Critiquing the Concept of Resilience in Health Systems
By Stephanie M. Topp, Walter Flores, Veena Sriram and Kerry Scott – Power in Health Systems (SHaPeS TWG) Thematic Leads
Hegemonic power
In social theory, the dominant state is known as the hegemon. In the 19th century, hegemony came to denote the “Social or cultural predominance or ascendancy; predominance by one group within a society or milieu”. However, commentators on power have also used the term to describe the power discourse – particularly in the field of governance. In this concept note we wish to draw attention to, and challenge, what we fear is an emerging ‘hegemonic’ discourse in the field of health policy and systems work – the discourse of resilience.
How is the term ‘resilience’ being used?
In the past five years ‘resilience’ has been increasingly applied in health policy and systems research (HPSR) to refer to the need for distressed health systems (micro or macro) to “bounce back” from shocks. Often implicit in this discourse, is the assumption that such systems were ‘there’ in the first place, or at the very least, that with a concerted effort they can get there. What a resilient health system means in this context is not clear – but we contend that, in a form of technocratic reductionism, resilience strategies and solutions are often divorced from meaningful assessment of the political economy and power dynamics that produced the health system crises in the first place.
What is lost?
Health systems in crises suffer from chronic deficiencies in many things – material and human resources central-level planning and coordination capacity and domestic financing to name but a few. The populations and communities seeking services from these deficient systems are more likely to have low levels of education, weak citizen engagement and to experience deep class inequity. Much of the technocratic discussion around ‘building resilience’ appears to bypass these issues, however, often focusing on tweaking inputs or health system components, and frequently emphasising self-reliance and behaviour change. This technocratic and formulaic approach to building resilience is at odds with the complex reality of health systems in each country.
‘Building resilience’ rarely seems to involve a direct examination of, or challenge to, the structural conditions that contribute to overarching health system dysfunction, including historical colonial legacies, current trade and aid structures, tax and health insurance structures. We are concerned that the discourse of resilience will follow the trend of global health policy reforms being fueled by the perceived immediacy of a problem instead of careful analysis of root causes and strategies likely to prevent recurrence in the long-term. Recent examples include the Ebola epidemic and now Zika, in which resilience discourse is getting close to that of global health security agenda in which the main concern is transnational epidemics from the south to the north. The rise of hegemonic resilience discourse has effectively enabled global health stakeholders to replace the conversation about systemic failures at multiple levels that supports a far more long term vision with an action-oriented discourse that implies much shorter time-frames.
What is needed?
Others, particularly from political science, have critiqued the use of the term in their writing (see: Evans and Reid, Remco van de Pas, Marc Neocleous). We welcome such debate in the HPSR community and suggest more such dialogue is necessary in the lead up to, during and after the Vancouver symposium.
A conscious discussion is needed to reframe what health system community means when we use the term ‘resilience’. Resilience (and the linked concept of sustainability of health programming) have value, as long as they are not divorced from the material changes that need to occur to support them and the requirement for a more balanced relation among national states (trade, flow of resources, and others). Use of these terms should build on previous work and consensus around social determinants of health, right to health and people-centered health systems. This means resilience should be situated on a continuum rather than replacing important advances around health systems and its relation with equity, fairness and human rights.
Ultimately, we contend that a more ambitious and nuanced application of the term ‘resilience’ is required if the term is to contribute to improving LMIC health systems’ capacity to withstand political, financial, epidemiological and environmental shocks. We must also do everything possible to prevent such shocks in the first place. But the very least, we in the health policy and systems community need to start acknowledging the dangers of using ‘resilience’ as part of a de-politicised and technocratic discourse.