The Work That Lasted

A Links Global case study from practice. Volume 2 cases are drawn from Links Global’s practice history since 2002, anonymized by sector and year. No client, organization, or individual is identified.

A Note on Volume 2

Volume 1 drew on the public record. Volume 2 cases come from inside the work. The first two cases in this volume describe excellent work whose effect on trust was never measured, or whose use was blocked by structure. This case is different. The work mattered, it held up, and it continues today in the institutions and careers of the people the initiative trained and partnered with. It is included because the Trust Audit, NSI, and ERA, applied in retrospect, explain why.

The Problem

Bacteria evolve to defeat the antibiotics designed to kill them. By the early 2000s this was already a documented crisis in the region. Patients bought antibiotics without prescriptions at corner pharmacies. Doctors prescribed broad-spectrum drugs for viral infections they cannot treat. Farmers and poultry producers added antimicrobials to feed to speed growth. Some manufacturers produced substandard medicines that exposed bacteria to insufficient doses. Each behavior was a public health problem on its own. Together they formed a system quietly producing resistant strains capable of defeating the treatments people’s lives depended on.

The initiative brought together a regional multilateral health organization, two federal health agencies from outside the region, a pharmaceutical management organization, a medicines quality body, a university-affiliated antimicrobial resistance coalition, and a communications firm tasked with planning and implementing communications, outreach, and advocacy across three countries, in Spanish, with national governments and civil society at every level.

Two trust conditions shaped the engagement, and they moved in opposite directions. Inside the consortium, the first in-country meeting set the tone. The international partners shared history, language, and a clear hierarchy. The communications firm arrived as the newest and smallest partner and was not welcomed into the team’s social fabric; at the first lunch break, the group went out together without inviting the firm’s delegation. Small gesture, significant signal. The officer coordinating the initiative used his authority in ways that created a culture of fear rather than collaboration. Working under those conditions meant a constant negotiation between keeping the contract and protecting the firm’s staff and integrity. It was exhausting. In retrospect, the internal condition in year one read as severely degraded: concentrated power, no accountability mechanism, no shared way to resolve disputes.

With country partners, the prior expectation of externally funded programs was reasonable skepticism. They had watched programs arrive and leave with the funding cycle.

The Solution

Year one was largely a wash; that is honestly recorded here. Year two produced a coherent logical framework. Year three and beyond saw real implementation. The turning point was research.

The initiative did not try to work around country partners’ skepticism. It worked through it. Its approach required genuine co-creation: identifying the specific resistance drivers in each country, designing interventions that fit each regulatory and institutional landscape, and involving national partners in designing communication materials rather than presenting finished products for adoption. The firm conducted qualitative and quantitative research with consumers, prescribers, and dispensers in each country. It did not assume it knew what the barriers looked like from the inside. It asked, then designed from the evidence.

The findings were specific and sometimes surprising. Consumers had internalized years of messaging that antibiotics worked for any infection, with no sense of the difference between bacterial and viral causes. Prescribers felt pressure from patients who arrived expecting antibiotics and left dissatisfied without them. Dispensers worked where enforcement was minimal and informal sales were economically necessary. These were not information deficits. They were behavioral patterns embedded in economic, professional, and social systems, and addressing them meant touching each system.

The program that grew from that research included study design and analysis; peer-reviewed publications; advocacy materials for national and regional policymakers; training for health promoters and community leaders; plain-language patient education; media training for journalists covering health and pharmaceuticals; digital content; and documentation for South-South knowledge exchange. The firm hired in-country communicators and embedded them in local health institutions as co-designers, not translators of decisions made elsewhere. And it brought in partners the scope had never anticipated: consumer protection organizations, patient advocacy groups, religious communities, and commercial actors in livestock and poultry whose antibiotic practices drove resistance. That changed the conversation from a top-down technical program into something closer to a multi-stakeholder public health movement.

The Results

By contract, the engagement met and exceeded its metrics throughout. Two results stand out on the record. The initiative secured international accreditation for a national pharmaceutical quality control laboratory, one of the first such accreditations of a government laboratory in the region; the announcement generated more than 70 million documented media impressions regionally and internationally. And the consortium’s own internal trust condition moved, not because the difficult dynamics disappeared, but because enough working relationships developed real depth to carry the collaboration, above all with the university-affiliated coalition, whose scientific director treated the firm as an intellectual peer. That relationship produced a chapter in a peer-reviewed book, a research study funded by a major international foundation, and capacity-building work that reached other regions, all beyond the scope and outlasting the contract.

The results that matter most arrived later. Years after the initiative’s formal end, the accredited laboratory still held its accreditation. Community health networks in program areas continued to educate their communities about antibiotic use. The communicators trained through the initiative went on to lead public health programs, national media initiatives, and university faculties. The policy frameworks developed with national partners were institutionalized in ministry of health guidelines that remained in force. A digital knowledge repository built by the program continued to serve national ministries.

Trust was still not formally measured. The informal evidence, from country partners, in-country staff, and observed shifts in engagement, says it improved substantially. But “seemed” and “we believe” are not the same as measured and replicable. Without a formal trust framework, the initiative cannot say precisely where the gains were largest or which mechanisms produced them. That remains the gap, even in the case that worked.

What We Would Add Now

Figure 1. The NSI architecture the program grew into by its third year.

In year one, the indicated ERA intervention for the consortium was predictability-first disclosure applied to the partnership: an agreement at launch on how decisions would be made, how contributions would be acknowledged, and what accountability would look like when behavior crossed professional lines. It did not exist. In its absence, peer relationships partially compensated, which is an important observation: ERA does not remove the need for institutional accountability, but genuine peer trust can create enough functional trust for the work to continue when the structure fails to support it.

For country partners, the indicated approach was NSI with ERA elements, and that is, in practice, what emerged. The research-before-design approach was an application of ERA’s consistency and shared- experience mechanisms: demonstrating respect for partners’ knowledge before asking them to adopt anything. By year three the program had developed something close to NSI’s full architecture, not against a planning document but through what worked: distinct narrative tracks for consumers, prescribers, dispensers, policymakers, media, and the agricultural sector; a research foundation that gave the messages credibility; an earned media strategy that extended reach; in-country communicators carrying the work through relationships; and a knowledge repository that outlived the program. Trust indicators for each of those groups, from dispensers’ willingness to refuse a sale without a prescription to in-country staff’s sense of ownership, would have made the gains legible; the full set is part of the Links Global library.

The Lesson

Good work under difficult conditions is still possible, and its durability depends less on the formal structure of an initiative than on the quality of the working relationships built within it.

The lesson is not that hostile environments are manageable if you are resilient enough. That framing puts the burden of a structural problem on the people who endure it, and it is neither fair nor accurate. The lesson is this: when the work is genuinely co-created with the people it is meant to serve, when the firm gets out of the way and helps country partners understand their own challenges, design their own answers, and build their own capacity, the work outlasts the initiative, the funding, and even the difficult people who made it harder than it needed to be. That is the standard worth reaching for.

Working With Links Global

Volume 2 continues with further cases from practice, developed with Links Global’s practitioner contributors. If you want communications work designed to last beyond the funding cycle, or have a case from your own practice to contribute, talk with us.

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Ownership and use

© 2026 Links Media, L.L.C. d/b/a Links Global. All rights reserved. Narrative Stewardship Infrastructure, NSI, Epistemic Re-Regulation Architecture, ERA, and the Links Global Trust Audit are proprietary frameworks of Links Global. The Links Global Case Study Library is a proprietary analytical resource of Links Global. Cases are anonymized; any resemblance in detail to a specific institution is not an identification.

You are welcome to read this case, link to it, and quote brief passages with attribution to Links Global and a link to this page. Reproducing it in whole or in substantial part, adapting it, or using its analysis, structure, or trust-indicator approach in training, consulting, publications, or derivative works requires prior written permission from Links Global. Please cite as: Links Global (2026). The Work That Lasted. Links Global Case Study Library, Volume 2, Case 3. www.linksglobal.org.