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Excerpts from a discussion on resilient health systems with the new 2016 EV batch

By Kristof Decoster
on October 5, 2016

Over the past few weeks a couple of thematic discussions were organized for the new cohort of Emerging Voices. One of them focused on resilience, the resilience “discourse” and resilient health systems more in particular. After going through a few background readings (including Kruk et al (2015), Kutzin & Sparkes (2016),  Gebauer (2016), among others )  and videos (including one by the fearless Mark Neocleous ), about 15 EVs started debating.  There were a couple of facilitators (Remco van de Pas & myself) and we also called upon a few external experts to shed some more light on this topic. (We will let you guess who they were 🙂  )

Even if this will turn out to be a rather lengthy post, we won’t try to give a full overview of the (meandering) discussion here, but will just provide some of the messages that popped up, via excerpts from participants. During the discussion, many of them referred to or brought up some of their own experiences in countries as diverse as Liberia, Uganda, South Africa, Sri Lanka, …  The format of the blog will be sort of a “Storify format”. We hope that by the end of this Storified blog, you’ll be a bit wiser  (and of course, we hope the same was true for the participants!). Do read on to the end, you won’t regret.


So here we go:


A brave EV2016 kicked off the debate, trying to get a grip on what resilience & resilient health systems implies, referring to some recent examples (Liberia, Nigeria) and some of the literature & videos in the process:


Resilience to my understanding is the ability to foresee future problems or deal with them if they occur, be able to adopt and overcome them by providing required services.

Michael Myers in the Aspen idea festival describes the history of the concept ‘Resilient Systems’. He described how Liberia in the year 2003 after two civil wars was on the road to recovery. The country was performing extremely well on the track of attaining the MDGs until Ebola hit the country and crumbled the systems. This was termed as a case of great achievement in silos but not integrated into a system or resilient health system. Larry Brilliant [also speaking in the same video ]on the other hand described how Nigeria was resilient in handling the Ebola crisis with lower incidence and fatality rate.”  

Like Myers, she then referred to five characteristics of resilient systems (aware; diverse; self-regulating; integrated; adaptive) (see also Kruk et al )


The system needs to be aware: know what the challenges are, have a surveillance system in place to detect what is coming, know its strengths and weaknesses; The system is diverse: it can redeploy people and systems when challenges come; Is self-regulating; Is integrated: integrated with the broader world, business, private sector, community, religious groups; Is adaptive: It can change in good times and bad times. “

She continued:

“Resilience is a cross sectional theme and entails people, communities, health systems, other inter linked systems and policies to be resilient. The impact of climate change, terrorism, water crisis, food crisis, trade policies on health have been realized. …..”

She ended, wondering how to measure resilience.


A facilitator then brought up the Kutzin & Sparkes  article including their mantra “HSS is what we do; UHC, health security & resilience is what we want.”


“…Policy making is partly about a political process (whether local, national or at international level) on setting priorities and allocate (finite) resources to certain policy problems.  My main question is: Could you reflect from your experience on how to prioritise between focusing on UHC (strong mechanisms to reduce financial risks and improve access to health services)  improving health security (e.g. preventing future outbreaks of infectious diseases) and having the system become more ‘resilient’ (adaptative, flexible, dynamic etc )? Ideally, there should be a balanced approach to these. Often, however, funding and attention are focusing on certain issues (e.g. in the past on responding to the HIV/AIDS epidemic) above others.  If you were a MoH, would you move equally forward on all the domains, or would you rather ‘sequence’ investments in the health system (perhaps responding to political demand by communities) ? What are contextual factors and which are the different organisations and actors you need to take into consideration?…”  (later in this blog, you’ll get some EV views on the trade-off/synergies between UHC, health security & resilience)


An (external) expert then came in, pointing out the added value of the concept of a resilient health system, especially in fragile settings, among others:


“.. Despite its over-use by the aid industry, I think it is an important aspect of healthcare development, particularly in relation to troubled health systems. In fact, shocks don’t occur randomly, but are more frequent in poor, unjust and misruled societies. Thus, while it is true that these features need political responses, it is wise to design these health systems so that they respond better to frequent stressors.

Building a resilient health system calls for a deeper understanding of the resilience concept. Translating resilience into a ‘larger and better-resourced’ system, as many commentators seem to assume, is reductive. If the health system is expanded without addressing its multiple vulnerabilities, the next collapse will be just more dramatic and costly. Thus, such vulnerabilities must be adequately unpacked, and the proposed interventions coherently linked to them. For instance, if the workforce remains dissatisfied because of inadequate pay, it will under-perform when the next shock strikes. In the same vein, the supply chain must be better managed if improved physical assets have to provide returns.

Resilience is an emergent property of a complex adaptive system. It is not a static characteristic, but can only be appraised in motion, when a disturbance occurs. It results from the interplay of many factors. Whereas some are tangible and easily measured, others are intangible but equally essential. In the first group raw resources can be included: health facilities, equipment, human resources, medicines, and funds. The procedures followed to manage such resources affect their value in response to disturbances: cumbersome, highly-structured, slow procedures constrain the redeployment of the available resources, even if they are abundant. Most donor contributions suffer from this constraint. Moreover, resource stocks above current utilisation levels facilitate prompt responses. Maintaining surge capacity is expensive, but essential when troubles arise.

Intangibles include capacity, intelligence, trust, communication, redundancy, flexibility, initiative, reputation and commitment. Only a qualitative appraisal of such factors in a variety of situations can reveal the extent of their presence, and their robustness under different stressors. These aspects are critically inter-related, and linked to the hardware mentioned above. One major weakness may fatally impair the system, even if other factors are adequate. Ebola created havoc precisely because many vulnerabilities were exposed at once, and potentiated each other.

Predicting the resilience of a health system is therefore difficult, also because soft factors change frequently: for instance, strong political leadership may be present for a few years, and wane afterwards. Waiting for the next stressor to reveal the degree of resilience embedded in the health system would however be unwise. Probing its responses to different events, at different levels and sites of the system, might suggest to decision-makers the measures needed to prepare for actual shocks. A recovering health system can be deliberately endowed with many of these intangible properties, so that a successful response to a shock is more likely to occur. They have to be promoted by conscious design during favourable times, by allocating to each aspect adequate capacity and resources. The awareness that other big crises (perhaps of an unexpected nature) will challenge the healthcare provision system should motivate actors to equip it adequately.

The final point is about measuring resilience. The search for a few clever quantitative indicators is clearly a delusion, widespread in donor circles. But its presence can be assessed through, or better inferred from a thorough review of strengths and vulnerabilities, a sort of stress test akin to what is done with banks. But predicting the future behaviour of present systems is famously difficult, as persuasively argued by NN Taleb.”


An EV then pointed to Uganda’s experience with Ebola and compared with the Ebola response in West Africa:

“… I want to have a snap shot at the Ebola epidemic in west Africa comparing it to Uganda that has been hit by Ebola 5 times in 15 years. On all these occasions, it was contained, did not spread to the other countries and the number of people lost to Ebola were few compared to those in west Africa. The argument could be that after the first epidemic in 2000, there could have been some resilience built. My thought to that is, there was never any resilient system built in Uganda. One key aspect of the health system that was key for containment of the epidemic is the human resources, surveillance systems and the psycho social aspects that helped the community to understand the disease and how it is spread. These were lacking in west Africa and hence the quick spread of the disease…. “


The expert replied:

Dear […], you have pointed to an essential aspect, when you stressed that in Uganda no resilience was deliberately built into the system. I think that, as in regard to capacity, the term building is misleading. Both characteristics emerge in complex adaptive systems, and what we can do is fostering their emergence with devoted interventions, which address the identified vulnerabilities of a given system. From what I know, Uganda responded better to Ebola from the first outbreak it faced, because it was already more resilient. At the other end of the resilience spectrum, Angola is consistently performing poorly despite the material resources it has at hand.

Thus, the way a system works is as important as the resources it can rely upon. For instance, peripheral management structures are critical in identifying threats and devising adequate countermeasures. If district managers are bound to follow strict plans and cannot reallocate available resources, their response to unforeseen events will be poor, individual competence and abundant resources notwithstanding. In this regard, mindsets affect performance as much as procedures. … … Kutzin and Sparkes (2016) capture well the whole point: “The resilience of a health system refers to its ability to absorb disturbance, to adapt and respond with the provision of needed services. Thus, resilience is not an action to be implemented but rather a dynamic objective of investments and reforms. In the case of Ebola-affected countries, for example, this has required efforts to not only restore how the system functioned before the crisis but to transform and fundamentally improve the health system.” …”


By then it was time for a (somewhat ) more cynical view on resilience & the resilience discourse– see this eloquent view from an EV.

Pardon me. I have a very limited understanding of the new buzzword in the global health community– ‘resilient health system’.  … …  I have read related literature on this topic in the past, but they are all painful to read; most of them are just echoing decade-old concepts enshrined in a plethora of health financing and health systems textbooks.  I am raising a cynical point of view because, at least to me, the introduction of motherhood concepts (such as ‘resilient health system’) might have created murkiness and tensions in many health policy discussions. Sometimes I think the aid industry are introducing so many motherhood concepts that less-developed countries do not even have the energy to digest.”

She then applied this view on health financing more in particular:

“When we talk about a resilient health system, we cannot veer away in thinking about existing concepts in health financing.  For example, in order for a health system to absorb shock (e.g. epidemic), the health financing system should be fiscally healthy.  And how do we make it healthy?  Well, we need to have a big risk pool. We need to have a constant funding flow. We need to have a regulatory system to promote fiduciary responsibility among insurance institution/s. We need to empower risk-pooling entities for them to properly manage risk.   These concepts have been in place from time immemorial. Stiglitz has written the concept of health insurance equilibrium when he was a PhD student, and he is almost retired now.  The concept of constant funding low is also enshrined in many decades-old UHC frameworks.  So, what can be done? For health financing to be resilient, countries should have strong regulatory power. They need to know how to look at liquidity/investment of insurance fund; maneuver political forces to impose premium ceiling and cost-containment mechanisms; and wrangle with other sectors for bigger fiscal space for health. These are the important issues that have not been resolved in many countries in Asia and Africa that are adopting health insurance models.  In term of service delivery, this is also the case.  How do me ensure the health system absorb external shock in time of calamities and natural disaster, of course, you need to strengthen public health, surveillance system and government coordination.

 I hope someone can enlighten me 🙂 … “  (lovely ending)


From a more cynical view on resilient health systems to the question on power imbalances in the resilience discourse and how to address them, is only a small step for humanity (and EVs), and so another EV weighed in:


My thoughts on the third question, on why the global health community has evolved towards this kind of discourse, is that the concept of resilience might have finally brought in a health systems-lens to global health, after decades of more vertically-oriented planning. The Ebola and Zika epidemics highlighted the potential drawbacks of such approaches, and, in a moment of interesting alignment, seemingly converged with calls for resilience from private philanthropy, a point noted in the piece by Gebauer. It almost felt as though in a period when the public was struggling to understand how such a situation can occur, the ‘right’ health systems-oriented solution appeared before them.

One of the issues that I have with this kind of framing is that it appears to once again directed by calls from global-level organizations, rather than an evolution from local contexts. This is not to say that stakeholders at the national, regional and local levels within countries do not concur with this direction; there’s every likelihood that they do. However, has there really been a groundswell of support for this concept? It’s unclear because the discourse has been dominated by only a few actors. Therefore, there appears to be an uneven power dynamic at play, one where those with the power and space to shape policy dialogues have done so, without perhaps fully engaging with the reasons why we got to this situation in the first place.

On the flip side, one of the benefits to this type of discourse is that we are including the word health systems in the discussion; and the resilience discourse has brought up key health system reform topics, such as human resources, surveillance, etc. Strengthening these systems will no doubt have an impact beyond communicable diseases.

… … Overall, my sense is that while the resilience discourse might represent a positive step for health systems strengthening, we need to engage further with the idea that power imbalances in the global health community could have also played a role in shaping this discourse, and that there is more work to be done on tackling the root causes of weak systems, such as economic inequity, poor accountability and misaligned priorities.”

Another EV also worried that “… resilience is another hegemonic discourse created by the ‘west’ based on their own concerns for protection or ‘national security’ that neglects to adapt across contexts, nations or cultures. Unfortunately, I think such a focus could become problematic in the very development of stronger health systems in many contexts due to the inequitable focus of western political agendas on funding, research agendas and often programmatic decision making with limited thought about what individuals and communities in other nations may desire.  For example, in the case of both Zika and Ebola, large focus has been on the provision of funding for vaccine development or control strategies, both of which are critically important, but as is so often the case funding for systems strengthening in a way that is context appropriate is somewhat lagging….  ”


Or in the words of a facilitator:


First, it would be good to distinguish between the use of ‘resilience’ in health systems as such and the use of resilience in the politics shaping health systems. While there is not so much to argue against the case that a health system must also be resilient, the question remains whether this is a contextual priority in a local, dynamic, health system or not. Keep it simple. In many places basic elements (workforce, finances, access to medicines, Health information system, service provision, management/ stewardship) are only partial in place. Perhaps we must focus on strengthening these basics first while at the same time considering their resilient features as a kind of cross-cutting theme without it being an aim in itself?

… … Secondly,  … … I am resisting the resilience discourse as been used in the political framing on why and how health systems need to adapt/ develop. The framing leads us to accept that we only have limited policy space to develop health systems (with an ‘ideal’ objective in mind). Rather we must ‘accept’ that  ongoing crises and emergency situations are the new ‘normal’ and that we need to adapt on a systematic and individual level to remain ‘secure’. This securitization/ risk mindset is rather nihilistic and might turn our imagination into a ‘zombie’ mode: be prepared for the worst,  even to monitor and kill your own neighbors (e.g. if he or she has potentially contracted a deadly epidemic viral disease, is a potential terrorist, or might potentially be a ”drug -abusing migrant rapist’!) On why and how this health security framing is used in the international policy field see this very insightful article by political scientist Simon Rushton (2011):Global health security: security for whom? Security from what?” … “


On a slightly different note, one of the experts (clearly, more a fan of resilience) weighed in on the cost of boosting resilience, and the (still rather dominant) equilibrium thinking in international health:

Raising cost concerns is absolutely legitimate, particularly in relation to resource-starved health systems, which are the most vulnerable. But the long-run costs of a resilient health system might be more acceptable than the short-run ones (which are likely to be higher, because of the lower operational efficiency of such a system). Consider this statement: “..maintaining resilience incurs costs. It comes down to a trade-off between foregone short-term benefits of high efficiency under narrowly constrained circumstances and the long-term persistence of the existing regime with reduced costs of crisis management” (Anderies et al, 2006).

Think of any poor health system we are familiar with. Within a ten-year span, it will go through two or three major crises of assorted nature, with its costs skyrocketing. Thus, its overall costs should be computed by looking at the balance between low-cost operations when everything is favourable, and high-cost emergency interventions. If the response to crises is stronger, such cost spikes would be lower.

This reasoning has huge implications for planning. Revisiting customary planning criteria while wearing a resilience lens forces a reconsideration of the way efficiency is usually appraised. If large disturbances occur frequently, the efficiency of a given health system should be assessed in the long run, with its see-saw of normal operations and disruptions. Any measure of overall efficiency would in this way be much lower.

A thoughtful way to unpack such a conceptual flaw is the following: “International health is still dominated by equilibrium thinking. Public health disciplines such as economics and epidemiology have traditionally promoted equilibrium thinking and purposively ignored the adaptive capacities (or resilience) of systems. The dominant approach has been to systematically implement standard health interventions in different countries [..,] based on the assumption that all variables (e.g. context and actors) stayed unchanged during the whole implementation period [..]. Equilibrium thinking is based on the assumption that every element in the world has a state of stability towards which they tend to return, whatever the changes in their environment. Assuming contextual stability is quite questionable considering the rapid contextual changes modifying our social networks on a more globalised world where the pace of change in human ecology has significantly accelerated during the past half century has even created new health challenges.” (Blanchet, 2015)

Finally, I cannot agree more than a qualitative, multi-disciplinary appraisal is needed to understand complex adaptive processes. And Natsios (2010) ironically sounded in agreement too, when he warned against the “Obsessive Measurement Disorder (OMD), an intellectual dysfunction rooted in the notion that counting everything in government programs (or private industry and increasingly some foundations) will produce better policy choices and improved management.”


As you are well aware, systems can be found at many levels ( from community, to the local (including cities) to national systems all the way to the global level). This complicated a bit more the discussion on resilient health systems.


One facilitator pointed for example to a recent piece by Jha, Ebola pandemic shows that cities, not nations, should lead on public health

“… Jha thinks it’s time to consider cities as the central organising principle for protecting human health, referring to examples like Lagos, Monrovia, Freetown, Conakry,… in the Ebola crisis. ……  Again the issue of levels (global, national, cities, …) and systems nested in others, comes up here. Would be interesting to hear your views on this….”


The expert (on fire by now) again:


Dear […], I fully agree that cities (particularly megacities) should occupy centre stage in any health policy discussion, but the issue deserves a thorough exploration, which we can start here. Good papers on it are welcome.

Large cities are linked by air, so they constitute a global network through which people and germs (but also ideas and medicines) travel. However, the cities of the Global South are not homogeneous. They are in fact constituted by kernels of privilege surrounded by large slums of dereliction. Whereas the elites of the affluent cities are connected with their counterparts all over the world, slum-dwellers maintain important links with the countryside, from where part of their livelihoods come, and where they travel often.

Poor-world city councils may care about the health of the better-off parts of their urban remit, but usually neglect the large peripheries they don’t know much about, perceiving them as threats rather than opportunities. In fact, in their view diseases, social unrest and crime must be contained at the gates of the modern town. Under this light, I doubt urban health authorities would necessarily enjoy a comparative advantage in relation to national ones. Actually, they are often managed by the same elite indifferent to the plight of poor people.

In any case, Ebola has demonstrated in glaring contours the dynamism of contemporary communicable diseases, which may start in a remote and under-governed border area, travel fast to town and back, and threaten the world. Thus, moving the responsibility from one level to another would just maintain a rigid structure in the face of a fast-moving process. The key point would be in the connections and interfaces between all the structures (within and without country) that may facilitate or hinder the response to an unexpected disturbance of unpredictable unfolding…. .


One of the facilitators tackled another level-related issue in a following contribution (clearly, late at night, decaffeinated  🙂 ):


“…While the merits of resilience thinking are undeniable for all systems (and thus also health systems), the main problem, I think, is this one: I sometimes wonder what the point is of trying to build ‘resilient health systems’ at the national level, if at the same time the overall (planetary level) economic system we have is anything but resilient (but rather auto-destructive)? The current global economic system causes planetary ill-health (as well as plenty of other injustices & havoc). So the focus on resilient health systems feels a bit like putting the cart before the horse….

… Would be good if in Vancouver some attention went to (lack of) resilience at different (especially the global) level(s) (and the interaction between these different levels).

I also hope that some of the emphasis will also lie on the last part of the symposium theme: “resilient & responsive health systems for a changing era“.  As without transformative change, in terms of economic paradigm and the values dominant in our economic system, we’re toast.  “If not now, then by the end of century :)”      Good luck then with building resilient health systems.”

Fortunately, most EVs had a more upbeat view, and pointed to the importance of resilient individuals & communities (with a view on resilient health systems).  One EV referred to Liberia in this respect (importance of communities in the Ebola outbreak), another example focused on the Asian tsunami and the response in Sri Lanka:

“… These adaptive systems are the resilient systems that we try to put in place. All in all, I feel that resilience, although seems to have garnered a lot of interest in the recent times in relation to health systems, has been around for pretty long period, firstly as an innate human quality. The bottom line is if we are resilient then we can build resilient systems. It is something we are born with. Why I say this is, when I recall the Asian Tsunami of 2004 which hit Sri Lanka too, which was devastating in terms of lives lost and the physical damage caused, the health system was able to respond without a single serious epidemic. We were able to deploy health workers in time and manage the situation although we were not at all prepared for a calamity of this nature. We received external support too. However, what I’m trying to say is it was not only the health system that had a crucial role to play, but the people affected and the people not directly affected were themselves instrumental. They were quite resilient too. So, when we talk of building resilient health systems, it’s not something achievable within a short time. It requires resilience of all systems that impact on health which has to be built perhaps over generations of people.. …”

Another example of such a view by an EV, linking the resilience discussion also to the concept of social capital:

“…I guess that for me as coming from a social science background resilience also poses a lot of questioning around how you can talk about issues such as social capital in the context of resilient health systems. In other terms how does the citizen, the patient fit in a resilient framework, how do they contribute towards strengthening the system and enabling the system to respond and adapt to shocks. I believe that the networks and relationships that are formed by communities in times of crisis are underrated and often resilience is seen only from the structural point of view. In Ecuador, the recent earthquake showed that in times of crisis society is able to mobilize and organize networks to support the systems in place. The citizen support was fundamental for the quick response from the health system to address issues such as sanitation, infections and psychological trauma that resulted from the earthquake. In that sense working in close proximity with the population can also result in a resilient system that is able to quickly respond to these type of crisis.

 Furthermore, I would also like to extend this idea of social capital to further think about resilience at the individual level and how people benefiting from the health system develop resilience over time to respond to shocks in their lives in terms of illness,  violence, unemployment, national crisis such as earthquakes, viruses, etc. I think that humans at the individual level are often able to quickly adapt to changes and seek strategies that can help them cope with crisis. These characteristics, I believe, are pivotal when addressing shocks in the larger system. For instance, the way in which the system is able to respond to crisis such as HIV or TB in South Africa depend vastly upon individual resilience in terms of how people can adapt to shocks in their lives and still keep themselves under treatment. Therefore, individual resilience can help build a resilience health system that is able to respond effectively to emerging crisis.”


Then it was time for another EV who, like many others, felt a bit puzzled about the relation between UHC, resilience, health security, … Quite some EVs think resilience should be some sort of second-order objective (unlike UHC, for example):

“…Kutzin and Sparkles in their paper unpack the terms health systems strengthening, universal health coverage, health security and resilience. They highlight that strengthening health systems involves a significant, purposeful effort to improve performance beyond merely investing in inputs; and translates to reforming how the health system actually operates. Universal health coverage on the other hand means that all people are able to receive needed health services of sufficient quality to be effective, without fear that the use of those services will expose them to financial hardship. Moreover universal health coverage aims for equity in service use, quality, and financial protection towards which all countries strive. They argue further that embedded beyond the objectives of universal health coverage, is individual and collective health security which entails; the ability of an individual to obtain quality health services without becoming impoverished as a result and reducing the vulnerability of societies to health threats that spread across national borders respectively.  The resilience of a health system refers to its ability to absorb disturbance, to adapt and respond with the provision of needed services. Thus, resilience is not an action to be implemented but rather a dynamic objective of investments and health systems strengthening is needed to make progress towards universal health coverage and health security. They conclude that health system strengthening is what we do; universal health coverage, health security and resilience are what we want.  

My thoughts seem to be inclined towards the arguments in this article.  Health systems’ strengthening is the process of achieving universal health coverage. Therefore universal health coverage is the goal that health systems should be targeting and health security and resilience are only intrinsic components of it.  My question then is why is resilience looked at as a separate entity and not an intrinsic component of universal health coverage?”


Another EV zoomed in on resilience, focusing on the experience in South-Africa:


“… I was struck by your quotation:  “a truly resilient health system stitches these above elements together into an interactive dynamic organism in which the whole is more than the sum of its parts“.

In South Africa, health care falls under stewardship of the state, and the bulk of people receive basic medical/clinical care from government-run health facilities. However, the more social aspects of health – housing, psychosocial support, job seeking – are largely driven by a non-profit sector. Furthermore, a relatively small pool of people receive both clinical and social support from a for-profit private sector, characterised by highly responsive and technological care. The problem is, these three sectors operate rather loosely from each other, and cooperate and collaborate in an ad-hoc manner rather in an integrative way. To me this is a massive drawback, since each sector offers key forms of capital that should be woven into a network of comprehensive, responsive and holistic care. To me that will certainly strengthen the health system as a whole to better deal with, for instance, growing chronic disease patterns. In a way South Africa’s HIV response from the past decade or so has shown glimpses of the possibilities that emerge when state and non-state sectors collaborate in an integrative way. Ultimately, shocks such as a global recession might be rendered less significant when a health system draws from its pool of resources more effectively. There are massive possibilities when one considers that array of health care providers across different sectors in health systems.”


And another EV asked a rather pertinent question:

“…it seems to me that there is an emphasis on resilience within the framework of complex adaptive systems (CAS). I like the latter concept and I think it captures and potentially explains to a great extent the complexity of health systems. What I am not sure about, however, is whether attempting to introduce resilience in a complex adaptive system can achieve the intended results. If I am not mistaken, unpredictability is one of the key features of CAS. Is there a way, perhaps intervening at the right time for example, that can ensure unpredictable or even counterproductive results?… “


Many EVs pointed to the key role of health workers in a resilient health system. For example this one:

“…The lesson learned from Ebola in Sierra Leone shows that the frontline health workforce, including community health workers and volunteers, play an important role in controlling the spread of Ebola outbreak through dissemination of accurate information, undertaking surveillance, contact tracing, and promoting hygienic practices (Oxfam, 2015). Nevertheless, the failure of responsiveness to the outbreak may due to the shortage of frontline health workers, coupled with their lack of knowledge and skills in responding the emergency….”


Another EV pointed to the importance of a One Health approach in trying to build resilient health systems:

“… I was participating in the team Building workshop of Economic Community Of West Africa State (ECOWAS) Regional Rapid Response team. The mission of this team is to provide immediate and effective technical support to West African Countries in order to contain and mitigate the effects of an epidemic or health emergency beyond the latter’s control, preventing its spread to other States. The constitution of this team justified the adoption of “ONE HEALTH” approach putting together experts from human, animal and environmental health sectors for well-rounded preparedness and response to epidemics. Those kinds of initiative must be sustained both at national and regional level  in building resilient health systems.”


Yet another EV then wondered whether ‘resilient health systems’ were all that new, implying that many of the ideas underlying resilient health systems have been around for a while, perhaps not explicitly stated though.

“… Very good thoughts over there. I wanted to draw to two declarations that speak to resilience. The Alma Ata declaration that affirmed that health is not just the absence of disease or infirmity but rather a social, economic, psychosocial, emotional and physical well-being. It also points to equality and social justice as an important aspect in ensuring distribution of services. The Universal Health Coverage notions all spring from this declaration. The Ottawa Charter for health promotion highlights building health public policy, Creating supportive environments, strengthening community actions, developing personal skills and reorienting health services as the health promotion action areas. When you compare these with what Kruk and colleagues mention in their Lancet paper as characteristics of resilient health systems. They are all related to the above mentioned action areas which implies that resilience is one of the aspects that earlier declarations and charters considered quietly. If they had been adopted we would be on track to ensuring resilient health systems.


And then it was time for another expert view, who sort of like a “Deus ex Machina” descended from heaven to wrap up the discussion. As we’ve come to expect from him, he offered some more clarity & wisdom:


“…If resilience is a property of complex systems, that does not mean that all complex systems are by default resilient and certainly not social systems, such as health systems. The health systems of Liberia, Sierra Leone and Guinée-Conackry were complex systems before the Ebola outbreak, but proved not to be resilient. On the other hand, resilience in my view is not just an emergent property of complex adaptive systems and therefore uncontrollable or unmanageable. While health systems are typically difficult to manage as a whole, we can identify strategies to make health systems more resilient. Adopting a fatalistic view is not necessary 🙂 .
If resilience is a property of a health system, it can be described in terms of its dimensions, precedents and outcomes. It can be thus assessed but also developed. However, to do so, a definition should be adopted. Unfortunately, resilience as a concept is fast becoming the next fad and the newest container concept on the block, defined in many different ways and losing its specificity in the process. In my view, it would help to think about resilience as more than being ready to deal with shocks and large crises; it becomes much more interesting as a concept (or a goal) if it is considered as more than just emergency preparedness or as not being fragile. It may help to think about resilience as also being prepared to absorb long-duration low-intensity challenges, such as a drain of personnel to the North, the continuing toll exacted by respiratory infections or the effect of HIV on both communities and health systems. We even need to push the definition to a level beyond responding to acute and long-term shocks: Resilient health systems are systems that continue to be responsive to the needs of the communities they serve when challenged. Resilience should thus be a concern of domestic policymakers and system managers, not just driven by security needs of countries in the North or by concerns of single disease control programmes. In other words, resilient health systems are just a means towards people-centred and responsive systems, not a goal in itself or a goal of global agencies with narrow interests. (Note this also means that resilience can be assessed by other means than assessing the effects of a crisis on a health system).
Resilience is more than being adaptive and is not equal to complex adaptive processes. Complex adaptive systems can be resilient, but resilient structures or systems do not always need to be complex. They do need, however, to be adaptive to be resilient. The capacity to be adaptive requires an agile workforce and thus an adequate workforce in the first place. Health systems are social systems – the people in it constitute the system. As a consequence, no health system can be resilient without a resilient health workforce. This is not a sufficient factor, but an essential one. It is health workers (in the broadest sense and thus including households and communities) who ensure that adaptation, flexibility and responsiveness is possible. This requires motivated and competent staff in the right place and with the right skill mix. It also requires coordination, communication and oversight – it requires a strong strategic management capacity, distributed leadership and effective representative inclusion of all actors in the decision-making and management processes.
Clearly, resilience in health systems is difficult to attain because it is multi-factorial. It requires long time horizons, sustained long-term policies in multiple fields (health workforce, training, infrastructure , etc.) and concurrent long-term investment. This messy nature of the issue in itself may explain why politicians and policymakers shy away from the difficult negotiations and decisions that are needed to develop resilient health systems: the results will take much longer to become visible than the electoral cycle allows for.  

He ended, appropriately:

“This discussion will continue at the Global Symposium and I’ll be looking forward to EV’s input in Vancouver.”


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