On the resilience of health systems: A methodological exploration across countries in the WHO African Region.

Sohel Saikat,Lindiwe Makubalo,Aminata Benitou-Wahebine Seydi,Ambrose Talisuna,Hillary Kipchumba Kipruto,Edwine Barasa,Regina Titi-Ofei,Mary Hamer Hodges,Gerard Schmets,Benson Droti,Prosper Tumusiime,Benjamin Tsofa,Humphrey Cyprian Karamagi,Matshidiso Moeti,Joseph Waogodo Cabore

doi:10.1371/journal.pone.0261904

Abstract

The need for resilient health systems is recognized as important for the attainment of health outcomes, given the current shocks to health services. Resilience has been defined as the capacity to “prepare and effectively respond to crises; maintain core functions; and, informed by lessons learnt, reorganize if conditions require it”. There is however a recognized dichotomy between its conceptualization in literature, and its application in practice. We propose two mutually reinforcing categories of resilience, representing resilience targeted at potentially known shocks, and the inherent health system resilience, needed to respond to unpredictable shock events. We determined capacities for each of these categories, and explored this methodological proposition by computing country-specific scores against each capacity, for the 47 Member States of the WHO African Region. We assessed face validity of the computed index, to ensure derived values were representative of the different elements of resilience, and were predictive of health outcomes, and computed bias-corrected non-parametric confidence intervals of the emergency preparedness and response (EPR) and inherent system resilience (ISR) sub-indices, as well as the overall resilience index, using 1000 bootstrap replicates. We also explored the internal consistency and scale reliability of the index, by calculating Cronbach alphas for the various proposed capacities and their corresponding attributes. We computed overall resilience to be 48.4 out of a possible 100 in the 47 assessed countries, with generally lower levels of ISR. For ISR, the capacities were weakest for transformation capacity, followed by mobilization of resources, awareness of own capacities, self-regulation and finally diversity of services respectively. This paper aims to contribute to the growing body of empirical evidence on health systems and service resilience, which is of great importance to the functionality and performance of health systems, particularly in the context of COVID-19. It provides a methodological reflection for monitoring health system resilience, revealing areas of improvement in the provision of essential health services during shock events, and builds a case for the need for mechanisms, at country level, that address both specific and non-specific shocks to the health system, ultimately for the attainment of improved health outcomes.

Highlights

Health systems are perceived to be functional when they are able to make available the services people need for their health and well-being
The practical application of interventions to make systems resilient has so far not been clear [10]. These interventions have focused on minimizing the disruptive event, through actions for “preparing for and effectively responding to crises; maintaining core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganise if conditions require it” [7, 9, 11,12,13]
We highlight in this paper a methodological exploration to build and monitor resilience against shock events, based on the existing conceptual understandings

Summary

Introduction

Health systems are perceived to be functional when they are able to make available the services people need for their health and well-being. Health systems have shown limited capacity to absorb unexpected increases in service demand, driven by shock events- an issue documented with disease events in low income countries but even following natural disasters such as earthquakes in Japan [4]. This effect of shocks on systems and services, including the large impact on indirect deaths have been documented extensively following the 2014–16 West African Ebola Virus Disease (EVD) outbreak, and currently in the context of the COVID-19 pandemic [5, 6]. These interventions have focused on minimizing the disruptive event, through actions for “preparing for and effectively responding to crises; maintaining core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganise if conditions require it” [7, 9, 11,12,13]

Objectives

Methods

Results

Discussion

Conclusion