On the 11th March 2020 the World Health Organization (WHO) declared COVID-19 a pandemic.1 This resulted in nations taking drastic measures to break the chains of transmission for example by introducing global mobility restrictions which fundamentally disrupted travel and exchanges.2 The coronavirus pandemic pushed countries to their limits as they faced consequences impacting not only the health system, but society as a whole. The virus suddenly changed the way of living, of learning, of working and surprised humanity with the magnitude of its impact.3 Global health partnerships were also impacted as travel was no longer possible, meetings and conferences were cancelled, and people were forced to work from home and online.
The importance of partnerships is highlighted by the Sustainable Development Goal (SDG) 174 with partnerships considered a powerful tool for capacity building, knowledge and experience sharing.5 The term “partnership” has increased in the field of Global Health6 and can encompass a wide variety of collaborations. The “partnership” literature focuses mainly on defining the term partnership and providing recipes to ensure successful collaborations.7–9 Mattessich et al.7 describe partnerships as a “collaboration is a mutually beneficial and well-defined relationship entered into by two or more organizations to achieve common goals. The relationship includes a commitment to mutual relationships and goals; a jointly developed structure and shared responsibility; mutual authority and accountability for success; and sharing of resources and rewards”.7 The global pandemic severely disrupted the modus operandi of partnerships.10 The existing global health literature does not describe the impact of a crisis on existing partnerships rather focusing on two aspects: how to use partnerships to overcome the specific circumstances11,12; and the need for partnerships to adapt in times of crisis.13–15
This study aimed to explore the impact of the novel coronavirus on partnerships, using example of the activities from the Division of Tropical and Humanitarian Medicine (DTHM) at the Geneva University Hospitals (HUG) with the objective to learn from the COVID-19 crisis with a view of improving global health partnerships in the future.
METHODS
This study took a qualitative approach using Grounded Theory involving the application of inductive reasoning.
Context
The DTHM at HUG in Switzerland, has its core mission to “develop partnerships with local and international organizations, favoring an interdisciplinary and interactive approach, to enable improving access to health taking advantage of the skills available at the HUG and engaging them in international activities”.16 This study included global health partnerships between the HUG and organizations in Bosnia-Herzegovina, Kyrgyzstan, Nepal, Peru and Ukraine. The chosen projects include various health-related focus areas from medical education reforms, community empowerment and prevention, to research projects on access to medicines. They also differ in the life span of the partnership between old collaborations (more than ten years) and brand-new ones (less than six months).
Recruitment & Data collection
For each project, one interviewee from the partner country and the other from the DTHM were purposively selected given their role and knowledge of a specific project. Some interviews were held online whereas others were held face-to-face. All participants were reached by email and provided written or verbal consent prior to collecting the data and all interviews were digitally recorded and transcribed verbatim for data analysis purposes. Audio files were immediately deleted once the study was concluded. For confidentiality, identifiers for each interview were developed with CH* (Switzerland) for DTHM colleagues and LP* (local partners) for foreign partners. All interviews were conducted in English and structured by a previously prepared interview guide in order to facilitate the discussion (Annex S1 in the Online Supplementary Document).
Data analysis
Themes were identified using an interpretive approach of Grounded Theory.17 During the interviews, memos, notes, reactions, ideas, or emotions were written down in a fieldwork diary. An iterative process was used to generate concepts for the emerging theory and verbatim were used for word-by-word analysis. Figures were produced to help understand and synthetize the result.
For the coding, ATLAS.ti18 was used for analysis. During the initial coding, many ideas were generated, these were then discussed between two of the authors to develop the analytical framework further. This research used grounded theory approach as described by Charmaz.17 For the second phase of the analysis, after some modifications in the coding, including the labelling and structuring of the data, a set of central themes were selected from the initial codes. The data was then categorized into different group of codes and subcategories, as described by Sbaraini,19 to show in a stratified way theoretically important concepts. This iterative process between the data and the analysis allowed visualizing possible relations and interactions between the categories.17
RESULTS
Interviews were conducted between February and March 2021. Five in-person interviews with DTHM colleagues and five remote interviews with the local counterpart from partner countries were carried out. All interviews lasted less than an hour.
The themes identified were hierarchically subdivided into three categories of codes. These include, as presented in Figure 1: redefining the way we work; the challenges encountered in this “new normal” situation and finally the lessons from COVID-19 and the possible changes for the future. To ensure understanding, each of them is divided into two subcategories.
Redefining “the way we work”
The theme of “Redefining the way we work” emerged as a core issue from the interviews. What is seen with the emergence of COVID-19, is that the way of working suddenly became different, with the way of collaborating needing to be adapted or redefined. This theme comprises two sub-themes of “New working patterns and their impact” and “Relationship with partners”.
New working patterns and their impact
New working patterns emerged, including working from home and interactions going online. These new ways of working came with both positive and negative impacts for the interviewees. With home based on online work there was the need to define new flexible and adaptive ways to collaborate. Many interviewees mentioned the need to have well-structured online meetings (minutes taking, agenda setting) basic principles that were not always undertaken before COVID-19 [CH2]. All interviewees mentioned that during COVID-19, organization and recurrent communication among partners became fundamental to ensure proper follow-up of the projects. Some interviewees even stated that these new ways of collaboration appeared as beneficial to the development of the partnership and the implementation of the project [CH2, CH4].
The transition period of adaptation to this new situation was longer for some projects than others. Some had a hard time adjusting to the new reality. In parallel some had a hard time realizing that the situation was going to last for a long period of time and preferred to wait a couple of months before switching to a new mode of operation [LP1]. On the other hand, others acted immediately based on pre-existing and developed emergency back-up plans.
“We produced a contingency plan with the adjusted activities, with the plan how the team shall function in a crisis like this one or in all other disasters or catastrophe. In terms of who does what, who replaced whom, who takes over from whom in case any of the team members were ill.” [LP3]
For this project a contingency plan had been previously prepared in case of a crisis and was adapted to the COVID-19 context. This allowed a clear analysis of the situation and a better anticipation and response to various scenarios. Almost all interviewees at some point had to go through their project’s action plan and make modifications. Some projects looked at what could be implemented even with COVID-19, activities that had to be postponed and those elements which would probably not be accomplished [CH4]. The changes and adaptations made to the collaboration and in the implementation of the projects was possible due to certain elasticity from all counterparts as reflected by LP4 in the next quote.
“[…] Well no one could foresee this and we are all together now in this, so we have now to deal with this together and have understanding that probably not everything works as perfect as planned but also to be creative and find ideas together.” [LP4]
The advantages of these new working patterns were clearly perceived: spending more time with the family, spending less money for transportation, and gaining from less travel time [LP4, CH1, LP1]. CH5 stated that, “I think worldwide it’s more efficient to have teleworking because actually I work even more hours - I am not distracted.” CH5 also added, "I think I prefer to go to the office, even when I spent more time going from home to the office, but after one year or more to be at home [I realized] you need interactions and to see other people."
The aspect of missed interactions with colleagues was also seen as a negative impact. This was mentioned by LP3 stating that working away from colleagues impacted the “Team Spirit”. LP4 describes missing the “human touch” and "brainstorming together in a nice atmosphere instead of sitting in front of your computer the whole day."
The interviewees not only reflected on the flexibility of the different partners, but also that of the donors who accepted delays, extensions, and alterations to the agreed plan of operations.
Relationship with partners
Relationships with partners before and during the pandemic impacted “the way we work” as well as being impacted by new working patterns. Overall interviewees stated that during the COVID-19 pandemic, deeper and stronger relations were created due to the concern and caring between partners.
In defining what factors meant having a good relationship with their counterparts, the interviewees mentioned several recurring words: Trust, Communication, Mutual Understanding, Support, Transparency and Friendship. With the emergence of this crisis, more frequent and personal interaction was perceived as essential.
"Well there were changes, but changes for the better, because we see each other more [through online tools] and work even closer and more intensively. […] And especially with COVID-19 that cooperation became more close, it is much closer than before." [LP3]
During these uncertain times more frequent dialogues took place and went beyond operational talk but more towards personal and friendship relations to show support to the local partner and vice-versa. CH3 describes how meetings started with both an update on the epidemiological situation as well as checking the partners’ well-being.
“We were doing a lot of COVID-19 update, because it was difficult for us in Switzerland to know…we could see numbers, but we didn’t really know what was the situation [there]. So we always started our meeting with a COVID-19 update […] making sure that they were okay, and they were also making sure we were okay so that’s when I felt we were closer and really felt like a small team.” [CH3]
Many interviewees saw their partnership during COVID-19 as “going together and helping each other” [LP5, LP4, CH1] and especially because of the epidemiological difference among countries, brought partners to need for different sort of support, e.g. emotional, financial, material, psychological, and so on.
“[A good partnership] it’s being loyal and supporting, and at the same time…when it comes to difficult situations, also to feel that there is someone who can jump in and support in that situation, give you some ideas, or give any advice, expertise, experience.” [LP4]
Furthermore, experiencing fear, illness, or death in the teams or among relatives resulted in this crisis being more personal and resulted in closer ties between partners.
Challenges of the “New Normal” situation due to COVID-19
The “new normal” implied adapting to the “COVID-19 reality” which brought challenges to the projects’ operational plan requesting shifts in priorities and following new opportunities. The other subtheme that emerged relates to the challenges encountered with online communication.
Operational Shifts of Priorities
Due to COVID-19, operational changes were inevitable in order to adapt to the emergency situation. Some interviewees stated that the projects they were working on immediately recognized the long-term effect that the virus would have and that it would become a global concern [CH2, CH4, CH5]. However, it was also mentioned that many of the projects and collaborations could continue to move forward in their implementation of their operational plan, but that this would require a different pace and approach. Even if the adjustments remained difficult at the beginning, the different projects seemed not to have suffered from this new environment and found ways to adapt their initial ambitions as stated by CH1.
“I think… if you take a strict view, you know, when we wrote the proposal and our activities for 2020, did we do what we said we would do? No! But I wouldn’t say that the project suffered, in terms of achievements, in terms of moving things forward, I think things moved forward.” [CH1]
The virus complicated the implementation of activities, especially due to the diverse health-related measures applied within and in between the countries and the global lack of unity towards the COVID-19 response action, as it can be grasped from the following quote.
“Well it was not easy because we had not the same measures there and here at the same time, so when they were in lockdown we were not and vice-versa, so it was not always easy I guess to align availability and objective.” [CH3]
In all the projects discussed by the interviewees, many activities were cancelled, put on hold, transformed to an online mode or the resources were shifted towards other priorities. A lot of trainings, meetings and big events that were planned face to face, were reprogramed online via available communication tools. LP4 describes how activities were adapted to the priorities of this new “normal” situation. Organizational challenges were encountered while redefining priorities, but almost all partnerships shifted some activities to contribute to the fight against COVID-19. Some provided Protective Personal Equipment (PPE) to their main local partners, others followed creative alterations by creating a Call Centre employing freshly trained medical students to provide assistance in the COVID-19 response or used a previously established network for end-of-life care activities shifting it to home visits for COVID-19 patients. Likewise, many projects supplied Telemedicine equipment to enable communication with remote regions and to avoid an interruption of training activities.
Online Communication Challenges
When COVID-19 emerged, the world rapidly shifted to online interaction, however some new challenges appeared. Technical and digital issues were widely encountered and were the downside of online communication. This new way of interaction widened the generational divide and caused some difficulties in the establishment of new partnerships.
The various technical issues encountered created strong disenchantment of online meetings, especially from the local partners’ view. For others, it became more complicated to reach their partners. Reasons presented by the interviewees were either because remote areas had internet connectivity limitations, or stakeholders such as ministries being reticent to use some of the popular communication channels or due to insufficient computer literacy. Lack of capacity in using online tools was sometimes perceived as a generational gap but even more as a lack of training from institutions [LP4]. Another “technical” challenge was working the whole day behind a computer leading to “screen tiredness” [CH1].
For new partnerships the use of these tools sometimes hampered communication and interactions as there had never been an in-person interaction. Among all interviewees there was a consensus that online communication is easier once you know each other well.
“If you work with people you know, and that you have been in touch for quite a long time, it is quite easy even in the distance to interact. With somebody new, you have never met in person, it becomes much more difficult.” [CH4]
LP4 adds that “it would have eased the process if they would have met the people directly.” [LP4]
Lessons from COVID-19: Changing the way of working in the Future
Some advantages of new working patterns became apparent through the adaptations needed to continue the partnership during the COVID-19 pandemic. The COVID-19 crisis taught the interviewees ways to “re-think” the means of collaboration and showed possible fields of improvement for the future of global health partnerships.
The Future of on-site visits
Travel for on-site visits is a key component of any project. On-site missions, as expressed by CH4, are often required to understand the local context where the project is being implemented, to understand the political and economic environment, to sense the team spirit and to feel the “temperature” of the different stakeholders, as described in the following quotes.
“You know there are a lot of things that you feel rather than you read.” [CH4]
“For the new project it is quite challenging because I have never been there so you need at least once to go there, to meet the people, to go to the field, to get the feeling.” [CH5]
Being constrained to work remotely and postpone missions during more than a year, because of COVID-19, raised the issue of the time and cost efficiency as well as the debate of the environmental impact of such travel. Many of the interviewees, realized the impact all these travels have from an environmental, cost and time perspective [LP4]; [CH1].
According to the interviewees’ statements, it was important to think twice if travelling was indispensable or if this visit could be done remotely. Almost all interviewees recognized that “at different stages of developing a project and partnerships, that lack of interaction is difficult” [CH1]. Both LP4 and CH1 highlight the importance of the in-person interactions at the early stage of the project, and beyond the initial phase; CH5 defines critical stages where on-site presence is crucial.
“So I think really critical stages of a project is the beginning of a project, then it’s about at mid-term evaluation when you need to decide at which way you need to go and then you need to talk with stakeholders, […] you need to know your local partners to be able to advise, if you don’t know them really you have to rely on second-hand information and it can get very challenging.” [CH5]
The Future of Online Interactions
This sub-theme is about future of online interaction considering the great progress of the virtual world. The availability and use of online communication tools allowed the partners to continue the daily work-related activities. Many advantages and opportunities are described by the participants of online interactions. For example, the projects which had training programs, events, or even research studies were able to reach a higher number of participants since access and capacity was increased due to the use of online tools. “It would have been absolutely impossible to have this audience if it was a live event.” [CH2]
Another perceived advantage was that by being in different time zones there was now the possibility to work almost twenty-four hours a day with partners across the globe. Some saw working across different time zones as a disadvantage stating that if you have more than three or four time zones it becomes very difficult to organize a meeting even online. Beyond these logistical challenges many interviewees reported a certain lassitude towards online meetings. The process of organizing an online meeting and inviting a person to join virtually is so easy, that the number of individual invitations became overwhelming and more time-consuming than in-person meetings. This was especially true when it involved time zones which required meetings at night or in the early morning. Aligned with the discussion about how travel for projects might change in the post-COVID-19 era, and that some travel might be necessary at key moments in a project, interviewees all highlighted that online interactions did not entirely replace the long-standing in-person contact and that online tools did not enable formal and informal discussions to take place.
“The corridors talk… the things you would say around a drink is obviously not the same as what you’re gonna share during the Video Conference, I think there are informal moments that are also extremely valuable. That’s why I think it cannot…whatever the quality and the structure of the VC [Video Conference] tool, it cannot fully replace direct interpersonal relationships that are of creating importance.” [CH2]
An additional aspect mentioned in the interviews, is that the lack of informal discussions that can only really happen in person may also result in less opportunities for networking, which is central for partnerships [CH1].
DISCUSSION
This study aimed to explore the impact of the COVID-19 on partnerships, using example of the activities from the DTHM at the HUG. This was achieved through a qualitative analysis with the objective to learn from the COVID-19 crisis with a view of improving global health partnerships in the future.
Exchanges through in person visits between partners is an integral part of most projects. However, the COVID-19 situation due to travel restrictions, forced partners to find new ways of collaborating mainly using online tools. In thinking about this new online way of working the interviewees mention both positive and negative elements of this. These range from technical issues around internet connectivity to enabling events to reach larger audiences as geographical access was no longer a problem. Other issues are related to “online” fatigue as well as a generational gap in the use of these technologies. The COVID-19 situation also led to reflections by the interviewees on the cost, time, and environmental impacts of online working. However, most stated that nothing could replace in person interactions and that these were key at different phases of the project. Beyond its impact on communication and interactions, COVID-19 also required immediate changes in the working patterns such as home and online working. Other subconscious changes happened naturally to adjust to the new reality, such as changes in behavior and in the interactions with partners, increasing the “caring” aspect. The operational plan of projects had to be modified and the priorities were shifted and more adapted to the COVID-19 response. Since everyone was in the same COVID-19 situation, these changes were empowered by the global phenomenon of “understanding” and “flexibility” of donors and partners.
In describing the need for partnerships to adapt to a potential complex situation, Emerson et al.13 present adaptation in two ways. Firstly, as a “direct response to the perceived effectiveness of actions and impact (e.g., leading to a new charge or mandate, the addition of new stakeholders, a new round of knowledge generation or resource leverage, or the decision to disband the collaboration)”. This can be seen as internal to the project or partnership. The second way, can be seen as adaptation to an external change in the environment where the partnership is operating. In this study, both direct and indirect types of responses were observed. Adaptation to the new normal situation, shifting the operational priorities towards COVID-19 response. Then, through the changes in the working collaboration and relations with the partners. However, as presented in Figure 2, this view of “adaptation” focuses on the short-term feature of a crisis, which implies a return to normal afterwards, and often only presents the impact on the “Southern” partner of this disruption. The partnerships used as case studies in this paper faced such disruptions in the past, with for example, political instability in Kyrgyzstan or in Nepal after earthquakes. These impacts were unilateral, only impacting the partner country and were also “short” in duration, with a return to normal afterwards. Therefore, the concept of adaptation does not entirely serve the cause for COVID-19 due to two factors. Firstly, with COVID-19, “everyone is on the same boat” [LP4]. The impact of this crisis was felt by both partners, as they experienced mobility restrictions, knew someone who got sick and all had disruptions to their daily life routine. In addition, COVID-19 resulted in a long-term crisis with the impacts continuing to persist and induce systemic changes. Therefore, the model of adaptation to a new “normal” situation seems inadequate for COVID-19 and strives for rethinking the partnerships in order to build back better rather than going back to normal. This concept of “building back better” has become a motto for the post-COVID-19 era. Despite having had an immeasurable human and social toll, some positives can be seen from these interviews with regards to global health partnerships and the COVID-19 pandemic. One of these was the strengthening of the bond between partners due to the global pandemic, which learned that in order to be able to confront the crisis, to allow partnerships to survive, strong relations6,9 are needed for a solid base. Also given the online tools available, the transition to online work was made possible, which a few years ago would have been inconceivable.20,21 Therefore, an investment in technologies is favored in this new modern world to ensure continuum of communication and activities anytime.22–24 Specifically for the DTHM the changes that have been implemented relate to the use of online communication tools, more structured online meetings which have replaced some in person interactions, and more targeted travel to partner countries. These changes will require ongoing assessment to see the long-term impact of the ways partnerships operate in a post-COVID-19 environment.
Building off of Holloway’s description of limitations in Qualitative Research,25 one of the prevailing limitations in this study is the selection of the interviewees. The sampling has been purposively based on a non-random criteria. Another limitation was that the main researcher was part of the DTHM team and knew some of the local partners personally. Furthermore, selecting the study population may introduce unintentional bias in the data collection and contextual limitations may arise due to the different cultures between the researcher and the interviewees. As the interviews were carried out in English, this meant only English-speaking colleagues were included. In addition, English is not the mother tongue for most of the participants, which may have led to some misinterpretation or imperfect responses. Additionally, the HUG is a recognized institution and known to be the source of funding for many projects, which may have led the local partners to answer in a biased manner and not fully disclose their true opinions and feelings. The analysis of the data was carried out by MG with support from DB and FC. All three of these individuals represent the “Swiss” side of the COVID-19 story and thus may not fully capture the experiences of counterparts in other settings.
CONCLUSIONS
As stated by one of the interviewees: “I mean working in Global Health…I need partners and countries that I can work with and trust, right? And I think 2020 showed how you, as a global health researcher need to potentially re-think certain things but still move forward” [CH1]. This quote underlines the importance of rethinking models of collaboration and even during such global disruption, not pausing the momentum of development.
Many sectors were impacted by COVID-19 and global health partnerships and projects were not spared. Given the far-reaching implications of the COVID-19 crisis rather than adapting to the crisis the interviewees describe a “redefining” of their approaches. With the notion of “building back better” being the ideal post-COVID-19 scenario, by considering partnerships there is the need to move away from the concept of adaptation to one of rethinking partnerships because of the fundamental changes that COVID-19 brought about. This change of paradigm, will enable us to build back better and modify the way partnerships work for improved global health.
Acknowledgements
Special recognition is given to all the in-country partners of the Division of Tropical and Humanitarian Medicine (DTHM) for their invaluable contributions to this research.
Ethics statement
Not applicable.
Ethics clearance was not sought as: all data was completely anonymous with no personal information being collected (apart from their name and their publicly available contact details). All participants provided written or verbal consent prior to collecting the data. Furthermore;
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The data is not considered to be sensitive or confidential in nature
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The issues being researched are not likely to upset or disturb participants
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Vulnerable or dependent groups are not included
For data protection purposes, the interview includes an audio recorded conversation provided the transcript is fully anonymized, the recording was then deleted.
There is no risk of possible disclosures or reporting obligations for research involving interviews with participants on subjects deemed to be within their professional competence and the subject matter is limited to topics that are strictly within the professional competence of the participants.
Disclaimer
The authors are members of the DTHM and paid by the Geneva University Hospitals for their involvement in the different activities described in the manuscript.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Funding
This research received no external funding.
Authorship contributions
MG analyzed and interpreted the participant’s data. DB was a major contributor in writing the manuscript. FC contributed in revising and correcting the manuscript. All authors read and approved the final manuscript.
Disclosure of interest
The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.
Additional material
This article contains the following additional information as Online Supplementary Document: The interview guide.
Correspondence to:
Marina Giachino
Division of Tropical and Humanitarian Medicine, Geneva University Hospitals
Rue Gabrielle-Perret-Gentil 6, CH - 1211 Genève 14
Switzerland
[email protected]