Since the watershed moment of the 2014 Ebola epidemic in West Africa and again in
the midst of the current COVID-19 crisis, the concept of health system resilience
has been a recurring theme in global health discussions.1 2 Although most frequently
used in the context of epidemic response, resilience has also been framed as a ‘key
pillar’ of health,3 and invoked in high-level calls for countries to ‘lead the work
on building health system resilience’.4 Yet, as the authors of one of several recent
reviews observed, the concept of health systems resilience remains ‘highly confusing’
and ‘still polysemic’.5 What it means ‘depends on one’s perception, one’s discipline,
one’s function and what one wants to achieve’.5 In this editorial, I will, from the
perspective of a health policy and systems researcher, draw out and reflect on some
of these tensions, and make some suggestions about how we might achieve greater clarity.
We should frame resilience as an ability, not an outcome
Building on the observations of Turenne et al, the first point is definitional. In
both peer reviewed and grey literature, there is still confusion about whether the
concept of resilience (as it relates to health systems) should be understood as an
outcome or an ability. This distinction is not semantic. Understood as an outcome,
some in the field have suggested that health system resilience can and should be measured
and monitored.6 By measuring resilience, it is argued, we can help to build more resilient
health systems through identification of areas for action.7 8 But an important consequence
of this framing is the implication that health system resilience is an uncomplicated,
even monolithic ‘good’; a goal synonymous with optimised performance. But a question
that then arises is whether health systems that produce suboptimal health outcomes
are somehow less resilient than those producing better ones?
The alternative framing of resilience as an ability, better aligns with the now broadly
accepted observation that health systems and services are social, complex and adaptive
in nature.9 When conceptualised in this way, enquiries about health system resilience
focus more squarely on the dynamic nature of adaptation, without needing to make statements
about the ends to which that adaptation occurs. This point is critical. History has
demonstrated that health system adaptation may steer a system towards improved outcomes
(normatively defined), but may equally worsen or protect less desirable features of
health system function. These latter ‘mal-adaptive’ processes do not necessarily imply
inactive or linear responses; individuals or groups may be highly innovative and willing
to change in some areas, while seeking to, indeed often in order to, protect or preserve
certain interests. As Gore observed in a study of primary healthcare in India, some
systems appear to adapt in ways that ultimately ‘sustain a deficient status quo’.10
Observers of the politics of healthcare in the USA over the past several decades may
come to similar conclusions.
Different types and intensities of shock: different forms of adaptation
A second and related point is about our understanding of the types and intensities
of ‘shocks’ against which health systems are supposed to be resilient. We need to
more clearly articulate the way: (1) health system shocks or disturbances occur on
a spectrum of intensity, from acute and large-scale emergencies to low-level chronic
stressors and (2) health system shocks or disturbances are the product of a range
of different drivers or causal factors—which in turn have implications for the types
of adaptation available and appropriate in response. As already pointed out by others,
the use of the phrase ‘resilient health systems’ in global health literature still
typically presupposes a positive response to some kind of large-scale negative shock
such as the current COVID-19 epidemic outbreak, a budget crisis and so forth. But
a burgeoning literature is starting to draw attention to the fact that health system
disturbances may not necessarily be acute in nature. Gilson et al
11 and Barasa et al
12, for example, detail the ‘chronic stressors’ at the level of front-line health
services, and describe ‘everyday resilience’ as emerging from a combination of absorptive,
adaptive and transformative strategies that enable continued health service function
in the face of such stressors.
But still largely ignored within the resilience literature is the possibility that
shocks and disturbances arise out of intentional choices made by actors in international
(eg, donor conditionalities; trade agreements), national (election promises; regulatory
changes; austerity measures) or local (citizen voice mechanisms, organisational instability)
spheres. Reforms to modes of governance, financing mechanisms or service delivery
models, for example, are all forms of health system disturbance, capable of producing
both intended and unintended consequences. Yet global health writing on resilience
still rarely equates these bureaucratic, socially and politically driven changes with
‘disturbances’, perhaps due to their less sudden, more structured, and inherently
political nature, features that do not align with our still default use of the term
‘shock’. Nor, again outside a few notable pieces, have the political and bureaucratic
responses to these intentional disturbances been acknowledged as a form of ‘adaptation’.
Health systems are social systems: shot through with power relations
Which brings me to my third point on conceptual clarity; which is, to observe a previous
criticism2 13–15 regarding the way resilience as a concept so often fails to incorporate
consideration of agency or power relations, both of which we know to be defining features
of health system function. In much of the health system resilience literature to date,
the agency of actors within the health system is, at best blurred, and at worst, masked.
With some few exceptions, the focus has tended to be on the ability of health systems
to recover from shocks, with far less attention paid to the choices exercised by individuals
or groups within the system, and the ways in which they do, or do not, exert control
over processes by which that system-level resilience is shaped.16 In part, this is
the natural consequence of transposing a concept originally developed with reference
to ecosystems, onto social systems. Despite some commonalities these two types of
systems retain key differences including that social systems ‘embody power relations
and do not involve analogies of being self-regulating or rational’.17 In scanning
recent reviews of health system resilience it is interesting to note the general absence
of mention of ‘power’ in the formulation of the concept.5 18 19
Explicitly linking the exploration of health system resilience to health system governance
Clearer recognition of the full spectrum of disturbances (from exogenous epidemic-type
shocks to political or bureaucratic stressors) in the context of social systems shot
through with power, brings me to a final point. If global health researchers and practitioners
are to continue to characterise health systems as social systems, then examination
of their resilience (defined as an ability rather than an outcome) makes most sense
when anchored to an exploration of the modes and dynamics of health system governance,
at whichever level appropriate. As summarised by Blanchet et al, governance relates
to the implicit and explicit rules and institutions that shape power, relationships
between actors, and the actions of these actors, meaning that: ‘managing resilience
of a health system resides in the capacity of managing actors, networks and institutions
that have an influence on the health system’.20 In other words, by taking governance
as the point of departure for enquiries about health system resilience, we are consciously
focusing on the actors and networks whose choices and actions we understand that resilience
to depend.
Anchoring explorations of health systems resilience on governance provides a guide
for considering both the explicit and implicit power dynamics, and the competing interests
and goals, of various actors who we know impact all domains and levels of the health
system. Such an approach does not preclude, but rather enables exploration of the
characteristics of resilient health systems, with cross-disciplinary learning suggesting
these characteristics are in any case actor-dependent, including for example: (1)
diversity; (2) flexibility; (3) inclusion and participation; (4) recognition of social
values; (4) acceptance of uncertainty and change at different levels and (5) and the
ability to foster learning.17
Two examples of analyses using different methods to examine such issues have been
recently published in BMJ Global Health. One is Saulnier et al’s account of health
system resilience from the perspective of Cambodian communities responding to floods.21
This nuanced work reveals a range of strategies implemented by individuals, families
and entire villages to mitigate the health access impacts of regular flood events,
but demonstrates how those same actors have limited ability to build systemic resilience
given their lack of decision making space or ownership of health system processes.
Such a scenario, the authors observe, leaves ‘the community vulnerable to more severe
floods and different shocks’ when their localised absorptive capacities fail. Here,
we are reminded that what makes health systems resilient in the real world, may or
may not depend on traditional supply side strategies (indeed it may be in spite of
such). More disturbingly, we see too that resilience may not in fact enable high quality
or equitable health services for vulnerable populations but rather, in Gore's words,
underpin a deficient status quo.
Lee et al in their article "How coping can hide larger systems problems: the routine
immunisation supply chain in Bihar, India"22 identify how persistent ‘coping behaviours’
by front-line health workers in aid of routine immunisation, mask systemic deficiencies
in the cold chain policy and logistics of that state. While coping behaviours may
on the surface be seen as a form of resilience, the authors demonstrate how long term
reliance on such behaviours is likely to contribute to systemic brittleness, not resilience,
since: ‘one set of personnel, those at the outermost level […] bear a disproportionate
burden in supporting the system, leaving them overstretched and in a potentially very
unstable situation. If circumstances were to further change or these personnel are
no longer able to cope, the entire system could break down very quickly.’22 The authors
make the critical, if somewhat counterintuitive observation, that instituting ‘anticoping
measures’ and encouraging a culture in which coping is discouraged may be necessary
to redress broader and deeper system-related dysfunction.
The above two articles highlight a critical distinction between asking whether the
health system has the ability to respond to, and learn from, a change or disturbance,
and an assessment of who or what benefits from that adaptation in the short and longer
term. If we do not ask the latter (‘who benefits from adaptation?’) we risk conflating
the pursuit of resilience with the pursuit of improvements in health and equity. Put
bluntly, the capacity to adapt and implied resilience it conveys become equally or
more important than whether that adaptation and resilience produces improved health.
And in this, there is a further risk: that resilience is used to help push for the
adoption of policies that ultimately undermine high quality or equitable systems or
which contract the space available for debating such alternatives.17 The linking of
resilience to health security agendas, for example, can be used to divert public attention
away from existing deeply embedded health inequities and the conscious choices that
shape our (often inadequate) health system responses to them, in favour anticipating
how, where, and when health emergencies will happen (ie, preparation), and what sorts
of responses are pragmatic and acceptable in those extreme circumstances (ie, adaptation
and resilience).2 The danger of the concept of resilience being thus mobilised is
greater, moreover, in the midst or immediate aftermath of dramatic systemic shocks,
such as the 2014 Ebolavirus epidemic and the current COVID-19 pandemic.
Conclusion
For global health and health systems researchers and practitioners, the concept of
resilience has utility, including for its ability to frame health-related challenges
within a systemic approach; accounting for different types of disturbance or shock,
multiple actors, dynamic processes and feedback loops occurring across different domains
and levels of the health system. But resilience in health systems should not be seen
as an apolitical outcome, synonymous with a strong health systems or improved population
health. What promotes the ability of a health system to be resilient must be assessed
in the context of the interests and intentions of health system actors and the ways
in which they mobilise and channel their power. Not to do so risks allowing some abstract
conception of ‘health system resilience’ to, intentionally or unintentionally, displace
attention and efforts away from the sorts of reforms necessary to address and improve
long-standing health inequities. In current COVID-19 context, we must be particularly
alert to such risks.