Introduction
A changing aid landscape
In recent decades, the international non-profit sector, including non-governmental organisations (NGOs), has grown substantially due to a changing aid landscape influenced by neoliberalism.1 Within this framework, international donors focused on ‘democracy’, ‘human rights’ and ‘good governance’ as key aid conditions under the ‘New Policy Agenda’.2
Throughout the 1990s, the ‘good governance’ agenda emphasised public–private partnerships,3 recognising community and participatory development, as well as the promotion of civil society,4 including NGOs.5
In the late 1990s, poverty reduction became the priority of new development policies,6 aimed at engaging civil society in development processes.7 This shift refined poverty, emphasising service provision in healthcare.8 Consequently, international donors have increasingly viewed NGOs as alternatives for delivering public services,9 10 especially in countries with weak government capacities.11
In this research, international donors include bilateral donors, multilateral organisations (eg, United Nations (UN) agencies), regional multilateral banks12 and private philanthropic charities.13 Some NGOs, mainly international NGOs, are also considered donors.
The contribution of NGO-donor relationships to health system resilience: gaps in the literature
A recent study by Al Asfoor et al14 indicated that bringing together diverse actors through relationships is a prerequisite for health system resilience.14 Other scholars argued that understanding health system resilience requires examining the role of relationships between actors within a health system.15–18 However, despite the NGO growth and the evolved NGO-donor relationships in the aid landscape, there is a lack of literature on how some NGO-donor relationships contribute to the strengthening of health system resilience.
In this research, strengthening health system resilience involves strengthening the capacity of a health system to absorb shocks (eg, natural and man-made hazards), but also to its capacity to adapt and transform, if necessary or required, during these shocks. This is seen as instrumental for the preparedness for and response to these shocks.
Through the above conceptualisation, health system resilience can result from any combination of three resilience capacities: absorptive, adaptive and transformative capacity. The absorptive capacity involves addressing population needs during shocks, through the same processes and/or using already available resources.19 20 Adaptive capacity involves addressing population needs during shocks, through new organisational adaptations introduced over the short-term.21 22 The transformative capacity is related to long-lasting changes, and is about transforming the health system’s function and/or structure to address shocks.23 These three concepts allow for the analysis of health system resilience.
Research objectives
This research explores the role of international donors in NGO-donor coordination and the contribution of this relationship to health system resilience in Lebanon. Particularly, it looks at coordination. In the health system resilience literature, coordination was commonly used to describe relationships between actors within health systems.18 20 24–29
Nevertheless, the main frameworks on health system resilience did not conceptually define coordination.20 25–30 In this research, coordination is defined as an inter-organisational relationship where actors share resources (eg, sharing information, material, human and financial resources) and/or work together on activities (eg, working on joint activities, and the referral of cases or patients) related to preparing for and responding to health system shocks.31
Coordination occurs through human interaction and socialisation processes (eg, face-to-face discussions, informal meetings), and technological systems.32–35
In this view, examining how NGO-donor coordination contributes to health system resilience carries significant importance. This aids for understanding the role of this relationship in preparing for and responding to shocks.
This research regards a health system as a complex system consisting of subsystems working on health.36 One of these subsystems is NGOs. Therefore, understanding the resilience of a broader health system involves understanding the resilience of its subsystems, including NGOs, in terms of their capacities to absorb, adapt and/or transform in shocks.