Interrogating resilience of health systems

Introduction Health systems have experienced major shocks and will continue to encounter various forms of disruptions as observed in the increased frequency and intensity of catastrophic events such as extreme weather events, natural disasters, political conflicts and pandemics. The term ‘resilience’ has been used and heavily debated in the global health sector since the West African Ebola outbreak in 2014, which has exposed serious inadequacies of international and national institutions in health systems responding to shocks. Albeit a consensus on the growing significance of resilience in improving responses to system level shocks such as that from the COVID-19 pandemic, a plethora of research thus far has remained mostly at a theoretical level with the discussions focusing on definitions, concepts, and principles. The unanimous voice from health system researchers echoes these concerns and recommends that research gaps should be filled through more applied research rooted in real life cases. This thesis is a timely response to this collective call for applied research in the field of health system resilience. This research highlights the vital role of resilient health systems in practical terms to prepare countries for future shocks, and bring out its crucial effect in bridging the disparate health and development agenda in order to address the nexus between humanitarian aid and development cooperation. The empirical evidence based on countries’ experiences responding to various shocks may illuminate valuable insight for practitioners and policy-makers to generate resilience-enhancing strategies for their own contexts. Aim and objectives The overarching aim of this doctoral research is to contribute to the health system resilience literature by bridging the gap between concept and practice of resilience in the health system through interrogating empirical evidence of low- and middle- income contexts. The specific objectives are: 1. To synthesize evidence on key features of resilient health systems in low- and middle- income countries 2. To improve the understanding of the characteristics of health system resilience based on a national response to a crisis and how countries can improve resilience in their health care systems 3. To explore the perspective of NGOs dealing with unexpected shocks on health systems and to reflect on the practical implications of resilience for stakeholders in global health cooperation Methods In order to bridge the gap between the concept and practice of resilience in health systems, we employed methodologies that may best capture the complex nature of the topic: a systematic review and qualitative approaches. The first study (Objective I) was addressed by a systematic review synthesizing key features of resilient health systems in low- and middle- income countries. It employed a best-fit framework synthesis approach, often used in a rapid evidence synthesis of qualitative data to generate context-specific models or programme theories that have potential relevance for policy-makers and field practitioners. We identified a best-fitting existing model of resilient health systems framework as an a priori framework to map and code the data from the included studies. The second and third objectives were tackled through qualitative studies that were based on semi-structured in-depth interviews with representatives of international organisations and non-governmental organisations (NGOs) in Myanmar (Objective II) and representatives of Swiss-based NGOs with on-going health project engagements in low- and middle- income countries (Objective III). The interviews were guided by semi-structured interview guides designed to explore the characteristics of resilience that have been salient or absent in responding to the crises and the different roles key stakeholders may assume to build resilience. Triangulation through supplementary data such as reports, event pictures and media clips provided by the participants was used to partially offset any potential recall bias due to the time gap between the actual event and data collection periods. Results and discussion Objective I) To synthesize evidence on key features of resilient health systems in low- and middle- income countries Empirical evidence of resilient health systems in low- and middle- income countries were reviewed by synthesizing the key features of resilient health systems. We proposed a refined conceptual framework for health system resilience that conceptually tracks the journey from the health system shock to the five attributes of the a priori themes. The five new themes, namely, “realigned relationships,’ ‘foresight,’ ‘motivation,’ ‘emergency preparedness,’ and ‘change management,’ have been identified as the foundations of resilience, which can serve as critical inputs for unlocking the five resilience attributes from the a priori framework. Social capital, which comprises of trust, shared vision, and collaboration, have been found to be common to both health system strengthening and resilient responses to crises, hence proving pivotal in both crises and calm. The review prompted low- and middle- income countries to consider building the foundations of resilience as a priority to better prepare for future shocks. Objective II) To improve the understanding of the characteristics of health system resilience based on a national response to a crisis and how countries can improve resilience in their health care systems Our previously developed framework on health system resilience was applied to examine the characteristics of resilience that have been salient or absent in Myanmar’s response to Cyclone Nargis in 2008. Strong social capital and motivation stemming from its deep-rooted cultural and religious networks were found as Myanmar’s greatest assets that filled major gaps in the system. In contrast, its postcolonial and military legacy posed barriers towards investing in building its long-term foundations for resilience. In Myanmar’s case, it can leverage its assets (social capital and motivation) as opportunities to achieve long-term health goals towards resilience. On a more practical level, Myanmar can invest on building its long-term infrastructures in remote areas, prioritise in human resource preparedness and redesign its institutions and organisational structures to serve its evolving purposes and to prepare for future shocks. Objective III) To explore the perspectives of NGOs dealing with unexpected shocks on health systems and to reflect on the practical implications of resilience for stakeholders in global health cooperation We examined how and to what extent Swiss-based NGOs with a focus on global health have dealt with unexpected shocks in the health systems of their partner countries and reflected upon the practical implications of resilience in development cooperation. We found that health system resilience is a collective endeavour and a result of many stakeholders’ consistent and targeted investments. These investments open up new opportunities to seek innovative solutions and to keep diverse actors in global health accountable. Strong governance, a bi-directional knowledge exchange and the focus on leveraging science for impact can draw greater potential for resilience in the health systems. In this regard, the governments and the NGOs have unique points of contributions to target the strongest determinant of resilience, which was found as the degree of investments made for building long-term infrastructures and human resource development which are well-functioning prior to any crises. Conclusion The COVID-19 pandemic has been a wake-up call for all health systems to build and maintain core health system functions in order to prepare for, manage, and learn from disruptions. The following recommendations outline what health system actors can do to improve resilience in the health systems: 1) Emergency preparedness: ensure that an emergency preparedness strategy and plan are built into the national health system at all levels Having an emergency preparedness strategy built into the national health system at all levels improves the chances that the strategies can be translated into action when required. The logical step for national level preparedness would be then to better embed the International Health Regulations (IHR) into health systems. There should be stronger accountability towards improving countries’ IHR core capacities through the Joint External Evaluation (JEE) exercise and country ownership is critical for the assessment results to align with its national action plan’s priorities, budgets and targets. 2) Realigned relationships: establish strategic alliances through effective coordination mechanisms and public engagements An effective coordination mechanism with clearly established roles and decision-making protocols is a critical first step to harmonise divergent actors amidst emergency responses. A resilient health system responds to disruptions by establishing and renewing partnerships and alliances according to shared goals and visions. Engaging non-state actors in a systematic way was proven critical not only to disseminate key information but also to gain trust and legitimacy by involving citizens, communities and the private sector in the decision making processes. 3) Foresight: invest in the long-term slow variables of the health system infrastructure and human resources Building resilience is more than preparedness. Health system actors ought to take a long-term perspective, investing in building robust infrastructure over time and cultivating a cadre of health professionals that can function in both crisis and calm. Countries ought to take a broader view of the health workforce and to make investments based on modelling and projections rather than from immediate surge capacity needs. 4) Motivation: foster strong political will and personal commitment One approach to encourage good political leadership can be to keep politicians accountable for their capacity to protect the health of their population through the use of participatory social media and data sharing. Establishing independent task force teams and participatory consensus building forums can distribute power and leadership and share responsibility within the bureaucratic system. Donors and NGOs ought to display a deeper sense of humility and patience on first restoring the fabric of legitimacy in the communities and creating a platform where different actors can collaborate based on trust. 5) Change management: integrate new initiatives and reforms into the system prior to the crises Various new initiatives can build resilience when they have been well-integrated prior to any crisis. Well-adapted and scaled-up digital innovations can support the flexibility required in times of shocks. This is an area where the NGOs and international organisations can make unique contributions to leverage science for impact. It is important, however, to build on the unique contextual strengths of the country’s health system structures in order for any new initiative to be contextualised and sustained