Ebola Treatment Unit (ETU) in Nízerekore, Guinea.
Ebola Treatment Unit (ETU) in Nízerekore, Guinea. Image credit: United Nations Photo, Creative Commons License 2.0

Resilience should not be the primary objective of a health system

By Angela Y. Chang, Doctoral candidate, Harvard T.H. Chan School of Public Health

Given the tendency of the health systems research field to adopt one or two buzzwords every few years (the last one being ‘universal health coverage’), it did not come to me as a surprise when the largest gathering in the health systems community also adopted this keyword (see the theme for the Vancouver symposium –resilient and responsive health systems for a changing world). The latest buzzword in town (i.e., the field of global health) is “resilience”. Ever since the Ebola outbreak, this adjective has been tagged on to the titles of numerous articles and events, regardless of its relevance to the topic or not.

While I agree with the (numerous) proponents of this concept in the global health community that resilience is a beneficial characteristic to expect from any health system there are two aspects that I have to question:

  1. The lack of clarity in its definition (at least when it comes to the global, local, regional levels); and
  2. My interpretation of it as a secondary rather than primary objective of a national health system (I consider as primary objectives improving population health, providing financial risk protection, and achieving user satisfaction).

Resilience at which level?

But let’s start with Margaret Kruk and co’s interpretation: “Health system resilience can be defined as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it”.

Whereas Kruk and her colleagues mostly seem to focus on national health systems (and do so in a rigorous way), when I scan some of the other articles and reports in the field, I’m a bit puzzled by how the word is used. There is a lack of clarity as to which level of the health system – global, regional, national, and/or local – one is referring to in the resilience discourse.

In recent articles and discussions, some discuss the failure of national health systems in West Africa in detecting and controlling Ebola, and argue that a more ‘resilient’ system should be built (pdf) – urgently. Others refer to the architecture of the global governance structure, pointing fingers at the failure of the World Health Organization (WHO) in enforcing the International Health Regulations, among others.

In other words, many put two vastly distinct systems – national and global – in the same (resilience) blame game. While some (like Kruk and others) are fairly consistent in how they apply the concept of resilience to health systems, in sum the health field seems to offer a mashup of recommendations and interventions aimed for vastly different targets, levels, with a diverse range of required investments. That is, in my mind, problematic when trying to translate all this into real-life actions.

What should resilience mean for a health system?

At the global level, I am in full support of pushing for a resilient system. A robust surveillance and reporting system is critical in this globalized world. However, at the national and local levels, I am less enthusiastic.

Looking at the origins of national health systems that we would now consider as being ‘resilient’, such as Germany, the United Kingdom, and Japan, having resilience as their primary objective was certainly not in their original plans. These systems started with simple (yet challenging) objectives of improving population health and minimizing impoverishments from health expenditures. Over time, as the basic foundations of the systems were established, and with the help of stable political climates, the health system strengthened, and with it, came other desired qualities, such as resilience.

In an ideal scenario, we want a health system to acquire all of the above. However, in real-life scenarios where the most rudimentary components, such as health workers and infrastructure, are inadequate, investments in basic service delivery should be the utmost priority. Other functions can only be built on top of these fundamental bricks. Furthermore, the success of the health sector is dependent on good governance and political stability of the external environment. If all this is in place, then sooner or later you’ll arrive at resilient health systems. The current framing and discourse seem to put the cart before the horse, though.

To prevent this phenomenon from becoming ‘just another phase’ in the field of global health, clearer definitions and more concrete action steps toward achieving “resilient” health systems locally, nationally, regionally, and globally, are required.

This blog post is part of a series addressing: ‘resilient & responsive health systems for a changing world’. These blog posts were originally essays written by members of the Emerging Voices TWG.

Image credit: United Nations Photo, Creative Commons License 2.0