Towards a fairer, healthier world: How can we build resilience in the frontlines of health systems?

Covid-19, as well as recent outbreaks caused by Ebola, SARS and HINI have highlighted the many devastating consequences on society when health systems simply aren’t up to the task of dealing with them. The vulnerable get most affected, and inequities in societies worsen.  We have realised that we can fight outbreaks and reduce their unfair impacts only if our health systems can plan for, adapt and sustain necessary changes. This realisation has generated a renewed interest in understanding how health systems across the world can be made more ‘resilient’.

Our health policy and systems expert, Dr. Sudha Ramani, spoke to Professor Lucy Gilson, keynote speaker at the most recent Community Health Workers: Frontiers of Thinking and Evidence webinar, to unpack the interpretation of this term 'health system resilience' and its application.

Dr. Ramani: Everyone is talking about building resilience in health systems nowadays. Drawing from your work, could you tell us what this term means to you?

Prof. Gilson:  First, it is important to recognise that resilience is a term widely used outside the health sector- for instance in fields such as engineering or in climate change conversations. We in the health sector do have something to learn from these wider experiences as well.

In the field of health systems, resilience seems to have come to the forefront of discussions particularly during disease outbreaks and now, COVID-19. But for me, resilience is not only about how to respond to disease shocks – although that is important. Rather it’s a characteristic of the health system that has relevance to its everyday functioning. It focusses on how this beast – the health system – which is complex and adaptive – operates, and how it responds to everyday stressors and manages these. Resilience, in terms of such thinking, then is a capacity or an ability, not an outcome to be achieved.

Resilience is also something that is embedded in processes that occur over time- we can think of resilience as entailing processes of anticipation, coping, adaptation, persistence, resistance, recovery, transformation and such.  So, resilience doesn’t come from a one-off action. Everyday resilience matters.

DR: So, when we talk of resilience, are we talking about the responses of individuals in the system or about the system as a whole?

PG: We need to remember that health systems are living, human systems – it is people who are central to what systems are and how they operate, and so it is people who are central to the processes of resilience. But individual responses and resilience, for me, are not the same as system-level resilience – which is a more collective notion that requires collective action by the system. People are important to resilience, but so too are processes of leadership and the routines of decision-making. When we talk of system-level resilience then, we also include the ways in which people come together to make decisions, what informs those decisions and what shapes them. So, to answer your question, it is a combination of collectives and people that we have to think about when we talk of resilience.

DR: The literature on resilience mentions strategies like ‘absorption’, ‘adaptation’ and ‘transformation’. Can you tell us more about these?

PG: So, these are notions originally drawn from thinking about social vulnerability. Absorption is the process of coping with stress and shock within the way systems currently work. Individuals are often central to absorptive strategies tackling the challenges as they find them, and keeping the system working.  Adaptation entails making some changes in system functioning to manage the stress. And transformative strategies represent new ways of working that not only manage the current crisis but actually strengthen the system to manage change better in the future – thus supporting more fundamental long-term change.

Also, our empirical work has shown that these strategies don’t unfold as a linear process– moving from absorption to adaptation to transformation. They might all be applied at the same time but to address different stressors, or different actors might apply different strategies to respond to a challenge.

DR: We’ve seen some sort of absorptive responses in our own work with Frontline Health Workers –they are great at innovating and coping with field challenges. Based on this, can we call our health systems resilient?

PG: We must remember that individual-level resilience is not system-level resilience. Whilst individuals do protect the system and maintain operations, they neither can do so for ever, nor should we expect them to do so. Putting the burden of managing stress on individuals is likely to only have short term gains. Adaptive and transformative strategies are needed to move the response to stress and shock to collective levels, and to support responses to higher intensity shocks.

DR: Could you share with us some ideas on how to bring about everyday resilience?

PG: We can talk about three kinds of resilience capacities - and we need to find ways to nurture these collective capacities in health systems. ‘Contextual’ capacities refer to relations within and outside of health systems. ‘Cognitive’ capacities are ways in which we think, for example- about problem-solving, and ‘behavioural’ capacities are the practices we adopt to solve the problems we perceive.

Within these capacities, it is the building of relationships that is important. We need to establish spaces for what we call “collective sense-making”, where people can come together in teams and think about how to address problems. Being positive around problems and also thinking you can make a difference is important. Sometimes tackling dysfunctional behaviours and even large organisational culture elements that restrain change is also important.

In our recent work in Cape Town, we have found that the simple act of changing the way routine meetings were organised and managed in health systems allowed frontline managers to come together, share experiences and take collective decisions. This enabled better service delivery. So even small changes in the way things get done can have long-term impact.

DR: Many frontline community health workers work in highly bureaucratic systems and they are also the last rung in the power hierarchy. Can resilience concepts help us engage with these power dynamics better?

PG: I think there is definitely a risk that power dynamics are overlooked in resilience thinking, and that existing power dynamics do lead to what we call ‘maladaptive emergence’ – a response to stress that can lead to undesirable outcomes, including inequality. But, so far, we have not explicitly thought through how the idea of everyday resilience addresses power dynamics.

However, I think starting with the idea that it is important to develop the system capacities to nurture resilience allows active consideration of how to tackle power asymmetries. For example, these capacities require thinking about who is involved in decision-making processes, what knowledge and experience those processes draw on, how those processes enable and encourage collective sensemaking or meaning making. Such thinking helps to understand how power plays out in health systems.

DR: Any last take-home messages for us on community health workers and resilience?

PG: Community Health Workers are the critical frontline in so many system responses to health shocks. But they should not be left to absorb the shocks by themselves. They must, as a critical first step, be brought into the processes of system decision-making because they have unique wisdom and knowledge - they should influence that decision-making. Their power to speak and act must be supported and enabled.

Professor Lucy Gilson is Head of the Division of Health Policy and Systems at the University of Cape Town and Faculty at the London School of Hygiene and Tropical Medicine.

Dr. Sudha Ramani consults on projects pertaining to health policy and systems research at Oxford Policy Management in India.