Revisiting Resilience in Health Systems Research

Kim Ozano: 00:00:04

Hello listeners.

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I'm Dr.

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Kim Ozano, and this is Connecting Citizens

to Science a podcast, where we talk about

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the ways that researchers connect with

communities to solve challenges together.

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I'm really excited to bring you

a brand new mini series called

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'Stories of Resilience - Local

Lives and Health Systems'.

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This mini series is brought to you

by ReBUILD for Resilience, which is

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a research consortium that examines

health systems resilience in fragile

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settings that experienced violence,

conflict, pandemics, and other shocks.

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Many people have joined the effort

to build resilience in healthcare

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systems, however it remains a concept

that is still quite contested and

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often difficult to comprehend.

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So, in this episode, we bring together

experts who work in the field of health

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systems resilience to talk about both

the concepts and the language that is

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used and how this invites participation

from communities and other stakeholders.

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We're also going to be discussing

how communities are central to

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health systems resilience and how

we can work with them in a way that

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suits them and to help us do that.

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We have a co-host with us today, Professor

Sophie Witter, who is a professor of

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International Health Financing and

Health Systems at the Institute for

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Global Health and Development Division at

Queen Margaret University in Edinburgh.

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She is also a member of the

Institute for Global Health and

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Development Research Centre.

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Our two guests today are Dr.

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Sushil Baral, who is the managing

director of HERD International, which is

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a research and development organisation

that is dedicated to addressing

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community needs and emerging health and

development issues in Nepal and globally.

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Our second guest is Dr.

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Seye Abimbola, who is an associate

professor at the university of

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Sydney and was the previous editor

in chief at the BMJ Global Health.

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Dr.

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Abimbola's teaching and research

has focused on knowledge practices

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and global health, health systems

governance, and the adoption and

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scale up of innovative health systems.

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So let's hear from our co-host

professor, Sophie Witter.

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Sophie, welcome to the podcast.

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And we're really looking forward to

this very important conversation.

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But before we begin, could you talk

us through some of the key concepts

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that we should be thinking about?

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And why it's important to

talk about health systems

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resilience now more than ever.

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Sophie Witter: Thanks for inviting

me onto this exciting discussion.

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I think the concept of resilience

in relation to health systems is

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something that has really grown

in the sort of public debate and

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academic discussion since the Ebola

crisis in West Africa in: 2014

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Then as we know, both regions and the

whole world have been hit by a series of

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shocks and pandemics, notably COVID, but

even now, there's really a sense that

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we're living in the era of poly crisis.

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So multiple different stressors and

shocks, which really create challenges

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for providing, um, essential and quality

healthcare for populations globally.

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So we were interested in resilience,

which is broadly understood as a capacity

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to maintain functions and health system

functions during shocks and crises.

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Um, and we try to look at some of

the learning from other areas of

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discipline, other, topics, other

literatures that look at kind of

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complex systems like health systems.

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Um, but we continue to debate the politics

of the term as well, like who is expected

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to be resilient and what does that mean?

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And who is bearing the brunt of, of sort

of managing these shocks and crises?

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So in ReBUILD, we're looking at research

on how to develop resilience capacities.

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We're focused on local health systems,

which are fragile and shock prone.

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So again today, I'm really interested

to talk about how we can do that.

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What's the action involved?

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Because I think a lot of the literature

has been around measurement and concepts,

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but less about how we engage to support

resilience, assuming it's a good thing.

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I'm going to start by just asking

Sushil and Seye about how they

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got involved in this topic.

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Um, and really what their experiences

were in terms of resilience in

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their local health systems and

what can we learn from that.

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So maybe over to you,

first of all, Sushil?

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Sushil Baral: Thank you, Sophie.

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I was born in village.

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I'm a village person, where I've seen

how the community engaged or disengaged

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when they were in need of health

care services in those communities.

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I come from a village where many

things were not put in place.

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The many basics were not put in

place, including the health system.

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My motivation working with the community

towards understanding the resilience

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and health system actually started

from those villages where I worked

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as a village health care provider,

walked hours and hours long to reach

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out to the community and provide

the basics when they were in need.

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So that is the main motivation

that engaged me in resilience.

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Sophie Witter: That's fascinating.

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And you've already gone

straight into this.

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One of the big topics in resilience is

around knowledge and how that is used

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and it's whose knowledge and how does

it feed back into building that system,

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which is exactly what you're describing.

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And you sort of witnessed

it from bottom to top there.

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So yeah, that's fantastic.

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Seye, how does that relate

to your, how you got involved

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in the resilience discussion?

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Seye Abimbola: I worked for about

three years at the National Primary

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Health Care Development Agency in

Nigeria, strengthening the primary

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healthcare system for services.

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And something that struck me as

remarkable was that at the community

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level in many instances, the community

health committees were responsible

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for picking up the failures of the

different levels of government that

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that were sort of in a sense above them.

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So in terms of helping to augment

the supply of services, helping to,

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facilitate the demand for services.

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And in some sense, that was where I

started to think about the idea of

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resilience, that what that level of

governance at the community level was

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doing is, in fact, ensuring that the

system was resilient to the failures

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of the government, the three layered

government that sat above them.

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Sophie Witter: I think that that

does lead really into this thinking

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about where does responsibility in a

system sit and where does power sit?

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Because they're often

divorced, aren't they?

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And maybe that's what we're getting

to here that often, you know, kind of

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power shifts upwards in a system, but

ultimately responsibility for keeping

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things going, especially when there's

a shock or crisis is often lower down.

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So perhaps resilience is a bit more about

connecting these levels effectively and

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making sure there's a fair distribution

of that power versus the responsibility,

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because one of the critiques, as you

know, and you've been part of that,

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that writing, Seye, is that, um, you

know, resilience puts the burden on

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local actors to cope and it says you're

doing well because you're coping.

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But actually, is that what we want when

we design a resilient system, just to put

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a lot of that responsibility and that

kind of managing shocks challenge at

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the bottom of the system for people who

often have the least power and resources.

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So any reflections on resilience?

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Is it a helpful term or are

we using it to put too much

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weight on those local actors?

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Seye Abimbola: I'm still not

convinced it's a helpful term.

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In health systems and global

health discourse, the question

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I kept asking myself is, how is

this different from strengthening?

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And when I was thinking about Nigeria,

as I described earlier, and I was

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saying to myself, well, um, a strong

health system is a robust health system.

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In other words, you want there to

be power and resources at different

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levels of governance and ability

to function and be connected.

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And to do that the system

needs to be robust in some way.

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In other words, it needs to have

not just what it needs to function

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today, but what it needs to function

in the instance of a shock or stress.

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And when we say system is resilient,

it often will seem to me that what

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we mean to say is that the system has

managed to cope in spite of the odds.

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Sophie Witter: There is quite a similar

debate about health system strengthening

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as well for similar reasons in as much

as the term came up a lot in relation

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to global health institutions initially.

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And so the question is, is

this an external agenda?

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Is this something that

actually resonates locally?

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So in a way, we can ask the same questions

about, I think, about health system

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strengthening as we can about resilience.

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Sushil Baral: The big question to me,

does the resilience mean same thing, a

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different thing for different people.

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I think it's, it's very hard to

come to a common consensus in any

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system including health systems.

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In any country, the health and

well being of the people is

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broadly guided by the politics.

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Politics, basically defines the policies

of system, uh, of the country and how

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that policies, uh, acted in reality,

uh, how those policies are well informed

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from the evidence, from the power, from

the community, from the context that we

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leave around is, is very, very important

to me, uh, when we talk about resilience.

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I think it requires to be a more,

more holistic concept, bringing the

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whole of the society, whole of the

government, whole of the actors together.

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But it's true that we have seen our

actors are guided by their own preferences

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where the politics come into play.

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Institutional preferences, all the

development partners, they have

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their own way of defining resilience

in their own work plan and agenda.

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Kim Ozano: When we talk about

communities and we use language like

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resilience or strengthening health

systems, this is the type of language

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as academics we use in our daily lives.

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But Sushil, you know, you were a village

health care provider and Seye, you talked

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about your connection with communities.

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And we know that language can often

create distrust within health systems,

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or language can facilitate spaces where

communities feel confident to participate.

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Is there something around

understanding how to communicate

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key concepts and using language that

is more inclusive for communities?

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Sushil Baral: It's very important.

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So to me, to answer your question,

engaging community by knowing the

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community better, because these

communities are different in different

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places, you cannot really take a blanket

approach of community engagement and

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communicating our language to them.

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Rather, I prefer listening their

language and building on that.

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Sophie Witter: Yeah, I'm just going

to jump in there as well with the

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reflection because I've one of

the things I've thought about is

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the extent to which resilience and

fragility kind of mirror each other.

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We were doing some work with

colleagues on fragility.

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Ultimately, I think we sort of came

down to the view that fragility

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rests in a kind of disconnect between

the system and the communities.

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That's where a lot of the kind of

fragility features come in, which

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exactly links, I think, to your

point, Sushil, about how well we're

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communicating in a very two way sense.

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Seye Abimbola: I think that resilience

is the term we use, is how we frame

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things, is how we try and interpret

what we see when we look at systems

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and how people act within those

systems and how they are designed.

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And it's not how people in the

system would necessarily describe

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or define what it is they're

experiencing or going through.

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And one of the things I care about very

deeply is the interpretive lenses we

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place on systems can in fact marginalise

people who function within the systems and

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how they interpret their own realities.

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And I'll give an example if you go

to many community health committees

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in Nigeria and sort of ask them what,

what is their role and responsibility,

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one of the things they will tell

you is that our role is to fill

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the gaps left by government action.

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In fact the paper that I wrote about,

committee of committees was titled 'The

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Government Cannot do it All Alone'.

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In other words, a lot of their own

reflection about their role speaks to how

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their role has been framed repeatedly.

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It is about quote unquote self

reliance, rather than accountability.

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They don't necessarily think of their

role in terms of making demands,

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putting pressure, um, and, and

functioning in that capacity, but

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rather what can we do for ourselves?

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Now that's important.

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What can we do for ourselves is

absolutely important, but so is what

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should the government be doing that

the government isn't doing, right?

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And I find that one of the things, one of

the harms, in my view that the language

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of resilience can do is to, in fact,

further, um, emphasise, um, that self

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reliance role at the expense, in many

cases, I suspect, of that accountability

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function that the community may, may play.

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Sophie Witter: So, okay, I think

that's a good point to move on to,

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in a sense, where do we go from here?

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Because what we've shown is

that it's very contested and

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it's debatable how useful it is.

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At the same time, it is being used because

I think it has some intuitive sense that

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clearly links to challenges that are

going on at the moment in the world.

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But if we think about how do we, build

the capacity of communities to both be

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self protective in some senses, if we use

that word rather than self reliance, but

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also demand accountability, because I'm

absolutely on board with you that that's

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something that in many settings is, is

really lacking and it's very problematic.

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Seye Abimbola: The way that I'm

coming to think about and talk

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about resilience is, is almost to

replace the word with learning.

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And I find, frankly, that in almost

every instance, learning does the

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job as well, if not better, in fact.

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And what learning does essentially to

put that active agency into resilience.

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A system that is resilient is one

that learns, that can learn from its

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past and present from its neighbours.

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And when I think about learning in that

way, I'm thinking to myself, how do

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we then build capacities for learning?

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And you mentioned connection earlier,

but also the ability to say, where

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are the platforms in each system that

allow for that connection to happen and

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could be in a, in a small community,

the marketplace could be the platform.

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It could be, it could be a village

square, so it could be a place where

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people discuss what the experiences

are and able to share ideas and

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learn and function differently.

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In other settings, it could be the media,

It could be academics like us who actually

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do move knowledge around as it were.

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when I think about resilience,

I'm thinking learning

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Sophie Witter: Yeah.

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Thank you.

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Um, I think that's an excellent point

and definitely the learning health

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system is again, a topic that's risen

up the agenda recently and I think

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rightly so, because it does validate

people understanding their own context

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better than others who are more removed.

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Um, Sushil, what should we be

doing in terms of our engagement?

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So we're building connectors, is the point

that Seye was making, which I think really

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builds on a lot of the literature around

resilience, which is about who has the

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connections, how do groups work together.

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Certainly we've seen that a lot in

our ReBUILD research, haven't we?

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What other areas should we be contributing

to, to pushing in terms of the agenda?

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Sushil Baral: You can describe the

resilience capacity in a number

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of, um, points and then really

understanding where the gaps are.

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And then working together, with

the co-creation component, with the

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stakeholders, including the community.

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I bring here the word co-creation

in a very meaningful way.

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You know, abiding the principles of

community engagement with the meaningful

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co-creation with them, having a joint

assessment, having a joint planning,

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and defining this coordination and

collaboration structure, uh, put in place,

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which continuously assist and acted upon

linking with the policy and the practices.

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It is not just a tokenism.

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It harmonises the power imbalances

when the co-creation is acted in local

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reality considering the local context.

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So the important point I bring here

is the properly defined and agreed

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coordination and collaboration

structure put in place, which often,

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you know, continuously works in terms

of enhancing the resilience capacity.

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Kim Ozano: Thanks very much Sophie

for guiding the conversation.

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I've really enjoyed learning.

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And I really liked the idea of

replacing language like resilience

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with learning health systems, it's

straightforward and language that is

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more accessible to all involved in

building health systems resilience.

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And once again, the value of co-creation

has come out really strongly.

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So for the final question, I would

like to ask all three of you, what

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is the one piece of advice that you

would give to people that are working

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in different contexts, trying to

strengthen or learn from health systems?

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Sophie Witter: It's the million

dollar question, isn't it?

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But I think to me and listening

to the conversation really,

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what's coming out is that the,

the key elements are connections,

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kind of knowledge and resources.

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And so I think our effort for all

of us should be, and this goes from

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kind of global level down to local,

should be on getting these three

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elements available at the local

community and health system levels.

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Because very often systems are set to

kind of move these three elements upwards.

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Whereas what we've been saying, I think a

lot of the conversation is that we need to

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be empowering local actors, and especially

those groups that are most marginalised.

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But I do also think we need to look at

the fair distribution of responsibilities

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across the system, because I also

recognise that some issues need

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national and international action.

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They can't all be resolved at the

local level, and we don't want to put

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all the responsibility there, so it's

about that balance has to be right.

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Seye Abimbola: One of the dangers

of playing the devil's advocate

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is that sometimes, sometimes

you become the devil yourself.

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And in this regard, I often

push back when people say

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fragmentation is such a bad thing.

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It's a term used pejoratively

and for me, a centralised unified

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system, is a system that is not

particularly resilient to shocks.

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Um, and so I'm always looking for where

the lines of decentralisation are and how

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to make sure that we don't remove them

simply because we want things to be simple

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and streamlined and straightforward.

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Sometimes those are valuable.

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Um, often we do that at the risk of a

potential future shock or stress really

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breaking, breaking apart the system.

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So one key advice is to not be too quick

to remove fragmentation, quote, unquote.

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And second is to be alive to the

possibility of facilitating learning

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connections anywhere in the system..

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Sophie Witter: Amen.

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Sushil.

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Sushil Baral: I would say we should

prioritise the learning aspects of the

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health system, feature that in policy,

and more strongly listen to the community.

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The system has to create space, ample

space and opportunities to bring the

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community into the mainstream and,

and hearing them is very, very vital

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towards the local system resiliency.

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There's a message to global health

actors, uh, in order to really have

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a coordination mechanism, better

coordination mechanism at the global

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level to this identified priorities and

collective mechanism to pull the resources

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towards the resilient healthcare system,

uh, with the evidence informed policy.

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Kim Ozano: Some excellent pieces of

advice there and lots to think about.

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So thank you for our guests, for joining

us and taking part in this conversation,

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we've really appreciated your being part

of Connecting Citizens to Science and

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thank you to our listeners as always for

joining us and listening to this episode.

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: 00:19:13

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: 00:19:17

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: 00:19:21

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: 00:19:30

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: 00:19:35

Bye from Connecting Citizens to Science.