The role of non-state actors in health system resilience: Exploring and developing their capacities in fragile and shock-prone settings

Non-state actors (NSAs), comprising a wide range of domestic and international organisations, are recognized to play an important role in fragile and shock-prone settings in particular, given the governance and resourcing constraints that these often face. However, their role in health system resilience is less examined. In this short report, we draw on a literature review and experience from research sites in four fragile and shock-prone countries to examine their strengths and challenges in contributing to resilience, and how their capacities could be built. We focus on domestic actors, including community leaders, informal providers, private for-profit providers, non-governmental (NGO) and civil society organisations (CSOs), as they are more embedded and able to respond during crises, as well as being less well described in the literature. We highlight the delicate balance between collaboration and competition in interactions between NSAs and governments, but also how NSAs may serve as the primary governance players and service providers in areas with limited statehood. Tapping into their strengths, which include local networks and trust but also the ability to mobilise resources from a range of sources, can be crucial in responding to shocks and stressors. However, risks also need mitigating, including duplication of effort, inequitable local power dynamics and unregulated provision. We conclude that governments and de facto authorities should recognise the critical role that NSAs can play in supporting health system resilience and have clear strategies for engaging them through structured partnerships and inclusive coordination mechanisms. • Non-state actors include a wide range of constituencies, including community leaders, informal providers, private for-profit providers, non-governmental organisations and civil society • They are sometimes neglected in public policy but can make a huge contribution to health systems, especially during crises and shocks • These groups can mobilise substantial social and financial resources, however, there are also risks, particularly in settings with weak governance • We offer insights on how to capitalize on NSA strengths for resilience while managing risks, for example through more structured partnerships