Original research•

Flexible ngo-donor coordination in aid interventions to strengthen resilience: the case of Lebanon’s primary healthcare system

Abstract

Introduction With shifts in international aid, international donors have increasingly regarded non-governmental organisations (NGOs) as capable of providing alternative public service arrangements. As funding flows to NGOs, particularly in contexts where both actors work towards strengthening health system resilience, NGO-donor relationships evolve. However, despite calls to investigate the contribution of relationships between actors within health systems, including NGOs and their donors, to health system resilience, empirical research is limited. Understanding these relationships is crucial for comprehending their role in fostering resilient health systems. This research fills this gap, by examining how NGO-donor coordination contributes to health system resilience in Lebanon.

Methods This research focuses on Lebanon’s primary health system, primarily managed by NGOs through contracts and heavily funded by donors. It examines NGOs operating under the national primary healthcare network (PHCN). The participants, including staff from these NGOs and donor agencies funding them, were purposively selected. 31 semi-structured interviews were conducted. The analysis framework relied on a thematic analysis.

Results The findings revealed that the flexibility in NGO-donor coordination in Lebanon depends on donors’ trust, regular coordination and donors’ willingness to listen to NGOs’ needs. In this light, they uncovered that flexible NGO-donor coordination enhances NGOs’ resilience capacities in shocks, allowing them to operate flexibly. By strengthening NGOs’ resilience, which contributes to the resilience of the broader health system, this relationship contributes to health system resilience.

Conclusion The findings contradict the mainstream development literature on NGO-donor relationships. The latter focuses on donor funding requirements that often result in rigid NGO-donor coordination, making it difficult for NGOs to be resilient. Rather, they emphasise the donors’ role in implementing flexible development approaches, through flexible NGO-donor coordination, strengthening health system resilience. Overall, this paper contributes to the health system resilience literature by exploring how specific configurations of NGO-donor coordination strengthen health system resilience.

What is already known on this topic

  • Prior to this study, there were calls to explore the contribution of relationships among actors in privatised health systems to health system resilience. Despite the evolving non-governmental organisation (NGO)-donor relationships in international aid, where donors fund NGOs to strengthen health system resilience, empirical research on their influence on health system resilience is lacking, making this study essential for understanding how specific configurations of these relationships, like coordination, can enhance resilience.

What this study adds

  • This study underscores the need for donors to adopt flexible NGO-donor coordination, allowing NGOs to implement development and humanitarian projects more flexibility and equipping them with the capacities needed to strengthen health system resilience.

How this study might affect research, practice or policy

  • This study informs policies and efforts that aim at strengthening health system resilience in contexts where health systems rely heavily on NGOs, through offering insights into the role of these NGOs’ donors in contributing to health system resilience through particular configurations of NGO-donor coordination. This study also opens up avenues for further exploration of health system resilience as a result of various practices by donors, which influence NGO-donor relationships and their contribution to health system resilience.

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.

Methodology

The context

Lebanon’s political and economic turmoil since the 1975–1990 civil war weakened the government and its provision of public services. This resulted in a rise in NGOs, filling the gap left by the public sector.31

After the war, the Ministry of Public Health (MoPH) initiated reforms, forming a national primary healthcare network (PHCN) by establishing contractual agreements with primary healthcare centres (PHCCs).37

As of 2023, the national PHCN includes 246 PHCCs,38 of which 67% are owned/run by NGOs, making them key providers of primary healthcare (PHC).39 The majority of these NGOs are local NGOs, followed by national and international NGOs. There are also NGOs that support PHCCs, by providing financial aid, capacity building and medical supplies or equipment.40 This research focuses on these NGOs that operate under the PHCN, as a case study.

An assessment, using a list of PHCCs shared by the MoPH and the ‘Operational Data Portal’ (ie, a web portal that displays data on the health sector), identified 131 NGOs operating under the PHCN. This was necessary due to the lack of documented information on NGOs in Lebanon’s health sector, particularly those under the PHCN.

What is interesting about this case is that, although most NGOs providing PHC are public service contractors, the majority of their funds come from international donors. For example, during the Syrian refugee crisis, different donors acted due to the absence of a solid national strategy to respond,41 notably through the Lebanon Crisis Response Plan (LCRP). Activities under the LCRP have been coordinated through ‘clusters’, or sector working groups, led by the UN and the government. In the health sector, the health working group is inclusive of all organisations, including NGOs, donors, UN agencies and government entities, working on health. In related meetings, these organisations share information on their projects, discuss their implementation activities and coordinate their efforts.42 Outside the LCRP framework, funds from sources, such as the European Union (EU), have also supported Lebanon’s primary health system, including NGOs operating under the PHCN.43

Furthermore, donors, such as the EU and some UN agencies, have been aiding the MoPH to tackle the challenges (eg, the absence of regular funding for vaccines, drugs and supplies at the PHCC level) exacerbated by the existing political and economic crisis.44 In this context, other donors have also been helping the government through schemes, such as the Multi-Partner Trust Fund of the United Nations Development Programme.41 This fund covered projects aimed at delivering a package of PHC services in 75 PHCCs under the PHCN.40

In addition, during COVID-19, some donors supported the provision of healthcare activities at the PHCC level.45 They funded NGOs to distribute hygiene products and masks, conduct community awareness sessions, develop protocols for patient intake, etc.46–48

Following the Beirut explosion, the MoPH developed the Immediate Response Model, which was a temporary model aimed at subsidising PHC for the beneficiaries of 21 PHCCs affected by the explosion. This model received US$118.6 million from donors.49

Therefore, NGOs operating PHCCs under the PHCN have been receiving funds from donors, working together to strengthen Lebanon’s health system resilience during the aforementioned shocks. Consequently, there are context-specific NGO-donor relationships. Thus, looking at how NGO-donor coordination contributes to health system resilience amid these shocks presents an area of exploration.

Research participants

The participants included individuals working in NGOs operating under the PHCN in Lebanon (ie, directors of the PHCCs owned by NGOs, project managers in the NGOs, project coordinators working in the NGOs and founders/co-founders of the NGOs). They also involved individuals working in donor agencies (ie, health programme managers and officers) supporting the NGOs operating under this network. Therefore, these participants are the key informants in this research, as they possess high-level knowledge and insights related to the research question.

The above participants were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data collection and analysis

Key informant interviews were conducted, using an interview guide developed after a thorough literature review. This guide focused on gathering data on NGO-donor coordination during shocks, and how this coordination contributes to health system resilience.

The interview guide was piloted with three individuals working in various NGOs that operate in PHC. Piloting these interviews ensured that the questions were clear and concise, and that the participants could understand and provide meaningful responses.

The interviews were arranged by contacting interviewees, who were purposively selected, via phone or email. The researchers had professional connections with different NGOs and international agencies. They had sometimes relied on these connections to request interviews, informing the purposive sampling technique.

For the NGOs included in the research, the sampling frame was based on a selection of interviewees working in various NGOs to represent differences in their scale of operation, level of engagement in PHC and scope of operation. A total of 31 participants accepted to participate and were interviewed (table 1). However, some participants directly refused, while others did not respond after follow-ups. The increasing workload from evolving shocks left donor agencies and NGOs too busy to participate. Therefore, the researchers’ obligations were to respect the decisions of those who were unable to engage.

Table 1
|
Total number of interviews

After agreeing to participate, interviewees received information sheets and consent forms via email. The data collection occurred between May 2021 and December 2021, following the receipt of ethical approval from the University College London Research Ethics Committee.

Due to safety concerns related to COVID-19, all interviews were conducted via Zoom by the researchers. The researchers asked the interviewees to confirm their consent to take part in the research via a voice recorder. Additionally, they asked if the interviewees were comfortable with the interviews being recorded.

After giving their consent, these participants were asked to confirm one of three options regarding anonymity, also onto a voice recorder: (1) agreeing for their name and role/affiliation to be used, (2) agreeing that their responses were to be presented anonymously but giving permission to connect their role/affiliation to their comments and (3) agreeing that their responses were to be presented anonymously but with no mention of their role/affiliation.

Research data was stored electronically and password-protected, accessible only to the directly involved researchers.

The data entry and analysis were conducted by the first author. Thematic analysis was used, guided by Braun and Clarke’s50 six phases of thematic analysis.50 This analysis offers a usable framework for doing thematic analysis.51 The first phase involved reviewing interview transcripts. The second phase included generating initial codes and applying codes to the data set, using NVivo 10. Both deductive (using a predefined codebook based on the literature review, and the concepts for the analysis of health system resilience) and inductive (data-led) coding approaches were employed.52 As for the third phase, the codes were reviewed with their data, in order to identify meaningful patterns that formed themes. For example, the codes on the flexibility of NGO-donor coordination and other-related codes led to the emergence of a main theme on the contribution of the flexible NGO-donor coordination to health system resilience. The following phases involved reviewing the themes, defining and naming them and lastly, weaving together the analytical narrative.

Results

Flexibility in NGO-donor coordination

This section investigates NGO-donor coordination by analysing how some factors made this relationship flexible.

Donors’ trust in NGOs’ work

Six participants mentioned trust as a factor that improved NGO-donor coordination. This trust originated from donors’ sufficient experience working with NGOs, which developed over years of working together. A project coordinator working in an international NGO said that ‘[over] the years, [the NGO has] developed a trustworthy relationship with its donors’ (International NGO, Interview 2). A senior health officer working in a large international NGO also linked trust to the ‘[NGO’s work] with some donors for over 10 years’ (International NGO, Interview 27). This allowed these donors to see the NGO’s good work in the field (International NGO, Interview 27).

Additionally, trust emerged when donors were aware of NGOs’ performance. A community development expert in a local NGO linked this trust to the good information sharing on NGOs’ performance in NGO-donor coordination (Local NGO, Interview 23). A field medical advisor working in a large international NGO stressed this point by saying that the NGO ‘[…] has the trust of all the donors because of the transparency in work’ [International NGO, Interview 13]. The latter was related to the act of sharing information on the NGO’s performance with donors through some reporting procedures (International NGO, Interview 13).

The trust rendered the NGO-donor relationship flexible, as noted by a health project officer working in a French donor agency. She stated:

[Our donor agency] and NGOs have a relationship built on trust […], which made this relationship flexible… (International donor agency, Interview 24)

Thus, the trust that donors place in NGOs’ work is an important factor that affects the flexibility of NGO-donor coordination.

Regular coordination

The findings show that, during shocks, regular NGO-donor sharing of information on the emerging needs of targeted populations resulted in flexible NGO-donor coordination. For example, as a result of these shocks, donors increased the frequency of the cluster (or working group) meetings at the level of the health sector under the LCRP. A health officer working in one international NGO commented that, in shocks, ‘cluster meetings were happening weekly, bi-weekly, or monthly…’ (International NGO, Interview 25).

Furthermore, a health project officer working in a French donor agency highlighted that the ‘context imposes changes that require modifications to original projects’. She further said that it is for this reason that the donor agency maintains ‘regular coordination with the NGOs so that they can introduce modifications, changes in budgets, changes in their work at the level of PHCCs…’ (International donor agency, Interview 24). As a result, this coordination allowed the donor to be close to the field of work and to NGOs, which facilitated the flexibility in coordinating with these NGOs (International donor agency, Interview 24). The findings further highlight that NGOs and their donors can coordinate informally. A project coordinator working in an international NGO said:

We always feel that (our donors) are with us on the field. We send them regular reports, not always very formal. It can be a random informal email… (International NGO, Interview 2)

This informality can add more flexibility to NGO-donor coordination, allowing donors to quickly meet with NGOs when faced with problems on the ground (International NGO, Interview 2).

Therefore, as a result of regular NGO-donor coordination, this relationship can become more flexible. The informality in this relationship can also increase its flexibility.

Donors’ efforts to listen to NGOs’ needs

During the interviews, two participants further expounded on donors’ willingness to listen to NGOs’ needs during shocks. For example, a health project officer working in a French donor agency stated that, through coordination, ‘[this donor agency does] listen, and is flexible’ (International donor agency, Interview 24). This coordination involved sharing information on NGOs’ needs, and happened through human interaction and socialisation processes (eg, meetings, field visits, joint health events, trainings or capacity building sessions provided by donors, emails and phone calls).

Furthermore, a monitoring and evaluation officer working in an international NGO stated that, during COVID-19 and the Beirut explosion, the NGO shared information with donors that revealed that the ‘needs on the ground are different and that [the NGO] needs to change its operations to ensure that the project is responding to these needs’ (International NGO, Interview 1). This participant linked this flexibility in NGO-donor coordination to the efforts of the NGO’s donor to listen to the NGO’s needs (International NGO, Interview 1).

Accordingly, NGO-donor coordination can also be considered flexible when donors listen to NGOs’ needs during shocks.

Flexible NGO-donor coordination and its contribution to NGOs’ resilience capacities

This section analyses how the flexible NGO-donor coordination enhances NGOs’ resilience capacities. It explores how this relationship enables NGOs to improve their absorptive capacity, and facilitates the emergence of new adaptive changes, contributing to the overall resilience of the health system.

Enabling flexible funding adjustments for the implementation of NGOs’ activities

The findings indicate that flexible NGO-donor coordination allowed for flexible funding changes in response to shocks. For example, a project coordinator working in an international NGO mentioned that ‘[…] if [the NGO wants] to request changes in budgets, it takes months for the request to process. […]. [The NGO has] to provide so much data explaining why this change is required’ (International NGO, Interview 2). However, after shocks, such as COVID-19, the donors became ‘more easy going in their NGO-donor coordination…’ (International NGO, Interview 2). This flexibility in NGO-donor coordination, which enabled flexible changes in funding allocation, allowed the NGO’s donor to respond faster to changes in projects. Consequently, the NGO was able to organise its activities. For example, the NGO used its existing processes to offer psychosocial support to people in need to absorb COVID-19 (International NGO, Interview 2).

Furthermore, during Lebanon’s political and economic crisis, the flexible NGO-donor coordination allowed a French donor agency to quickly change some of its priorities and provide fuel funding to support NGOs. As the crisis worsened and the local currency devalued, NGOs funded in Lebanese pounds faced budget constraints. However, due to the flexible NGO-donor coordination facilitated through WhatsApp, this donor agency adapted by allocating additional funds for fuel to NGOs, enabling them to continue operating through their established organisational processes. This allowed the NGOs to absorb the shock (International donor agency, Interview 24).

The findings also uncover that a flexible NGO-donor coordination enabled funding adjustments, helping NGOs to incorporate new activities that responded to shocks. For example, during the Beirut explosion, a project coordinator working in an international NGO mentioned that, due to the flexible NGO-donor coordination, the NGO was able to include food distribution activities in its work to respond to this shock. When the NGO coordinated with its donor to submit a revised project proposal that included these new activities, the donor approved, reallocating part of the budget for food distribution (International NGO, Interview 2).

Another international NGO also coordinated with its donors to include a response to the Beirut explosion in its proposal, after this shock happened. Through flexible coordination, these donors approved this proposal so that the NGO can introduce new activities and make the necessary organisational adaptations to deliver PHC services. A senior health officer working in this NGO said:

The Beirut explosion was not a part of the proposal. However, donors knew that we could respond immediately in terms of activities, staff recruitment, etc. (International NGO, Interview 27)

Therefore, the flexible NGO-donor coordination, allowing for flexible funding changes for NGOs’ activities, helped NGOs organise their operations and introduce new organisational adaptations to address shocks in the short-term. This led to improved NGOs’ absorptive and adaptive capacities during shocks.

Enabling flexible changes in the focus of NGOs’ activities without funding adjustments

Four participants mentioned that, in cases where no budget changes were required for NGOs’ activities, flexible NGO-donor coordination provided flexibility in the way NGOs implemented their work. This happened when some NGOs wanted to change the focus of their activities to respond to shocks. For example, a health and protection focal point working in an international NGO highlighted that, due to the flexible NGO-donor coordination, both actors were able to negotiate the geographical focus of the NGO’s activities to address the Beirut explosion. Consequently, these activities shifted from being implemented in the Akkar region to being implemented in Beirut (International NGO, Interview 18).

Thus, this flexible NGO-donor coordination helped NGOs to make new organisational changes to adapt to shocks. A health project officer working in a French donor agency said:

Coordination provides NGOs with the flexibility to respond quickly to emergent needs. They know that, whenever there is an urgent need, [the donor agency] is willing to respond to these needs in the best possible way for the project. (International donor agency, Interview 24)

The flexible NGO-donor coordination also allowed NGOs to change the target of their activities to better serve their beneficiaries. For example, during the Syrian crisis, an international NGO had flexible coordination with its donor, which facilitated the NGO’s ability to shift its focus from solely assisting Syrian refugees to also supporting vulnerable Lebanese. This allowed the NGO to adapt to shocks (International NGO, Interview 2).

Hence, in cases where no funding changes for NGOs’ activities were required, flexible NGO-donor coordination helped NGOs to make new organisational adaptations to deal with shocks, by allowing for flexible changes in the focus of NGOs’ activities. This coordination improved NGOs’ adaptive capacities.

Based on the above, this research showed that flexible NGO-donor coordination enhanced NGOs’ absorptive and adaptive capacities in shocks, by allowing for flexible implementation of NGOs’ activities. The link between the adaptive and absorptive capacities of NGOs to respond to shocks and their contributions to health system resilience is elaborated on in the following discussion.

Discussion

While NGO-donor coordination allows NGOs to work on the basis of clearly defined aims, objectives and outcomes, the findings highlighted that the flexibility in this relationship is crucial to enhance NGOs’ resilience. Specifically, the findings showed that flexible NGO-donor coordination enhanced NGOs’ resilience by enabling them to implement their activities flexibly. This is through flexible funding changes for these activities. Furthermore, the findings showed that flexible NGO-donor coordination helped some NGOs to adjust funding for new activities addressing shocks. Building on the work of some authors, such as Valters et al53 and Desai et al54, these findings underscore the importance of flexibility within budgets to support humanitarian and development activities. They highlight the importance of flexible NGO-donor coordination in enabling such a flexibility, which improves NGOs’ resilience capacities.

To further elaborate, the findings suggest that donors, despite their work to ensure that implementation proceeds in accordance with their objectives,55–57 can still provide flexibility in NGO-donor coordination.57 In this regard, there is a need to move away from rigid financial procedures in terms of ‘limited, logically framed, measurable outcomes favoured by many donors’,58 which can limit the flexibility of NGOs in implementing their activities and their resilience. This goes counter the commonly perceived effects of upward accountability reporting requirements that often seem inflexible and hardly provide a space for NGOs to report their views and experiences on the ground. In other contexts, the literature showed that inflexible funding mechanisms during the Ebola epidemic in Sierra Leone limited NGOs’ capacities to be resilient. This is because donors were overly prescriptive regarding how funds should be spent.59 Donors should be encouraged to work towards flexible funding arrangements,60 through flexible NGO-donor coordination. This flexibility helps NGOs navigate unforeseen issues during shocks, improving their resilience and, subsequently, health system resilience.61 This alleviates the challenges NGOs face in meeting donor expectations, allowing them to prioritise enhancing their resilience capacities over strict reporting requirements.55 56 62 63

Recent studies during COVID-19 documented that some donors have shown efforts to support flexible funding arrangements that can accommodate changes in NGOs’ projects to meet needs during shock.64–66 For example, donors, such as the European Civil Protection and Humanitarian Aid Operations, have encouraged flexible funding models allowing for adaptations to existing cash programmes.66 A study on cash assistance to address COVID-19 in Jordan noted that some donors were flexible, by allowing NGOs to make their own decisions on how best to adapt-related programmes and creating budget flexibility (eg, creating new budget lines and flexibility in reporting timelines).65 In a study on multipurpose cash assistance programmes in Lebanon, NGOs that implemented these programmes mentioned that their donors showed flexibility in payment modality and targeting criteria, enabling coverage of newly vulnerable populations.64 In Nigeria, the flexibility between some NGOs and their donors allowed these NGOs to make new organisational changes, such as purchasing face shields and gloves, enhancing their resilience capacities during the shock.67 However, while these studies explored the flexibility of donors and NGOs in their work, they did not specifically investigate the flexibility in NGO-donor coordination and its contribution to NGOs’ capacities. The findings make a valuable contribution in this area.

Furthermore, the findings uncovered that flexible NGO-donor coordination also helped NGOs to make new organisational adaptations to deal with shocks, even when funding changes for NGOs’ activities were not required. This was through allowing for flexible changes in the focus of NGOs’ activities. For example, flexible NGO-donor coordination allowed NGOs to change the target of their activities to serve their beneficiaries’ needs. These findings support the argument put forth by Scholten et al68 that flexibility in the work of organisations necessitates flexibility in coordination, particularly for those operating in constantly changing environments. Moreover, flexible NGO-donor coordination that enables flexible changes in the focus of NGOs’ activities signifies a departure from donor models, which were termed as ‘silver bullets’.69 These models are derived from best practices implemented elsewhere.70 71 They are about replicating or scaling up standard interventions, criticised for overlooking the local context.60 In this view, NGO programmes involve a ‘predictable range’ of activities that vary little by organisation or sector or country.69 72 73 Rather, the flexibility in the NGO-donor relationship responds to calls for a fundamentally different approach to development that is more flexible, allowing NGOs to expand their impact.69 Due to this relationship, NGOs can better adapt to the specific beneficiaries’ needs and expand their impact beyond interventions that may fail to consider the local context. By becoming more flexible, NGOs are also more able to innovate. Banks et al,69 perceive NGO innovation as crucial to their effectiveness.

Therefore, such flexibility in NGO-donor coordination enhances the capacities of NGOs to absorb and adapt to shocks, which are resilience capacities contributing to health system resilience. In other words, since NGOs are a subsystem of a larger health system, enhancing their adaptive and absorptive capacities contributes to the resilience of the broader health system.

In addition to the above points, the findings revealed that the flexibility in NGO-donor coordination was related to three key factors. First, the findings highlighted that the flexibility in this relationship was a result of donors’ trust in NGOs’ work. The findings are consistent with Keating and Thrandardottir’s13 research that showed that donors with prior experience working with NGOs were more likely to trust them, and that those who had information about the work of NGOs were more inclined to view them as trustworthy. In contrast to Zoraster’s74 argument that states that trust is an indirect output of NGO-donor relationships, the findings align with the conclusion of several studies indicating that trust enhances coordination.75 76 The findings further contribute to this body of knowledge, by demonstrating that trust not only enhances NGO-donor coordination, but also leads to flexibility in this relationship. Second, the findings highlighted that flexible NGO-donor coordination also emerged from regular coordination. Third, the findings demonstrated that the flexibility in NGO-donor coordination happened when donors listened to NGOs’ needs in shocks, through NGO-donor information sharing. This aligns with Uddin and Belal’s77 argument that donors can be flexible by listening to NGOs’ challenges. A similar finding was reported in a study in Myanmar, highlighting that NGOs’ donors listened well to NGOs’ needs, fostering good NGO-donor relationships.78

Conclusion

This research uncovered that the flexible NGO-donor coordination enhanced NGOs’ resilience in shocks, thereby contributing to health system resilience, by enabling flexible implementation of NGOs’ activities. This flexibility in NGO-donor coordination was influenced by donors’ trust, regular coordination and donors’ efforts to listen to NGOs’ needs.

The findings challenge the discussions on the mainstream approach to development planning. As explained, the latter revolves around inflexible donor funding models and project requirements, which result in rigid NGO-donor coordination, leaving little room for NGOs to be flexible and respond to shocks. Instead, the findings expand on existing debates on how to best tailor development projects. They are in line with the calls for new and more flexible approaches to development,68 69 79 80 and the call for flexible donor approaches to strengthen resilience.80 In this view, the findings underscore the need for donors to embrace flexible NGO-donor coordination to enable NGOs to implement development and humanitarian projects with flexibility, whether at the national and local levels in Lebanon and globally, equipping them with the capacities required to enhance health system resilience.

While the outcomes of aid interventions are context-specific, this research’s findings inform the planning and implementation of these interventions that need to consider the specific configurations of NGO-donor relationships, such as coordination, in health systems that largely involve NGOs. Further research on NGO-donor relationships in other privatised systems that include NGOs can enhance the understanding of how these relationships play out to contribute to health system resilience.

Limitations

There are some limitations related to methodological issues in using thematic analysis, which affected research quality. The intent of this analysis was not to generalise findings, but to collect data for an in-depth exploration of the research question. Validity and reliability need to also be acknowledged.81 However, these concepts are not viewed similarly by qualitative and quantitative researchers. From the qualitative researchers’ perspective, reliability and validity are framed as ‘trustworthiness’, ‘credibility’, ‘applicability’ and ‘consistency’.82

  • Trustworthiness: The thematic analysis was clearly explained, allowing readers to follow the analytical process and its rationale.

  • Credibility: Credibility was ensured through a thorough description of the interpretation process. Furthermore, using a reflexive lens, it is important to draw attention on the positionality of the researchers and how this influenced the research. The researchers’ positionality as Lebanese facilitated a shared understanding with participants about Lebanon’s context, influencing the way the researchers understood and analysed the data.

  • Consistency: Consistency of the results is the criterion for assessing the reliability of the research. In qualitative research, reliability pertains to factors such as familiarity with the research, sufficient data collection as well as reaching data saturation to answer the research question, constructing relevant themes, making logical links between the themes and the research question and providing evidence allowing the reader to form an independent assessment of the findings, all of which were addressed in the methodology.83

  • Applicability. A criterion of applicability is when the findings of a research can fit into other contexts.82 As discussed above, the research’s findings are useful in other contexts.

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