When there’s a problem in a system that is resilient, the problem should not only be an indication of what is amiss; but also of the inherent and latent resources available for remedy. Resilience denotes a system’s capacity and elasticity to absorb, appropriately respond to, and rebuild from shock – features that are tested and proven in crises. Resilience is both an emergent and definitive feature of the complex, adaptive environments that characterize health systems. Whether assessed as quality, or measure, resilience in the system must be reflected in its parts. As the Health Policy and Systems Research and Practice (HPSR) community, resilience is our responsibility to influence global systems for sustainable development. It is demonstrated in our responsiveness towards evidence needed to build healthy and inclusive societies that are politically stable, and economically strong.
Looking back
In hindsight, our responsiveness as a community towards evidence, though not always timely, has gained traction since the advent of major health policy reform that occurred in the 70s. Building on the work of British historian Thomas McKeown, Canada’s 1974 Lalonde Report, was the first government document to argue the importance of social over biomedical determinants of health. Granted, the report lacked objective targets and timelines (MacDougall, 2007). Yet, five years later, the US Surgeon General’s 1979 Healthy People Report concluded that capital-intensive investments in ‘medicalized’ healthcare did not yield parallel improvements in health (Irvine, 2006). The report also set national targets for radical reform of health policy and systems in the United States. That critical paradigm shift remains a pillar of public health policy and promotion today; supported by extensive work, such as “Closing the Gap in a Generation” – the report of the WHO Commission on Social Determinants of Health (WHO, 2008).
These and other developments culminated internationally in the WHO Declaration of Alma Ata in 1978 – a milestone with an enduring legacy of primary health care. The Alma-Ata agenda of “Health for All by the Year 2000” redesigned public health systems around the concept of primary health care, and pushed the boundaries from disease-oriented to appropriate technology; from medical elitism to involving lay and traditional providers from a community-engagement stand point; and, from dependent, consumer-driven health services, towards health as an enabler for socio-economic development. Alma-Ata was a game changer. It made a strong case for comprehensive primary health care, by linking health to development, with obvious political implications (Ceuto, 2004). It stressed the need for action against persistent social and economic inequalities that impact health. It emphasized equity, community empowerment, and participatory planning – principles which still guide our work as a global community. On the downside, comprehensive primary healthcare was difficult to implement, criticized as unwieldy, and replaced within a year by a selective, disease-specific approach to promising cost-effectiveness through measurable and attainable goals. This appealed to our community of scholars, experts, donors and policy makers (Evans et al. 1981), leading to wide proliferation of programs, projects, and organizations focused on developing countries. The impact is undeniable – 20 million lives saved from HIV/AIDS, Tuberculosis, and Malaria – the Big Three. Yet, parallel programs siphon human resources from overburdened national health systems, leaving them worse off than before. (Scott, 2016, Cueto, 2004). Their legacy also includes a growing conundrum of neglected and re-emerging diseases. Case in point – guinea worm eradicated from 186 countries as of 2013, re-surfaced in 2016, long after many donor-supported programs became defunct. Clearly, the difficulty of implementing Alma-Ata principles tested our collective resilience to evidence-based health systems reform. And? We gave way. We chose economic expediency over systemic viability. While the cost implications of such choices are often delayed, they are also often compounded until disaster strikes.
Disaster certainly struck the international community in 2014 during the West African Ebola Virus Disease outbreak in Guinea, Liberia, and Sierra Leone. Despite well-funded parallel programs on HIV/AIDS, Tuberculosis, malaria, and maternal and child health, health systems in these three countries came to a grinding halt. Limited capacity to isolate and contain the epidemic, dismal outcomes for hordes of infected people, and fear mongering aggravated the costs of this deadly hemorrhagic fever beyond direct counts of 28,000 cases, and 11,600 deaths. Guinea, Liberia and Sierra Leone together lost 240 doctors, nurses and midwives combined, creating bottlenecks to essential services delivery, and maternal mortality, increased by 30% over the period to more than 111% across the three countries. Failure to comply with the International Health Regulations, which would have ensured better preparedness and responsiveness, came at a dear price, especially for frontline health workers in the eye of the storm. Not unexpectedly, these poorly resourced health systems caved, making recovery and reorganization more challenging and capital intensive. Along with trying to make sense of the rubble that remained of a society brought to its knees, survivors must live with the painful final memories of loved ones – mothers, children, family, and front line health workers carried in body bags to a makeshift gravesite as a final resting place. The lessons are well rehearsed among many experts. In times of calm, resilience building is vital; in moments of crisis, reaction time is priceless.
The world was outraged to learn about the ill-timed and uncoordinated response to early evidence of the outbreak from the WHO and its AFRO region office. Yet historical examples suggest an unfortunate precedent of professional and political inertia to evidence that challenges the status quo. In 1980, the Black Report released in the UK, identified poverty as a major determinant of ill health and death, and yet was sidelined for purely socio-political reasons. In 1997, the WHO Jakarta Declaration identified poverty as the greatest threat to health (WHO, 1997). We as a solution-oriented community could have been two decades ahead in the fight against global poverty, if our response to evidence was resilient to political shocks. Like society, shocks to health systems have morphed into complex factors. Today’s political shocks include migration, displacement and human mobility, or an influx of refugees. Economic stress comes in funding cutbacks, and donor driven-agendas giving rise to buzz words that distract from the core value of health systems strengthening, and push us further apart into artificial disciplinary silos. Long-term strains include the burden of non-communicable diseases, emerging and re-emerging infections, global health security, and climate change. In the face of these challenges, governments, civil society, local communities, frontline health workers and managers, and the international community rely on us for insight into current challenges.
So how can the HPSR community avoid being crippled by our own expert criticisms, and overridden by political agendas, in order to contribute to health systems resilience? We must continue to draw on our collective expertise to build a unified resilience in the system as a whole.
We must be strategic to ensure routine healthcare delivery is effective, and health systems responses and recovery during global health emergencies are timely. We must recognize that the mainstay of resilience lies in the dynamic strength of its stakeholders, and in how effectively we communicate, to ensure convergence across our diverse contexts. This “C3” approach – communication, convergence, and context – must be core to activities health systems strengthening to build resilience over the long-term.
Communication requires the HPSR community be on the cutting edge of information technology (IT), to enable real-time innovation for care delivery and decision-making. We should support routine monitoring, evaluation, and surveillance to boost health workforce capacity and function. And we must be clear with our communication – yes, including what we mean by resilience and responsiveness.
Context questions our intrinsic values as a research and practice community. Do the social determinants of health undergird preemptive research to demystify the underlying drivers of health inequities? Have we championed transparent governance to improve fiscal responsibility of low-income governments, for instance, on compliance with international health regulations? Do we demand accountability of multinational corporations, international trade and development agreements? How has our work supported fair-trade negotiations, that enable residual capacity building across multiple sectors? Have we truly acknowledged that these issues are fundamental to boost economic development particularly in low-income settings, thus making universal health coverage (UHC) feasible, and equitable health services delivery attainable?
Convergence highlights the rich diversity within the HSRP community. We can efficiently broker research uptake in practice and policy decision-making, to expand health system capacity, and to support primary healthcare delivery, which in some regard is an informal indicator of the general health of the population. Beyond identifying what works and how in various contexts, we should strategically engage and re-align key players and motives, to level the field, making universal health coverage attainable and broad-based services accessible to all, including poor families. Hiding behind knowledge brokers and power brokers to interpret our pet jargon to decision makers, only widens the divide between evidence generation and decision-making.
Looking forward
Building resilient health systems requires research policy, and practice that acknowledges and values local champions – those with invested, long-term relationships of mutual trust with communities we seek to improve. We must identify whose input these communities consider critical to their welfare, which champions they trust to represent their best interest and not just ours, and therefore whose voices should be represented at brainstorming and decision-making tables. And we must endeavor to work collaboratively towards solutions.
We, as the HSRP community, must now go ‘long and deep’ – the era of enabling ‘elite experts’ (or with our best efforts ‘expats’), who ‘parachute’ into crisis situations, provide their expert opinion and leave, is outdated. Much too often, this strategy does not build residual (localized) capacity that is essential for resilience. A beautiful example is how BBC Media Action, had worked in Sierra Leone for ten years before the 2014 Ebola outbreak. They brokered innovation with their long acquired ‘social capital’ to promote socio-culturally informed communication strategies, which helped to reduce misinformation, and was vital to save lives.
Investing in local capacity also allows us to apply lessons learned from one end of our increasingly smaller global village to the other. What works in urban planning to mitigate poverty and improve livelihoods in Khayelitsha, a largely impoverished urban sprawl in Western Cape, South Africa, may be applied to reduce unsafe gas emissions, and possibly, to improve containment of a potential disease outbreak in the slums of Dharavi in Mumbai, India.
As we consider a post 2015 sustainable development agenda, with our goal to build resilient health systems, let’s rethink our response strategies to evidence, events, and emergencies. Our emergency paratroopers (the experts) are critical to analyzing a crisis. However, their expertise may be better translated to effect desired change by the ground troops who are invested in raising, and in leveling the field to provide equitable health care. This involves long-term resilience building – the kind that is needed to overcome latent stresses. Like resilience, trust is built over time, and is tested in difficult circumstances. Crises create time windows of opportunity for establishing trust between affected populations and those in a position to help.
We have made much progress in strengthening our responses towards systemic and external shocks. We continue to invest in systems that enable timely and coordinated responses to evidence, events, and emergencies. Arguably, containment of the Zika virus outbreak in multiple countries earlier this year attests to this. To sustain this momentum in building stronger and resilient health systems, we must amplify stakeholder engagement, maximize the opportunities presented in and out of crises, pursue integration along health and all other sectors, and remain flexible to adapt our strategies as needed.
The next two years will be critical to what becomes of ‘resilient and responsive health systems’. Let’s do the due diligence to streamline central tenets that promote synergy within our interdisciplinary community. Let’s have the audacity to bridge the divide across professional silos. We are one community and we represent more than policies and programs, budgets and building blocks – there is no identity crisis here. We are the critical link between health systems strengthening, resilience, and achieving the 2030 Sustainable Development Goals. Resilience will require much more than each of us striving to do better; it will take us striving to do better together.
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