Exploring Health Systems Resilience with Experts.

This podcast episode, hosted by Dr. Kim Ozano and co-hosted by Professor Sophie Witter, engages in an insightful discussion on health systems resilience, particularly in fragile settings affected by violence, conflict, pandemics, and other shocks. This conversation is part of a mini-series titled 'Stories of Resilience - Local Lives and Health Systems', powered by the ReBUILD for Resilience research consortium (see 'useful links' for links to the other episodes from this series).

The episode features insights from Dr. Sushil Baral of HERD International and Dr. Seye Abimbola from the University of Sydney, who share their experiences and reflections on building resilience in health systems. The discussion navigates the complexities of resilience as a concept, emphasising the importance of community engagement, co-creation, and adopting a learning approach to health systems strengthening. The panel explores the balance between self-reliance and demanding accountability from government systems, addressing the power dynamics and the necessity of a fair distribution of responsibilities across levels of governance.

In this episode:

Dr. Sophie Witter - Professor of International Health Financing and Health Systems, Institute of Global Health and Development, Queen Margaret University, Edinburgh

Sophie has worked in health and development for the past 35 years, starting with development roles at Save the Children and moving on to academia. Much of her work has focused on reducing financial barriers to accessing health care – how can people get the essential care they need without having to make terrible sacrifices? – but she has also worked on many other important health system topics, such as incentivising health care workers and health system strengthening more generally. All of her research is oriented towards implementation – how to make systems work better for people, especially those who are most disadvantaged.

Dr Sushil Baral - Managing Director, HERD International

Dr. Baral, hailing from a remote hill district in Nepal, brings over two decades of experience in health systems, public health policy, and implementation research, with a particular focus on South Asia. His contributions have significantly impacted national and global health systems, policies, and public health agendas. He emphasises evidence-based practices tailored to local contexts, reflecting a dedication to global health research excellence. Dr. Baral's academic journey highlights innovative problem-solving and substantial contributions to health systems, policies, and disaster response in fragile and shock-prone settings in LMICs.

Dr Seye Abimbola - Associate Professor of Health Systems, University of Sydney, Australia

Seye Abimbola is a health systems researcher from Nigeria, where he has worked at the National Primary Health Care Development Agency on initiatives to strengthen the Primary Health Care system across the country so that it can deliver integrated health services to communities. Seye has also been involved in research on how decentralisation affects health system performance and how community health committees influence and support health services in their own communities. Seye is currently based at the University of Sydney in Australia, where his teaching and research focus on knowledge practices in global health, health system governance, and the adoption and scale-up of health system innovations.

Useful links:

• The Health Workforce in Times of Crisis - Connecting Citizens to Science - This episode is part three of the six-part mini-series "Stories of Resilience: Local Lives and Health Systems," brought to you by ReBUILD for Resilience. In this episode, we discuss the challenges faced by the health workforce in fragile settings such as conflict zones and areas hit by political and economic crises. Our guests share their first-hand experiences and insights on how health systems and workers strive to provide care under extreme conditions.
• Gender, health systems resilience and equity - Connecting Citizens to Science - In the second episode of a six-part mini-series by ReBUILD for Resilience, we explore the intersection of gender and health systems in fragile settings. Hosted by Kim and co-hosted by Abriti Arjyal from HERD International, the episode features insights from Dr. Rouham Yamout from the American University of Beirut and Dr. Val Percival from the Norman Paterson School of International Affairs (NPSIA) at Carleton University. The discussion covers the impact of gender dynamics on health systems during crises like the COVID-19 pandemic and armed conflicts, emphasising community-led, participatory approaches to promote gender equality and resilience in health systems.
• ReBuild for Resilience - ReBUILD for Resilience examines health systems in fragile settings experiencing violence, conflict, pandemics and other shocks. Their aim is to produce high-quality, practical, multidisciplinary and scalable health systems research which can be used to build health systems resilience and improve the health and lives of many millions of people.

Want to hear more podcasts like this?

Follow Connecting Citizens to Science on your usual podcast platform or YouTube to hear more about the methods and approaches that researchers apply to connect with communities and co-produce solutions to global health challenges.

The podcast covers wide-ranging topics such as NTD’s, NCD’s, antenatal and postnatal care, mental wellbeing and climate change, all linked to community engagement and power dynamics.   

If you would like your own project or programme to feature in an episode, get in touch with producers of Connecting Citizens to Science, the SCL Agency.  

Kim Ozano: 00:00:04

Hello listeners.

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I'm Dr.

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Kim Ozano, and this is Connecting Citizens

to Science a podcast, where we talk about

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the ways that researchers connect with

communities to solve challenges together.

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I'm really excited to bring you

a brand new mini series called

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'Stories of Resilience - Local

Lives and Health Systems'.

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This mini series is brought to you

by ReBUILD for Resilience, which is

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a research consortium that examines

health systems resilience in fragile

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settings that experienced violence,

conflict, pandemics, and other shocks.

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Many people have joined the effort

to build resilience in healthcare

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systems, however it remains a concept

that is still quite contested and

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often difficult to comprehend.

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So, in this episode, we bring together

experts who work in the field of health

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systems resilience to talk about both

the concepts and the language that is

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used and how this invites participation

from communities and other stakeholders.

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We're also going to be discussing

how communities are central to

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health systems resilience and how

we can work with them in a way that

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suits them and to help us do that.

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We have a co-host with us today, Professor

Sophie Witter, who is a professor of

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International Health Financing and

Health Systems at the Institute for

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Global Health and Development Division at

Queen Margaret University in Edinburgh.

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She is also a member of the

Institute for Global Health and

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Development Research Centre.

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Our two guests today are Dr.

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Sushil Baral, who is the managing

director of HERD International, which is

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a research and development organisation

that is dedicated to addressing

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community needs and emerging health and

development issues in Nepal and globally.

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Our second guest is Dr.

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Seye Abimbola, who is an associate

professor at the university of

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Sydney and was the previous editor

in chief at the BMJ Global Health.

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Dr.

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Abimbola's teaching and research

has focused on knowledge practices

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and global health, health systems

governance, and the adoption and

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scale up of innovative health systems.

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So let's hear from our co-host

professor, Sophie Witter.

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Sophie, welcome to the podcast.

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And we're really looking forward to

this very important conversation.

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But before we begin, could you talk

us through some of the key concepts

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that we should be thinking about?

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And why it's important to

talk about health systems

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resilience now more than ever.

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Sophie Witter: Thanks for inviting

me onto this exciting discussion.

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I think the concept of resilience

in relation to health systems is

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something that has really grown

in the sort of public debate and

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academic discussion since the Ebola

crisis in West Africa in: 2014

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Then as we know, both regions and the

whole world have been hit by a series of

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shocks and pandemics, notably COVID, but

even now, there's really a sense that

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we're living in the era of poly crisis.

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So multiple different stressors and

shocks, which really create challenges

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for providing, um, essential and quality

healthcare for populations globally.

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So we were interested in resilience,

which is broadly understood as a capacity

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to maintain functions and health system

functions during shocks and crises.

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Um, and we try to look at some of

the learning from other areas of

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discipline, other, topics, other

literatures that look at kind of

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complex systems like health systems.

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Um, but we continue to debate the politics

of the term as well, like who is expected

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to be resilient and what does that mean?

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And who is bearing the brunt of, of sort

of managing these shocks and crises?

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So in ReBUILD, we're looking at research

on how to develop resilience capacities.

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We're focused on local health systems,

which are fragile and shock prone.

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So again today, I'm really interested

to talk about how we can do that.

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What's the action involved?

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Because I think a lot of the literature

has been around measurement and concepts,

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but less about how we engage to support

resilience, assuming it's a good thing.

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I'm going to start by just asking

Sushil and Seye about how they

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got involved in this topic.

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Um, and really what their experiences

were in terms of resilience in

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their local health systems and

what can we learn from that.

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So maybe over to you,

first of all, Sushil?

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Sushil Baral: Thank you, Sophie.

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I was born in village.

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I'm a village person, where I've seen

how the community engaged or disengaged

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when they were in need of health

care services in those communities.

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I come from a village where many

things were not put in place.

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The many basics were not put in

place, including the health system.

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My motivation working with the community

towards understanding the resilience

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and health system actually started

from those villages where I worked

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as a village health care provider,

walked hours and hours long to reach

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out to the community and provide

the basics when they were in need.

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So that is the main motivation

that engaged me in resilience.

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Sophie Witter: That's fascinating.

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And you've already gone

straight into this.

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One of the big topics in resilience is

around knowledge and how that is used

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and it's whose knowledge and how does

it feed back into building that system,

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which is exactly what you're describing.

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And you sort of witnessed

it from bottom to top there.

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So yeah, that's fantastic.

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Seye, how does that relate

to your, how you got involved

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in the resilience discussion?

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Seye Abimbola: I worked for about

three years at the National Primary

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Health Care Development Agency in

Nigeria, strengthening the primary

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healthcare system for services.

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And something that struck me as

remarkable was that at the community

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level in many instances, the community

health committees were responsible

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for picking up the failures of the

different levels of government that

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that were sort of in a sense above them.

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So in terms of helping to augment

the supply of services, helping to,

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facilitate the demand for services.

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And in some sense, that was where I

started to think about the idea of

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resilience, that what that level of

governance at the community level was

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doing is, in fact, ensuring that the

system was resilient to the failures

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of the government, the three layered

government that sat above them.

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Sophie Witter: I think that that

does lead really into this thinking

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about where does responsibility in a

system sit and where does power sit?

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Because they're often

divorced, aren't they?

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And maybe that's what we're getting

to here that often, you know, kind of

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power shifts upwards in a system, but

ultimately responsibility for keeping

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things going, especially when there's

a shock or crisis is often lower down.

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So perhaps resilience is a bit more about

connecting these levels effectively and

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making sure there's a fair distribution

of that power versus the responsibility,

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because one of the critiques, as you

know, and you've been part of that,

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that writing, Seye, is that, um, you

know, resilience puts the burden on

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local actors to cope and it says you're

doing well because you're coping.

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But actually, is that what we want when

we design a resilient system, just to put

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a lot of that responsibility and that

kind of managing shocks challenge at

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the bottom of the system for people who

often have the least power and resources.

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So any reflections on resilience?

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Is it a helpful term or are

we using it to put too much

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weight on those local actors?

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Seye Abimbola: I'm still not

convinced it's a helpful term.

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In health systems and global

health discourse, the question

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I kept asking myself is, how is

this different from strengthening?

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And when I was thinking about Nigeria,

as I described earlier, and I was

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saying to myself, well, um, a strong

health system is a robust health system.

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In other words, you want there to

be power and resources at different

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levels of governance and ability

to function and be connected.

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And to do that the system

needs to be robust in some way.

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In other words, it needs to have

not just what it needs to function

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today, but what it needs to function

in the instance of a shock or stress.

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And when we say system is resilient,

it often will seem to me that what

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we mean to say is that the system has

managed to cope in spite of the odds.

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Sophie Witter: There is quite a similar

debate about health system strengthening

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as well for similar reasons in as much

as the term came up a lot in relation

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to global health institutions initially.

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And so the question is, is

this an external agenda?

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Is this something that

actually resonates locally?

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So in a way, we can ask the same questions

about, I think, about health system

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strengthening as we can about resilience.

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Sushil Baral: The big question to me,

does the resilience mean same thing, a

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different thing for different people.

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I think it's, it's very hard to

come to a common consensus in any

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system including health systems.

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In any country, the health and

well being of the people is

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broadly guided by the politics.

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Politics, basically defines the policies

of system, uh, of the country and how

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that policies, uh, acted in reality,

uh, how those policies are well informed

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from the evidence, from the power, from

the community, from the context that we

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leave around is, is very, very important

to me, uh, when we talk about resilience.

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I think it requires to be a more,

more holistic concept, bringing the

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whole of the society, whole of the

government, whole of the actors together.

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But it's true that we have seen our

actors are guided by their own preferences

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where the politics come into play.

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Institutional preferences, all the

development partners, they have

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their own way of defining resilience

in their own work plan and agenda.

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Kim Ozano: When we talk about

communities and we use language like

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resilience or strengthening health

systems, this is the type of language

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as academics we use in our daily lives.

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But Sushil, you know, you were a village

health care provider and Seye, you talked

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about your connection with communities.

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And we know that language can often

create distrust within health systems,

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or language can facilitate spaces where

communities feel confident to participate.

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Is there something around

understanding how to communicate

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key concepts and using language that

is more inclusive for communities?

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Sushil Baral: It's very important.

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So to me, to answer your question,

engaging community by knowing the

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community better, because these

communities are different in different

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places, you cannot really take a blanket

approach of community engagement and

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communicating our language to them.

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Rather, I prefer listening their

language and building on that.

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Sophie Witter: Yeah, I'm just going

to jump in there as well with the

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reflection because I've one of

the things I've thought about is

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the extent to which resilience and

fragility kind of mirror each other.

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We were doing some work with

colleagues on fragility.

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Ultimately, I think we sort of came

down to the view that fragility

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rests in a kind of disconnect between

the system and the communities.

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That's where a lot of the kind of

fragility features come in, which

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exactly links, I think, to your

point, Sushil, about how well we're

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communicating in a very two way sense.

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Seye Abimbola: I think that resilience

is the term we use, is how we frame

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things, is how we try and interpret

what we see when we look at systems

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and how people act within those

systems and how they are designed.

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And it's not how people in the

system would necessarily describe

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or define what it is they're

experiencing or going through.

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And one of the things I care about very

deeply is the interpretive lenses we

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place on systems can in fact marginalise

people who function within the systems and

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how they interpret their own realities.

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And I'll give an example if you go

to many community health committees

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in Nigeria and sort of ask them what,

what is their role and responsibility,

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one of the things they will tell

you is that our role is to fill

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the gaps left by government action.

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In fact the paper that I wrote about,

committee of committees was titled 'The

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Government Cannot do it All Alone'.

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In other words, a lot of their own

reflection about their role speaks to how

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their role has been framed repeatedly.

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It is about quote unquote self

reliance, rather than accountability.

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They don't necessarily think of their

role in terms of making demands,

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putting pressure, um, and, and

functioning in that capacity, but

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rather what can we do for ourselves?

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Now that's important.

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What can we do for ourselves is

absolutely important, but so is what

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should the government be doing that

the government isn't doing, right?

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And I find that one of the things, one of

the harms, in my view that the language

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of resilience can do is to, in fact,

further, um, emphasise, um, that self

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reliance role at the expense, in many

cases, I suspect, of that accountability

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function that the community may, may play.

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Sophie Witter: So, okay, I think

that's a good point to move on to,

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in a sense, where do we go from here?

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Because what we've shown is

that it's very contested and

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it's debatable how useful it is.

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At the same time, it is being used because

I think it has some intuitive sense that

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clearly links to challenges that are

going on at the moment in the world.

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But if we think about how do we, build

the capacity of communities to both be

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self protective in some senses, if we use

that word rather than self reliance, but

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also demand accountability, because I'm

absolutely on board with you that that's

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something that in many settings is, is

really lacking and it's very problematic.

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Seye Abimbola: The way that I'm

coming to think about and talk

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about resilience is, is almost to

replace the word with learning.

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And I find, frankly, that in almost

every instance, learning does the

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job as well, if not better, in fact.

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And what learning does essentially to

put that active agency into resilience.

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A system that is resilient is one

that learns, that can learn from its

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past and present from its neighbours.

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And when I think about learning in that

way, I'm thinking to myself, how do

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we then build capacities for learning?

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And you mentioned connection earlier,

but also the ability to say, where

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are the platforms in each system that

allow for that connection to happen and

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could be in a, in a small community,

the marketplace could be the platform.

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It could be, it could be a village

square, so it could be a place where

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people discuss what the experiences

are and able to share ideas and

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learn and function differently.

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In other settings, it could be the media,

It could be academics like us who actually

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do move knowledge around as it were.

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when I think about resilience,

I'm thinking learning

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Sophie Witter: Yeah.

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Thank you.

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Um, I think that's an excellent point

and definitely the learning health

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system is again, a topic that's risen

up the agenda recently and I think

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rightly so, because it does validate

people understanding their own context

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better than others who are more removed.

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Um, Sushil, what should we be

doing in terms of our engagement?

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So we're building connectors, is the point

that Seye was making, which I think really

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builds on a lot of the literature around

resilience, which is about who has the

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connections, how do groups work together.

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Certainly we've seen that a lot in

our ReBUILD research, haven't we?

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What other areas should we be contributing

to, to pushing in terms of the agenda?

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Sushil Baral: You can describe the

resilience capacity in a number

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of, um, points and then really

understanding where the gaps are.

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And then working together, with

the co-creation component, with the

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stakeholders, including the community.

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I bring here the word co-creation

in a very meaningful way.

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You know, abiding the principles of

community engagement with the meaningful

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co-creation with them, having a joint

assessment, having a joint planning,

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and defining this coordination and

collaboration structure, uh, put in place,

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which continuously assist and acted upon

linking with the policy and the practices.

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It is not just a tokenism.

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It harmonises the power imbalances

when the co-creation is acted in local

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reality considering the local context.

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So the important point I bring here

is the properly defined and agreed

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coordination and collaboration

structure put in place, which often,

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you know, continuously works in terms

of enhancing the resilience capacity.

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Kim Ozano: Thanks very much Sophie

for guiding the conversation.

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I've really enjoyed learning.

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And I really liked the idea of

replacing language like resilience

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with learning health systems, it's

straightforward and language that is

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more accessible to all involved in

building health systems resilience.

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And once again, the value of co-creation

has come out really strongly.

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So for the final question, I would

like to ask all three of you, what

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is the one piece of advice that you

would give to people that are working

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in different contexts, trying to

strengthen or learn from health systems?

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Sophie Witter: It's the million

dollar question, isn't it?

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But I think to me and listening

to the conversation really,

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what's coming out is that the,

the key elements are connections,

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kind of knowledge and resources.

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And so I think our effort for all

of us should be, and this goes from

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kind of global level down to local,

should be on getting these three

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elements available at the local

community and health system levels.

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Because very often systems are set to

kind of move these three elements upwards.

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Whereas what we've been saying, I think a

lot of the conversation is that we need to

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be empowering local actors, and especially

those groups that are most marginalised.

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But I do also think we need to look at

the fair distribution of responsibilities

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across the system, because I also

recognise that some issues need

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national and international action.

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They can't all be resolved at the

local level, and we don't want to put

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all the responsibility there, so it's

about that balance has to be right.

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Seye Abimbola: One of the dangers

of playing the devil's advocate

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is that sometimes, sometimes

you become the devil yourself.

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And in this regard, I often

push back when people say

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fragmentation is such a bad thing.

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It's a term used pejoratively

and for me, a centralised unified

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system, is a system that is not

particularly resilient to shocks.

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Um, and so I'm always looking for where

the lines of decentralisation are and how

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to make sure that we don't remove them

simply because we want things to be simple

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and streamlined and straightforward.

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Sometimes those are valuable.

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Um, often we do that at the risk of a

potential future shock or stress really

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breaking, breaking apart the system.

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So one key advice is to not be too quick

to remove fragmentation, quote, unquote.

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And second is to be alive to the

possibility of facilitating learning

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connections anywhere in the system..

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Sophie Witter: Amen.

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Sushil.

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Sushil Baral: I would say we should

prioritise the learning aspects of the

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health system, feature that in policy,

and more strongly listen to the community.

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The system has to create space, ample

space and opportunities to bring the

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community into the mainstream and,

and hearing them is very, very vital

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towards the local system resiliency.

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There's a message to global health

actors, uh, in order to really have

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a coordination mechanism, better

coordination mechanism at the global

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level to this identified priorities and

collective mechanism to pull the resources

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towards the resilient healthcare system,

uh, with the evidence informed policy.

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Kim Ozano: Some excellent pieces of

advice there and lots to think about.

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So thank you for our guests, for joining

us and taking part in this conversation,

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we've really appreciated your being part

of Connecting Citizens to Science and

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thank you to our listeners as always for

joining us and listening to this episode.

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: 00:19:17

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: 00:19:21

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: 00:19:25

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: 00:19:30

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: 00:19:32

For now enjoy the rest of

your day until next time.

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: 00:19:35

Bye from Connecting Citizens to Science.