The Vancouver Health Systems Research Symposium (with its theme: Resilience and responsive health systems for a changing world) is long over – but resilience is everywhere, in academic, practitioner and policy literature (e.g. Kruk et al; Witter & Hunter; and statements by the WHO Director Generals immediately past, and newly inducted). Perhaps others feel differently, but more than a year after writing a critique of the concept of resilience with colleagues (see here) I do not feel like there is a great deal more clarity about whether this concept brings something useful or positive to global health.  And in fact – as I read more about resilience as a framing concept for global health governance (e.g. Blanchet et al) it strikes me that there are some important and poorly recognized risks.

I recently re-read a paper presented by Prof. Mark Neocleous in 2015 in which he makes the point that security and the related concept of resilience are essentially modes of governing.  Security is a political technology and technique of power through which individuals, groups, classes and capital are reshaped and reordered.  Part of that exercise of power involves the state constantly anticipating and imagining how, where and when emergencies will happen (preparation), and how it should respond (resilience).  Neocleous argues that security and resilience as modes of governance come to shape the way people imagine the future and its possibilities, and simultaneously provide a rationale for the use of security measures and modes of organisation that often promote and defend the established order.  As he states: No political imagination except an imagination of attack and recovery; no political future except an infinite preparation for war.

We all want our health systems to be prepared for, and able to adapt to, environmental, disease and conflict-related shocks.  But what if health system strengthening – in a deep and comprehensive sense – requires a reimagining of the established order?  The now accepted vision for Universal Health Coverage, for example, challenges us to confront a range of socially embedded inequities in low and high income countries, and the ways in which current health systems may actually mirror and deepen those inequities.

With this in mind, Neocleous’ critique helped me crystallize a nascent concern.  That is, if we pursue health system strengthening via a resilience agenda, the necessary focus that this brings on anticipating, preparing for and responding to emergencies may stymy our capacity or willingness to be bold in our vision for better health systems.  Some commentators have urged us to view resilience in broader and deeper terms (e.g Haldane et al; Gilson et al).  But in reality, the concept is still commonly defined and understood as the capacity to absorb shocks and sustain gains.  By focusing on this preparedness and response to ‘shock’ events, our attention is thus drawn away from the hard grind of responding to problems or dysfunctions that do not manifest as an acute emergency.  Despite its conceptual alignment with systems thinking, a resilience focus may paradoxically increase the risk of ignoring the way in which the current alignment of interconnected actors and structures underpin dysfunctional health systems.

I recognise that this argument risks setting up a straw man.  Resilience is of course a desirable quality in a health system; and building resilience, especially in fragile systems such as in post-conflict settings is important.  But the global health fraternity has also made it clear that we have other, high-level aspirations for health systems that go beyond resilience.  We want health systems to be equitable; to deliver high quality care; and to provide financial protection.   In order not be (silently) subsumed by the resilience agenda, which may have specific appeal to certain (often powerful) actors, therefore, health system strengthening advocates must make a conscious decision to promote the qualities of resilience, but to frame the reform and strengthening agenda in far more holistic terms.  We must, as always, be conscious of the power of discourse to influence the way we articulate and act on our priorities.