What is a resilient health system? Lessons from Ebola

The fragility of health systems has never been of greater interest—or importance—than at this moment, in the aftermath of the worst Ebola virus disease epidemic to date. The loss of life, massive social disruption, and collapse of even the most basic health-care services shows what happens when a crisis hits and health systems are not prepared. This did not happen only in west Africa— we saw it in Texas too: the struggle to provide a coherent response and manage public sentiment (which often manifests as fear) in a way that ensures that disease does not spread while also allowing day-to-day life to continue. In other words, we saw an absence of resilience. This Viewpoint puts forth a proposed framework for resilient health systems and the characteristics that defi ne them, informed by insights from other fi elds that have embraced resilience as a practice. Health system resilience can be defi ned as the capacity of health actors, institutions, and populations to prepare for and eff ectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath. Resilient health systems can also deliver everyday benefi ts and positive health outcomes. This double benefi t—improved performance in both bad times and good—is what has been called “the resilience dividend”. Response to a crisis, be it a disease outbreak or other disruption resulting in a surge of demand for health care (eg, a natural disaster or a mass casualty event) needs both a vigorous public health response and a highly proactive and functioning health-care delivery system. These two systems must work in concert during a crisis—and indeed long before crisis strikes. Health-care systems are complex adaptive systems and resilience is an emergent property of the health system as a whole rather than a single dimension. Building resilience is thus context-dependent and iterative, needing advance assessments of system capacities and weaknesses, investments in vulnerable components of the system before a crisis, reinforcements during the emergency, and review of performance after a crisis. Resilience is not a static construct—for example, the rapid pace of recovery from crisis is a cardinal measure of success. The Ebola epidemic has illustrated that several preconditions for resilience were lacking. The fi rst of these preconditions is recognition of the global nature of severe health crises and clarity about the roles of actors at all levels of the global health system. Although national governments are fundamentally responsible for their health systems, they need the capacity to mobilise the full range of local actors and to rapidly draw on external resources if necessary. The need for a global resilience network is both a moral imperative and a recognition of the fact that pathogens do not respect borders. Shocks to the health system of one country can reverberate across regions and the world. Health system resilience is thus a global public good and needs a collective response from the global community. Funding for this response can come from traditional domestic and donor sources or, as recently suggested, a new international health systems fund to which all countries contribute. A second precondition is a legal and policy foundation to guide the response and establish accountability. The implementation of International Health Regulations, which call on countries to build core public health capacities and establish a means of coordinating a response to health emergencies with regional and global partners, is a prerequisite for eff ective emergency response. Additionally, legislation that clarifi es the authority of public health agencies and the roles and responsibilities of private and public health actors is needed as are policies for involving the private and voluntary sector in the response and allowing fl exibility in sharing and reallocating resources across the health system. Third, there is a need for a strong and committed health workforce, characterised by health personnel who show up for work that might be diffi cult and dangerous. Establishing such a workforce begins with training and deployment of a suffi cient number of doctors, nurses, managers, and outreach workers—a colossal task in a country such as Liberia with a population of 3·5 million people and fewer than 100 doctors—but also building and banking a stock of social capital in the health system before crisis strikes. Just as strong social capital in communities promotes individual psychological resilience after mass trauma, social capital in the health system promotes system-wide recovery from crisis. In the health system context, social capital has two dimensions: a sense of worth, community, and responsibility among health actors (clinicians, managers, engineers, outreach workers) and an inclusive and robust community engagement with the health system. Health systems that earn the trust and support of the population and local political leaders by reliably providing high-quality services before crisis have a powerful resilience advantage. Strong management of district level health systems is key to gaining that trust. Diverse fi elds such as ecology, engineering, complex adaptive systems, psychology, and public health have produced resilience frameworks. The Rockefeller Foundation has developed substantial data about resilient Lancet 2015; 385: 1910–12