Evidence to enhance health system resilience in fragile settings

Two billion of the world’s poorest people live in fragile and conflict-affected settings. This figure is rising, fuelled by growing inequality, violence, conflicts and other shocks. In these fragile and shock-prone areas, progress towards Universal Health Coverage is slow.

Project team members

Kate Gooding , Sophie Witter , Priya Das , Shuchi Srinivasan , Mahwish Hayee , Adiba Khaled , Gloria Olisenekwu

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ReBUILD for Resilience examines health system resilience in fragile settings, generating evidence on strategies that can enhance resilience and strengthen health services. ReBUILD is an international research consortium, funded by the UK government, with partners in Lebanon, Myanmar, Nepal, Sierra Leone and the UK. The consortium produces high-quality, practical, multidisciplinary and scalable research that can be used to strengthen health systems and improve the health and lives of many millions of people.

We have practical and analytical expertise in health systems resilience through research, evaluations, technical assistance and programme implementation in a wide range of fragile and shock-prone settings. We use this experience and our policy networks to support and extend ReBUILD research, and to maximise the impact of ReBUILD findings.

The challenge

Health systems in fragile settings face severe resource constraints, and shocks such as epidemics, floods, drought and conflict compound their problems. Shocks have both short and long-term effects on core health system capacities - such as health workers, supply chains and financing. Shocks also affect communities’ ability to access whatever services are available, often creating financial and physical barriers. At the same time, shocks often create new demands on health services – such as management of malnutrition due to increased food insecurity, heightened infection control, or treatment for new diseases, as seen with Covid-19.

Some health systems collapse under the pressure of shocks, unable to provide services. Others make maladaptive responses that negatively affect health care. In other cases, additional needs can be absorbed by the existing health system, there are short-term changes to cope with shocks, or the system undergoes transformation, with longer-term changes that improve future resilience.

There is limited evidence about how to develop stronger, more resilient health systems that can manage shocks and provide Universal Health Coverage in fragile settings. ReBUILD seeks to meet that need. We study how health systems respond to shocks and stressors, to identify strategies that enable delivery of gender-equitable care and high-quality health services

Our approach

OPM is an associate partner within the ReBUILD for Resilience research consortium. We bring wide-ranging practical and analytical experience of health systems in fragile and shock-prone settings, including technical assistance, research and evaluation in countries such as Bangladesh, Ethiopia, India, Kenya, Mozambique, Nepal, Nigeria, Pakistan and Sierra Leone. Our work in these contexts has covered a range of shocks – such as floods in Pakistan, drought in Ethiopia and Kenya, and Covid-19 in many of these countries. Examples include research on health system shock-responsiveness in several countries through Maintains, research on the effects of Covid-19 on essential services in Bangladesh, research and technical assistance for the government of Ethiopia to build disaster resilience, and technical assistance in Nepal, Pakistan and Ethiopia to manage Covid-19. Our wider work on disaster risk management and climate change also brings valuable insights for strengthening health system resilience. This research and technical assistance covers a range of health system dimensions, including governance, health workers, information and early warning systems, financing, supply chains, community engagement, the role of donor support, and the significant influence of gender relations and social inequalities on health system resilience. We use this thematic and methodological expertise and leverage synergies with other OPM projects to share learning and extend ReBUILD’s research and impact.

This work provides considerable learning and opportunities that can contribute to ReBUILD’s research aims. We use our experience to contribute thematic and methodological expertise, and leverage synergies with our work to extend ReBUILD’s research and impact. Activities include synthesising our research on Covid-19 to identify cross-country lessons on health systems resilience and linking related ReBUILD and our research projects; this enables mutual learning and wider cross-country comparison. We will also use our policy networks and technical assistance opportunities to support the dissemination and use of ReBUILD findings.

As well as contributing to ReBUILD's overall strategic thinking, we are working with REBUILD on a range of specific activities. A first initiative involved synthesising OPM research on Covid-19 to identify cross-country lessons on health systems resilience. We brought together findings from OPM projects on community health worker experiences during Covid-19 in Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia to identify the roles played by community health workers and the challenges they faced. Read more in this blog post and article on the findings, or watch the presentation at the 2022 Global Symposium on Health Systems Research. We also synthesised OPM research on the role of coordination and partnerships for emergency response, bringing together evidence from 11 countries in sub-Saharan Africa and South Asia to identify lessons and recommendations for effective coordination. To learn more, read the working paper, and article published in BMC Health Services Research, or the poster presented at the 2022 Health Systems Research symposium.

We are also working with ReBUILD to share our experience in supporting resilient public financial management (PFM) systems, including in fragile settings. As members of the consortium, we collaborated on a policy brief and webinar that identified strategies to build resilience into routine PFM systems before disasters occur, and options for responding when a shock hits, drawing on OPM experience in Ethiopia and Pakistan. Under the Building Resilience in Ethiopia programme, we have supported the government to develop a range of measures that enable a more effective response to shocks, for example, quantifying disaster-related fiscal risks to help budget for the cost of disasters. In Pakistan, our collaboration with the government under the strengthening Sub-National Governance programme has helped develop strategies for resource allocation, budget execution and expenditure tracking that can enable an effective response to disasters and reduce economic costs. We are now working with ReBUILD to document learning about strengthening subnational public financial management in Nepal, building on OPM’s technical assistance under the Nepal Health System Strengthening Programme.

Outcomes and wider impacts

ReBUILD will provide high-quality practical evidence that can be used by governments and development partners to strengthen health systems in fragile settings. By identifying strategies that can enhance resilience and health system capacity to manage shocks and stresses, ReBUILD’s research can help to build Universal Health Coverage and promote equitable health services. Together with other ReBUILD partners, we are working closely with country stakeholders in research design and implementation, to ensure that research responds to practical policy needs and supports decision making.

Partners: LSTM, Queen Margaret University, Burnet Institute, COMAHS, HERD international, American University of Beirut. 

 https://www.rebuildconsortium.com/partners/

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Health Research and Evidence (R&E) Cross-cutting themes