Antecedents to social-ecological resilience in local humanitarian supply chains: evidence from African cataract camps

The degradation of social and ecological systems has accelerated in recent decades, driven by a combination of human-induced climate change, biodiversity loss and increasing inequality (Forster et al., 2023; Hadjiat, 2023; Kohli, 2024). Extreme weather events disrupt access to critical resources (Alcántara-Ayala, 2025), compelling researchers, practitioners and policymakers to consider supply chain management’s (SCM’s) role in exacerbating or mitigating these challenges (Folke et al., 2016). In fact, there is an urgent need to move beyond traditional supply chain models’ focus on mere efficiency and robustness in times of crisis (Vega et al., 2023), to a new paradigm in which supply chains actively contribute to the restoration and regeneration of social-ecological systems (Gualandris et al., 2024). In humanitarian supply chains (HSCs), this evolution is already occurring (Altay et al., 2018, 2021). They are designed to address humanitarian challenges, often under extreme social or ecological conditions (Connelly et al., 2016; McLachlin and Larson, 2011). Yet, despite the critical role they play, there is surprisingly limited integration between HSC practices and the construct of social-ecological resilience (SER) (Kovács and Falagara Sigala, 2021).

To this effect, the SER construct offers a valuable theoretical framework for rethinking how HSCs operate (Kotikot, 2023). Going beyond robustness and perseverance of supply chains, SER involves their capacity to respond adaptively to changing conditions (Wieland and Durach, 2021). While the practical importance of SER is increasingly acknowledged, this area remains underexplored in the literature (Di Paola et al., 2023; Lin et al., 2023; Rodríguez-Espíndola et al., 2023). The absence of comprehensive empirical data and case-study analyses on related humanitarian settings, hinders the development of robust, widely applicable frameworks (Behl and Dutta, 2019; Vega, 2018a; Wieland et al., 2023).

SER is particularly relevant in the context of cataract camps, where success is dependent not only on the medical services provided but also on the broader environmental and social contexts (Lin et al., 2021; Mailu et al., 2020). Vision impairment, especially due to cataracts, represents a significant global health crisis. According to the World Health Organization (WHO), 2.2 billion people worldwide suffer from vision impairments, with at least 1 billion of these cases being preventable or treatable (WHO, 2023). In regions of Africa, where access to health care is often limited, cataract camps have emerged as a viable solution to address this crisis (Courtright et al., 2007; Gogate and Kulkarni, 2002; Herrod et al., 2024; Schulze Schwering et al., 2014). These camps are complex social-ecological systems whose success hinges on their ability to adapt to local conditions, engage with local communities and operate sustainably despite the environmental and social pressures they face (Aboobaker and Courtright, 2016; Bamashmus and Al-Barrag, 2008; Finger et al., 2007), emphasizing the importance of SER-building capacities for them.

In this way, accounting for SER-related antecedents in these cataract camps allows for a comprehensive approach that accounts for not only medical factors but also the environmental and social conditions that influence the effectiveness and long-term sustainability of these interventions (Finger et al., 2007; Gogate and Kulkarni, 2002; Sandi et al., 2024). Such an approach can result in more sustainable local health outcomes by enabling these interventions to adapt to and withstand long-term challenges, such as environmental changes or shifts in community dynamics (Berkes and Ross, 2016), which can, in turn, influence the uptake of cataract surgeries (Mailu et al., 2020) and their success (Lee et al., 2023). Similarly, gathering best practices in local HSCs requires a deeper understanding of how systems function in developing regions (Schwarz et al., 2023).

There are numerous reasons for examining the antecedents to SER in the outlined humanitarian setting. First, the construct of SER in local HSCs offers unique benefits, particularly when compared to traditional commercial supply chains (Wieland et al., 2023). Second, it is crucial to understand the distinctive characteristics and needs of HSCs, as they are closely linked with local communities and environmental conditions (Altay et al., 2021). These supply chains rely heavily on the support of both the local community and the surrounding environment. Third, unlike commercial supply chains, which primarily aim to maximize efficiency and profitability, HSCs focus on minimizing human suffering and loss of life during crises (Friday et al., 2021). This mission necessitates a strong connection with local communities, whose acceptance and cooperation are crucial for the effective delivery of aid (WHO, 2016). Fourth, without community acceptance, humanitarian efforts are likely to fail, as local support is essential for the distribution and utilization of resources (Altay, 2013; Behl and Dutta, 2019). Such considerations give rise to the research question guiding our investigation:

In answering this research question, we make four contributions to the existing SCM literature. First, we advance the understanding of sustainable supply chains by exploring the antecedents that foster SER in the local HSC context of cataract camps in the African region (Anjomshoae et al., 2023). Second, we respond to calls in the SCM literature for a better understanding of supply chains’ SER, in both commercial (Lin et al., 2023) and humanitarian contexts (Michel et al., 2023). Our study thus provides novel insights into the factors underlying SER, which will inform the design of future generations of supply chains. Third, we adopt a qualitative empirical approach that can generate unique qualitative insights, differing from the quantitative approach that has previously predominated in SCM research (Wieland et al., 2024). In doing so, we respond to recent calls for more inductive and qualitative empirical research in the area of (humanitarian) SCM (Gualandris et al., 2024; Vega, 2018a, 2018b). Fourth, our findings offer structured guidance for humanitarian organizations to future-proof their HSCs with SER based on presented managerial insights from ethnographic participation in cataract camps and interviews with international and local humanitarian professionals.

This paper is structured as follows. In Section 2, we explore the theoretical background of SER in HSC management (HSCM). In Section 3, we describe our methodological steps. In Section 4, we present our findings, and in Section 5 discuss them with reference to the prior literature. Section 6 discusses limitations posing potential directions for future research. Section 7 then provides our conclusions.

Despite a wealth of literature on supply chain resilience (SCR), including numerous definitions of the construct, no robust overarching theory has been established (Castillo, 2023). Traditionally, SCR has been predominantly examined through a lens focused on controllability and efficiency (Wieland and Durach, 2021), reflecting an engineering-based perspective. This earlier view tends to be linear and operational, whereas more recent approaches advocate a holistic perspective that captures multiple layers of complexity (Gualandris et al., 2024; Vega et al., 2023). A ‘new’ SCR paradigm, however, proposes a multi-layered, adaptive and transformative approach to understanding and managing supply chains (Novak et al., 2021; Wieland, 2021). The COVID-19 pandemic has further compelled practitioners worldwide to rethink their supply chain strategies (Azadegan and Dooley, 2021; Herold et al., 2021).

In line with this, recent scholarship increasingly frames supply chains as complex adaptive systems (CAS), moving away from a purely engineering-centric view of resilience (Adobor, 2020; Vega et al., 2023; Wieland and Durach, 2021). This view positions the supply chain as a dynamic network of organizations operating across multiple regional, national and supranational boundaries, thereby requiring multilayered considerations (Azadegan and Dooley, 2021; Saïah et al., 2023; Scholten et al., 2020). A core recommendation for advancing SCR theory is to integrate insights from other disciplines such as engineering and ecology (Beichler et al., 2014), following examples of how these fields have developed their own theoretical foundations of the resilience construct (Wieland et al., 2023). This cross-disciplinary approach can offer strategies for building a more unified and robust theory of SCR (Castillo, 2023).

Central to the understanding of SCR in an environmental context is the concept of social-ecological systems (SES) (Buckton et al., 2023). SESs are integrated systems comprising human (social) and environmental (ecological) components, which are characterized by their complex interactions and interdependencies shaping their collective ability to respond to disruptions and changes (Ostrom, 2009). Analyzing supply chains through a SES lens emphasizes the interconnectedness between human activities, such as supply chain operations or humanitarian interventions, and ecological dynamics, including environmental change and community affection (Wieland et al., 2023). Adopting this perspective reveals that resilience arises not only from effective SCM but also from the supply chains’ capacity to adapt continuously to the surrounding social and ecological conditions.

From an ecological standpoint, the construct of resilience has its origins in Holling’s (1973) early works, who examined how living beings survive and adapt in changing environments, whether as prey or predator. Over time, this notion broadened from wildlife contexts to include SESs, wherein human interactions play a critical role. Holling (1996) then was able to distinguish between two main forms of resilience:

1. Engineering resilience, which is linked to designing fail-safe systems that can quickly bounce back to a stable equilibrium.

2. Ecological resilience, which emphasizes an organism’s – or system’s – capacity to adapt and persevere in the face of environmental change.

Applying this differentiation to SCR, Wieland and Durach (2021) delineated two theoretical perspectives:

• Perspective 1: A supply chain’s capacity to absorb changes (“engineering resilience”).

• Perspective 2: A supply chain’s capacity for continual adaptation, evolution and transformation (“social-ecological resilience”).

They follow Holling (1973) when defining Perspective 1, for whom resilience is a system’s “ability to absorb change and disturbance” (p. 14). Perspective 1 thus emphasizes the importance of building redundancy, flexibility and robustness into supply chains to provide the capacity to withstand and bounce back from disruptions. Perspective 2, in contrast, is bound to the dynamic nature of complex environmental systems, positing SCR as a process of continuous adaptation to changing environmental conditions and emerging risks (Wieland and Durach, 2021). Perspective 2, therefore, aligns closely with SER, which refers to the capacity of SESs to absorb and/or withstand perturbations while maintaining their structure, functions, identity and traits, emphasizing the interconnectedness of social and ecological systems and their spontaneously self-organizing capacities (Beichler et al., 2014). In this article, we follow Gualandris et al.’s (2024) contemporary definition of SER, which encompasses the (humanitarian) supply chain’s capacity for self-organization, learning and adaptation, ensuring its requisite level of regenerability.

To this end, regenerability is characterized by the supply chain’s proportionality, reciprocity and polyrhythmicity (Buckton et al., 2023). In the SER context of SCM, Gualandris et al. (2024) explicated these notions as follows: The regenerative principles of proportionality represent a sustainable balance of supply and demand safeguarded by supply chain actors. Reciprocity relates to the way supply chain actors “co-manage the mutual impact of their activities on the social-ecological system and vice versa” (p. 58). Poly-rhythmicity involves (humanitarian) supply chains genuinely synchronizing with the “rhythms” of surrounding SESs.

HSCM research has evolved significantly over the past two decades (Altay et al., 2021; Kovács and Spens, 2009; Oloruntoba and Gray, 2006; PAHO, 2001). Despite the diversity and uniqueness of contexts explored, the literature consistently identifies certain shared characteristics and trends in HSCs. Emerging trends in HSCM involve digitalization (Jayadi, 2024), medical supply chains (Dolinskaya et al., 2018), community-centric logistics (Crowther et al., 2016) and humanitarian SCR (Altay et al., 2018). Among these trends, the construct of SER has also become increasingly important (Vega et al., 2023; Wieland et al., 2023).

To this effect, HSCM-related studies have explored the relationship between sustainable practices and resilience in regional humanitarian efforts (Renteria et al., 2021), or explored the crucial role of preparedness in effectively responding to crises (Jahre et al., 2016). This proved critical for related HSC actors in sustaining performance of HSCs (Abidi et al., 2014). In this context, SER has been argued to be fundamental to designing supply chains that support the well-being of interconnected systems (Gualandris et al., 2024), and allowing HSCs to adapt to their environment (Wieland et al., 2023). This requires that HSC managers increasingly focus on contextual dynamics (Wieland and Durach, 2021). Furthermore, SER has been discussed in relation to a number of local contexts, such as a large food bank network during hurricane Florence in the Carolinas (Hasnain et al., 2023), the role of wild edible plants in supporting Kenyan nutrition supply (Shumsky et al., 2014) or an earthquake case study in Haiti (Shakibaei et al., 2024). In fact, Shakibaei et al. (2024) argued that most articles in the HSC field tend to overlook the significance of social-ecologically resilient capacities, which aligns with dynamic capability-based studies on SCR (Joussen et al., 2024). Haavisto and Kovács (2019) further suggested that certain sustainability aspects are under-researched in HSCM, implying that aspects affecting SER are also neglected.

We therefore argue that understanding the role of SER in HSCs is essential to safeguarding their long-term success. Prioritizing environmental sustainability fosters trust with local communities, enhancing effectiveness and resilience (Connelly et al., 2016). SER safeguards the interconnectedness of HSCs with the environment, highlighting the need to consider both the operational aspects of resilience and the broader environmental and social dimensions that influence related supply chain activities (Wieland et al., 2023). This holistic approach enhances immediate crisis response and contributes to the long-term well-being of the communities served (Crowther et al., 2016). Integrating SER into our understanding of HSCM can therefore help humanitarian organizations develop a more holistic approach to managing disruptions and uncertainties (Vega et al., 2023). Doing so involves (a) recognizing the interdependencies between human and natural systems, (b) anticipating and mitigating supply chain activity impacts on ecosystems, and (c) fostering adaptive HSCM strategies that promote long-term thinking about both social and ecological systems (Gualandris et al., 2024).

While cataract camps have been widely investigated from a medical perspective (e.g. Finger et al., 2007; Gogate and Kulkarni, 2002; Herrod et al., 2024; Lin et al., 2021), the characteristics of their supply chains remain largely underexplored. Extant studies typically adopt a clinical lens, emphasizing medical procedures and outcomes rather than addressing overarching supply chain dynamics (Mailu et al., 2020). In fact, when supply-related aspects are discussed, they are often narrowly confined to logistics as a specific operational function to ensure public health preparedness (McMaster and Clare, 2022). Consequently, developing comprehensive insights into the antecedents of SER and related supply chain practices within the HSCs of cataract camps holds significant potential for advancing their effectiveness and long-term impact.

In this regard, pertinent literature consistently points to shared characteristics in HSCs, which typically adhere to the stakeholder sequence as well as material, service and information flows depicted in Figure 1. It underscores a collaborative approach involving donors, international agencies, non-governmental organizations (NGOs), as well as local NGOs, suppliers, service providers and partners (Oloruntoba and Gray, 2006). For cataract camps, this involves the flow of essential medical supplies, equipment, services and related information involved in their operations (no. 1–5).

Similar to the typical HSCM setup, the primary stakeholder in the cataract camp is often the donor. The donors fund the NGOs, which are then responsible for providing humanitarian care through local partners and organizations (Gualandris and Klassen, 2018). Frequently, they stipulate funds to be allocated directly to tangible resources like materials and food, rather than to indirect services, such as information systems, staff training, marketing or disaster preparation activities (Connelly et al., 2016). As a result, unlike conventional business supply chains, HSCs within cataract camps often face operational instability, necessitating elevated levels of SER to sustain operations (Michel et al., 2023).

Cataract camps in Africa are vital SESs (Mailu et al., 2020). Offering free, high-quality cataract surgeries, pre- and post-operative care and educational initiatives, they contribute to poverty reduction, improved health and well-being and the creation of sustainable communities (WHO, 2019). However, these camps often face challenges in delivering effective eye care services, including accessibility, affordability and environmental vulnerability (Aboobaker and Courtright, 2016; Lin et al., 2021). To establish resilient and sustainable humanitarian supply networks within these camps, a structured approach involving ex ante preparation, concurrent execution and ex post follow-up is required (Jahre et al., 2016; WHO, 2016), resulting in related activities owned by the individual stakeholder groups (Table 1).

This involves integrating regenerative principles that ensure a sustainable balance between available resources and the demand for logistics as well as health-care services, particularly in resource-constrained settings (Altay, 2013; Courtright et al., 2007), such as African cataract camps. By understanding and anticipating the interdependencies between the human actors and surrounding ecosystems, these camps can better mitigate the impacts of environmental and social challenges, ensuring they remain viable and effective over the long term (Aboobaker and Courtright, 2016; Ramke et al., 2017).

In fact, neglecting SER in cataract camps may have several adverse consequences. Without SER, cataract camps can become vulnerable to disruptions from extreme weather events or environmental changes, significantly affecting their ability to deliver consistent eye care services (Fraser, 2024). Additionally, overlooking SER may result in resource shortages, inadequate waste management and greater environmental degradation, ultimately reducing their capacity to sustain medical services long-term (Sandi et al., 2024). Furthermore, failure to integrate ecological and social considerations risks weakening community trust and collaboration (Berkes and Ross, 2016), ultimately jeopardizing the whole health-care intervention.

To the best of our knowledge, no relevant studies on SER have been conducted to address this issue in comparable contexts. Our study, therefore, explores how SER setup and practices can address such challenges by making the associated HSCM setup and practices more (socially and ecologically) resilient.

The study uses a qualitative interpretive research design (Gioia et al., 2013), guided by a grounded theory approach (Charmaz, 2014), which follows distinct steps to investigate the antecedents of SER in the HSC context of cataract camps in the African region (Figure 2). This methodology aligns with our study’s aim to derive generalizable insights through inductive exploration of SER within complementary operational settings.

For this purpose, Namibia and Tanzania were strategically chosen as representative African countries due to their contrasting socioeconomic and health-care conditions, which provide a rich comparative basis for analyzing SER in local HSCs (Azevedo, 2017). Namibia, situated in Southern Africa, has a relatively small population with limited local industry and a heavy reliance on imports. Conversely, Tanzania, located in East Africa, has a larger population and a more robust local market, enabling local procurement and reducing transportation costs. These contrasts allow the study to capture diverse regional dynamics that influence SER. To capture these complementarities, we purposefully sampled the participating experts of our empirical study following Suri (2011) (Table 2).

Our in-depth semi-structured interviews allowed us to explore novel themes related to SER while addressing our research question (Galletta, 2013). Conducted over 33–126 min via in-person or virtual platforms, the interviews followed a conversational yet structured approach, with iterative refinements to the interview guide after each session to focus on the emergent themes (Oliver et al., 2005; Williams and Moser, 2019). Using ATLAS.ti, we transcribed, analyzed and coded the data through a three-stage process – open, axial and theoretical coding – following Gioia et al.’s (2013) and Corbin and Strauss’s (1990) guidelines. This yielded our detailed data structure comprising seven aggregate dimensions of antecedents to SER in local HSCs (Figures 3 and 4).

The HSC professionals we interviewed were involved in the setup and operations of temporary cataract camps in Tanzania and Namibia. Thereby, their delivery of medical treatment to patients in need was heavily dependent on local HSC conditions:

To cater to individual patient needs, the professionals relied on SCR (in the “Perspective 2” sense defined above) – namely, remote access, sanitary care, educational campaigns:

We further found that the SER construct has various antecedents and underlying themes that contribute to local HSCs’ ability to exert proportional, reciprocal and poly-rhythmic traits. This is closely related to the way that cataract treatment supplies contingently catered to local patient demands in line with local environmental conditions:

To do so, the professionals organized the camps to be deeply entrenched in local ecosystems across multiple regional conditions:

In this sense, the cataract camps we studied were poly-rhythmic in nature because they were periodic setups following local patient-care cycles:

Our findings thus highlight the antecedents shaping SER in HSC contexts, such as investigated cataract camps, which we now discuss in turn. These antecedents align with the regenerative principles of proportionality, reciprocity and poly-rhythmicity, ensuring that interventions are balanced, collaborative and adaptable to changing conditions.

The operational complexities of the HSCs under consideration are closely related to the socioeconomic environment of the broader regional context. Namibia revealed limited local supplies and infrastructural accessibility, necessitating a stronger reliance on imported medical equipment to meet the population’s medical needs. In contrast, Tanzania’s larger economy and resource accessibility allowed for local purchasing, which reduced transportation costs:

Importation introduced logistical and storage challenges in Namibia, requiring careful coordination with distributors, efficient storage at the camps and streamlined logistics for delivery and sterilization. While Namibia exhibited stronger efficiency in these areas, solutions were necessary to further optimize related processes. On the flipside, high transport costs, especially for Asian and European imports, have led to an increased demand for local purchasing. This necessitated a balancing act between managing costs and ensuring the quality of locally available materials.

From a social perspective, patient mobilization in Namibia then depended extensively on local figures (i.e. tribal leaders) and institutions (i.e. churches or mosques), emphasizing the need for targeted community engagement approaches:

Tanzania, with its significantly larger economy, demanded increased coordination for sourcing and storage of local medical supplies. Medical teams played an active role in material and patient selection, requiring increased personal engagement to ensure health-care service deliveries and treatments:

Tanzania has further shifted from a heavy reliance on imports to an increased focus on local purchasing, often from other African countries. This shift was driven by a significant economic uptake and growing confidence in the quality of locally available materials. However, it also introduced challenges, especially regarding material quality, necessitating careful considerations of material suitability for health-care provision:

From a social perspective, Tanzania grappled with challenges related to the local populations’ qualifications, such as English language and administrative proficiency, adding extra layers of complexity to challenging patient-care and partner interactions. Despite its size, Tanzania’s socioeconomic environment still depended on external institutions and sources for training and research materials, underscoring the importance of developing more localized resources:

To this end, strategic utilization of local partnerships emerged as pivotal for enhancing SER. Enabling stakeholders to collectively address local challenges through local partnering improved the camp operations’ overall efficacy. In fact, building upon local collaborations significantly contributed to a dynamic and responsive health-care system:

The transition to locally sourcing materials in Namibia is an example of such collaborations, which resulted in notable cost reductions and logistical simplifications. This shift, though beneficial, was accompanied by certain challenges, such as locally sourced surgical knives initially falling short of required sharpness standards.

Local partnerships played a crucial role in overcoming such quality challenges by ensuring that local health-care professionals were equipped and trained to use available tools and materials effectively. Close collaborations with local health-care providers, community leaders and government officials were imperative for garnering support, understanding and participation during health-care campaigns. In this way, such collaborations extended beyond local transactions, but involved active engagements with local stakeholders:

Collaborations between governments, NGOs and international partners further proved essential in pooling resources and sharing expertise to ameliorate financial and resource constraints:

Local Namibian teams, especially in urban centers like Windhoek, played a pivotal role in preparing and planning health-care campaigns, coordinating logistics and resources and preparing equipment. Harnessing local teams’ capabilities, local supply chains and logistical setups thus ensured the agility, responsiveness and efficiency of camp operations:

Additionally, Namibia’s cataract camp operations exhibited innovative approaches to broadening collaborations. Local partnerships with organizations working in areas such as sanitary institutions and hygiene care providers, for instance, safeguarded high-quality health-care treatments. This underscored the professionals’ commitment to addressing broader health issues and enhancing the SER of associated HSCs in the region.

The evolving knowledge base of local humanitarian institutions constitutes another antecedent to SER-building, as evidenced in our interviews. This knowledge base was nurtured by local knowledge acquisition and sharing initiatives. Introducing tally sheets for inventory management is an example of how knowledge was meaningfully captured and transferred:

Such easy-to-implement solutions were imperative in the challenging local conditions. The same applied to establishing internal knowledge transfer mechanisms, evaluating new methods and tools for their viability and applicability. This ensured that innovations seamlessly integrated into the existing SESs.

Furthermore, standardized tools facilitated smooth knowledge transfer of local health-care requirements. This assured that health-care initiatives were responsive to the population’s specific needs and behaviors:

Such a community-centered approach enhanced the efficacy of investigated cataract camps and related health-care initiatives while fostering greater acceptance among local communities.

Training the “next generation” of health-care professionals further proved essential to ensure knowledge continuity, safeguarding the sustainability of the camp operations. A representative example highlights the challenges involved when using imported surgical equipment, typically requiring intensified knowledge transfer mechanisms:

This underscores the importance of transferring knowledge to the local people involved, which ensured that locals were well-trained and capable of transferring valuable knowledge to others. This, in turn, enabled HSC managers to mitigate knowledge gaps when leading experts retired.

The strategic orchestration of resources and governance emerged as another pivotal antecedent to SER-building. In this regard, the distinctive characteristics of regional health-care systems shaped the impact of the cataract camp-related humanitarian initiatives.

Namibia proved to have a relatively robust health-care system characterized by strong central government coordination. This influenced the entire HSC, from the systematic organization of material imports and campaigns to predefined patient selection processes. Well-defined infrastructure and logistics, including sterilization processes, enhanced camp operations’ hygiene protocols and efficacy. Centralized decision-making processes streamlined patient selection and treatment. This governance model promoted a resilient health-care system:

In contrast, Tanzania exhibited less centralization, posing challenges for patient selection and operational efficacy during health-care campaigns, typically requiring greater personal efforts of the professionals involved in the camps:

Reduced central governance in Tanzania also limited the standardization of health-care services and surgical capacities. This often resulted in local teams not being able to identify patients in need while managing their daily operating tasks. Therefore, international support and coordination became increasingly important in addressing these resource limitations, especially in camps with low accessibility and lack of suitable equipment:

Similarly, institutional capabilities proved critical for SER-building. These capabilities were principally built by enhancing the professionals’ learning capacities, collective understanding and continuous improvement. This included understanding blindness distributions in local communities (e.g. through population-based studies), which provided accurate data on cataract impairments and prevalence. Medical teams were thus able to address specific patient needs:

Deploying ophthalmic camp officers for pre-operative screenings and post-operative care further demonstrated a commitment to the continuous improvement of the camps. It increased the awareness and understanding among local staff and patients:

Systematically documenting experiences created additional opportunities for capability enhancements. Detailed notes on materials, equipment and changing requirements to logistical flows contributed to a continuously evolving camp operation:

Moreover, tailoring the camps’ publicity campaigns to resonate with local communities enhanced their efficacy. Using local languages and addressing culturally relevant aspects ensured a relatable message. Aligning surgical campaigns with the local agricultural calendar in Namibia, for instance, increased patient availability and reduced the likelihood of canceled surgeries due to agricultural commitments.

Inventory management capabilities, such as combining packages for easier transportation, leveraging digital technologies and standardizing logistics and surgical processes, were key to addressing logistical challenges in resource-limited settings:

Continuously improving and adapting to local conditions, being open to new technologies and providing training opportunities for local staff thus reinforced these operational improvements. This also reduced dependence on international expertise and facilitated the initiation of self-sustaining health-care systems:

Customs procedures represented a regulatory requirement that presumably posed one of the biggest challenges: delays, unpredictable clearance processes and corruption. Here, meticulous documentation and proactive communication with customs officials were crucial:

Safeguarding the customs clearance process necessitated targeted measures. Responsible logistics managers had to detail steps, document requirements and establish presentation protocols. Securing pre-arranged agreements and exemptions further assured collaborative efforts with government entities. Moreover, material safety concerns, especially regarding theft, underscored the need to engage trustworthy local partners to supervise material storage and thus safeguarded supplies:

As customs officials did not always understand the urgency of humanitarian imports, involved personnel had to be prepared to ensure cooperation and reduce misunderstandings:

Appointing customs liaison officers facilitated target-oriented communication and provided local political expertise. Public awareness campaigns targeting customs officials and communities additionally educated them about the importance of the humanitarian initiative. Ethical training further combated their demands for ‘under the counter’ payments:

Addressing perceptions of a negative impact on local businesses or tax revenue through the camps required transparent communication and a continuous dialogue with customs officials to clarify intentions and dispel concerns:

In this way, local governmental donations or tax exemptions occasionally provided financial uplifts for the teams, thus reducing the financial burden on the humanitarian organization.

Ultimately, the surrounding environmental conditions demonstrated criticality in facilitating SER of the camp operations. Achieving sustainable health-care structures indeed involved the consideration of multiple environmental factors, such as the surrounding ecological system, local culture and demographic environment:

Continuously adapting to local conditions ensured “non-invasive” health-care treatments and prevented the deterioration of surrounding SESs through excessive medical supplies. A shift from temporary camps to permanent health-care structures, in fact, reflected increasing environmental awareness among the HSC actors:

Thus, an increasing emphasis on environmental, social and governance (ESG) priorities represented a salient success factor for the camp operations. This involved reducing waste, enhancing operational efficacy and a sustainable supply of cataract treatments:

From a social perspective, empowering local health-care professionals went hand in hand with appreciating their local culture and educational background. Doing so reduced dependence on external support and enabled growth of local expertise and confidence, contributing to the long-term sustainability of the camps:

From an ecological perspective, climate conditions and poor infrastructure risked negatively influencing demographic developments in the region. Overcoming associated logistical hurdles, especially in sparsely populated areas, required innovative and bespoke approaches. This involved deploying mobile camp “offshoots” or implementing outreach programs, for instance, to effectively reach remote areas:

These approaches ensured that the camps’ health-care services were accessible to the majority of the population, regardless of arising environmental challenges. By integrating local culture and environmental considerations into the planning and execution of the camps, involved HSC actors not only enhanced their immediate effectiveness but also contributed to their long-term sustainability and resilience in the African region.

The findings reveal a multifaceted spectrum of antecedents to enhancing SER in local HSCs like cataract camps in the African region through strategic orchestration of local partnerships, knowledge acquisition and transfer, centralized resource governance or adaptive institutional capabilities. Navigating regulatory support and addressing environmental conditions are also pivotal. By focusing on local engagement, cultural sensitivity and innovative logistical solutions, these strategies aim to create sustainable and resilient health-care systems capable of meeting the needs of remote and underserved communities.

Based on the typical setup stages adopted from WHO (2016), including pre-camp and preparedness as well as camp-day and follow-up activities, the identified antecedents play a crucial role throughout the camps’ operational stages. This is captured in our derived integrated framework (Figure 5).

Further in line with our initial theoretical outlining of SER’s role in local HSCs, our study of cataract camps in Africa reveals that its antecedents are inherently linked to the three regenerative principles of SER (Gualandris et al., 2024): proportionality, reciprocity and poly-rhythmicity. In the context of the local HSCs’ operations, these principles explain how derived antecedents enable the build-up of their SER profile, as evidenced in our outlined findings.

To this end, proportionality proved critical to balancing available medical resources with actual patient needs. Their socioeconomic adaptation also played a crucial role, particularly in contexts where resource availability varied. In Namibia, for instance, reliance on imported medical supplies necessitated careful inventory planning, while in Tanzania, local sourcing strategies helped optimize the cost of logistics. Similarly, knowledge availability ensured proportionality by equipping medical teams with localized information on patient demographics, logistical constraints and treatment protocols. This enabled corresponding actors to allocate medical staff and equipment efficaciously.

Reciprocity further underscored the importance of collaboration between international medical teams, local partners and community stakeholders. Local partnerships played a critical role in this regard by facilitating knowledge exchange, trust-building and patient mobilization. In Namibia, for instance, engagement with tribal leaders and religious institutions significantly improved patient outreach. Institutional capabilities further strengthened reciprocity by enabling operational continuity and shared decision-making across actors. In this way, the principle of reciprocity in the related HSCs of investigated cataract camps fostered deeper engagement with affected communities, encouraging co-ownership of humanitarian interventions and reducing dependency on external stakeholders.

Ultimately, poly-rhythmicity reflected the need for investigated cataract camps to synchronize their operations with local socio-ecological dynamics. To this effect, central resource governance proved critical in enabling flexible coordination mechanisms that aligned centralized oversight with local communities. By structuring governance frameworks to accommodate seasonal, cultural and logistical variations, camp-related interventions remained responsive to shifting local conditions. Environmental regeneration further ensured that the camps operated in line with local ecological conditions by accounting for seasonal weather patterns, agricultural cycles or resource availability, which influenced scheduling, logistics or patient accessibility. Furthermore, regulatory support needed to be safeguarded to accommodate local governance structures and cultural rhythms, preventing harmful administrative bottlenecks. The resulting poly-rhythmicity in the camp operations thus ensured that humanitarian interventions were continuously adopted to the local communities and environments they served.

Our integrated framework highlights this central role of SER across all operational stages of investigated cataract camps, from pre-camp preparation to post-camp follow-up activities. Rather than being a static outcome, building SER required all interviewed participants to embed related regenerative principles into the design, execution and long-term sustainability of their interventions. This meant conducting context-sensitive assessments of community needs and fostering collaborations with local stakeholders. Strengthening SER across all camp stages thus ensured that the investigated cataract camps not only provided critical medical care but also contributed to the long-term resilience of the local health-care systems and surrounding environments.

Our study advances the understanding of SER in local HSCs by emphasizing the interplay between local conditions and broader systemic factors (i.e. antecedents), characterizing SER in the context of African cataract camps. While prior research highlights the need for context-specific and responsive HSCs (Altay et al., 2021; Kovács and Spens, 2009), our findings extend this understanding by illustrating that their SER is shaped not only by the local adaptation of HSCs but also by distinct antecedents influencing the regenerative principles of the SER construct itself as outlined by Gualandris et al. (2024). In this context, Baharmand et al. (2021) emphasize the potential for increased global transparency and standardization in HSCs through advanced technologies (like blockchain applications). Our findings, however, suggest that a balance between local adaptation (i.e. local partners) and global standardization (i.e. institutional capabilities) enhances the SER of respective HSCs.

Unlike commercial supply chains, our findings confirm that HSCs must be deeply embedded within local contexts to align with community needs and related socio-ecological dynamics (cf. Altay et al., 2021; Crowther et al., 2016; Michel et al., 2023). While the literature highlights agility and “lean thinking” in HSCs (Mishra et al., 2022), our findings reveal that long-term resilience and sustainability emerges from structured yet adaptable systems, where local partnerships, knowledge transfer, governance structures and regulatory frameworks work in tandem to strengthen their SER. These insights align with extant (humanitarian) SCM and resilience research, which underscores the importance of localized, adaptive strategies in line with generic global approaches (Friday et al., 2021; Wieland and Durach, 2021).

Through the synthesis of our data structure, we provide initial empirical evidence for the antecedents of SER in the HSCM context of African cataract camps, addressing a critical gap in extant research where empirical validation of the SER construct remains scarce (Gualandris et al., 2024; Wieland et al., 2023). Specifically, our study extends the pertinent theoretical discourse on SER in SCM and HSCM (e.g. Hasnain et al., 2023; Lin et al., 2023) by integrating these antecedents into a structured framework grounded in its regenerative principles, demonstrating their systemic role in SER-building. In this way, our findings align with existing SER conceptualizations (Gualandris et al., 2024), reinforcing the theoretical foundations of regenerative and sustainable supply chains while offering a context-specific application that enhances its practical relevance (Anjomshoae et al., 2023; Buckton et al., 2023). In fact, our findings provide valuable practical insights for humanitarian managers and policymakers, reinforcing that SER emerges from the strategic orchestration of the derived antecedents, rather than isolated interventions, as we will outline in the following sections.

Above all, our study responds to calls for a deeper integration of SER within SCM and HSCM research (Altay et al., 2021; Gualandris et al., 2024; Vega et al., 2023; Wieland et al., 2023); specifically, by refining the conceptualization of SER and demonstrating how its regenerative principles shape humanitarian logistics (cf. Connelly et al., 2016). We anticipate four salient theoretical contributions:

First, our findings integrate resilience research with sustainable and regenerative supply chain theories, offering a unified framework that moves beyond traditional risk-based and response-based perspectives (Castillo, 2023; Jahre et al., 2016). While previous research typically viewed SCR as a reactive measure, we position SER as a proactive and adaptive capability, which is to be embedded within localized governance structures and collaborative operational frameworks (Friday et al., 2021; Kunz and Gold, 2017), following the established regenerative principles of corresponding HSCs (Gualandris et al., 2024).

Second, our study answers multiple calls for more interdisciplinary approaches to SCR-related research (Altay et al., 2021; Beichler et al., 2014; Wieland et al., 2023), by providing insights from humanitarian and/or public health-related contexts such as African cataract camps (Friday et al., 2021). Furthermore, our qualitative empirical research design for grounded theory development (Charmaz, 2014), involving inductive data analysis techniques (Gioia et al., 2013), complements the growing demand for interpretive approaches in SCM research (Wieland et al., 2024), which is to offer an enhanced empirical foundation for understanding SER in local HSCs.

Third, we thus extend theoretical insights into the antecedents of SER-building in the research humanitarian setting (cf. Altay et al., 2018), emphasizing how socioeconomic adaptation, local partnerships and governance mechanisms interact to build and sustain their resilience profiles. While prior HSCM studies acknowledge resilience factors, such as robustness and redundancy (e.g. Connelly et al., 2016; Friday et al., 2021; Michel et al., 2023), they overlook the regenerative dynamics shaping SER. By detailing how proportionality, reciprocity and poly-rhythmicity emerge across the operational camp stages, we offer a structured yet adaptable model for humanitarian logistics, addressing the gap between resilience theory and real-world HSC challenges (Kovács and Spens, 2009).

Fourth, our findings have implications beyond SCM literature, contributing to broader discourses on public health, NGO partnerships and strategic management. Socioeconomic adaptation aligns with public health research on health-care accessibility in vulnerable regions (Yang and Geng, 2022), while local partnerships resonate with collaborative governance studies in social sciences (Batti, 2017). Additionally, institutional capabilities, regulatory support and environmental regeneration tie into strategic management concerns regarding knowledge management, resource allocation and sustainability governance (Idrees et al., 2023). By positioning SER as a cross-disciplinary construct, our study thus provides valuable theoretical touchpoints for scholars exploring resilience across diverse humanitarian contexts.

Our findings further offer critical managerial insights for HSC practitioners and policymakers in building SER in their local HSCs as summarized in Table 3.

By integrating proportionality, reciprocity and poly-rhythmicity into their decision-making processes, HSC actors can create more adaptive, collaborative and sustainable humanitarian operations. These insights translate into several practical recommendations:

First, practitioners must systematically assess and address the antecedents of SER in their HSCs as they provide a structured foundation for their resilience-building efforts. HSC managers can use the derived antecedents and underlying themes, represented in our data structure, as a checklist or evaluation criteria to diagnose vulnerabilities in existing supply chain structures. For example, before initiating humanitarian aid, humanitarian organizations should conduct socioeconomic assessments to align resource distribution with patient needs, ensuring that medical supplies, personnel and logistics are proportionally balanced.

Second, community engagement and knowledge transfer mechanisms are essential for strengthening local ownership and operational continuity. Beyond establishing partnerships, humanitarian actors should integrate formalized local training programs, mentorship structures and cross-sectoral collaborations. Lessons from the investigated cataract camps highlight the importance of empowering community leaders, religious figures and local NGOs to facilitate patient mobilization and public awareness. To institutionalize knowledge, humanitarian organizations can implement RAAB-based data collection, training workshops and digital documentation practices that support the transfer of expertise from international teams to local health-care workers and HSC actors.

Third, HSC practitioners should embed SER principles into operational workflows by leveraging local governance structures and aligning interventions with regional policy frameworks. Instead of viewing regulations as constraints, humanitarian organizations should collaborate with government health agencies to standardize customs protocols, harmonize patient selection criteria and integrate camp operations into national health-care strategies. Furthermore, assigning local coordinators or liaison officers with expertise in local languages, governance and cultural contexts facilitates smoother communication between international HSC actors and local community members.

Fourth, environmental safeguarding must be prioritized throughout the entire humanitarian project cycle. Many cataract camps operate in fragile ecosystems, where seasonal factors such as weather conditions, agricultural cycles and infrastructure limitations influence camp setup and execution. To minimize environmental disruption, humanitarian organizations should adopt low-waste medical practices, energy-efficient logistics and climate-sensitive scheduling. For instance, scheduling cataract surgeries outside of peak agricultural seasons prevented workforce shortages and ensured patient availability as evidenced in our study. Establishing long-term partnerships with local environmental agencies further helped embed these regenerative practices into the camp operations.

Fifth, HSC managers must institutionalize a continuous learning process by systematically disseminating and capturing operational lessons. As revealed in our findings, the employment of simple yet effective tools such as tally sheets, structured debriefing reports and knowledge-sharing platforms allowed teams to document what worked, what did not, and how future interventions can be improved. Encouraging staff to record and share insights – particularly on overcoming logistical bottlenecks, addressing regulatory hurdles and optimizing patient outreach strategies – can thus create a foundation of institutional capabilities that strengthens future responses of respective humanitarian organizations.

Ultimately, policymakers play a critical role in enabling the transition from short-term medical camps to integrated, sustainable and resilient health-care services by fostering institutional and financial stability as well as regulatory alignment. Beyond supporting co-investments in permanent training centers and standardized operational procedures with private donors, policymakers should institutionalize SER principles into national health-care frameworks to ensure humanitarian interventions align with long-term public health goals. To this end, scaling temporary humanitarian setups into permanent health-care structures requires targeted policy measures that incentivize local capability-building and infrastructure development. For instance, tax exemptions, import duty waivers or streamlined regulatory support for medical equipment and pharmaceuticals helped reduce logistical bottlenecks and accelerate camp-to-clinic transitions in our study of African cataract camps. In this context, legislation supporting telemedicine, mobile health units or cross-border medical cooperation could further extend health-care access in remote or underserved regions. Moreover, incentivizing local entrepreneurship in health-care service provision – such as community-managed clinics or social enterprises – could create self-sustaining health-care solutions that outlive donor-funded initiatives.

Based on the discussed findings, we acknowledge four major limitations to our study, which in turn provide fertile ground for future research.

First, by identifying the key antecedents and themes shaping SER in the specific local HSC context of African cataract camps, our study provides an empirical starting point for the theoretical construct of SER, rather than a fully validated theoretical framework. Future qualitative research could extend these findings by examining derived antecedents in different HSC contexts, such as globalized HSCs (cf. Son et al., 2025), public–private stakeholder-networks (cf. Fontainha et al., 2017) or digitally enabled humanitarian logistics (cf. Jayadi, 2024). Longitudinal research could then provide insights into the dynamic evolution of SER across various humanitarian settings (cf. Sabri et al., 2019). This could be done by tracking how specific antecedents interact over time to influence SER outcomes under changing environmental conditions, resource constraints and/or stakeholder constellations.

Second, relying on semi-structured interviews with a limited number of experts captures nuanced, context-specific insights but may be constrained by a lack of diverse perspectives and potential interviewer bias. While qualitative research involves trade-offs between depth and breadth (Guest et al., 2006; Vega, 2018a, 2018b), our focused sample ensured data saturation and thorough exploration of key antecedents influencing SER in humanitarian cataract camp operations (Hennink et al., 2019). Yet, we do acknowledge that the specificity of this setting calls for future research to adopt broader cross-case analyses to validate and refine these findings (Eisenhardt, 1989). That is, to enhance generalizability and capture greater contextual diversity, future studies could use multiple-case study designs across varied humanitarian settings to allow for comparative insights or theoretical replication. For this purpose, a nuanced sampling among national or socioeconomic contexts could help include a wider range of stakeholder perspectives across communities or demographics. Finally, combining the qualitative insights with quantitative survey-based studies would offer a promising path to validate the emerging antecedents and themes in larger samples.

Third, there is a possibility of coding bias due to our selective coding of higher-order concepts and themes. Although the data structure points to 41 distinct first-order concepts, 18 second-order themes and seven aggregate dimensions, there are blurry boundaries and potential overlaps may exist. Future research could build upon this level of detail by exploring (a) the cause-effect relationships and interdependencies of the underlying themes and (b) their impact on (humanitarian) supply chains’ SER more deeply. Causal mapping (Hays et al., 2007) or system dynamics modeling (Sterman et al., 2015) can be employed to uncover interdependencies and causal pathways between the identified SER antecedents. In addition, qualitative comparative analysis (Russo et al., 2019) and/or necessary condition analysis (Dul, 2016) could offer promising methodological approaches to identify which of them are necessary as opposed to merely sufficient for achieving SER.

Fourth, the focus on two representative countries may limit the generalizability of our findings. Future research could broaden the scope by incorporating additional countries or regions to assess the global applicability of our framework. Triangulating our results with data from diverse geographical contexts and varying governmental or regulatory environments could provide valuable cross-regional insights into whether the identified antecedents remain consistent across different humanitarian settings. Specifically, using multi-regional samples that encompass countries with varying levels of economic development, governance structures or health-care infrastructures would further elucidate how SER dynamics unfold within different humanitarian and regulatory contexts.

The construct of SER is currently underdeveloped in the SCM/HSCM literature. This results in diverging interpretations (Beichler et al., 2014; Gualandris et al., 2024; Lin et al., 2023; Wieland et al., 2023). Our study contributes to streamlining the various interpretations by uncovering primary empirical insights to provide a nuanced understanding of the theoretical SER construct. That said, challenges remain for future SCM/HSCM research.

Researchers, practitioners and policymakers will need to resolve discrepancies and clarify the nature of the SER construct in varied humanitarian contexts. We contend that researchers should focus on developing unified definitions and frameworks to lay the groundwork for further explorations and applications. Practitioners and policymakers should then be able to practically translate these concepts and develop strategies that strengthen HSCs’ SER through (a) a deeper understanding of interactions between social and ecological systems, and (b) the ability to flexibly respond to changes and implement sustainable solutions. This clarifies the need for future research, collaboration, and integration of diverse perspectives across disciplines to propel the understanding of the SER construct and its relevance for SCM/HSCM literature.