Setting out the latest thinking, evidence and lessons from a recent literature review undertaken for our flagship MAINTAINS project
The rapid spread of the novel coronavirus COVID-19, with over 75,000 cases, 2,000 deaths and infections in 29 countries (as of 19th February 2020), illustrates how health systems often have to cope with “shocks” whether epidemics, natural hazards, such as droughts and floods, or population displacement. In many low- and middle-income countries, it is a challenge for under-resourced health systems to maintain essential services as well as respond to those shocks.
OPM is currently undertaking research on what it takes to build “shock-responsive health systems” in Pakistan, Ethiopia, Sierra Leone, Kenya and Uganda, through the DFID funded Maintains programme. A literature review has identified the latest thinking, evidence and lessons on how to build shock responsive health systems.
Overall, the literature shows that, whilst preparation for shocks is key, building ‘planned resilience’ in health systems goes beyond a narrow preparedness agenda, and requires investment in institutions, preconditions and other ‘slow variables’. Not everything can be planned for, and preparation also needs to focus on developing ‘adaptive resilience’ so that actors are equipped to manage the response to and recovery from shocks when they occur.
The factors identified by the literature can be broadly categorised as related to the building blocks of a health system, governance, capacity, and intangible software.
Health system inputs
Whilst there is an overlap between a strong health system and a shock responsive health system, they are not synonymous. There are targeted ways in which the “input” building blocks of a health system - workforce, supplies and commodities, information systems and finance - need to be invested in. This includes ensuring a strong, committed, well-distributed and skilled workforce, and sufficient supplies, logistics and infrastructure with emergency stocks and procurement plans. Information systems need investment in surveillance infrastructure and early warning systems, the integration of other sector data with health management information systems, and the cultivation of informal and local data sources that can overcome the inherent delays in producing formal data, including reports from front line providers who can be the first to observe emerging shocks. Adequate and predictable finance, with fiscal stabilisers, reserve accumulation mechanisms and robust expenditure management systems are also crucial.
Perhaps the most important building block is governance. It is imperative to pre-emptively build a legal and policy foundation to guide responses to shocks, covering all levels of the health system, private and non-profit sectors, international agencies and inter-sectoral coordination. Planning for shocks, building networks, and appropriate decentralisation to allow decision-making by local managers helps provide a platform for responding to shocks when they occur. For example, the limited decentralised decision space was highlighted as a limitation of the response to Ebola in West Africa. Furthermore, shocks often affect countries in multiple ways, and interdependencies with other sectors, such as social protection, WASH, nutrition, and Disaster Risk Management, need to be identified and planned for in advance.
Building capacity across all system areas underpins planned resilience. This includes the cognitive capacity to collect, integrate and analyse formal and informal information, make sense of it and develop appropriate responses; and planning and management capabilities including to anticipate and cope with uncertainties and manage interdependencies, relationships and feedback. The literature argues that building capacity to manage the day-to-day exigencies facing health system actors – and developing “everyday resilience” – can also help actors face more serious shocks.
As shocks are often times of stress, trust and social capital are imperative to allow an effective response underpinned by conducive ‘intangible software’ – the norms, values, incentives and relationships that drive behaviour. For example, there are currently worries in Hong Kong about the willingness of frontline health workers and the general population to comply with directions from the government, caused in part by the low levels of trust emanating from recent political turbulence. Trust needs to be cultivated in advance, through healthy power dynamics, an organisational culture that leads to pro-social decision-making, community engagement and responsiveness to changed needs and contexts. The literature suggests that this needs to be underpinned by leadership practices that build trust, motivation and empowerment and create a learning organisational culture that promotes collaboration; practices that are amenable to change through coaching and mentoring.
Responding to a shock
When a shock hits, the optimal response will depend on the nature of the shock, its duration, speed of onset, scale, intensity, epidemiology and knock-on effects. This mitigates against generalisability. Strategies can include changing the service delivery bundle provided by a system – either adding services or stripping them back to their core, amending pricing policies (either making services free or non-core services more expensive to generate more resources), redistribution of the health workforce, and provision by informal, private, not-for-profit and international organisations. The impact on health outcomes will depend on the level of planned resilience built, the connected system response, and the capacity of communities to cope with shocks.
In the longer run, the experience of shocks provides an opportunity to build better, more shock-responsive health systems. In an ideal world, adaptive resilience emerges post-crisis as new capabilities are developed in the face of emergent situations. This requires nurturing resilience through creating the conditions, such as a culture of learning, underpinned by good leadership, that enable systems to adapt, rather than imposing simple and mechanistic cause and effect type solutions to current problems. Indonesia is cited as a prominent example of a health system that emerged more shock responsive after the 2004 Indian Ocean tsunami. Learning from experience, nine regional crises mitigation centres were established, strategically located in disaster prone areas, and equipped with staff, vehicles, and emergency supplies. In between times of crisis, staff perform community outreach with local health facilities, teaching basic first aid and natural hazard response.
The Maintains programme will explore some of these issues in our research over the next few years, working in Sierra Leone, Ethiopia, Uganda, Kenya and Pakistan. Ultimately, the aim of Maintains is to improve health, nutrition and education outcomes for disaster-affected people. It will do this through undertaking operational research to develop a stronger evidence base on how health and other social systems can respond more quickly, reliably and effectively to changing needs during and after shocks, whilst also maintaining existing services. The research will be supported by technical assistance and research uptake activities, to inform policy and practice globally.
OPM wishes success and safety to all those responding to the COVID-19 outbreak.
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