Beyond Hardware: The role of NGO-Public-sector relationships in strengthening fragile health systems: A case study of Zimbabwe
1
Health Policy and Systems Division, University of Cape Town, Cape Town, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1784
ABSTRACT
BACKGROUND:
Most NGO-led health systems strengthening (HSS) efforts in fragile and conflict-affected states (FCAS) have focused on hardware components such as infrastructure and financing. However, persistent weaknesses, compounded by COVID-19 and shifting donor landscapes, undermine these investments and threaten sustainability. Software components—relationships and power—are critical to system functioning, yet their role in achieving HSS goals of sustainability, resilience, learning, and integration remains underexplored. This study examined NGO–public sector relationships in Zimbabwe to generate empirical evidence linking relational dynamics to implementation outcomes in FCAS.
METHODS:
A descriptive multiple case study was conducted between 2022 and 2025 in two phases. Evidence mapping was combined with comparative case studies of NGO–public sector collaborations in HIV, MNCH, and vaccination programs. Time-series and thematic analyses explored how relationships influenced implementation outcomes.
RESULTS:
Contextual and historical factors shaped relational dynamics. Distrust stemming from unpaid MOHCC staff allowances compromised collaboration, while NGOs’ rigid compliance with donor requirements and contrasting mandates weakened system responsiveness. Centralized budget controls and fleet management protocols further constrained local autonomy, undermining decision-making during shocks. Conversely, cordial and mutually beneficial relationships fostered innovation and resilience. For example, prior to the Integrated Sample Transportation system, synergies between NGOs and MOHCC staff enabled efficient specimen transport.
CONCLUSIONS:
Findings highlight that relationships are not peripheral but central to sustainable HSS in FCAS. While relationships alone may not determine outcomes, they profoundly shape implementation practices that strengthen or weaken fragile systems. Intentional investment in relationship-building should be prioritized alongside hardware interventions to enhance resilience, continuity, and sustainability of NGO-supported initiatives.
Most NGO-led health systems strengthening (HSS) efforts in fragile and conflict-affected states (FCAS) have focused on hardware components such as infrastructure and financing. However, persistent weaknesses, compounded by COVID-19 and shifting donor landscapes, undermine these investments and threaten sustainability. Software components—relationships and power—are critical to system functioning, yet their role in achieving HSS goals of sustainability, resilience, learning, and integration remains underexplored. This study examined NGO–public sector relationships in Zimbabwe to generate empirical evidence linking relational dynamics to implementation outcomes in FCAS.
METHODS:
A descriptive multiple case study was conducted between 2022 and 2025 in two phases. Evidence mapping was combined with comparative case studies of NGO–public sector collaborations in HIV, MNCH, and vaccination programs. Time-series and thematic analyses explored how relationships influenced implementation outcomes.
RESULTS:
Contextual and historical factors shaped relational dynamics. Distrust stemming from unpaid MOHCC staff allowances compromised collaboration, while NGOs’ rigid compliance with donor requirements and contrasting mandates weakened system responsiveness. Centralized budget controls and fleet management protocols further constrained local autonomy, undermining decision-making during shocks. Conversely, cordial and mutually beneficial relationships fostered innovation and resilience. For example, prior to the Integrated Sample Transportation system, synergies between NGOs and MOHCC staff enabled efficient specimen transport.
CONCLUSIONS:
Findings highlight that relationships are not peripheral but central to sustainable HSS in FCAS. While relationships alone may not determine outcomes, they profoundly shape implementation practices that strengthen or weaken fragile systems. Intentional investment in relationship-building should be prioritized alongside hardware interventions to enhance resilience, continuity, and sustainability of NGO-supported initiatives.
| eISSN: | 2654-1459 |
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