Getting unstuck: reframing health systems strengthening and resilience in fragile and conflict-affected settings

Abstract

The concepts of health systems strengthening and health systems resilience are conceptually different but often used interchangeably in health policy and systems research and practice. Operationalising them can be difficult, but both are particularly relevant in contexts of conflict, violence and institutional fragility. In the current landscape of increasing complexity of humanitarian crises and constrained resources, understanding their meaning can be helpful to reaffirm their significance and value for achieving equitable access to care for the most vulnerable populations.

We propose reframing health systems strengthening and resilience across three key dimensions: actors, levels and time. Donors and multilateral and international organisations need to explicitly recognise and engage a broader range of local health systems actors, including community-based, faith-based and non-state actors, alongside national authorities. Actors should work across levels, from individual and communities to district and national domains, minimising gaps and vulnerabilities. It is also crucial to adopt longer time frames in the conception, design, implementation, monitoring and evaluation of interventions to strengthen health systems and increase their resilience in fragile and conflict-affected settings. This timeframe shift can help mitigate potential unintended long-term consequences of short-term interventions, support sustainability, improve learning capabilities and enhance transformation.

Such a three-pronged shift demands a deeper engagement with the affected communities and local health actors. It entails transferring decision-making power to them rather than exclusively transferring risks. This can ground health systems strengthening and resilience interventions in the contextual reality and needs rather than in externally defined priorities and frameworks.

Summary box.

• Health systems strengthening and health systems resilience are two distinct concepts that are often conflated, but they both are particularly relevant for fragile and conflict-affected settings.

• The relevance of these concepts for achieving equity in access to care for the most vulnerable populations can be increased through shifting the focus to the centrality of people and the communities they are part of across three dimensions: actors, levels and time.

• A more inclusive understanding of pluralism and diversity in health systems is critical to identify key actors who can contribute to strengthening health systems and operationalise their resilience, especially in areas where state health actors have no capacity or legitimacy.

• At the same time, coordination and convergence of efforts to strengthen health systems and their resilience needs to happen across levels, from individuals to communities, from providers to policy makers.

• Finally, and critically, humanitarian aid must move toward a longer time horizon, integrating sustainability and learning into donor investments and international interventions.

Introduction

During the eighth Global Symposium on Health Systems Research (HSR2024), a session was dedicated to ‘Strengthening health systems in fragile and conflict-affected settings’. The presentations explored post-conflict decision-making spaces in Kurdistan, Iraq [Hafez, oral presentation], the organisational resilience of humanitarian actors as a prerequisite to support the resilience of the health systems in which they intervene [Truppa, oral presentation], the motivation of healthcare providers to continue working in conflict settings,¹ and the principles and practices of health systems strengthening (HSS) in fragile settings [Bertone, oral presentation]. A thread ran through the question-and-answer session that followed: are there better ways to operationalise the concepts of HSS and resilience so that the health of vulnerable populations in fragile settings can be improved?

Though often conceptually conflated, HSS and health systems resilience are distinct concepts.² HSS focuses on interventions that lead to sustainable improvements within a health system across the six building blocks in a systematic and integrated fashion.³ HSS progress can be monitored quantitatively and qualitatively as an outcome at specific points and tracked over time to ascertain progress toward defined targets.4,6 Health systems resilience has emerged later in the health policy literature, to describe the absorptive, adaptive and transformative capacities of health systems confronted by shocks and stressors.^{7 8} Resilience has developed as a distinct analytical lens that considers conceptualising health systems to be as dynamic and evolving, and hence not fully analysable through the traditional HSS frameworks.⁹ While HSS focuses on interventions that aim to improve health systems performance in a sustainable and comprehensive way in order to achieve positive health outcomes over time, interventions aiming at increasing resilience promote the dynamic capacity of health systems, in which continuity, flexibility and adaptability in health system functions can protect and sustain the progress achieved through HSS efforts.^{10 11} Health systems that demonstrate strength under stable conditions can lack resilience when confronted with shocks, as was the case for many European health systems during the COVID-19 pandemic.¹¹ On the other hand, health systems traditionally considered as weak and fragile can demonstrate resilience under stress, as some African countries did during the pandemic, particularly those where community engagement is a systematic and organic component of their health system functioning.^{11 12}

The concept of HSS has historically been used by international organisations, including multilateral and bilateral agencies and non-governmental organisations (NGOs), to inform the design, implementation, monitoring and evaluation of health interventions intended to address weaknesses in the functioning of health sub-systems, such as supply chains and information systems.⁴ It has been interpreted in varied ways by NGOs and agencies to describe their experience and learning, particularly in contexts characterised by weak and fragile institutions,13,15 but it has been argued that its understanding has not been homogeneous among global and local actors.³ The expression was used in the first place by international and multilateral organisations to address the system’s dysfunctions, inadvertently triggered by vertical interventions.³ However, there is little evidence on how HSS interventions are taking into account the needs of communities and local health actors, and whether they are acceptable for the latter, which is essential for sustainability of processes and programmes and for full ownership of this concept at the local level.¹⁴

At the same time, the concept of health system resilience has grown in popularity among health actors globally.^{2 16 17} The debate on resilience has been embraced with interest and, at times, scepticism by humanitarian actors and development agencies, who have, in some instances, tried to document its value,18,21 while in others questioned it in relation to its utility and relevance for humanitarian action.22,24 Ambivalence towards the concept of resilience also has roots in its understanding by some actors and how it implies normalising crises, ignoring the structural violence and putting the responsibility of dealing with crises and violence onto the affected populations and frontline health staff.²²

While conceptually different, the concepts of HSS and resilience are both increasingly relevant in FCAS, particularly in light of the ongoing aid cuts. These are in fact deepening the pre-existing fragility of low and lower-middle income countries that already bear a disproportionate burden of conflict. These recent developments have compounded effects on the health systems of affected contexts, disrupting service provision and weakening governance structures across both humanitarian and development aid interventions.²⁵ Still, cuts in aid funding may create an opportunity to shift our understanding of HSS and resilience in three ways. In particular, in this paper, we argue that more attention needs to be given to explicitly supporting plurality and diversity of actors engaged in health systems, to make greater efforts to strengthen health systems and enable their resilience at all levels of the system, and to use longer time horizons for interventions in FCAS. This longer timeline is particularly important given the cycles of violence, displacement and conflict are increasingly protracted, such that the emergency phase is no longer a short-lived period but often extends over years, as we observed in decade-long crises in Syria, Palestine and Somalia. In this context, longer-duration interventions are intended to bridge the humanitarian-development transition, minimise disruptions to essential services and support institutional development and adaptive capacity in FCAS.26,28

Promoting a more inclusive understanding of the diversity in health systems in fragile and conflict-affected settings

To understand how HSS and resilience could be better operationalised in FCAS, it is necessary to examine the meaning of ‘health system’ for humanitarian organisations and development agencies working in these settings. In the humanitarian and development discourse, ‘health system’ is often used as shorthand to denote the public health services provided by the state.²⁹ However, the critical role that non-state actors, such as civil society and the private for-profit and not-for-profit sectors, can play in contexts of fragility and instability is increasingly recognised in shaping the definition and framing of ‘health system’.^{30 31} This definition moves towards that of the WHO, which defines health systems as ‘all the organisations, institutions and resources that are devoted to producing health actions’.³²

Diversity in health systems is beneficial in practice as it ensures collateral pathways for service provision and adaptability to the needs of diverse population groups, and as such, it contributes to both resilience and HSS.^{17 33 34} Diversity relates to the heterogeneity in the type and nature of actors, encompassing different organisational forms, purposes and governance mechanisms.^{33 35} The case studies presented during the HSR2024 symposium focused on the diversity of actors involved in HSS and resilience efforts in FCAS. Research in Kurdistan, Iraq showed the variety in types and dynamics of actors involved in decision-making on HSS interventions for the Syrian refugees and internally displaced Iraqis. The actors providing services for Syrian refugees often differed from those assisting Iraqi IDPs, particularly in camp settings. These actors included traditional humanitarian actors, such as the Red Cross and Iraqi Red Crescent, and non-traditional actors in this context, such as diaspora-organised groups and faith-based organisations, each targeting specific population groups and employing differing models of health service delivery. Different interests and priorities were observed among the federal Ministry of Health, the regional Kurdish Ministry of Health and the decentralised Directorates of Health [Hafez, oral presentation].

External actors, such as international NGOs and donors, traditionally aim at strengthening the capacity of governmental actors. However, in some cases, they can also compete with governments by setting up parallel healthcare services or programmes due to divergent interests and priorities. In other cases, national health authorities might be weak or absent at the operational service delivery level, but there may be local health authorities with whom NGOs could develop partnerships for HSS. Enhancing the visibility of local health authorities, as well as their actual role in the health system, can be crucial for continuity of access to care, collaborating on health system reform and longer term HSS. An example of practices that promote HSS was documented in Somalia, where an NGO has been supporting local governance mechanisms to ensure the visibility of local health authorities through community meetings [Bertone, oral presentation]. In Myanmar, examples of cooperation to increase coverage of essential services have been documented, in which ethnic health organisations and community-based, non-partisan health organisations work in collaboration with non-state actors to address healthcare gaps in conflict-affected areas. These efforts have persisted for several decades, including during relatively stable periods when government services remained inaccessible. In the current context, as some external actors suspended service provision due to funding cuts, these actors have again sought to increase coverage by prioritising essential services, mobilising local contributions and reducing human resource costs. While such approaches have enabled continuity over decades, they may entail trade-offs related to service quality and workforce capacity, including staff turnover.^{1 36 37}

Over the past decade, collaborations between community-based networks, humanitarian organisations, development actors and academic institutions have multiplied.^{19 38 39} However, these operational partnerships often face problems of coordination, alignment with local priorities, competition for funding, accountability towards affected populations and sustainability of the interventions.²⁸ In addition, the majority of partnerships remain limited to international organisations intervening in humanitarian crises rather than including local civil society organisations.³⁰ These selective partnerships are often justified by the lack of suitable accountability structures and capabilities on the ground in FCAS, while in reality, they reflect deeper power imbalances between donors, NGOs and multilateral agencies.⁴⁰ We argue that all health actors must more explicitly recognise diversity in health systems in FCAS and acknowledge the agency and legitimacy of state and non-state actors. Legitimacy here is understood beyond the legal terms, as a social construct based on trust following McCullough’s and Alkhalil’s conceptualisation of non-state actors’ legitimacy as ‘the acceptance of its authority among both political elites and citizens, enacted through voluntary compliance, legal authority, and coercive power.’^{41 42} As tensions in governance, representation and compliance arise, understanding the complexities of trust and legitimacy in these contexts is critical for shaping health interventions that are both effective and socially acceptable. Therefore, we argue that legitimate local leadership must be supported and locally led action must be enabled, beyond merely transferring risks, shifting financial liabilities and operational threats without providing adequate safeguards and resources. Doing so may help to engage communities and other local health actors, co-define local priorities and complementary roles to achieve the identified objectives, and adopt strategies to expand coverage of, access to and equity in services utilisation.⁴⁰

Bringing all levels into health systems strengthening and resilience in fragile and conflict-affected settings

One challenge to practitioners and researchers operationalising the notions of HSS and resilience in conflict and post-conflict situations is the need to support different capacities at different system levels. Once the diversity in health systems actors is acknowledged, it is fundamental to also recognise their horizontal and vertical interdependences within health service levels and domains and across geographies and hierarchies.¹⁰ HSS and resilience are often analysed at one single level of the system, overlooking their cross-scale dimensions and the cross-boundary capacities of individuals, communities, providers, policy makers and funders.³⁴

Absorption, adaptation and transformation are not sequential steps,⁴³ and capacities may differ between neighbouring health districts or between the national and community level, resulting in differential overall resilience, as in the case of districts in Kurdistan, Iraq after the conflict in Mosul [Hafez, oral presentation]. In taking decisions in health, Duhok Directorate of Health (DoH) showed a stronger ability to take decisions in operational planning, service delivery and coordination functions, compared with Erbil and Sulaymaniyah DoHs. Duhok DoH also demonstrated a stronger decision-making capability than the regional Ministry of Health in Kurdistan Iraq regarding operational planning and coordination, suggesting greater authority and flexibility in managing day-to-day health service operations for displaced populations [Hafez, oral presentation].

Resilience as a capacity is not causally linked to shocks or stresses: it is not a binary state associated only with outcomes following disruptive events, but rather an emergent system attribute.^{12 44} However, the international aid architecture tends to prioritise humanitarian responses to shocks and stressors: for example, in protracted conflicts in the Middle East such as in Iraq and Syria, repeated cycles of emergency assistance have frequently overlooked long-term system strengthening and chronic care needs.²⁸ Necessary as this is, short-term interventions tend to limit opportunities for transformation and learning, which is a fundamental capacity for a system to manage change and hence to be resilient.⁹ At the same time, learning organisations, meaning systems that are able to integrate iterative learning processes at the individual, team and institutional level,^{45 46} appear to be better equipped to innovate and more agile in adapting to changes [Truppa, oral presentation].

The examples from the case studies show how the different hierarchical, geographic and organisational levels need to be accounted for in operational initiatives and responses if we want to be able to identify and support specific capacities at specific levels over time.

Shifting the time horizon in health systems interventions in fragile and conflict-affected settings

While donors’ exits are unavoidable, sustainability and the conditions required for learning need to be considered when conceptualising, implementing and analysing HSS interventions.⁶ Due to cuts in international aid, the majority of international NGOs have been obliged to suspend their work at the Myanmar and Thailand border, but local hospitals and organisations continued to deliver services, stretching their capacity to absorb the shock, adapting modes of delivery to operate with lower budgets and transforming core functions, such as training health staff in ethnic areas to fit local realities [Yamonn, personal communication].

In interviews during study data collection, many international NGOs reflecting on their experiences of doing HSS programming in FCAS acknowledged that positive results in terms of strengthening local health systems cannot be achieved without having a long-term strategy that aims at effectively integrating activities in the local service delivery platforms, coordinating with local health system management bodies, and having a continuous dialogue with other health actors to enable local ownership of interventions [Bertone, oral presentation].⁴⁷ Findings from Kurdistan, Iraq reflect the perspectives of local and national health actors and echo this conclusion. The study highlighted concerns over the rushed exit of humanitarian health actors and emphasised the preference of local actors for sustained, long-term collaboration to strengthen health system resilience [Hafez, oral presentation].

Resilience capacities also need to be analysed over longer time frames to understand how they develop and to facilitate transformation. In a study analysing the resilience capacities of a humanitarian organisation intervening in Lebanon over a 10-year period of compounded crises, absorptive, adaptive and transformative capacities developed simultaneously rather than consequentially in relation to cumulative shocks and stresses. Learning from the flexible funding mechanisms and operational models adopted by the organisation to respond to previous shocks was progressively embedded over time within the organisation’s structures and strategies, becoming the standard operating model. This transformative change was enabled by the permanence of key decision-makers within the organisation, who ensured that the learnings from the experience could be maintained over time. The new model allowed for more agile operations as new stressors arose, while the organisation was developing new absorptive and adaptive capacities to respond to emerging shocks [Truppa, oral presentation].⁴⁸

Even though crises are often seen as acute and transient, a longer time horizon needs to be used for action in FCAS. Most investments made by the national and international community (including governments, donors, and humanitarian and development organisations) are short-term, due to the risk aversion that is triggered by the volatility that characterises these contexts and by the timeframes imposed by elections and funders. Recent developments in humanitarian and development funding demonstrate how volatility of aid is also an intrinsic characteristic of the current aid financing structures, which remain heavily dependent on the influence of a few countries in the Global North and are driven by agendas that are not focused on local needs and priorities.⁴⁹

The need for a longer time horizon refers to the accountability of external actors, rather than to their long-term presence as service providers. External interventions are inherently disruptive to existing institutional and operational arrangements among local providers. Sustainability therefore depends on how external interventions interact with, support and progressively hand over to legitimate national and sub-national health systems over time.⁵⁰

Acting on a longer time horizon can create longer-term and higher-quality engagement of both institutions and individuals, which strengthens the governance of the health system and may enhance transformation, challenging as this may be in the current global context. This ultimately means transferring decision-making agency to legitimate local health actors, who have a stake in the affected communities they are part of and commitment to act in their interest. This would help operationalise the localisation agenda promoted by the World Humanitarian Summit in 2016, which has so far translated mostly into transferring risks instead of true decision-making power.^{51 52}

Centring people and local communities in health systems strengthening and resilience

It is worth noting that organisations engaging in fragile settings often rely on the leadership of individuals who are involved in decision-making, and the commitment and motivation of those engaged in service provision to deal with constrained resources and institutional vulnerabilities. In the qualitative study presented by Truppa on the organisational resilience of a humanitarian organisation operating in a protracted crisis, the human capital of the organisation was a key enabler for the continuum of absorption-adaptation-transformation [Truppa, oral presentation]. This confirms the findings of other studies conducted in humanitarian organisations, in which social networks, existing or emerging relationships among individuals, and power dynamics play a vital role in enabling – or hindering – organisations from tailoring their programmes to identified needs and capitalising on what they have learnt on the ground.⁵³

Findings from Kurdistan, Iraq attributed the better decision-making capacity of the Duhok Directorate of Health not only to advanced public health training, good coordination skills and strategic planning capabilities, but also to being connected to formal and informal networks of public health and health system strengthening experts [Hafez, oral presentation]. While top-down processes can enable absorption, adaptation and transformation at the organisational level, the crucial value of local health workers, with their commitment and motivation to serve their communities, was highlighted in the example of Myanmar as a central element of resilience capacities across levels, from the individual to the community and the health system level.¹ This echoes findings from several studies that have emphasised the value of social capital in increasing resilience in FCAS.^{54 55}

Relying on centralised and standardised processes for decision-making, coordination and service delivery can exacerbate the fragmented governance arrangements and create deep mistrust between communities and authorities, and between formal and informal healthcare providers in conflict and post-conflict settings.⁵⁶ For example, the Ethnic Health System Strengthening Group in Myanmar made notable progress toward shared health goals with the government health system during a relatively stable period – not only at the central level, but also at the local level. Such collaboration was previously unimaginable due to decades of mutual mistrust between these actors. However, these collaborative efforts stalled following the escalation of the conflict in 2021, compounded by the active involvement of local health personnel in the Civil Disobedience Movement and an increasingly unfavourable political environment, which eroded trust once again among the stakeholders.^{57 58}

Informal and community-based health providers are often employed in short-term humanitarian interventions in FCAS. However, such investments of humanitarian organisations in non-state actors are often not aligned with local priorities and policies, nor coordinated with those of the development sector. The experience shared by the panel confirms what emerges in other field-based studies: strengthening local communities and the health providers they trust can be beneficial for both periods of stability and shocks.⁵⁹ Horizontally, strengthening the governance mechanisms of community-based health systems could expand the coverage of health services, and vertically, it may make healthcare needs of specific vulnerable groups visible within the health system and influence policies to address them.¹⁰

A proposed shift for health systems strengthening and resilience in fragile and conflict-affected settings

The examples discussed during the HSR2024 session and summarised in this paper point to new ways of thinking about and acting on HSS and resilience, based on the experience of embedded researchers and frontline actors and their shared perspectives.

De-emphasising short-term responses demands that governments, donors and the international community increase their risk appetite and engage in more flexible and coordinated support directed primarily at strengthening the governance capacity of local actors. It is worth considering new models in humanitarian and development interventions that support existing health systems, avoid setting up unsustainable parallel arrangements and synchronise emergency responses with HSS interventions. The prioritisation of locally led integrated service delivery models, along with flexible pooled financing mechanisms, has already proven successful, but evidence on community-based networks still remains limited.³⁰ It is also important to move beyond quantitative monitoring metrics for pre-defined outcomes and adopt qualitative evaluation approaches.⁶ These reflect a deeper understanding of the complex settings in which HSS and resilience interventions are designed and implemented, thereby facilitating more adaptive and context-responsive programme adjustments. We argue that this will strengthen the development of absorptive, adaptive and transformative capacities, rather than focusing on the former two in short-term interventions and on the latter in longer-term ones.

The needs of people and communities and health service provision tailored to these needs should be the starting point for HSS. It should support the long-term development of health services while addressing the acute needs of people. All international and local agencies are made of individuals, and the continuity of vision, commitment and motivation of these individuals are essential enablers for long-term learning and change across levels – from the individual to the organisational and system level. Our understanding, stemming from our experience in health systems in FCAS, confirms that a shift is needed that acknowledges the diversity and pluralism of actors, their multi-level and within-level interactions, and long-time horizons as necessary to operationalise the concepts of HSS and resilience. Such a shift would help to adjust power imbalances that often emerge between donors, humanitarian organisations and ‘recipients’.

Conclusion

This viewpoint is a joint effort among health systems researchers and practitioners to confirm the operational usefulness of the concepts of HSS and resilience in FCAS. At the same time, we have offered arguments that challenge assumptions about the two concepts. We believe that both concepts of HSS and resilience can be used to design health systems interventions that can ultimately contribute to ensuring that well-being, equity, justice and dignity of the affected people are at the centre of operational health interventions and research implemented in FCAS. Achieving this requires not only an inclusive understanding of the diversity in health systems within these contexts, but also deeper engagement with local actors, community-based organisations and partner institutions that navigate the realities of conflict-affected settings. Moreover, a less linear, more multidimensional approach to the scope, scale and time horizon of HSS and resilience efforts is essential for policymakers, donors, managers and implementers.

The substantial cuts in external aid at the beginning of 2025 make our points both more challenging to implement and also more urgent. Strengthening local health systems and empowering local actors is critical for the sustainable delivery of healthcare services to the most vulnerable populations.⁴⁹ Health programmes that support localised, pluralistic, embedded and long-term approaches to strengthening health systems and resilience capacities are the way forward to ensure the efficient and equitable use of decreasing funds and ultimately ensure well-being, equity and justice for the most vulnerable people living in fragile settings.

Data availability statement

There are no data in this work.