Article Text

Download PDFPDF

Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa
  1. Lucy Gilson1,2,
  2. Edwine Barasa3,
  3. Nonhlanhla Nxumalo4,
  4. Susan Cleary1,
  5. Jane Goudge4,
  6. Sassy Molyneux3,5,
  7. Benjamin Tsofa3,
  8. Uta Lehmann6
  1. 1School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
  2. 2Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Center for Geographical Medicine, KEMRI-Wellcome Trust Programme, Nairobi, Kenya
  4. 4Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
  5. 5Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
  6. 6School of Public Health, University of the Western Cape, Cape Town, South Africa
  1. Correspondence to Lucy Gilson; lucy.gilson{at}


Recent global crises have brought into sharp relief the absolute necessity of resilient health systems that can recognise and react to societal crises. While such crises focus the global mind, the real work lies, however, in being resilient in the face of routine, multiple challenges. But what are these challenges and what is the work of nurturing everyday resilience in health systems? This paper considers these questions, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach. The paper presents evidence of the instability and daily disruptions managed at the front lines of the district health system. These include patient complaints, unpredictable staff, compliance demands, organisational instability linked to decentralisation processes and frequently changing, and sometimes unclear, policy imperatives. The paper also identifies managerial responses to these challenges and assesses whether or not they indicate everyday resilience, using two conceptual lenses. From this analysis, we suggest that such resilience seems to arise from the leadership offered by multiple managers, through a combination of strategies that become embedded in relationships and managerial routines, drawing on wider organisational capacities and resources. While stable governance structures and adequate resources do influence everyday resilience, they are not enough to sustain it. Instead, it appears important to nurture the power of leaders across every system to reframe challenges, strengthen their routine practices in ways that encourage mindful staff engagement, and develop social networks within and outside organisations. Further research can build on these insights to deepen understanding.

  • resilience
  • district health system
  • leadership
  • organisational software

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from


  • * More specifically we have worked in one geographic area in which health services are managed by two different health authorities. The area is the Mitchell’s Plain subdistrict of the City of Cape Town, a local government authority, which falls within the Mitchell’s Plain/Klipfontein substructure, one of four within the provincial government’s Metro District Health System.

  • The learning site work in Kilifi County and Sedibeng began later and moved at a slower pace than in Mitchell’s Plain, with fewer opportunities at the time of writing to support locally led changes in managerial practice.

  • Although Bene et al22 use the term capacities, we propose they are more usefully seen as strategies as they reflect alternative courses of action that might be taken by a system in responding to challenge.

  • § The evidence in this paragraph is drawn partly from an unpublished manuscript, based on the Kilifi work: Nyikuri M, Tsofa B, Okoth P, Barasa E, Molyneux S. ‘We are toothless and hanging, but optimistic’: Sub county managers' experiences of rapid devolution in Coastal Kenya.

  • These insights reflect the wider experience of development practitioners,38 including those working specifically on organisational capacity development8.

  • Contributors All authors were involved in conceptualising this paper and in conducting analyses for it. LG, EB and UL were responsible for initiating the drafting and revisions of this paper. NN, SC, JG, SM and BT read and commented on successive paper drafts. All authors were also involved in the underlying data collection and analysis processes in the different learning sites. LG, SC and UL work together. JG and NN work together. EB, SM and BT work together. The work that provided the foundation for this paper is continuing; data already collected remain available to the researchers only.

  • Funding Funding for the work reported here was provided, in part, by Atlantic Philanthropies. In addition, this document is an output from a project funded by the UK Aid from the UK Department for International Development (DFID) for the benefit of developing countries.

  • Disclaimer The views expressed and information contained in the article are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.

  • Competing interests None declared.

  • Ethics approval London School of Hygiene and Tropical Medicine, University of Cape Town, University of the Witwatersrand, KEMRI, Kenya.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.