Supporting health system resilience – if not now, when?

10 December 2020

By Professor Sophie Witter, Institute for Global Health and Development at Queen Margaret University, UK

As we mark Universal Health Coverage (UHC) Day 2020, we do this not only against the background of the COVID-19 pandemic, but also against a global background of widespread ongoing conflict and shocks which continue to affect millions of the world’s poorest people (see OECD’s States of Fragility 2020). Fragile contexts are home to almost a quarter of the world’s population, and to the majority of all those living in extreme poverty globally, and none of these contexts were on track to meet the Sustainable Development Goals on hunger, health, and gender equality and women’s empowerment.

Some of the already most disadvantaged people are the worst affected by fragility, conflict and shocks, and this represents one of the greatest challenges to “leave no-one behind” in progress towards achieving UHC.

When we wrote our plans for ReBUILD for Resilience in 2019, we proposed to focus on health systems in fragile and shock-prone settings. That seemed like a sub-set of the world at that time. If 2020 has demonstrated anything, it is that we are all shock-prone. And if we weren’t feeling fragile then, we probably are now – the pandemic having put pressure on the economic and social fabric of much of the world.

Labels such as fragility were always contestable, covering diverse issues, diverse degrees of these issues, and based often on external judgements (see Diaconu et al 2019, Understanding fragility: implications for global health research and practice), but 2020 has made any binary classification, such as fragile/non-fragile, even less plausible. We are all on the spectrum.

In ReBUILD for Resilience we are interested in understanding and supporting capacities to manage shocks of varying types, sizes and durations. What are the features which have allowed some areas to cope better, to develop positive adaptive strategies, rather than spinning into downward spirals of distrust, resource misuse, population non-compliance with messages? Most importantly, how can they be nurtured and supported, even in challenging contexts? To build the type of resilience needed we are:

• Looking at health systems as complex and adaptive, with continuous interactions and feedback loops between different actors, sectors and functions, recognising the importance of the systems, norms, values and relationships which drive or undermine collaborative, prosocial action. (See our resilience framework here.)
• Focusing on local health systems, where the rhetoric of national strategies hit the bedrock of what is practical and possible, given the resources, system constraints, complex health marketplace of public, private and informal providers, and diverse community needs.
• Examining leverage points to develop more distributed control, stronger collaborative networks, better use of data, greater accountability and community engagement, and more flexible, reliable finance and supplies.
• Understanding the role of past experiences in setting norms and expectations, which frame current action, and the interaction of health systems with wider societal and multi-sectoral responses.
• Highlighting the changes to national and external support that are needed to support resilience capacities.

The shocks and stressors that we are facing as a global community, and which are especially hard to manage for contexts with low resources and low social cohesion, will continue in varying forms. They are not all vaccine-preventable. Supporting health systems to absorb, adapt and transform is therefore more relevant than ever, and calls for broader collaboration with other researchers, policy-makers and practitioners to jointly support this area of health system strengthening.

ReBUILD for Resilience would love to hear from those working in this area or have ideas or suggestions to make. You can contact us via the link below.

Without resilience, there is no effective UHC. UHC for all, and especially marginalised populations, should remain our goal as a global community.