People and countries today experience a constant barrage of shocks and stresses that impact health. From Katrina in New Orleans to Ebola in West Africa to the refugee crisis in Europe, countries are faced with constant challenges that put people and their health in harm’s way. These challenges are more than just disease threats, they also take the form of social, economic, political, or environmental disturbances. In addition to these unpredictable events and emergencies, country health systems are overwhelmed with the implications of longer-term challenges – people are living longer, the global burden of disease is shifting from infectious to non-communicable, and commonly used treatments are becoming ineffective (e.g., antimicrobial resistance) – and are not able to provide services and care effectively. These health challenges require more than strong health systems; they require resilience in the face of ongoing shocks and stresses. A resilient health system is aware of imminent threats, able to absorb a shock or stress, prepared to adapt to a crisis situation, and can reorganize as needed to respond quickly and effectively while maintaining continuous service delivery. A resilient health system is able to effectively draw on resources outside of the health system – transportation, government, the private sector, civil society, physical infrastructure – and, as a result, is often more agile than a strong health system.
Health systems around the world stand to benefit from investing in building resilience. Low- and middle-income countries (LMICs), in particular, struggle to provide healthcare to their citizens effectively. Many LMICs today face the ongoing challenge of infectious diseases (e.g., HIV, malaria, Ebola, Zika) while simultaneously confronting rising rates of non-communicable diseases (e.g., cancer, heart disease, diabetes). Limited infrastructure and resources in LMICs further compound their inability to provide services and exacerbate health system weaknesses.
Significant efforts to strengthen core system building blocks – such as service delivery, the healthcare workforce, information and data systems, supply of medicine and medical commodities, and healthcare leadership and governance – have been undertaken in LMICs by national governments and international donors with mixed success. Given the continuing fragility or lack of these building blocks in many LMICs, however, there is broad agreement among global health stakeholders that investment in these areas will remain a priority for both countries and donors for the foreseeable future. Nonetheless, high-profile health systems failures – from HIV to Ebola to Zika – have made it clear that making investments to strengthen health systems may not be enough to protect human health.
Ultimately, a health system is just one piece of a broader network of systems (political, financial, social, emergency response, etc.) that operate across the community, national, and international levels. Understanding the connections between the health system and other systems – not only between the components within a health system – is important in thinking about how best to build resilience. One way to approach this complex web of networks, resources, actors, and relationships is through systems mapping.
Systems mapping provides a useful lens for thinking about touch points for building resilience in health systems. It provides a visual catalogue of key resources, actors, and actions and their relationships to each other. By focusing on how these components are used, deployed, and/or coordinated, systems mapping helps shed light on an often overlooked element in health system strengthening: the connective mechanisms and means of deployment between and among health system resources. As systems mapping also provides a quick way to contextualize the health system within the broader ecosystem of other systems at all levels (community, national, and international), it allows for the identification of new entry points and potential contributions from non-health actors in building health system resilience.
Rabin Martin undertook a health systems mapping exercise with a focus on LMICs that uncovered three potential areas for intervention to support building resilience in health systems: governance and leadership, data and information, and community engagement. We found:
- Well-established and responsive governance structures with strong leaders are often a critical component of any system – and the health system is no exception, whether at the community, national, or global level. The definition of leadership in the health system, however, has traditionally been limited to formal government or health authority leaders. To build resilience, leadership should be defined more broadly and include de facto leaders (community leaders, the private sector, non-profit organizations, other non-governmental actors, etc.) who often step up in an ad hoc fashion to address health crises. Communication, engagement, and information flows up and down the chain of command among all health leaders – both within and outside and the formal system – is often the key to an effective response to a health shock or stress.
- Consistent information flows are critical to inform evidence-based decision making and to build trust among the array of actors essential to a resilient health system. Health systems benefit from having systematic and widespread data collection processes that facilitate rapid status assessments. As health systems in LMICs often lack sufficient IT infrastructure, maximizing all existing channels for information aggregation and dissemination is important. These information flows should be two-way to ensure that authorities are sharing information with communities at all times, not just during an emergency. Additionally, the value of informal channels, such as social media platforms and non-governmental organization member networks, should not be discredited.
- Community members themselves are a vital part of the health system that should not be overlooked. They are not only recipients of health services, they are key participants and often become frontline leaders during a crisis. By ensuring individuals are integrated in the health system, active in managing their own health, and able to access accurate health information, communities will become more engaged on the issue of healthcare. A more engaged community can result in improved local responses to health shocks and stresses in the short term and, at the individual level, can contribute to sustained positive health behavior change in the long-term.
In light of the spate of highly visible and ongoing public health crises in recent years – Ebola, Zika, persistent maternal and child deaths, increasing deaths from preventable non-communicable diseases, and so on – the critical need to address health system failure is indisputable. As global health stakeholders continue to advance the Sustainable Development Goal (SDGs) agenda, recognizing ongoing opportunities to prioritize investments that build resilience and to engage new stakeholders and non-health actors in these efforts is essential for developing health systems that are prepared for the health challenges of the future, especially those just over the horizon.
The research that informed these findings was funded by The Rockefeller Foundation.