To understand health system resilience requires at least some exploration of the wider uses of the term resilience, not only its original Latin conception but also critiques of its current and recent sociopolitical usage—does frequently using this term affect our consciousness, outlook, and actions positively or negatively? The term resilience in academic literature was evident in the late 1990s but started to increase significantly from around 2004 after an outbreak of severe acute respiratory syndrome (SARS) that occurred in China 2002–2003. Now resilience also starts to be linked with health systems. Increases in emerging disease outbreaks, natural disasters, extreme weather events due to climate change, and economic crises all put stress on communities and health systems. Do they cope with the shock, can they continue to provide some basic services, and can they recover to normal functioning afterward? These are the basic questions of health systems resilience. Health systems are complex, as are the contexts within which they function. Inevitably, discussion on health system resilience frequently takes on a broad “whole-of-system” approach encompassing individual, environment, community, and infrastructure resilience, as well as resilience in the many subsystems that make up a health system. In fact, resilience can be seen as a feature needed by everything in our complex and interconnected world. Then the question has to be asked, is the concept of resilience in health systems different from a robust health system, or a well-functioning health system? What would be the features of resilience that go beyond robust or well functioning? What do we have to add to activities in health system strengthening to achieve resilience? How broadly should the net be cast? Health system strengthening in recent years has focused on the six health system building blocks (stewardship/governance, financing, human resources, medicines and technologies, information, and service delivery), emphasizing their interconnectedness, as in systems thinking: make a change here and unexpected consequences might occur over there. More recently, the World Health Organization (WHO) has proposed five essential attributes that health systems need in order to progress toward universal health coverage (UHC)—equity, efficiency, quality, accountability, and sustainability and resilience. Within the latter, community resilience is featured. It can be difficult to distinguish directions of impact, but it is certain that health system resilience and community resilience are interlinked. Interconnectedness of complex adaptive systems is a thread weaving through this article. While the focus aims to be health system resilience, some references on community resilience are included where the connection to health system resilience is strong. Neither individual resilience, as often used in mental health, nor ecosystem resilience is covered in this article.
The term “resilience” is of 17th-century origin, used in physics to indicate the ability of an object to absorb and then release energy when it is changed by a force. Most documents writing on resilience give one or more related definitions. Norris, et al. 2008 provides a table of definitions from several disciplines. Castleden, et al. 2011 reports on a systematic review on the use of the term. Maresso, et al. 2013 also briefly describes how the term resilience is used in different fields of study, and then, in conversation with several experts, considers what resilience means in a health system. They pose a strong linkage with good governance. Allmark, et al. 2014 says that resilience is always (i) of a material or object (ii) to a force or event (iii) to an endpoint; for example, as with (i) a rubber ball (ii) hitting a wall or bat, (iii) changing shape and then returning to its original shape. Applying this, resilience engineering lists four essential abilities for organizations: the ability (a) to respond to what happens, (b) to monitor critical developments, (c) to anticipate future threats and opportunities, and (d) to learn from past experience—both successes and failures. Kutzin and Sparkes 2016 distinguishes between actions to strengthen health systems and resilience as an achievement. Chandra, et al. 2011 makes strong linkages between individual, health system, and community resilience. Using the construct in Allmark, et al. 2014, “health system resilience” might be (i) of system components, (ii) to a flu pandemic or major disaster, (iii) with the endpoint to return to normal functioning. Resilience as applied to health systems gained greater prominence after the SARS and Ebola outbreaks. Kieny and Dovlo 2015 stresses the ability to absorb a shock like Ebola and, at the same time, continue to provide regular health services, with particular concern on primary health care. World Health Organization 2016 and Maresso, et al. 2013 include the need to prepare for and adapt to changing environments. This deals with Allmark, et al. 2014, which argues that as the previous state may not be desirable, an improved state should be sought. Similarly, looking at resilience in the built environment, Whorley 2015 comments that increasingly a comprehensive approach is used with ecological, engineering, and evolutionary resilience. Resilience is not an isolated construct. It is a result of inputs, processes, culture, and relationships in local, national, and regional contexts. It could be considered a critical aspect of and a result of all systems interconnectedness.
Allmark, P., S. Bhanbhro, and T. Chrisp. 2014. An argument against the focus on community resilience in public health. BMC Public Health 14:62.
Identifies three key aspects of resilience: (i) of something, (ii) to something, (iii) to an endpoint, as in (i) a rubber ball, (ii) to a blunt force, (iii) to its original shape. Then argues that often the previous endpoint is not desirable, so something better is needed. For example, a chronically deprived community cannot have an endpoint of returning to chronic deprivation.
Castleden, M., M. McKee, V. Murray, and G. Leonardi. 2011. Resilience thinking in health protection. Journal of Public Health 33.3: 369–377.
Reports on a systematic review of literature on concepts of resilience. Table 1 provides sample definitions and studies related to different types of resilience: community, disaster, socio-ecological, individual, infrastructure, and organizational resilience. Important elements of resilience include communication, learning, adaptation, risk awareness, and “social capital.”
Chandra, A., J. Acosta, S. Howard, et al. 2011. Building community resilience to disasters: A way forward to enhance national health security. Santa Monica, CA: RAND.
Makes strong linkages between individual, health system, and community resilience. Staff performance and competency is important to build resilience in the public health system, which depends upon the ability of people to successfully accomplish the key activities that support resilience. Maps definitions of resilience from a literature review against identified elements of resilience. Provides sample measures of resilience.
Kieny, M. P., and D. Dovlo. 2015. Beyond Ebola: A new agenda for resilient health systems. Lancet 385.9963: 91–92.
A resilient health system is one able to absorb the shock of an emergency like Ebola and, at the same time, continue to provide some essential regular health services. This is necessary so that other sectors of the economy can function with a healthy workforce. The paper argues for the need to build health systems that are grounded in primary health-care principles and capable of responding to routine as well as unexpected challenges. This is generally not achieved through vertical programs.
Kutzin, J., and S. P. Sparkes. 2016. Health systems strengthening, universal health coverage, health security and resilience. Bulletin of the World Health Organization 94.1: 2.
This one-page editorial provides clarity on meaning and use of terms: health system strengthening is what we do; universal health coverage, health security, and resilience are what we want to achieve.
Maresso, A., M. Wismar, S. Greer, and W. Palm. 2013. What makes health systems resilient and innovative? Voices from Europe. In Special issue: Building resilient and innovative health systems. Edited by D. McDaid, A. Maresso, and J. Cylus. Eurohealth 19.3: 3–6.
Gives a brief summary of definitions from different fields, such as physics, biology, psychology, to show how the term resilience has been used and the similarity of conceptual components. Goes on to explore the features and components of resilience in health systems from the perspectives of several experts. Resilience is clearly linked to good governance in health systems, and details of what this means are presented. Implications for health systems in Europe are discussed.
Norris, F. H., S. P. Stevens, B. Pfefferbaum, K. F. Wyche, and R. L. Pfefferbaum. 2008. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology 41.1–2: 127–150.
Presents detailed discussion on community resilience in four areas of adaptive capacity—economic, social, information, and community competence. Provides a table of definitions of resilience, interesting diagrams of networked adaptive capacities, and an extensive bibliography. Links community resilience to population wellness, social capital, and networks.
Whorley, F. 2015. Building resilience: A framework assessing costs and benefits of resilient design strategies. Perkins+Will Research Journal 7.1.
Examines costs and benefits of different design strategies. Designing for resilience considers acute and chronic hazards, climate change, interconnectivity between systems, and scales of functioning. Outlines how the threat of crises fundamentally changes the way we live. How resilience is viewed and how its components are identified influence which hazards are considered in infrastructure design. For the built environment, three predominant approaches to resilience are ecological, engineering, and evolutionary resilience. Increasingly, a combination of all three is used.
World Health Organization. 2016. Universal health coverage: Moving towards better health. Geneva, Switzerland: World Health Organization.
Resilience is the ability of health systems to cope with internal and external shocks and recover quickly, while also adapting to changing environments. Disasters, emerging diseases, and economic volatility pose serious threats to public health security. To ensure resilience for combating shocks, countries can take action to improve public health preparedness, assist communities in health promotion, and encourage health system adaptability.
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