Resilience: A Tool for a New Era of Health Threats

If the Ebola crisis in West Africa and the global Zika outbreak taught the world anything, it is that all health systems – regardless of size and available resources – must be better prepared to respond to and recover from threats of all kinds. Not only are today’s health system threats more diverse, their geographic reach and increased frequency make these health systems increasingly vulnerable as they strive to promote, improve, and sustain the health of populations.

For more than a decade, The Rockefeller Foundation has helped build the field of resilience, which aims to make people, communities, and systems better prepared to withstand, bounce back, and emerge stronger from both natural and man-made shocks and stresses. Almost in parallel to this work on resilience, the Foundation launched Transforming Health Systems (THS), an initiative born from a shift in the Foundation’s approach to advancing the health of vulnerable populations around the world. In a departure from its history of supporting vertical, disease-specific programs, the Foundation has instead focused its investments on horizontal, systems-level change that could address multiple health threats. Under the THS initiative, the Foundation’s health team began to explore what it would take to make health systems stronger across a variety of contexts, for a variety of populations, and to advocate for this point of view.

As the global health community continues to debate the health system design best suited for our times, the application of resilience principles may prove useful for unlocking innovative ways to meet the broadened set of challenges facing these systems.

More recently, our growing recognition of both the direct and indirect factors that impact health outcomes provoked a new set of questions:

• What would be needed to make health systems not only stronger but also resilient?
• Would applying resilience principles to health system design yield unrealized benefits?

To answer these questions, the Foundation’s Search team, in collaboration with its Advance Health and Resilience teams, led an exploration to identify potential opportunities to build resilience in health systems across a range of health and non-health shocks and stresses. Our efforts built on years of Foundation experience in pioneering the field of resilience, as well as ongoing work in shaping the concept of health system resilience. Three key lessons emerged from the exploration:

1. Resilience-building does not need to be resource-intensive. Established approaches to health systems strengthening are often more resource-intensive, leading many to argue that a country’s income-level can predict the success of its health system – but this is not always the case. Resilient responses to health system threats hinge largely on how a health system responds to a threat, rather than what it uses to do so, a point that became clear when middle-income country Nigeria successfully contained Ebola by repurposing the finely tuned surveillance system it had originally developed to counter polio.  Resilience can also be built by leveraging existing assets and capacity beyond the conventional health sector. For example, deploying school buses for transport during mass-casualty events when emergency care systems are overwhelmed can allow for quicker responses and rapid adjustments that do not sacrifice the mission of the health system’s business-as-usual.
2. Intangible assets matter just as much as tangible assets. The value of infrastructure, staff, and medicines notwithstanding, when the consequences are high and the timelines are short, intangible assets such as effective coordination and public trust in health officials might well be what ensures appropriate health care finds those who need it most, when they need it most. Such assets include two-way communication streams and functioning feedback loops between: health sector actors at national and sub-national levels, non-health and health sector actors, and health sector actors and the populations they serve. These ‘soft’ assets form the connective tissue that builds health system resilience by creating operational links across the system as well as outside of it. For example, across West Africa, traditional healers can inspire greater trust within some communities than Western science can provide. These individuals can play an important role in bridging skeptical communities to appropriate care while dispelling rumors that could otherwise harm their health.
3. Anticipating threats makes systems more resilient and less reactive. Very few health systems prepare for unknown or unlikely threats. While there are legitimate reasons for this approach, it creates health systems that are largely reactive to the last known crisis. We saw this in Liberia, where infrastructure built for Ebola left the rest of the health system vulnerable to other less immediate threats, resulting in outbreaks in both measles and whooping cough. Resilient health systems seek to anticipate new threats, both known and unknown, and proactively plan ahead, while at the same time making sure that the most imminent threats to the system and the populations they serve are still addressed. The efficiencies that emerge from this kind of approach could potentially redefine the scope and expectation of what exactly health systems are designed to deliver, and to whom.

As the global health community continues to debate the health system design best suited for our times, the application of resilience principles may prove useful for unlocking innovative ways to meet the broadened set of challenges facing these systems. Moreover, investing in resilience can also yield benefits both within and beyond the health system itself – a return on investment that The Rockefeller Foundation calls the resilience dividend. These benefits are realized not only as improved health outcomes, but also as improvements in less tangible outcomes like social cohesion and public trust. The adoption of approaches that further health system resilience may someday provide valuable proof points that frame health as an investment in, rather than a drain on, government, community, and individual resources.