Public Health Resilient Health Systems
by
Laura Hawken
  • LAST MODIFIED: 28 March 2018
  • DOI: 10.1093/obo/9780199756797-0177

Introduction

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.

Definitions

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.

Critiques

Even though now widely used in many sectors, resilience is not universally accepted as an appropriate concept to guide our thinking and efforts. Gebauer 2015 is concerned that resilience is being used as a simplistic panacea for all the threats society faces in the early 21st century. Evans and Reid 2015, Gebauer 2015, and Neocleous 2015 are worried that so much focus on resilience is actually changing the consciousness of society and politicians, limiting our imaginations for a better future by making catastrophe appear normal and inevitable. In turn, narrowed thinking restricts efforts for social improvement and, instead, expects communities to look after themselves, with the poorest and most vulnerable worst affected. Topp, et al. 2016, seeing resilience as the new dominant mode of thinking in health system development, advises against attempts to strengthen weak health systems without considering the broader political and economic context that actually created their debilitated situation. On a different perspective, Hollnagel and Braithwaite 2013 urges that the complex features of medical care should be well understood in order to improve its resilience. Linear approaches to building resilience, quality or efficiency, will not succeed. Allmark, et al. 2014 (cited under Definitions) debates alternatives to the idea of “bouncing back.” The authors suggest using better-known and well-tried approaches to strengthening communities, such as social capital, rather than the vague idea of resilience.

  • Allmark, P., S. Bhanbhro, and T. Chrisp. 2014. An argument against the focus on community resilience in public health. BMC Public Health 14:62.

    DOI: 10.1186/1471-2458-14-62Save Citation »Export Citation » Share Citation »

    Community resilience has to go beyond bouncing back. It is difficult to distinguish indicators of community resilience from general community well-being. Community well-being has been described with reference to social capital. Proposes that building social assets could be a more useful approach, with its focus on human capital, built capital and natural capital, rather than the more intangible concept of community resilience.

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  • Evans, B., and J. Reid. 2015. Exhausted by resilience: Response to the commentaries. Resilience 3.2: 154–159.

    DOI: 10.1080/21693293.2015.1022991Save Citation »Export Citation » Share Citation »

    A philosophical discussion on why, in this age of catastrophe, we are persistently asked to think about resilience. Discusses resiliency as a new form of political nihilism, with claims and policies that force people to embrace servitude as liberation. Believes that a focus on resilience creates a world image where disaster and insecurity are assumed as natural and inevitable. Expecting communities to be resilient reduces burdens on social services but places it on communities, even if they are impoverished.

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  • Gebauer, T. 2015. Resilience: Fit for disaster. Medico International, 19 May 2016.

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    A political discussion on how resilience changes our consciousness—moving from social ideals for a safe and healthy world to how people and systems can protect themselves against economic, social, and environmental disasters, and how to survive in a profoundly unbalanced world. Working together for the future is now about adapting to processes of destruction instead of correcting those destructive conditions. We are urged more to work on disaster management instead of disaster prevention. Not to stop or slow down climate change, but to adapt to it—if you can. The poor will be worst affected.

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  • Hollnagel, E., and J. Braithwaite, eds. 2013. Resilient health care. Vol. 1. Farnham, UK: Ashgate.

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    Emphasizes the multifaceted nature of health care with multiple stakeholders and warns against using simplistic linear approaches in attempting to find solutions to quality and efficiency issues. To improve health care and make it more resilient, the complex components of clinical work must be well understood. Yet many policy, management, accreditation, and regulation solutions focus on “work as it ought to be,” not how it actually is. Available online for purchase.

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  • Neocleous, M. 2015. Resisting resilience: Against the colonization of political imagination. Medico International, 9 June 2015.

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    Connects the resilience and security agendas at the political level. Resilience is apprehension of the future, imagined as disaster/attack and recovery. Resilience explicitly links security with urban planning, civil contingency measures, public health, financial institutions, corporate risk, and the environment, previously difficult for the state to do. But, when there is no political imagination except for war or catastrophe, then there is no political future except infinite preparation for attack.

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  • Topp, S. M., W. Flores, V. Sriram, and K. Scott. 2016. Critiquing the concept of resilience in health systems. Health Systems Global, 12 April 2016.

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    Questions the “hegemonic” or predominant focus on resilience in health policy and systems work. Weak health systems exist in complex realities with their many deficiencies largely due to poor policies, badly managed economy, and unfair power dynamics. Doing bits here and there to “strengthen” the health system, without dealing with the politics, economy, and power dynamics, will not be successful in building resilience. Encouraging community self-reliance in these conditions of created poverty is also unrealistic and unfair.

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Frameworks

Definitions are usually statements, whereas frameworks are usually presented as a diagram, a table, or a list of attributes or components. European Commission 2015 provides a simple framework of resilience in health systems, including six components: workforce, funding, costing of services, information, risk adjustment, and governance (p. 11). Note the similarity to World Health Organization 2007, a framework with six health system building blocks. World Health Organization 2016 describes a new health system framework that comprises five attributes: quality, efficiency, equity, accountability, and sustainability and resilience. Here, resilience is only one of five attributes, or in the European Commission 2015, one of three (effectiveness, accessibility, and resilience). In alternative views, such as Ho, et al. 2016, other identified attributes are needed to build resilience. Certainly, World Health Organization 2016 emphasizes the interconnectedness and interdependency of the attributes. Gottret, et al. 2009 presents a simple framework in moving from the shock of the 2008 economic crisis back to population health. Major components of the framework are household, government, and other resources, and also availability, quality, demand, and access to health services. Rodin 2014 presents a framework of different characteristics for resilient health systems: aware, diverse, integrated, self-regulating, and adaptive. O’Sullivan, et al. 2013 presents a more complex diagram, a framework for critical social infrastructure to promote population health and resilience that involves networks, resources, coordination, and adaptive responses. World Health Organization 2017 uses sustainable development goals (SDGs) and health system components to develop a resilience framework for improving child protection and care.

Global Risks

Ecotrust 2012 warns against overexploitation of the world’s resources and examines the operational systems that increase human vulnerability and reduce resilience and well-being. Lovell, et al. 2016 presents graphic and visual evidence that the concept of resilience has grown in use since the outbreak of severe acute respiratory syndrome (SARS) in China 2002–2003. The World Economic Forum produces an annual report looking at major risks facing countries and their populations. World Economic Forum 2015 and World Economic Forum 2016 both specify the spread of infectious diseases among the top ten risks with potential for enormous impact globally. Resilient health systems will help to detect and control these outbreaks (Nicholson, et al. 2016). World Economic Forum 2017 does not specify spread of infectious diseases as one of the top ten global risks, but does list a range of factors that would inevitably impact on health, categorized as technological, societal, geopolitical, environmental, and economic. In particular fiscal crises, extreme weather events, interstate conflict, food and water crises, and misuse of technologies could have broad impact on human health. In response to these global risks, United Nations 2015 sets out seventeen sustainable development goals (SDGs) with 169 targets, including a set for SDG, three on health. These seventeen interdependent and indivisible goals demonstrate the interconnectedness and complexities of our natural and man-made systems. Harm in one area will inexorably result in harm to another. Are we collectively socially and politically strong enough to turn the risks around and build a better, more resilient world?

  • Ecotrust. 2012. Resilience and transformation: A regional approach. Portland, OR: Ecotrust.

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    Examines how our current systems and institutions of social, political, and economic relations are stuck in entrenched ways of thinking, leaving human populations vulnerable. Lists a set of core principles of resilience for functioning more efficiently within the world’s linked ecological and social systems to provide for human well-being. Advocates for smaller, more local and diverse ventures to promote resilience. Uses interesting maps, photographs, quotes, and recommendations to explain the ideas and actions proposed.

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  • Lovell, E., A. Bahadur, T. Tanner, and H. Morsi. 2016. Resilience: The big picture. London: Overseas Development Institute.

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    This report uses big data and infographics to demonstrate key themes and emerging trends in resilience thinking and practice. Climate resilience was the most frequent resilience topic on Twitter, featuring in around 39 percent of resilience conversations in 2015, followed by conflict (21 percent) and water resilience (12 percent). All influence health.

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  • Nicholson, A., M. R. Snair, and J. Hermann, eds. 2016. Global health risk framework: Resilient and sustainable health systems to respond to global infectious disease outbreaks; Workshop summary. Papers presented at conferences on Global Health Risk Framework: Resilient and Sustainable Health Systems, held in Washington, DC, 2015. Washington, DC: National Academies of Sciences, Engineering, and Medicine.

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    This book is in response to the infectious disease outbreaks that have occurred since the 2000s, highlighting the disturbing recognition that an outbreak in one part of the world can threaten the health of the entire world. P. 89 presents a systems framework for pandemic disaster response and provides details on each aspect of the framework. Requires free registration to access online.

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  • United Nations. 2015. Transforming our world: The 2030 agenda for sustainable development. Geneva, Switzerland: United Nations.

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    An ambitious agenda of seventeen goals with 169 targets. The goals are integrated and indivisible—they require and depend on each other to succeed. To progress requires people, planet, partnerships, peace, and prosperity to eliminate poverty and ensure everyone has sustainable and resilient access to food, water, shelter, energy, education, employment, and health services, in safe environments with their human rights respected. Aims to reduce the risks outlined in the Global Risk Reports.

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  • World Economic Forum. 2015. The global risks report 2015, 10th edition. Geneva, Switzerland: World Economic Forum.

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    In 2015, the spread of infectious diseases was ranked as a risk likely to have the second greatest impact globally after water crises, which would also have significant and devastating health consequences. Interesting charts throughout the paper. Has a section on health in cities with the need for robust plans to face the threat of pandemics. Mitigating, preparing for, and building resilience against global risks is a long and complex process, a necessity often recognized in theory but difficult in practice.

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  • World Economic Forum. 2016. The global risks report 2016, 11th edition. Geneva, Switzerland: World Economic Forum.

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    In 2016, spread of infectious diseases ranked number eight of top ten risks in terms of impact. In the chapter on global disease outbreaks, discusses risks. Current and new emerging infections as well as increasing antimicrobial resistance all pose challenges for weak or overstretched health systems. Discusses causes, vulnerability, and impact of increasing infectious diseases outbreaks, including the economic impact of aversion behavior. Emphasizes the importance of health communication, collaboration, financing, and vaccine development.

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  • World Economic Forum. 2017. The global risks report 2017, 12th edition. Geneva, Switzerland: World Economic Forum.

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    In 2017, disease outbreaks is not listed as one of the top ten global risks. Instead, health is covered in the section on social protection, and deals largely with increasing demand and cost of services with changing demographics, more in some countries than others. Questions whether health systems and their supporting financing systems can adapt fast enough to maintain the levels and quality of service delivery needed due to health transitions and changing population health. Adaptation is a key feature of resilience.

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Books

Two volumes on resilient health care, Hollnagel and Braithwaite 2013 and Wears, et al. 2015, focus in on clinical care rather than being concerned with the overall health system. Rodin 2014 and Bui, et al. 2016 both describe numerous examples of efforts across many countries where resilience has been demonstrated. Rodin 2014, also cited in Frameworks, can be purchased online at low cost. Buckley, et al. 2014 sees investment in building resilient health systems as a global public good. Similarly, Hallegatte, et al. 2017 makes a strong link between building disaster preparedness among poor and vulnerable groups with poverty reduction. So much more could be done at relatively low cost and with powerful impact. Nicholson, et al. 2016 also focuses on building resilient health systems to respond to major disasters. Commission on a Global Health Risk Framework for the Future 2016 emphasizes that building health system resilience is not a one-off activity but multiple continuing efforts that need to be coordinated and interconnected.

  • Buckley, G. J., J. E. Lange, and E. A. Peterson, eds. 2014. Investing in global health systems: Sustaining gains, transforming lives. Washington, DC: National Academy of Sciences.

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    This report sets out broad trends in global health and explains how functional health systems support health, encourage prosperity, and advance global security. It proposes how foreign aid to low and middle-income countries could be most effective. One key conclusion is that supporting strong health infrastructure in low- and middle-income countries will improve health, but it will also have consequences beyond health to building a more resilient, stable, and prosperous world. Available online by free subscription.

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  • Bui, T., J. Evert, V. McCarthy, et al., eds. 2016. Reflection in global health: An anthology. San Francisco: Global Health Collaborations.

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    A compilation of reflections on experiences from around sixty health science trainees and young doctors confronting both illness and injustice in health systems around the world. Does not use the term resilience, but gives examples of how health systems in different countries function in specific circumstances—some showing resilience, and others not.

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  • Commission on a Global Health Risk Framework for the Future. 2016. The neglected dimension of global security: A framework to counter infectious disease crises. Washington, DC: National Academies.

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    Strengthening public health is the foundation of a resilient health system and first line of defense in pandemics. Building resilience is an ongoing commitment, not a one-off effort. Improving public health capabilities and resilience should be integral to governments’ fundamental duty to protect their peoples. Too many countries have not built their capacities as legally required by the 2005 International Health Regulations. This puts their populations at risk, as well as all humankind.

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  • Hallegatte, S., A. Vogt-Schilb, M. Bangalore, and J. Rozenberg. 2017. Unbreakable: Building the resilience of the poor in the face of natural disasters. Washington, DC: World Bank Group.

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    This book has three main messages: (1) efforts to reduce poverty and disaster risks are complementary; (2) natural disasters affect well-being more than what traditional estimates suggest—disasters keep people in poverty; (3) policies that make people more resilient—and so better able to cope with and recover from the consequences of disasters that cannot be avoided—can save one hundred billion dollars a year. Maps, graphs, and diagrams show socioeconomic resilience, risks to well-being, and potential solutions.

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  • Hollnagel, E., and J. Braithwaite, eds. 2013. Resilient health care. Vol. 1. Farnham, UK: Ashgate.

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    The focus here is clinical care and its context, and thus moves into health system components. Warns that clinical health care delivery is different from most other forms of production, and so finding solutions to issues of efficiency, quality, safety, and sustainability must take clinical and context complexities into account. Available online for purchase.

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  • Nicholson, A., M. R. Snair, and J. Hermann. 2016. Global health risk framework: Resilient and sustainable health systems to respond to global infectious disease outbreaks; Workshop summary. Papers presented at conferences on Global Health Risk Framework: Resilient and Sustainable Health Systems, held in Washington, DC, 2015. Washington, DC: National Academies of Sciences, Engineering, and Medicine.

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    This book has chapters on leadership and management; health system strengthening (workforce, supplies, and service delivery); information systems, technology, and information sharing; and strengthening outbreak management and emergency response. Each chapter starts with a set of key points. Case examples are presented in boxes. Has several interesting graphs and diagrams, and the book is perforated with poignant quotes. Requires free registration to access.

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  • Rodin, J. 2014. The resilience dividend introduction: Being strong in a world where things go wrong. New York: Public Affairs.

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    This book consists mostly of a range of stories from around the world to show how people, organizations, businesses, communities, and cities have developed resilience in the face of otherwise catastrophic challenges. Poses a framework for resilient health systems characteristics: aware, diverse, integrated, self-regulating, and adaptive. P. 293 shows a diagram describing the resilience dividend and the resilience deficit. Introduction is available free online. Complete book can be purchased at low cost.

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  • Wears, R. L., E. Hollnagel, and J. Braithwaite, eds. 2015. Resilient health care. Vol. 2, The resilience of everyday clinical work. Farnham, UK: Ashgate.

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    This is the second volume to Hollnagel and Braithwaite 2013. It contains contributions from international experts in health care, organizational studies, and patient safety as well as resilience engineering. Whereas many safety approaches primarily aim to reduce or eliminate the number of things that go wrong, Resilient Health Care aims to increase and improve the number of things that go right. Book has to be purchased.

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Books from the World Health Organization

World Health Organization 2000, World Health Organization 2007a, and World Health Organization 2016 are important texts on effective health systems functioning—necessary for resilience. World Health Report (World Health Organization 2000), on health system performance, has detailed chapters on health financing, human resources, and governance for protecting public interest. World Health Organization 2007a sets out a framework with six interconnected building blocks and four health system goals, including responsiveness, effectiveness, financial protection, and better health and equity. World Health Organization 2016 has a focus on universal health coverage with a specific section on health system resilience as one of five essential system attributes. Kickbusch and Gleicher 2012 makes a strong link between resilience and smart governance of health systems. World Health Organization 2017a highlights the role of public health law as another essential component for health system resilience. Formerly dealt with as part of health system governance, the pivotal role of law in health is now recognized more explicitly and receives more specific attention. The International Health Regulations (IHR) 2005 (World Health Organization 2007b) is an international legal framework outlining what countries are expected to do in order to protect national and global health security, including preparedness for disease outbreaks, natural disasters, and climate change. World Health Organization 2010 presents a regional action plan to assist countries in the Western Pacific Region to meet their legal obligations under the IHR. With the sustainable development goals as an overall interconnecting structure, World Health Organization 2017b uses the six health system building blocks in resilient health systems for child health care. It outlines prevention and mitigation of environmental hazards that threaten child health and well-being. World Health Organization 2017c presents risk profiles on natural disasters and communicable diseases for countries in the World Health Organization (WHO) South-East Asia Region.

Health System Strengthening

In the section on Books from the World Health Organization, we have general texts on well-functioning health systems, and in the section on Frameworks, we see that different authors see different components and attributes of resilience as important. The references included here are mostly studies or experiences in health system strengthening, showing changes in models of service delivery needed for future resilience. Coiera and Hovenga 2007 applies concepts of resilience in nature to a health system. A fundamental focus is on efficient use resources for effective functioning to meet health system objectives. De Savigny and Taghreed 2009 is based on extensive fieldwork in Tanzania, identifying practical interventions that local health managers can implement and that make a difference to system functioning. Health systems are complex, and Dickens 2013 is concerned with the requirements for system self-organization. He identifies principles of complex adaptive systems that support resilience. RESYST 2016 reinforces this based on district health systems research, with a list of factors essential for a resilient health system: system software includes knowledge, skills, and management, while system hardware includes finances, human resources, and infrastructure. This looks similar to the list in European Commission 2015 and the six health system building blocks in World Health Organization 2007, both mentioned in the section on Frameworks. World Economic Forum 2013, in considering scenarios for the future, identifies reducing demand for health care services as a critical approach to building resilience. It advocates for greater emphasis on health promotion and illness prevention. Recognizing the importance of health systems to program and service delivery, Global Fund 2015 outlines its approaches to health system strengthening to include: integrated service delivery, supply chain management, financial and risk management, and involving communities in national decision making. The frequency of medical errors in hospitals is frighteningly high. Carthey, et al. 2001 looks at resilience from the perspective of increasing patient safety and proposes a checklist to strengthen approaches to improve patient safety. Prowle and Harradine 2015 identifies that pressures causing increased demand for services in the face of reduced resources means that the arrangements of current health systems must adapt. But country populations tend to resist these changes, so there is an imperative to communicate the need for change in order to strengthen systems to be sustainable and resilient for the future. International Council of Nurses 2016 also comments on the need for different health system arrangements and explores the role of nurses in system strengthening and cross-sectoral work for resilience. Kruk, et al. 2017 proposes a set of indicators to measure health system resilience across five characteristics to help countries to assess readiness to cope with future shocks.

Subsystems in Health

Health systems are not individual systems, but rather complex interacting subsystems. Some writing on health system resilience focuses on one or more subsystems rather than the overall system. Lengnick-Hall, et al. 2011 is not health specific, but presents interesting information on human resources policies and management as a foundation for organizational resilience. Kutzin, et al. 2017 outlines steps and content for a coherent health financing strategy in support of universal health coverage. As with human resources, resilient financing is a critical subsystem for a resilient health system. Fiorini, et al. 2015 looks at resilience in telemedicine for psychotherapy services. Hafner, et al. 2017 uses systems thinking to consider resilience in a hospital pharmaceutical system. Ho, et al. 2016 describes a generic health system resilience framework and applies it to digital tools in health. Smith, et al. 2014 also looks at resilience in electronic systems in health with a view to safety and privacy of information. Martin-Moreno, et al. 2012 examines the imperative for maintaining preventive services in the face of financial austerity and decreasing health budgets.

Antimicrobial Resistance

Millions of lives and trillions of dollars are at risk due to rising drug resistance in the coming decades if effective action is not taken comprehensively (O’Neill 2016). Antimicrobial resistance (AMR) occurs when microorganisms such as bacteria, viruses, parasites, and fungi change so that the drugs used to treat the infections they cause become ineffective. Work to control the urgent and terrible global threat from AMR involves input from agriculture, animal husbandry, fisheries, and health and pharmaceutical research and development. O’Neill 2016 reports on a UK-commissioned review of the risks and action required to stem the spread of AMR. Similar to World Health Organization 2015, key actions include raising public awareness globally, developing new drugs, using antimicrobials more sparingly in humans, and seriously reducing their use in animals and fisheries. Health system resilience is critical for infection control, appropriate drug use, and monitoring AMR, but this is not enough, as action across several sectors must also be implemented. Resilient heath systems must work with other sectors to support the necessary comprehensive controls. World Health Organization 2015 outlines detailed actions required to control AMR to be undertaken by countries, the World Health Organization (WHO) Secretariat, and partners. United States Agency for International Development 2016 outlines the agency’s work in controlling AMR across many countries through strengthening their health systems.

  • O’Neill, J. 2016. Tackling drug-resistant infections globally: Final report and recommendations. London: Wellcome Trust.

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    Many of the urgent problems regarding the huge and troubling impact of continuing antimicrobial resistance (AMR) are economic. But two of the seven recommended interventions to reduce demand for antimicrobials are directly health system related: improve sanitation and prevent the spread of infection, and improve the number, pay, and recognition of people working in infectious diseases. This report details all nine recommended interventions with a series of interesting infographics, quotes, and summary tables.

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  • United States Agency for International Development. 2016. Combating antimicrobial resistance with stronger health systems. Arlington, VA: US Agency for International Development.

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    This paper outlines the work of the US Agency for International Development in controlling the spread of antimicrobial resistance (AMR) by strengthening health systems in many countries. Activities include advocacy; supporting national AMR strategies and plans; raising awareness; working with partners to strengthen infection prevention and control, developing standard treatment guidelines and essential medicines lists, establishing drug and therapeutics committees, and strengthening regulatory control; and developing online and mHealth tools and improving health worker education.

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  • World Health Organization. 2015. Global action plan on antimicrobial resistance. Geneva, Switzerland: World Health Organization.

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    In this action plan, WHO sets out detailed actions for control of AMR, specific to its Member States, its own secretariat, and partners. Even though much action is required outside the health sector, health authorities worldwide have obligations for advocacy across sectors and for monitoring impacts on populations. This requires resilience in national health systems, particularly surveillance and laboratories capacity.

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Case Studies on Financial Shocks to Health Systems

The economic crisis of 2008 affected the health systems of many countries, both developed and developing. Also, continuous funding restrictions put ongoing stress on systems struggling to continue provision of services. Olafsdottir, et al. 2013 describes how good governance in the Icelandic health system fostered adaptation to the financial reductions they faced. Thomas, et al. 2013 compares health system functioning in Ireland against a set of indicators to assess different forms of resilience. Zhang, et al. 2014 takes a historical review of China’s health sector reforms and concludes that resilience was fostered by effective Ministry of Health leadership. Nyikuri, et al. 2015 looks at how primary health care managers provide services under a devolved system with continual lack of funds. National Health Service 2016 outlines how the United Kingdom is progressively moving some care away from hospitals to community and social care, aiming to meet the triple objectives of providing more care, better quality care, and a lower overall cost. Imison, et al. 2017 reviews these efforts in changing models of care in the United Kingdom and conclude that quality may be better, but cost savings are likely to be more elusive. Ammar, et al. 2016 describes functioning of the Lebanese health system during conflict and consequent resource constraints.

Ebola

The Ebola virus disease outbreak in West Africa in 2014 demonstrated to the global community that weak health systems in countries far away can result in serious loss of life in many other countries as well as disruption of economies. This is why Cuffy 2015 and Kruk, et al. 2015 list resilient health systems as global public goods, and why there has been a proliferation of writing on these topics. But the question remains—what is a resilient health system? Because it is not clear or easy to define, different authors put forward different sets of characteristics. Kieny, et al. 2014 outlines the progress of the Ebola virus disease outbreak and contemplates, when with so much investment put into vertical programs in the affected countries, why were their health systems not adequate to cope with a basic response of infection control? Cuffy 2015 looks at some basic requirements for a resilient health system and outlines the specific gaps in the health systems of the Ebola affected countries. Kieny and Dovlo 2015 also defines a resilient health system and shows its importance to other sectors and general functioning of the economy. The authors specifically argue for the role of effective primary health care as a foundation for a resilient health system. Kruk, et al. 2015 also presents a framework of characteristics to describe a resilient health system and puts emphasis on coordination between the public health and care-delivery systems. Siekmans, et al. 2017 discusses specific actions health workers needed to take in order to continue with routine vaccination and other aspects of child health care while also implementing the touch and contact restrictions required for Ebola infection control. Martineau 2016 puts a strong emphasis on understanding the community and gaining their trust as a prerequisite for a resilient health system.

Case Studies on Infectious Disease Shocks to Health Systems

The HIV/AIDS epidemic and the outbreak of Ebola virus disease placed great strains on already-weak health systems. These case studies identify various factors that influence health system resilience and are needed to further develop resilience to face future shocks. Maunder, et al. 2008 links health worker resilience to organizational resilience and culture, and compares differences in health worker stress during a severe acute respiratory syndrome (SARS) outbreak and influenza pandemic. McKenzie, et al. 2015 identifies that in Nigeria during the Ebola outbreak, activities on all six health system building blocks are needed to develop resilience, along with other factors such as good governance, community engagement, a minimum package of activities, monitoring, and accountability. Cancedda, et al. 2016 is written from the perspective of a nongovernmental organization (NGO) working with affected health facilities in Sierra Leone to deliver clinical care to Ebola patients and also maintain other routine services. The authors’ emphasis is on the health workforce, the importance of trust, community engagement, and the actions taken to strengthen the health system to continue providing services. Lembani, et al. 2014 looks at factors that support resilience, such as having options and flexibility, for example, in activities and allocation of staff and alternative drug supplies. Otu, et al. 2016 has a more specific focus on how mHealth tools can rapidly train health workers to cope with Ebola patients and do village visits for tracing people with symptoms in Cote d’Ivoire. Rockefeller Foundation 2016 uses three case studies in West Africa, Singapore, and United States of America, along with expert opinions to identify best practice in public health communication. Though they may not have all the capacity themselves, resilient health systems need to partner with those who can effectively reach the public for accurate and honest information sharing during disease outbreaks. Again, this highlights the importance of interconnectedness of systems for resilience.

Climate Change and Health Systems

Climate resilience was the most frequent topic in resilient conversations on Twitter in 2015 (Lovell, et al. 2016, cited under Global Risks). In the health sector, in addition to emerging diseases such as Ebola virus disease and Mediterranean Respiratory Syndrome, much discussion on health system resilience is related to climate change. Extreme weather events have become more frequent and severe, for example, heat waves, droughts, cyclones, snowstorms, and floods (Keim 2008). All these impact individual and population health. Persistent increases in global temperature result in widening the ranges of vector-borne communicable diseases. World Economic Forum 2015, World Economic Forum 2016, and World Economic Forum 2017 (all cited under Global Risks) list top-ten risks that the world is facing in terms of likelihood and impact. Climate change and its consequences feature prominently, including disruptions to individual and population health. All parts of the health system have a role in reducing human vulnerability to climate change. Her Majesty’s Government 2011 provides statements of priority on building infrastructure resilience to climate across nine sectors including health. James and Friel 2015 emphasizes the interconnectedness of systems, for example, health services need the electricity system for power, the transport system for supplies, the telephone system for communications, agriculture for food, etc., and thus the imperative for cross-sectoral planning and preparation for adaption to climate change and emergency preparedness and response. Whorley 2015 notes increasingly combined consideration of ecological, engineering, and evolutionary resilience in adapting and preparing built infrastructure to withstand environmental onslaughts. Panic and Ford 2013 identifies a range of inadequacies in fourteen Organisation for Economic Co-operation and Development (OECD) countries regarding their planning for health system adaptation to climate change, including inadequate consideration of the needs of vulnerable groups. Ebi, et al. 2016 sees climate change as an issue of social justice, human rights, and equity. As in so many situations, the most vulnerable are the worst affected, and thus there is obligation on the health system to plan for protecting services to meet their needs.

Extreme Weather Events and Other Disasters

Related to climate change in general, there has been an increase in writing on extreme weather events and other disasters, both natural and caused by human activity. Ben Yahmed and Koob 1996 outlines an early World Health Organization (WHO) approach to building community resilience to reduce vulnerability to disasters. Castleden, et al. 2011 notes that disaster resilience and community resilience are often used interchangeably. In addition to looking at the survivability of infrastructure and utilities, the authors comment that public trust and social cohesion are important factors in our “ideal view” of community resilience to disasters (note also Kieny and Dovlo 2015 and Martineau 2016 on trust, both cited under the section on Ebola). Bayntun 2012 presents results of a literature review that appear to indicate that few health facilities use a comprehensive or holistic approach to disaster management. This is further echoed in Rodriguez and Aguirre 2006, noting a lack of hospital resilience after hurricane Katrina and the need for hospitals to work with their communities on their disaster planning. Interconnectedness of systems, an interlacing thread throughout this article, is again highlighted in O’Sullivan, et al. 2013. In addition, the authors underscore the need for forward thinking and open communication to prepare for and manage dynamic, complex disaster situations. Paturas, et al. 2010 also advises hospitals to work with their communities on their disaster surge plans and necessary service adjustments. Similarly, Takahashi, et al. 2015 underscores the role of schools as a community refuge and resource during disasters. Rockenschaub and Harbou 2013 encourages planning on the whole disaster management cycle, including prevention, mitigation, preparedness, response, and after-disaster recovery. When resources are limited for prevention, mitigation, and preparedness, inevitably more resources are required later for response and recovery. Elmer and Lurie 2011 notes that when rebuilding after disasters, a similar level of investment needs to go into social and community capital, as goes into infrastructure, so that community resilience can contribute to and support health system resilience.

  • Bayntun, C. 2012. A health system approach to all-hazards disaster management: A systematic review. PLOS Currents Disasters 4:e50081cad55861d.

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    Presents a systematic literature review to collate experiences of disaster management by components of a health system. Of the 143 disaster management documents found, none described a holistic health system approach to disaster management, and none evaluated such an approach. Thus, the results of this 2012 review indicate that a holistic health system approach to disaster management has not yet been established in practice.

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  • Ben Yahmed, S., and P. Koob. 1996. Health sector approach to vulnerability reduction and emergency preparedness. World Health Statistics Quarterly: Rapport Trimestriel de Statistiques Sanitaires Mondiales 49.3–4: 172–178.

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    This early WHO article discusses increasing community resilience to decrease disaster vulnerability. Poses that the concept of vulnerability has two aspects, susceptibility and resilience. Vulnerability reduction decreases susceptibility, increases resilience, and protects human development. Vulnerability reduction is the responsibility of all sectors, including health. Concerned that diverting aid from development to emergency response reduces efforts to build community resilience. Refers to the need for suitable indicators to monitor vulnerability reduction. Electronic version not currently available.

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  • Castleden, M., M. McKee, V. Murray, and G. Leonardi. 2011. Resilience thinking in health protection. Journal of Public Health 33.3: 369–377.

    DOI: 10.1093/pubmed/fdr027Save Citation »Export Citation » Share Citation »

    Community and disaster resilience are often used synonymously, describing a community’s intrinsic capacity to resist and recover from a disturbance. Includes components such as fault tolerance of power, water, and communications systems; the survivability of buildings, bridges, and other physical infrastructure; organizational preparedness and good governance; and less tangible but important factors such as public trust and social cohesiveness. These components contribute to a normative ideal of community resilience to potential disasters.

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  • Elmer, S., and N. Lurie. 2011. The missing piece meets the Big O: Disaster mental health recovery and community resilience. Ethnicity and Disease 21.3 Suppl. 1: S1-5–S1-7.

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    Resilience involves rebuilding communities after disasters to be better than they were before. To achieve this, there needs to be investment in human capital on an equal basis with investment in physical infrastructure.

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  • O’Sullivan, T. L., C. E. Kuziemsky, D. Toal-Sullivan, and W. Corneil. 2013. Unraveling the complexities of disaster management: A framework for critical social infrastructure to promote population health and resilience. Social Science and Medicine 93:238–246.

    DOI: 10.1016/j.socscimed.2012.07.040Save Citation »Export Citation » Share Citation »

    Highlights the interdependencies between health and other social systems to promote health and resilience. Crises usually cross sector boundaries. Population health and resilience requires sector collaboration for adequate surge capacity and effective communication when infrastructure is disrupted. Study results underscore the need for thinking ahead, for organizations to dismantle silos, and for creating functional linkages to manage the dynamic context during a disaster. Available online by subscription.

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  • Paturas, J. L., D. Smith, S. Smith, and J. Albanese. 2010. Collective response to public health emergencies and large-scale disasters: Putting hospitals at the core of community resilience. Journal of Business Continuity & Emergency Planning 4.3: 286–295.

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    Emphasizes the broader role of hospitals in emergency response beyond medical care, including a location for survivors to get food, water, shelter, and information on disaster impact or further likely dangerous events; tracing missing people; and a communications hub in coordination with local services such as schools. Hospitals have to plan community wide, to be ready to quickly adapt normal routine to surge response and reallocate staff to achieve all necessary roles. Available online by subscription.

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  • Rockenschaub, G., and K. V. Harbou. 2013. Disaster resilient hospitals: An essential for all-hazards emergency preparedness. World Hospitals and Health Services 49.4: 28–30.

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    This three-page article briefly introduces WHO tools on emergency preparedness and management and provides an overview of their implementation in countries of the WHO European Region. Thinking needs to move from prioritizing reactive emergency response toward a more comprehensive emergency risk management approach. Thinking and preparation needs to consider all parts of the disaster management cycle encompassing prevention, mitigation, preparedness, response, and recovery. Available online by subscription.

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  • Rodriguez, H., and B. E. Aguirre. 2006. Hurricane Katrina and the healthcare infrastructure: A focus on disaster preparedness, response, and resiliency. Frontiers of Health Services Management 23.1: 13–23.

    DOI: 10.1097/01974520-200607000-00003Save Citation »Export Citation » Share Citation »

    The aftermath of Hurricane Katrina in 2005 exposed a lack of resilience of hospitals when their transport and supply lines were broken, challenging their ability to provide key services. In looking at communities affected by Katrina, the authors identify lessons for the future. Planning, access to supplies and utilities, communication plans, and training health workers are essential in developing resilient healthcare infrastructure capable to provide needed services to communities affected by future disasters. See discussion on pages 25–30. Available online by subscription.

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  • Takahashi, K., M. Kodama, E. R. Gregorio, et al. 2015. School health: An essential strategy in promoting community resilience and preparedness for natural disasters. Global Health Action 8:29106.

    DOI: 10.3402/gha.v8.29106Save Citation »Export Citation » Share Citation »

    Aims to emphasize the importance of schools in reducing damage and trauma in disasters. Before disasters, schools are places of community education, organization, supply storage, and practice. During and after disasters, schools are landmarks, places of evacuation and refuge, centers of rescue and communication. Schools and their local communities can work together to build capacity for disaster preparedness and response.

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Case Studies on Disasters and Extreme Weather Events

One of the impacts of climate change is an increase in the number and severity of extreme weather events. Countries and their health systems have to cope with the impact of these as well as other natural and man-made disasters. Based on the author’s experience after the 2011 tsunami in Japan, Kuroda 2011 emphasizes the importance of resilience in patient health information systems. Runkle, et al. 2012 describes primary and secondary surges in need for care after a chlorine spill in South Carolina—a technological disaster. Sea level rise and increased storms with flooding are leaving their impact on communities and health systems. National Center for Disaster Preparedness 2012 presents a series of papers on lessons from the 2012 Hurricane Sandy in the southern United States. Cash, et al. 2013 describes how in Bangladesh, public health activities have also helped reduce the impact of storms and floods. Secretariat for the South Pacific 2015 synthesizes forty case studies on adaptation to climate change in Pacific Island countries that are at serious risk of sea level rise. Natuzzi, et al. 2016 takes lessons from the 2014 floods in Solomon Islands.

Resilience Toolkits and Toolkit Reviews

There are an increasing number of toolkits being developed to guide health facility workers and managers on preparing for climate change, extreme weather, pandemics, and other disasters by building system resilience. The Canadian Coalition for Green Health Care and the U.S. Climate Resilient Toolkit are web-based toolkits to help health-care facilities to build their resilience to climate change and extreme weather events. UK Cabinet Office 2011 provides a general sector guide to strengthening infrastructure such as buildings, power, transport, supply, and communication systems to cope during all forms of disaster. Commonwealth Secretariat 2017 outlines a plan and assessment tool to help Commonwealth countries with developing policies for health protection. Chase 2013 presents the World Health Organization’s toolkit: “A Model Policy for SMART Health Facilities, Safe+Green=Smart.” Balbus, et al. 2016 compares these three toolkits (United States, Canadian, and World Health Organization) providing succinct comparison tables on several features, and further identifies attributes important for sustainability and resilience. The tool presented in Matthiessen, et al. 2009 outlines seven areas where health facilities can take action to reduce their own massive carbon footprint. A theme throughout many resilience resources is the interdependence of systems and subsystems, both natural and man-made. Baker 2011 presents a guide relevant to all sectors and encourages cross-sectoral planning for resilience and incident or disaster response. Sorensen, et al. 2011 provides a checklist that accounts for all types of hazards, organized by nine components. This toolkit also provides lists of additional resources for each of the nine components. Shumake-Guillemot 2015 is a World Health Organization guide on ten key components that health authorities and programs can implement to anticipate, prevent, prepare for, and manage climate-related health risks.

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