Reimagining health systems resilience

The concept of health systems resilience has predominantly been defined as a health system’s ability to rebound from shocks and sustain gains.2 Nevertheless, the multitude of terms and variations in its conceptualisation has introduced ambiguity, hindering its practical implementation and accurate assessment.3 The concept of resilience in literature is fluid and lacks a consistent definition, making one question its practical applicability.

The Philippines, as an island nation in Southeast Asia, faces significant vulnerability to the climate crisis and ranks among the world’s most at-risk countries.4 Situated within the Pacific Ring of Fire, a belt encompassing over 900 volcanoes and prone to earthquakes and volcanic eruptions, the country has experienced several catastrophic events throughout history. Additionally, its proximity to the Pacific Ocean exposes it to a high frequency of storms, with an average of 20 typhoons annually for decades. These storms have grown increasingly intense, leading to devastating consequences such as storm surges, landslides and floods, particularly in low-lying regions. The impact of super typhoon Haiyan in 2013 serves as a grim example, resulting in the loss of approximately 10 000 lives and leaving a path of destruction that took years to recover from.5

In this context, what does it mean to portray health system resilience? Is it limited to the repetitive reconstruction of health infrastructure following typhoon devastations? Does it solely involve the consistent mobilisation of resources and coordination of multisectoral responses to meet healthcare demands during major emergencies? Despite the resonance of this concept within international organisations, the truth remains that there is a lack of substantial evidence to effectively illustrate the impact of resilience-enhancing interventions on health system performance and outcomes in practical settings. Essentially, this concept may inadvertently promote the acceptance and perpetuation of the existing status quo, while disregarding alternative visions of fair and equitable health systems.6

It is imperative to challenge and reconceptualise the notion of resilience, as it often implies passivity—a state rather than an active process for improvement—thus lacking transformative action. Resilience warrants sustained intellectual engagement that aims to deconstruct and reconstruct a paradigm along several critical dimensions. First, we must embrace social and political factors that are often overlooked in the current concept.7 This entails recognising and addressing broader social determinants of health and power structures that significantly influence the functioning of health systems. Second, we should prioritise addressing equity concerns by ensuring equitable access to healthcare services and resources, especially for populations disproportionately affected by climate-related hazards. Lastly, we must adopt a long-term vision that goes beyond an excessive focus on response and recovery, aiming instead for sustainability and robustness.8 Therefore, resilience should be reimagined as a fundamental cornerstone and a driving force that instigates necessary transformations within health systems, rather than being perceived solely as an incidental and temporary coping mechanism when confronted with unpredictable threats.

Establishing redundant mechanisms for resilience

This leads us to the concept of redundancy, which involves the ability to carry out a task or function even if the primary unit encounters failure or setbacks.9 In disaster management, redundancy is frequently employed as a risk mitigation strategy to safeguard against system failures.10 While it is often emphasised in the literature on disaster preparedness and business continuity planning, the concept is seldom incorporated into current discussions on resilience. In the context of health systems resilience, incorporating redundancy would involve establishing backup systems, resources or capacities to ensure the uninterrupted delivery of essential functions and services in the face of disruptions. This underscores the importance of having duplicated or overlapping elements to mitigate single points of failure and therefore minimise vulnerabilities.

The existing body of literature provides numerous examples that demonstrate the potential advantages associated with integrating redundant mechanisms for resilience. First, redundancy ensures the continuous provision of essential health services during periods of disruption and crisis, guaranteeing their continuity even when specific infrastructures are inaccessible.11 Second, redundancy enables swift response and adaptation by providing additional resources and capacities, facilitating a more agile and effective response to promptly meet healthcare needs.12 Third, redundancy enhances the flexibility and adaptability of the health system by allowing for resource reallocation and the utilisation of alternative pathways and mechanisms as needed, enabling the system to effectively respond to unforeseen challenges and adjust operations accordingly.13 Finally, redundancy supports learning and improvement within health systems by capturing valuable data and insights on performance, identifying areas for enhancement and informing future actions.

As we reframe resilience, there exists a significant opportunity to delve deeply into the concept of redundancy as a pivotal element in fortifying health system resilience. By embracing redundancy, we offer a concrete application of how to enhance the ability of health systems to endure shocks and sustain essential services.

Shifting from resilient to robust health systems

When confronted with extreme climate events and similar vulnerabilities, it becomes essential to go beyond mere resilience and give precedence to the establishment of strong health systems as a prerequisite.8 This shift necessitates not only advancing the aspects of resilience discussed in earlier reflections but also swiftly integrating additional elements to ensure the long-term strength and effectiveness of health systems. Depending on the specific context and needs, this transition may involve strengthening human resources, infrastructure and technological capacities.14 Key steps include investing in workforce development, designing climate-resilient infrastructure and adopting technologies that enhance the efficiency of healthcare delivery.

At the core of this transition is the promotion of strong primary healthcare, which places significant emphasis on preventive measures and health promotion.15 It entails integrating primary care with public health initiatives, fostering collaboration among healthcare providers through effective referral systems and ensuring seamless care transitions. Additionally, a robust health information system is essential for facilitating informed decision-making, monitoring and evaluation.

Finally, community engagement plays a vital role in this process. Actively involving local health actors and communities in the design of a strong health system that aligns with their distinct needs and preferences is crucial.14 The involvement of local stakeholders brings valuable knowledge and perspectives to the table, aiding in the identification of vulnerabilities, formulation of effective solutions and fostering a sense of community ownership. By empowering these individuals and groups, the health system can effectively tackle the specific challenges and requirements of the community it serves.