Inclusion, power, and coordination: a relational analysis of health system resilience in fragile and shock-prone settings

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Health systems in fragile and shock-prone settings face recurrent crises that challenge their ability to sustain essential services. While governance inclusion is frequently cited as a key determinant of health system resilience, empirical evidence on how inclusive governance shapes adaptive capacity in practice remains limited.

This paper presents a secondary, cross-country analysis of qualitative and relational data from Lebanon, Myanmar, Nepal, and Sierra Leone. Drawing on relational sociological approaches, we analysed stakeholder configurations, coordination practices, and decision-making processes using a combination of retrospective and participatory social network analysis, cognitive network mapping, and mixed-methods stakeholder evaluation.

Across all sites, governance inclusion enhanced resilience conditionally, not as a normative attribute of governance arrangements but through specific relational mechanisms. Analysis revealed how power operated through the capacity to convene, broker access, and include or exclude actors from coordination spaces. Where spaces were conducive to inclusion and exclusionary practices were challenged, stakeholders more easily distributed roles and leadership functions in times of shock, and were able to mobilise diverse resources. Learning-oriented platforms supported gradual relational reconfiguration in some contexts, while political instability and risk constrained inclusion in others.

These findings suggest that health system resilience is produced through contextually grounded relationships rather than structures alone. Governance inclusion strengthens resilience when it expands relational access to coordination and decision-making, but may reproduce exclusion and concentration of power if not sustained or politically supported.

Suggested citation

Dakessian A, Arjal A, Regmi S, Khalil J, Yamout R, Kamara H, Osborne A, Idriss A, La T, Paing AK, Diaconu K, Inclusion, power, and coordination: a relational analysis of health system resilience in fragile and shock-prone settings, SSM – Health Systems, Volume 7, 2026, https://doi.org/10.1016/j.ssmhs.2026.100310.

Further information

This paper draws from the study Embedding Social Network Analysis in Health Systems Resilience Research