental, exacerbating vulnerability to future shocks.
"If we look into some of the things they've done well, like investments in the adequate health service package in the health facilities, it always comes with some resources obviously. Finance gaps are critical and we see this in countries like Yemen, Somalia, Afghanistan and Iraq, where the gaps in terms of all basic needs, in terms of health are so massive" (I04)
There is always a trade-off, however, in investment decisions, which also applies in the case of investing in resilience. A respondent recommended that countries set aside a portion of their GDP dedicated to resilience, whether it takes the form of a social insurance or improved health coverage. Financial investments towards emergency preparedness and resilience building are undoubtedly a precondition for a strong foundation of resilience.
"So, in my point of view, it is a matter of money.. as there is always a trade-off in decisions. For instance, do we do less cancer treatment and invest in resilience?" (I01)
"(For resilience building I would advise the government) Make sure you have enough financial resources. 20% of your GDP? You need financial resources. The work to increase these resources and to decrease individual risks through social insurance system. Work towards universal health coverage and health insurance." (I08)
Key resilience attributes expected of national governments: ‘Integrate,’ ‘Adaptive,’ ‘Diverse’
The attribute to ‘integrate’ was shown to be one of the most significant characteristics of resilience expected of the national governments from the NGOs, followed by the attributes to be ‘adaptive’ and ‘diverse,’ as depicted in figure 2. The figure visualises the frequency of responses by the participants when asked about the most prominent feature of resilience expected of governments.
Most of the participants in one way or another emphasized how important it is to have a solid governance system and to have a government that exemplifies responsibility in responding to health system shocks. Governments were ultimately seen as duty bearers, and the sustainability of any project requires good governance to plan, invest, and anticipate future shocks.
"(to build resilience you need) good governance. Governments are the duty bearers and you can have shiny health infrastructure and train staff for a period of time but then if it's not sustained with good budget planning, good investment, good governance, then everything can fall apart quickly." (I20)
The NGOs expected the governments to assume a stronger coordination role to minimise duplication amongst external and internal partners, and to provide guidance based on the needs of the population. A respondent echoed that a badly equipped primary health care system often stems from an underlying fragility of governance, more so than from dilapidated infrastructures or ill-trained staff.
"What I often see what is lacking is a really strong coordination role of the government to make the best out of what is coming from the inside and outside. Often there is a lack of guidance to be honest. We have still issues where there are two organisations doing exactly the same work in the same region which is a waste of money. More guidance would also help in making the system more resilient." (I06)
Though many partner countries may not have foresight and long-term planning as strengths, they exhibited exceptional skills to be ‘adaptive,’ which was proven more vital in fragile contexts where the shocks are multiple and continuous. One participant described this ‘adaptive’ attribute as an attitude to change, switch gears and seek new ways to deal with the evolving situation when thorough planning is not possible.
"I think the attitude to be able to change, switch gears and to find new ways and to be creative somehow and to deal with situations where you can't plan everything, this resilience, that's a resort where i've learnt and still learn from Uganda." (I03)
Another respondent underscored that this attitude to be adaptive and flexible was a clear indication of resilience shown by the Haitians responding to the devastating earthquake in 2010. There was clear self-sufficiency to intervene even before any external help had access to the area. This improvisation is a clear indication of the ‘adaptive’ attribute of resilience.
"A part of resilience of the Haitian people is, they for me, they are the best at improvisation. They are very bad at preparation and foreseeing. They are very bad at anticipation. I remember when we had the floodings before the earthquake, immediately before and after the collapsed bridges, they have built up kiosks and you could get transports through the rivers. That's the way we could transport from one side to the other side. Thanks to this improvation. It was the same after the earthquake. Even without the help of external organisations, privately they have built up streets. Well, this is a positive side of resilience." (I05)
The third most prominent resilience attribute expected of the governments was to be ‘diverse,’ allowing care to extend to new and diverse needs arising from the crises. Endemic health problems, such as cholera and measles, forced governments to make difficult decisions between conflicting priorities. If the shock was substantial, the already scarce resources were redirected to dealing with the immediate crisis whilst leading to major disruptions in routine care.
"If you take the case of DRC, it's a clear example. Very recently we had Ebola now. But, even before we had other Ebola outbreaks. You could have seen that COVID was not seen as an issue because they had at the same time, cholera, Ebola, measles and other outbreaks. So for them, in terms of prioritisation, you will see that is difficult. (I04)
"What we noticed but our partners is that already scarce resources that were there are redirected then to COVID-19 sensitization, PPE and taken away by budget that you actually have for other purposes. This is something all partners experienced and noticed." (I15)
Health needs arising specifically due to the crisis, such as mental health issues, are often neglected and undervalued. In a resource-constrained setting, life-saving and treatment-based approaches crowd out equally key services such as trauma care and counselling services.
"I think the mental health systems are undervalued and understaffed. As global North, we are not prepared for the fall-out of the pandemic from a mental health aspect and when I think about that it's such a taboo even where it's much more available versus in low-income countries, it's very much relying on the informal networks. And that's something we are worried about. Take India as an example. Post traumatic stress disorder is a real thing and we're not sure whether the community health workers are equipped to be able to deal with that or even to see it within themselves." (I10)
Ngos: Perspectives And Roles In Resilience Building
The alignment of resilience with organisational priorities
As illustrated earlier in Table 1, each organisation has a distinct priority area of intervention and primary target groups, whether it be maternal and child health, HIV/AIDS, or people with disabilities. Nevertheless, over the years of implementation, the organisations realized the benefit of an overall health system strengthening approach to achieving their goals, which is why many of them have expanded their health programmes to take on a broader health system strengthening agenda. This meant an increased project investment towards training health workers, refurbishing key health infrastructure, and restocking supply of medicines as such.
"it has to do with that we really expanded much more into health system strengthening that we have to look at it holistically from all sides. That was why it was a logical step to introduce this aspect of resilience and even to highlight it. We wanted to highlight it as a cross-cutting issue so that we actively work on it." (I06)
In the same light, more NGOs started to view resilience as a cross-cutting issue. This has shifted their disease-specific perspective towards a more holistic, health system strengthening approach to programming, enabling multiple sectors working collaboratively to weave resilience into their respective programmes.
"For us, but this is only recently with the new strategy since 2020, we look at resilience as a cross-cutting issue. We look at resilience when it comes to the engagements with the communities. But we haven't looked at it from a purely health system resilience aspect. That's also anyway a fairly new perspective on health system." (I06)
Meanwhile, one NGO regarded resilience as an ultimate goal, even specified within the health results chain of its programmes with an underlying logic that “healthy people contribute to resilience.” This impact-driven approach to resilience brought about a fresh perspective that disaster risk management serves the purpose to build resilience for all.
"The ultimate impact from the disaster risk management is that the resilience of the communities is improved, and the ultimate impact of our health result chain is that the health state of the people are improved. If you look at resilience and the resilience that we use as part of the resilience framework of the federation, is that healthy people contribute to resilience. So, actually the ultimate impact should be resilience for everybody." (I01)
NGOs’ unique role for resilience building: knowledge exchange and science for impact
The NGOs believed that albeit their different views on resilience within their organisations, they nevertheless have a unique role in building resilience of their partner countries’ health systems thereby referring to the areas of knowledge exchange and innovations. Almost all participants believed that capacity building at both organisational and individual levels would be one of the best investments towards fostering resilience. There were already significant contributions from the NGOs through skills trainings of frontline workers and medical professionals. A participant believed that future investments should also prioritise in strengthening the capacity building of frontline workers and the communities in particular to equip resilience on the ground where the NGOs may draw on their strengths.
"We still have some interesting things to bring is really the work at the community level and really building the capacities in terms of delivering first response at the community level, training community leaders and key community representatives with the basic package of first aid and mental health support. It doesn't necessarily need to be super technical. We can identify some people with basic backgrounds in social work or even first aid is accessible to anyone really. So that's really where we are trying to make a difference." (I20)
One NGO pointed out that improving the capacity of the ministry of health itself and better coordinating with the ministry of education for licensing can also have an enormous effect in facilitating policy dialogue and enhancing the training quality of the entire system. The expected impact would be at a wider level as opposed to that from vertical programmes.
"(what NGOs can do) Supporting people from far and really strengthening the capacity. I think NGOs can change enormously the way they work and absolutely collaborate with the ministry of health to improve the capacity. There are gaps everywhere, from medical point of view, psychological. I think NGOs should really specialise on these and supporting ministry of health rather than vertical programmes. And they could really reinforce the capacity of the central level and not only peripherical level. The NGOs should be involved in changing the current training and dialoguing with the ministry of health that the current initial training for health providers are improved." (I09)
An additional role NGOs may take on is to facilitate dialogue and knowledge exchange not only from North to South, but also from South to South, where good practices can be mutually shared.
This is what I see a bit as our role that when we have a good experience in Chad, we try to also make use of it and have this exchange (South South exchange), to facilitate the knowledge exchange." (I06)
As most NGOs focused on a priority area of intervention, whether it be women and children’s health, gender violence, or HIV/AIDS, the NGOs were able to see issues from multiple angles, working with various ministries and partners to have their interventions benefit from a cross-sectoral approach. Resilience in most cases provided a link to connecting these different sectors.
"Looking a bit beyond the health system. Women for example have been affected by fistula. They are not just physically affected but also psychologically and often they are isolated. Even if they are cured from the fistula, they still are super marginalised as they have been an outcast. So, we are also supporting with income generating activities to strengthen their opportunities with financial independence, which also in turn strengthen their resilience towards shocks in the future." (I06)
Finally, the NGOs can support their partner countries to leverage science for impact. As the demand for adopting new digital tools and innovations is growing, one NGO interviewed has started introducing new mobile applications to improve children’s medical diagnosis and treatment, strengthening the overall primary health care system in rural West Africa (20). In addition, innovative training modules have been adopted for health workers in order to adapt to the evolving context as well. This emerging need for digital approaches such as teleconsultations or telemedicine was most evident during the COVID-19 pandemic when travel restrictions compelled all exchanges to switch to virtual means. It will not work for all contexts, but the NGOs may be able to fund relevant technological and innovation gaps arising in their partner countries to maximise impact.
"The entering of digitalisation to health workforce training, duel training models, how to use them for health workforce, that's for us the core element." (I08)
Future Outlook: Practical Steps Towards Resilience Building
Complex nature of future shocks
The shocks experienced by the low- and middle- income countries were no longer a disconnected, one-time event, but a series of complex, interconnected shocks that are increasing in both frequency and intensity. The nature of shocks were classified as political shocks and protracted conflicts, natural disasters and climate change, pandemics or epidemics, and financial crisis or economic shocks.
"But the Sahel being so volatile with so many factors of stress and shock interconnecting, it's quite difficult to achieve impact..and most importantly for us, how it (conflicts) interacts with the prevalence of natural disasters in an area and just having exacerbate vulnerabilities where we work. So, the combination of these factors together..But at the same time, we have to acknowledge that this (epidemics/pandemics) is also a risk that is going to continue and it is linked with environmental degradation. We know that environmental degradation may lead to more health issues and epidemics." (I20)
The most distressing aspect of all these shocks were that either multiple shocks were occurring in a country simultaneously or a shock has led to further shocks, aggravating contextual vulnerabilities and diminishing the impact of the NGOs’ interventions. For instance, a participant described how the financial crisis in Zimbabwe led to political and social unrests, which brought about a total shutdown of the health care system. Then the arrival of the COVID-19 pandemic and massive lockdowns thereafter, further depreciated the value of the currency. In many contexts, the root causes of the shocks were often interconnected and the NGOs found this a severe bottleneck to achieving impact. Hence, it appeared necessary for the NGOs to take a holistic approach beyond the health sector to understanding the shocks and stresses in the system in order to better interrogate resilience.
"It was a whole cascade of things. There was the currency collapsing, political distress and strikes of course, people who got very upset…That (economic crash) was 2019 and then corona came. It was really bad. You had a very fragile system, and then you had the economic collapse, then you had strikes, so literally there were no people in the hospitals anymore, in the pharmacies. If people had problems, public health was not existing anymore. Then came corona and massive lockdowns, the value of the money was down." (I11)
Strongest determinant of resilience: investing in context-based long-term health system hardware and software
According to the participants, the strongest determinant of resilience in the health system was the degree of investments made for building long-term health system infrastructures. Health systems are comprised of hardware and software components (21). Hardware such as physical buildings, equipment, ambulances were equally critical as system software such as strong capacity of human resources and a shared work ethic. One respondent emphasized that the combination of these hardware and software ought to be sufficiently established and functioning prior to any potential crises.
"(the most important element in health system resilience is) to have sufficient supplies, to have stocks, to have sufficient human resources, to have an infrastructure that withstands disasters that's non-existing. So, what resilience are we talking about if even the basics are not there. That's where I personally feel that the issue should be to work and contribute towards a resilient health system. Maybe first of all a functional and after the functional, resilient, as that is not guaranteed in all countries." (I01)
Many organisations saw that rather than having a specific disaster preparedness plan, an overall strengthening of the health system would better contribute to building systemic resilience. For instance, when there are committed and competent nurses in the field, they would be the ones administrating COVID-19 vaccinations and serve in the frontlines during the crisis.
"to make it more resilient, I think it is less important to have a specific disaster preparedness, but rather to strengthen the health system as such. Is there much more nurses on the spot, more midwives on the spot, these people stay on the spot also in a flooding or in an Ebola crisis, or in a COVID crisis. If you have a health workforce, they can do a COVAX vaccination now. If you don't have them, you can't. It's not about once you have a crisis, then you need to react. You need to really strengthen the system before. Indeed a system with a sufficient number of infrastructure, equipment, medication, well-trained health workers, and community which is interacting well, is quite resilient." (I08)
When approaching resilience building, it is crucial to understand and build on the unique contextual strengths of the country’s health system. Whether it be through existing community health worker structures, doctor brigades, or traditional birth attendants, countries themselves should leverage their health care system’s assets to see what works best in their given context.
"Why not distribute it through the house doctors when this is our network distribution? It's a matter of knowing your health system well enough. I think one important thing for resilience is to build on the strength of the system that you have. Know the strength, build on them." (I01)
"For example, we work with traditional birth attendants. They are not considered part of the health system in many countries but still they are the closest to the patients and therefore it's good to work with them and to make their services better. So, it's not an either or. You have to look at the picture and see where it makes more sense in the moment in time to strengthen which system." (I06)
A case in point comes from Cuba where the government had invested in building a family doctor system, allocating a doctor and a nurse to serve each catchment area. During the COVID-19 pandemic, this system was fully utilised to enable a door-to-door service to monitor the health of its people and conduct contact tracing.
"For example, one of the ways to prevent COVID was to look closely to the person that has symptoms or there were contacts. They used family doctors and medical students going from door to door everyday to check the temperature of the people. 20,000 medical students. Because of this, the first two waves of COVID in 2020 were very well controlled by the government because of this. The contact cases were alerted and ones that were vulnerable or had health problems they went to the hospitals to follow up. At the end of 2020 there were only a little more than 100 deaths in the whole Cuba." (I14)