A health systems resilience research agenda: moving from concept to practice.

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

Shifting the paradigm: using disease outbreaks to build resilient health systems

[...]events push weak health systems to a breaking point, as witnessed during recent outbreaks of cholera, drug-resistant tuberculosis, Ebola virus disease and Zika virus disease.1–4 The current COVID-19 pandemic is testing the response and resilience of health systems worldwide, including well-resourced systems in Europe and North America, where health institutions and public health agencies are operating beyond capacity, diagnostics are lacking, triage systems are faltering, personal protective equipment are insufficient, and front-line health workers are facing risks of disease and death.5 Building responsive and resilient health systems is an imperative for the global health community. [...]many aspects of outbreak response lay the groundwork for health system strengthening (HSS), such as enhancing surveillance systems and training the health workforce.12 Over the last two decades, numerous mechanisms, frameworks and agreements have been developed to promote health systems that are resilient to outbreaks and major health emergencies, such as the International Health Regulations (IHR)—an agreement between 196 countries to work together to mitigate global health security threats and a cornerstone of efforts aimed at ensuring sufficient health system infrastructure to detect, assess and report major events impacting public health.13 Through the IHR, in 2016 the Joint External Evaluations were created to identify critical gaps within health systems and prioritise actions to enhance preparedness and response within a country.14 There is not yet a framework, toolkit or formalised targets for HSS activities during outbreaks. [...]during the current COVID-19 pandemic the USA approved a US$2 trillion-dollar stimulus bill, of which US$157 billion was directly allocated to the health system and research.15 While it is critical and ethically necessary to prioritise immediate response activities, the organisational infrastructure, capacity and networks which typically result from these investments could be leveraged to also strengthen health systems, in particular those components that are directly impacted during the outbreak, such as health information systems, healthcare services, medical and public health workforce, supply chain management and essential medicines and vaccines. Lessons could be learned from industries, such as military, nuclear, oil and gas and aviation that have similar high-pressure and complex environments as the biomedically oriented institutions and experience major events and disasters, and have used methodologies to effectively address acute challenges while building better, more sustainable systems and processes along the way.16 Methodologies like systems analysis and applied systems thinking could be adapted and used during an acute response to both further enhance response effectiveness and strengthen health systems.16 We have identified 10 activities that could be implemented during health emergencies to ensure that health systems are strengthened during the response.

Systems thinking for health emergencies: use of process mapping during outbreak response.

Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease outbreaks to strengthen response and health systems. Process mapping exercises were conducted during three unique emerging disease outbreak contexts with different: mode of transmission, size, and health system infrastructure. System functioning improved considerably in each country. In Sierra Leone, laboratory testing was accelerated from 6 days to within 24 hours. In the Democratic Republic of Congo, time to suspected case notification reduced from 7 to 3 days. In Nigeria, key data reached the national level in 48 hours instead of 5 days. Our research shows that despite the chaos and complexities associated with emerging pathogen outbreaks, the implementation of a process mapping exercise can address immediate response priorities while simultaneously strengthening components of a health system.