Diagnosis

Those holding a reformist perspective consider the root problem of inadequate health system resilience to be insufficient self-reliance (ie, specifically, a lack of funding and/or capacity) (I4, I9) and/or deficient health security (I4, I7). Accordingly, resilience is a means to strengthen health security, ensuring that countries are able to withstand and adapt to shocks.54 Furthermore, reformists, while acknowledging a range of possible shocks, consider shocks to the system as primarily acute and often catastrophic in nature.55–57 Examples include disease outbreaks,58 59 insecurity,60 and natural and man-made disasters.61 62 This is emphasised in USAID’s Global Health Resilience BluePrint, underscoring the agency’s experience in ‘preventing, preparing for, responding to and recovering from a range of infectious disease outbreaks’, including the global HIV epidemic, the Ebola outbreak in West Africa, and the COVID-19 pandemic, that ‘provided lessons to inform health resilience efforts’.63 This perspective is also reflected in a majority of systematic and scoping reviews of empirical literature on the subject of health resilience.

In contrast, those holding a transformational perspective describe the root problem to be structural, such as historical colonial legacies, as well as current trade, tax, health insurance and aid systems and policies.64 Resilience is thus a means to address structural crises weakening the system, deeply embedded health inequalities and the deliberate choices that shape inadequate health system responses to structural crises and health inequalities.60 65 66 Furthermore, they tend to conceptualise shocks as chronic, slower-burning and occurring over a longer time-span. These include LMICs’ regular health systems challenges resulting from human error, dynamic political environments, dysfunctional and unclear policies, limited funding, inadequate human resource capacity and high levels of disease.67–70 There is also emphasis on shocks and disturbances arising from intentional choices made by international, national and local actors, resulting in deliberate and inadvertent consequences. These include donor conditionalities and trade agreements at the global level; election promises, government reforms and regulatory changes at the national level; and changes to citizen voice mechanisms and organisational instability at the local level.64

Prognosis

In discussing health system resilience solutions, reformist and transformational perspectives differ on the extent of cruciality of technical or political strategies. Reformists tend to focus on technical solutions for fostering resilience, most of which lie within health or closely adjacent sectors including emphasising community mobilisation, disease surveillance, integration or collaboration of sectors, partners and services.63 Some respondents emphasised how the words fragility analysis, crisis sensitivity and complexity-aware monitoring frequently overlapped discussions of health system resilience among donors and implementing partners, underscoring the technocratic approach employed (I4, I6, I9). Accordingly, reformists give priority to hardware resilience building blocks—a bias more broadly reflected in the field of global health71—including finances, infrastructure and governance understood as organisational structures and legislation (ie, hospitals, standards and surveillance systems).72 Reformists tend to stress health system stability as the ultimate goal, emphasising maintenance, control, recovery, learning and/or ‘bouncing back’ to be the key resilience outcomes73–78 (I4, I6, I7, I19). Furthermore, they stress ‘preparedness’ as a strategy (I4, I7, I9, I12). They see crises as permanent; actors thus have to be continuously prepared for the worst. The focus is on anticipating how, where and when crises will happen (ie, preparation) and what sorts of responses are pragmatic and acceptable in those extreme circumstances. A respondent working in an intergovernmental organisation explained the rationale for strengthening preparedness in countries as it relates to advancing resilience:

You know a flood is going to happen; so be prepared so that once it happens, you have the structures to respond to it and be back at where you were before the flood as quickly as possible (I7).

In contrast, transformationalists see that any approach to resilience necessitates long-term commitments to finding socioeconomic and political solutions that tackle the roots of structural violence, challenge leaders of ‘weak’ states that maintain power by controlling interactions between their country and the rest of the world, and other reasons that put populations at risk.69 Accordingly, strategies and solutions advanced for creating resilient health systems cannot be divorced from meaningful assessment of the political economy and power dynamics that produced or shaped the health system crises.64 68 69 73 79 Transformationalists tend to stress the importance of software elements—’the ideas and interests, values and norms, and affinities and power that guide actions and underpin the relationships among system actors and elements’.80 These include leadership capacity, power relations, values, relationships and organisational culture.68 Transformationalists also highlight the commitment to address a range of interconnected issues that often extend beyond the health sector (I11). Instances include, an LMICs’ dependent position in the world economy, the ‘brain drain’ of medical and other professionals because of externally promoted austerity measures, and policies that uphold user fees for medical services and medicines.69 Furthermore, those with transformational ideology question if maintenance or ‘bouncing back’ to a health system’s baseline functioning prior to shock is the right goal, given that it is likely to ignore existing challenges and deficiencies and assume that the system was in an ‘adequate’ state prior to the shock or that it even existed to begin with.81 Finally, transformationalists are wary of the constant focus on anticipating a crisis, since it likely stymies the capacity or willingness of involved actors to have a bold vision (ie, fundamentally changing power relations in the governance of health). Undue continuous anticipation of catastrophe distracts attention from deeply embedded health inequities, the choices that shape health system responses, and the ‘hard grind’ of responding to chronic stresses that do not manifest as acute shocks.82

Rationale

Reformists and transformationalists also differ on who is responsible for ensuring health system resilience; the former values equal engagement across various stakeholders and communities impacted, while the latter puts the responsibility on the most powerful. Reformists are more inclined to see the importance of engaging all relevant stakeholders, especially communities and individuals, in creating health system resilience. USAID, for example, advances a ‘whole of society’ approach in building resilience by building partnerships across public, private and non-governmental sectors. Respondents with this perspective place particular emphasis on empowering communities to have agency in building resilience:

Resilience transports us back to the community…. Resilience is only built when communities own their health and they are able to…set aside resources and able to access health facilities, clean and safe delivery, family planning methods, [and] immunization. [They] are able to demand it and find ways and be creative [to secure it] (I13).

An expert in disaster risk reduction and international development explained:

A focus on resilience means putting greater emphasis on what communities can do for themselves and how to strengthen their capacities, rather than concentrating on their vulnerability to disaster or environmental shocks and stresses, or their needs in an emergency (Twigg, 2009 in83).

A LMIC government representative underscored an individual’s agency in a resilience approach:

Resilience is the ability of bouncing back after having the worst of scenarios, like an experience that puts you down so hard and all of a sudden, even with the pain and suffering, you dust yourself and stand up (I19).

In contrast, transformationalists tend to be critical of the dominant ‘whole of society’ approach employed in resilience discussion by donors and implementing partners—cautious that it is translated in practice as coping, with more powerful actors putting undue burden on the poor and disadvantaged, expecting them to ‘draw on their internal strengths and resources’ to make up for health system weaknesses.66 Such operationalisation of resilience masks the fact that resources are far from equally shared among states and within communities.84 These actors seek to change the loci of power and foster new governance structures and relations rather than reinforcing existing, dysfunctional health systems.66

Diagnosis

From the reformist perspective, the implicit problem is that countries require, or are perceived to require, external support from bilateral donors in order to reach a goal. Many respondents articulated a problem definition that aligned with this perspective (I4, I8, I18, I11, I10, I21). These respondents from HICs explained:

I think, my understanding of self-reliance…means you no longer need a donor. I mean, that’s the way they [donors] understand it, because…at some point the support should end; you can’t keep on supporting a group of communities or a country forever on the same thing (I13).

…Mov[ing] us towards a situation where the countries are doing all this themselves without our external support (I11).

We used to call it decades ago when I started off in the sector as self-sufficiency, right? And then OECD [Organization for Economic Co-operation and Development] came in [and] they started using the word sustainability. And now we’re talking self-reliance. All the same things. And it’s the whole idea of getting rid of dependency (I21).

In articulating the problem, respondents holding reformist perspectives tended to attribute the dependence on external resources to national system level deficiencies, including a country’s low domestic health spending, inadequate capacity and/or lack of political will. As a respondent from a donor agency explained:

The perfect example might be [informant gives two country examples in Africa] where we know [there is] corruption or government issues… [while] there’s a lot of development that goes into those two countries, [there is] very little commitment from the governments themselves to take on some of that work that they do have…[so its about] increasing country commitment and promoting domestic resource optimization and transparency and mutual accountability between donors and country partners (I14).

In contrast, transformationalists see the problems underlying self-reliance to be generally focused on liberal, capitalist models of development, structural inequities in the world economic and political system, and the resulting, unequal power dynamics manifested in the ‘first world’ and the ‘third world’.85–88 These structural inequalities, in addition to trade and power imbalances, have resulted in financial outflows from poorer countries that are at least US$3 trillion per year or 24 times that of incoming aid.89 These outflow calculations include debt with interest, profit repatriation from foreign direct investment and capital flight, and are likely underestimated given additional, unaccounted costs associated with slave trade, climate change and the commercial determinants of health that are disproportionately shouldered by poorer countries.90 91 Several respondents residing in or originally from LMICs connected self-reliance to the independence of their countries and/or recent efforts by national champions and governments to counter the costs of global political economy on local human development (I8, I9, I18, I19).

Prognosis

Reformists emphasise working within the existing system to resolve the identified problems by fostering localisation of funding, subawards, domestic resource mobilisation, private-sector engagement and commitment from country actors. One respondent related the term to countries ‘driving the train’, where external assistance can still provide support but countries are in control of their development trajectories (I11). Historically, reformist efforts to advance self-reliance were reflected in structural adjustment programmes devised by the International Monetary Fund, which made loans to indebted countries conditional on privatisation, economic liberalisation and reductions in public expenditures;89 the proclaimed aim was to increase government spending for healthcare and innovations to enable borrowing countries to protect health spending from broader austerity measures.92

Respondents holding reformist perspectives advanced a number of solutions for advancing self-reliance, including working through local organisations, staffing local country offices with national rather an international workforce (I1, I11, I17, I20), and gradually working towards ‘graduating from assistance’ so that as a donor’s ‘funding drops off, [a country’s] domestic resources and their advocacy…increases…[enabling them to] ‘graduate out’ when they're able to cover their own costs for that area’ (I2). This perspective embraces social entrepreneurship as part of the solution—fundamentally embracing a political economy that emphasises individual agency.89 Respondents also emphasised capacity building as part of the solution to building self-reliance (I1, I2, I4, I9, I10). One from a bilateral donor commented:

We really need to make sure that we're building an organization’s capacity to be our partners, to handle the logistics and the funding that we have or to be at a place where they don't need to have our funds…[but] I don't think that there is a need to completely erase what we've started and start over. (I10).

In contrast, transformationalists desire a system overhaul and uprooting of entrenched power dynamics, including redefining trade terms (especially historically) and developing country strategies that focus on national leadership (especially presently). The solutions proposed are fundamentally emancipatory in nature. Nationally and historically, this is reflected in a call for community-led development approaches and self-reliance of individuals—particularly rural communities—from dependency on government support.93–96 LMIC leaders like Julius Nyerere, the first President of Tanzania, advocated for wealth transfer across and within nations. They advanced that the uneven tolls of the global political economy must be equalised for true empowerment of the Global South.89 More recently, LMIC leaders such as China’s President Xi Jinping and India’s Prime Minister Narendra Modi have called for self-reliance with the latter, for instance, calling for import restrictions and local manufacturing bolstering (Patel, 2021). At the international level, this is reflected in calls to change the terms of economic markets, trade and finance in an effort to rebalance global economic and political power dynamics in the postcolonial era.96–98 For example, this practically could include ‘debt cancellation, providing predictable, unearmarked budget support to enable recipient governments, and the people to whom they are accountable, to finance health systems they imagine’.89 This entails a complete reclaiming of agency and the narrative by country actors. One respondent with origins from an LMIC explained:

I use expressions like self-reliance, get them out of our country. Get them to stop doing stupid things in [a particular LMIC]. Can’t we take control of the narrative in [a particular LMIC]? (I26).

Rationale

Reformists acknowledge the need to put LMIC actors in the ‘driver’s seat’ while articulating a role for HIC actors in achieving self-reliance in LMICs by helping strengthen individual and government capacity and accountability. One HIC NGO respondent noted this:

As you strengthen that [individual capacity], you [also] strengthen government…I think international donors have put more pressure on governments to be responsive as well, and to take responsibility (I9).

In contrast, transformationalists see responsibility for advancing self-reliance to rest squarely on LMIC actors, whether national governments or local communities.99 Unless fully dictated by LMICs, HICs and agencies can’t have a role, especially not one that detracts from an LMIC’s agency. Several respondents from HICs working in donor agencies or NGOs explained how some LMICs have exhibited this approach:

Ethiopia is a good example. They’ve thrown most donors out of the country, they have their own plan for being a middle income country by 2030, upper middle income country by 2030. Now granted, they’ve got a lot of problems but at least they have their own vision that they own…. (I11).

Ethiopia and Rwanda are able to hold donors accountable and say: ‘You were committed to the Paris declaration, you said one plan, one monitoring framework, one report, etcetera…You need to live up to it and if you don’t, we don’t sign any agreement and you are out of the country’ (I9).

Diagnosis

A reformist sees suppressed LMIC voice in global health as the absence of inclusiveness in global health governance, which includes imbalances or complete exclusion from agenda setting processes, study and programme design, and knowledge creation (I1, I23, I25).100 This stems from differential access to funding, knowledge, networks and educational opportunities.101 102 Those embracing this perspective highlight how key decision-making bodies and forums in global health are mostly represented by academics, donors, and implementing agencies in HICs like North America and Europe, with few individuals from LMICs (I14). This is in large part a result of significant differences in economic power (I5, I22) given those ‘who ha[ve] the dollar hold the power’ (I5). It is also in part driven by the need to produce quick results in-country, as well as existing project and funding proposal structures that privilege HIC actors who are most familiar with navigating the complex funding application submission and reporting systems, and leave many LMIC actors at a comparative disadvantage (I14, I22).

From a reformist standpoint, the lack of country voice is a result of little ‘local buy in and local ownership’ and inadequate efforts to ‘understand what the locals need’ given the ‘really poor understanding of the local context.’ (I15). Several respondents noted how the majority of members of the working groups of global health initiatives are white males from Europe and North America, representing donors and research organisations. One donor agency respondent described their personal experience:

We had an initial meeting and I realized that there wasn’t a single person in that meeting from any of our partnering countries and, like this is absolutely ridiculous; like why are we all coming together trying to decide what we should be focusing on and why are we not listening to our colleagues who are on the front lines and dealing with post-partum hemorrhage on a daily basis? (I14).

In contrast, transformationalists describe the problem as stemming from racialised hierarchisation of humanity and health systems, sexism, environmental racism as well as exploitative neoliberalism and the predatory nature of capitalism.41 102 103 Accordingly, seen and unseen racism, and its intersections with other systems of oppression fundamentally underlie suppression of voices with the least decision-making power.

Prognosis

Reformists view better LMIC representation in global health agenda-setting forums and shifting the decision-making locus to LMIC offices to increase country voice, as reflected by one respondent from an HIC NGO:

Elevating country voices means more [LMIC] representation in different global fora, more research where they [those from LMICs] are primary authors, more interaction with them, [and] they are in leadership positions where they can state their own opinion (I5).

Reformist ideas around how to facilitate increased local leadership is represented, for example, in Oxfam America and Save the Children’s Local Engagement Assessment Framework, which has been adapted by donor and NGO agencies working in health and other development sectors.104 It presents a spectrum of approaches that donors, partners and communities can engage in working together to shift agenda-setting and decision-making power into the hands of local actors. These range from consulting local actors on their views and preferences, to embedding them into a system that sees them as formal partners, to encouraging them to lead within jointly agreed parameters. Similarly, a Panel of Movers under the auspices of the Global Health Decolonisation Movement in Africa advances pragmatic approaches to increasing country voice.105 For example, their framework recommends global health organisations use holistic review methods when recruiting employees to reduce hiring bias against Africans and other persons who are under-represented in global health.106

In contrast, transformationalists view current operationalisation efforts of ‘increasing country voice’ to be insufficient where: ‘people have figured out the right things to say, and few actually go through the process of getting local ownership and getting the perspectives of the people on the ground’ (I5). From a transformational perspective, democratising global fora by increasing LMIC representation alone is an unhelpful goal because tokenism rather than representation is achieved. As one respondent working in a donor agency noted, one or a few people invited to join the discourse may not truly represent the country, and is more likely to reflect the voice of the most privileged in LMICs:

I don’t think that having one person is representative of the country… but again, we checked the box, right? (I10).

Rather, recent scholarship on decolonising global health describes the solution to be the removal of all forms of supremacy within all spaces of global health practice, within countries, between countries and at the global level.107 Efforts should be dedicated to creating a political economy that genuinely prioritises human well-being. This fundamentally requires ‘decolonisation of the mind’36—directly addressing the structural drivers of discrimination and barriers to self-determination that have led some HIC actors to feel superior and some LMIC actors to feel inferior.43 Such principles are encompassed in the efforts of groups like Campaign Against Racism, which seek to uncover and dismantle ‘historical connections between racism and capitalism to radically imagine a future in which sociocultural, political and economic systems work towards health equity, rather than against it’108 Specifically, this entails, for example, organising people to practice social medicine and collectivising their actions for structural change, transforming health education to make social medicine the norm for health professionals, and developing local leadership in LMICs that prepares people to lead and be change agents.109 It also necessitates creating new learning platforms in global health that safeguard reciprocal knowledge flows, with contributions from LMICs driving discussions and practice, both locally and globally.41 Other scholars drawing on Freire’s110 The Pedagogy of the Oppressed advance the need to move away from the Eurocentric cultures that insist on “‘professional’ dress, presentation of speech, modes of argumentation and ‘correct’ formats and literature to be used when disseminating ideas”.103 Rather, increasing voice requires ‘reparations, repatriation of indigenous land, abolition of oppressive systems and more’.103

Rationale

Reformists see the responsibility for increasing LMIC voice on HIC donors and actors, as noted by one HIC respondent working in a UN agency:

Richer countries and donors have to be able to provide the means that actually ensure that those voices are at the table (I11).

Several respondents embracing this perspective employ justifications that are instrumental in nature. Specifically, they advance that practices intended to ‘increase country voice’ will lead to a ‘better way to do development’ (I1). One respondent clarified this rationale, rooted in business economics:

Global health is a business with competition with people competing for dollars, and it’s expensive, we have large organisations that have operation costs and management fees and all kinds of things (I1).

Others call for ‘metrics,’ ‘checklists’ and a ‘road map’ to hold global health organisations based in HICs accountable in redressing wrongs and creating space and voice for the less powerful.111

Transformationalists, in contrast, see the onus on powerful actors to ‘lean out’ on an individual, national and institutional level to stop reproducing racist and colonialist ideologies,112 and more fundamentally transform their perspective on global health work. Specifically, seeing it as an act of justice instead of saviorism. A thought leader of the decolonising global health movement explained:

Instead of thinking about fixing the problems of people in poor countries, they [HIC actors] [need to] think of what they’re doing as an act of justice. And if you begin from thinking of it as an act of justice, then you don’t think about even saving someone else. You think about saving yourself… (I26).

Transformationalists also emphasise the agency of LMIC actors in advancing their voice. An LMIC scholar provides guidance for other investigators in low-income countries on ‘navigating the violent process of decolonisation in global health research’113:

I have tried to distill what I have seen, witnessed, experienced, or heard accounts of over the past 12 years into workable guidelines, for I have also seen that the extent of violence depends on the degree of power imbalance.