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Applying Resilience to health system research: beyond a personal journey in the Gaza Strip

By Majdi Ashour
on November 12, 2016

Every time when the despair reaches its peak in the Gaza strip, we are confronted by the western media, international expatriates and researchers praising our ability to withstand our conditions. They point to our Resilience in the face of the inhuman circumstances in which we are submersed. They describe our experience as the Epitome of Resilience. I, therefore, have become fond of the word ‘Resilience’ which converts our vulnerability in Gaza into a positive meaning – one which epitomizes survival and steadfastness. I’m especially hugging to the concept of Resilience, now that the American people face the era of Trump.

Resilience in my research

In 2013, I analysed data from the latest round of the Palestinian Households Expenditure and Consumption Survey   (PHECS). I was intrigued by the paradox of resilience that emerged from the data. The p-values indicated  less incidence of catastrophic health expenditure among the population in the Gaza Strip, as compared to the more affluent Palestinians in the West Bank and that catastrophic health expenditure in the Gaza Strip was more prevalent among the better-off socioeconomic groups, than the worse-off, while it is more concentrated among the poor in the West Bank.

The data led to an epiphany – call it my very own “Newtonian” moment!

Rather smug about my small, but neat discovery, I interpreted the initial findings as being indicative of a population’s ability to withstand repeated shocks such as the Gaza Strip has been exposed to during its modern history. I have even chosen resilience as the overarching theme for my doctoral studies – to explore it from the perspective of Out Of Pocket  (OOP) expenditure on health.

As a PhD student, I have considered “resilience” as reason enough to use in my research. I have begun thinking about the appropriateness of integrating and operationalizing resilience-thinking in my research on the changes in the catastrophic OOP health expenditure in the Gaza Strip over the last three decades – a time which saw repeated economic shocks, military onslaughts and challenges to the healthcare system. The announcement by Health Systems Global that “Resilient and Responsive Health Systems for a Changing World” would be the theme of the 4th Global Symposium on Health Systems Research in Vancouver fuelled my enthusiasm further.

The implications of the resilience lens

Resilience has been used across disciplines, especially during the last decade; yet its use in health system research is at an embryonic stage. The recent Ebola outbreak in West Africa was instrumental in framing resilience within the context of health systems. However, the fuzziness and buzz-wordiness of resilience coupled with its limited use in HSR have made its operationalization an elusive mission.

The trial of integrating resilience thinking into my doctoral research soon turned into an investigation into the appropriateness of using the resilience-lens in assessing changes in catastrophic and impoverishing OOP payments on health, the applicability of resilience to the vulnerability of the people in the besieged strip, and even questioning the usefulness  and the harmlessness of the resilience doctrine itself.


Agency and Adaptive preference

When it comes to catastrophic OOP payments, resilience could veil important issues: Agency and Adaptive preference.

The agency of individuals and households relates to the action taken by them to overcome their conditions. In contexts where access to health care is far from universal, the ability to pay may (and does) influence the ability to access health care services, which often requires the ability to pay. Context can impact health seeking behaviour; for example, poorer people may self-medicate more than the better-off. Often in low-resource settings, where available, and acceptable, public health services may be the preferred option for poorer people. The poor also rely on social capital – borrowing, selling assets, extra work, eating less, etc. – often leading quantitative data on catastrophic OOP as indicative of “resilient” populations.

Adaptive preference is the deliberate or reflexive process by which people adjust their expectations and aspirations when trying to cope with deteriorating changes in their living conditions. Preventing high OOP may happen alongside the occurrence of adaptive preference. As a result of deteriorating living conditions, and loss of  income, households or individuals may change their health seeking behaviours by choosing less expensive health providers.. Less expensive health services may decrease OOP and increase the “resilience” and ability to cope with the change in their capacity to pay, but it could also potentially be at the expense of the quality and continuity of care.

Vulnerability and resilience

Vulnerability and resilience are often thought of as two sides of a coin. One could imagine a health system (or a community or an individual) isn’t resilient because it is vulnerable; conversely it is vulnerable because it lacks resilience. In the Gaza Strip resilience and vulnerability are actually interrelated. The relationship between them is not as circular as you might imagine. Gaza is vulnerable and dangerously exposed to recurrent military onslaughts, protracted isolation and political conflict, chronic poverty, among other health system challenges.

The vulnerability of the strip and its growing population has made the political and humanitarian wings of the international community aware of the situation in which the strip is immersed. The international community has intervened since the start of the conflict and the plight in Gaza in 1948. While these have enabled people to survive, prevented starvation and disease,  they have not put an end to the conflict nor vulnerability – instead, they managed them. These interventions created a “health” system for vulnerable and surplus population. They enable people to survive and to live – but live a bare existence. Currently, more than two-thirds of the two million people in Gaza live under the poverty line, two of five are unemployed, and 80%of households receive food assistance. Despite this economic and financial deprivation, there is no starvation. Isn’t it wonderful how “resilient” the people areJ ! The health system is far from dysfunctional, but the suffering of the people continues; people queue for hours to access basic healthcare – creating, in a nutshell “resilient” systems for vulnerable populations which lack dignity.

Resilience is, in some ways at least, the vulnerability and disposability.  Resilience is created for us. For the vulnerable and disposable people. It is created for the majority of people, who should be satisfied by their mere survival and ostensible “resilience”. It is created for the people who are dangerously exposed; for us who “should” survive the repeated shocks and catastrophes, and keep smiling. It is created for us in Gaza, who could be swallowed by the sea, isolation, military attacks, and poverty, but should never give up. It is created for the global south. It is for the vulnerable; the 90% who could lose their jobs in the blink of an eye. All for the greater good of the elite; one wonders who came up with the idea of resilience.

About Majdi Ashour

Majdi Ashour is a Medical Officer at the UN Relief and Work Agency for Palestine Refugees, a PhD candidate in International Public Health Policy, and an alumni of the University of Minnesota and ITM. He was also a New voice for Global Health at the World Health Summit in Berlin in 2013.