Resilience Without Foundation? Interrogating Health System Governance in Shaping Health System Resilience in Haiti – A Qualitative Study of Stakeholders’Perceptions

St Louis, Patricia; Bigdeli, Maryam; Paul, Elisabeth

Resilience Without Foundation? Interrogating Health System Governance in Shaping Health System Resilience in Haiti – A Qualitative Study of Stakeholders’Perceptions

Articles in Press

Document Type : Original Article

Authors

Patricia St Louis

Maryam Bigdeli

Elisabeth Paul

Research Centre on Health Policies and Systems - International Health (Polissi), School of Public Health, Université Libre de Bruxelles, Brussels, Belgium

Abstract

Background
Health system resilience (HSR) is a priority in Haiti, one of the world’s most fragile and poorly governed countries. It depends on the capacity of communities, institutions, and actors to anticipate, absorb, and adapt to shocks. Health system governance (HSG) – policy processes, institutional arrangements, and stakeholder relations – is a core determinant of HSR. This study examines how health system stakeholders in Haiti understand HSR and the role of HSG in shaping it.

Methods
We conducted an exploratory qualitative study using semi‑structured interviews with 15 strategic decision‑makers, senior and operational managers, and healthcare providers in July 2023 in Port‑au‑Prince and Southern Haiti. Participants were recruited through purposive and snowball sampling. Data were analysed thematically, combining deductive codes from HSR frameworks, with inductive identification of emerging HSG themes. Social contract constructs identified in participants’ accounts informed the application of a social contract lens as an ex post interpretive framework for discussion.

Results
Participants framed HSR as a collective political commitment to health systems strengthening (HSS) and advancement of an integrated health and development approach, rejecting interpretations that shift responsibility onto communities. HSG was considered foundational to HSR, with three interdependent dimensions emerging from analysis: organisational‑structural, politico‑institutional, and ethical‑citizen. Weaknesses across dimensions—including weak planning capacity, constitutional ambiguities, budget opacity, donor‑driven power asymmetries, inequitable access, limited accountability, and legitimacy gaps—were mutually reinforcing. Trust emerged as a cross-cutting determinant.

Conclusion
From a social contract perspective, coherence across HSG dimensions rather than adherence to isolated principles appears to be a key condition for HSR in Haiti. Strengthening institutional capacity, credible planning, and legitimacy require simultaneous actions across these dimensions. Provider-community trust constitutes an HSG resource on which to build. Despite the small sample and absence of community perspectives, the study offers a basis for further exploration in countries facing similar HSG challenges.

Keywords

Haiti

Caribbean Region

Health System Governance

Health System Resilience

Fragile State

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