Resilience is the next “big thing” in global health and health systems development. It is a reaction to the impact of the Ebola epidemic in West Africa, the financial meltdown in the US and EU, and global climate change. The principle has been firmly anchored in the Sustainable Development Goals (SDGs): “By 2030, build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social and environmental shocks and disasters” (UN Sustainable Development Goals, target 1.5).
The term now also frequently appears in global health policies. “Resilient health systems” was the theme of this year’s World Health Assembly, but in the first meeting of the WHO Review Committee on the Role of the International Health Regulations in the Ebola Outbreak and Response in August, the concept was not mentioned. It also doesn’t appear in WHO DG Margaret Chan’s opening remarks to the Review Committee. On the other hand, the World Bank favors the resilience approach, and also the Rockefeller Foundation has developed much interest in resilient health systems. This is not surprising as its president Judith Rodin is the writer of the book “The Resilience Dividend”. The theme of next year’s 4th Global Symposium on Health Systems Research in Vancouver will be “resilient and responsive health systems for a changing world”.
I argue that we should distinguish between the resilience discourse as applied in complex adaptive systems, ecology and psychology and its use in normative, political, decision making for health systems. While the first is a useful method to assess the flexibility, responsiveness and shock-absorbing capacity of health systems there is much criticism of the resilience discourse by political scientists. One of those critiques is that the resilience discourse colonizes our political imagination. It hinders us to develop universal and strong systems based on the principles of health equity and to take action on the Social Determinants of Health. As resilience is mainly about anticipating a future crisis, we maintain the status quo. My analysis of the resilience approach to health systems is that it is a modern expression of the decades-old debate of selective versus complementary primary health care, and the political choices behind it. In a recent interesting political sciences article called “Exhausted by resilience” the authors even move beyond this: “The real tragedy for us is the way the doctrine forces us to become active participants in our own de-politicisation… It promotes adaptability so that life may go on living despite experiencing certain destruction. Indeed it even demands a certain exposure to the threat before its occurrence so that we can be better prepared. Resilience as such appears to be a form of immunization. Yes, the doctrine of resilience at the level of policy and power is ubiquitous. And yet in terms of emancipating the political, it is already dead.”
The authors challenge their readers to “a new imaginary for rethinking politics, emancipation and the formation of political communities in the twenty-first century.” Applied to global health, this would mean a reformulation of what we consider as the necessary conditions for a meaningful, dignified and healthy life. The capability approach developed by Martha Nussbaum and Amartya Sen can guide us. Universal access to essential health services whether people live in high-, low- or middle-income countries would be a core element in this. Such a cosmopolitan approach will move us beyond the iron cage of the nation states we live in and the false security it brings.
Yes, it is a re-imagination of an alternative world order. But we can’t continue with the status quo where we continuously consume beyond Earth’s carrying capacity, global temperature is to rise, global financial markets are casinos beyond control, and refugee patterns are likely to continue. There is no other option than moving beyond the status quo and working on true alternatives for social justice and health. At the minimum, we have to move beyond resilience.
(This article is cross-posted from the MMI Network September newsletter, where it was first published as the editorial)