Power and politics: the case for linking resilience to health system governance

Correspondence to Dr Stephanie M Topp; globalstopp@gmail.com Since the watershed moment of the 2014 Ebola epidemic in West Africa and again in the midst of the current COVID-19 crisis, the concept of health system resilience has been a recurring theme in global health discussions.1 2 Although most frequently used in the context of epidemic response, resilience has also been framed as a ‘key pillar’ of health,3 and invoked in high-level calls for countries to ‘lead the work on building health system resilience’.4 Yet, as the authors of one of several recent reviews observed, the concept of health systems resilience remains ‘highly confusing’ and ‘still polysemic’.5 What it means ‘depends on one’s perception, one’s discipline, one’s function and what one wants to achieve’.5 In this editorial, I will, from the perspective of a health policy and systems researcher, draw out and reflect on some of these tensions, and make some suggestions about how we might achieve greater clarity. With some few exceptions, the focus has tended to be on the ability of health systems to recover from shocks, with far less attention paid to the choices exercised by individuals or groups within the system, and the ways in which they do, or do not, exert control over processes by which that system-level resilience is shaped.16 In part, this is the natural consequence of transposing a concept originally developed with reference to ecosystems, onto social systems. If global health researchers and practitioners are to continue to characterise health systems as social systems, then examination of their resilience (defined as an ability rather than an outcome) makes most sense when anchored to an exploration of the modes and dynamics of health system governance, at whichever level appropriate. [...]an approach does not preclude, but rather enables exploration of the characteristics of resilient health systems, with cross-disciplinary learning suggesting these characteristics are in any case actor-dependent, including for example: (1) diversity; (2) flexibility; (3) inclusion and participation; (4) recognition of social values; (4) acceptance of uncertainty and change at different levels and (5) and the ability to foster learning.17 Two examples of analyses using different methods to examine such issues have been recently published in BMJ Global Health.