oto by EVG Kowalievska on Pexels.com
Michel Majdalani1, Lea Stadtler2, and Charles-Clemens Rüling2
1Lebanese American University, Beirut, Lebanon, 2Grenoble Ecole de Management, France
Picture a familiar scene in international development: A well-established organization from the global North partners with a hospital, school, or community-based group in the global South. Expertise travels South. Funds travel South. Protocols and standards are adapted. Over time, the Southern partner grows stronger, but the partnership remains marked by asymmetry. So what happens when the Northern partner changes direction? And what possibilities arise when the Southern partner is ready not just to receive, but to lead?
Our recent study, published in NVSQ1, examines exactly this question through the evolution of a long-standing North-South twinning relationship in global health. The case shows that partnerships do not have to end in conflict, withdrawal, or dependency. They can evolve.
More specifically, we show how a Southern organization built on the resources gained through collaboration, while the Northern organization shifted into a more supportive, less directive role. Over time, the relationship moved toward greater balance, not by cutting ties, but by reshaping them.
What we studied
For more than two decades, a North American research hospital supported a university hospital in the Middle East through a pediatric cancer twinning partnership. Together, they developed clinical expertise, training programs, data systems, and fundraising models. A dedicated children cancer center emerged in the Southern hospital, with outcomes comparable to those in high-income countries. In 2016, the Northern partner decided to restructure its global outreach. Instead of one-to-one twinning partnerships, it moved toward a large international network model. This decision meant the Southern partner no longer had dedicated access to Northern expertise. This turning point is where our study begins. We asked: How does a Southern partner navigate a shift in a long-standing North-South relationship? And how can it use the resources built through that partnership to develop a more balanced and resilient future?
What we found
Our interviews and document analysis revealed a three-staged trajectory. The first stage showed that, despite the imbalance in resources, the years of collaboration equipped the Southern hospital with critical assets. These included advanced clinical and data capabilities, strong fundraising capacity, a state-of-the-art children’s cancer center, durable professional ties with Northern experts, and a strong regional reputation for high-quality care. These were not symbolic gains but concrete capabilities that positioned the Southern partner to take on greater responsibility in the next stage.
Specifically, when the Northern institution stepped back from exclusive support, the Southern partner faced uncertainty. But it also inherited an opportunity. Years earlier, with help from the Northern partner, a regional network of pediatric oncology professionals had been established. After the strategic shift, the Southern hospital was selected to host the network’s central office. This marked an important transition: The relationship moved from a strictly North-South twinning model to a more triangular structure. The Southern partner became a regional connector, coordinating activities across more than twenty countries and linking regional hospitals both to one another and to Northern expertise.
From this regional hub role, a third stage emerged, one that became increasingly South-South centered. The Southern hospital coordinated physician trainings across the region, co-organized research and data initiatives, supported other regional hospitals (with input from the Northern partner when needed), attracted new donors and international agencies, and developed national and regional networks that no longer required Northern mediation. The Northern partner did not disappear, but its role changed. It provided support when needed while allowing the Southern partner to steer regional development. The relationship did not dissolve. It evolved.
Why these insights matter
Many studies highlight how North-South relationships either end or Southern organizations manage North-South imbalances by resisting demands, hiding information, or symbolically complying. Our findings show another pathway. The partnership evolved in a way that enabled the Southern partner to lead regional development while the Northern partner remained relevant in a different role. It did not lose influence. Instead, its influence became less direct and, in some ways, more effective. That shift made the relationship more balanced without ending the collaboration.
Three practical insights emerge. First, long-term twinning can create durable learning, infrastructure, and reputational assets for Southern partners. But this takes time, trust, and sustained commitment. Second, reduced dependence does not mean reduced relevance. Northern organizations may worry that empowering partners reduces their own importance. Our case suggests the opposite. Northern expertise became more valuable when embedded in a strong regional network coordinated from the South. Third, balance comes from nurturing relationships over time. The most important lesson is that a more equal partnership emerged not from severing the North-South relationship but from reshaping it into a broader collaborative structure.
What is next?
As development actors explore more equitable forms of collaboration, this case provides a useful template. It suggests that Northern organizations can support partners in building sustainable capacity, step back strategically while staying engaged, and recognize Southern partners as regional leaders, not just recipients.
For Southern organizations, the case illustrates how North-South accumulated resources can support broader South-South agendas, strengthen local legitimacy, and create diverse and resilient networks.
The story returns us to the hospital corridor where the partnership began. North met South to address an urgent health need. Years later, the South is welcoming peers from across the region, sharing expertise, and shaping a wider landscape of cooperation. This is not the end of a North-South partnership. It is what partnership can become when it evolves.
Click here to read the free full-text article: Majdalani, M., Stadtler, L., & Rüling, C.-C. (2026). Expanding From North-South to South-South: The Evolution of a Twinning Relationship in Global Health. Nonprofit and Voluntary Sector Quarterly, 55(1), 255-276. https://doi.org/10.1177/08997640251330994 (Original work published 2026)
NVSQ Blog 