Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

Concept analysis of health system resilience

BACKGROUND

There are several definitions of resilience in health systems, many of which share some characteristics, but no agreed-upon framework is universally accepted. Here, we review the concept of resilience, identifying its definitions, attributes, antecedents and consequences, and present the findings of a concept analysis of health system resilience.

METHODS

We follow Schwarz-Barcott and Kim's hybrid model, which consists of three phases: theoretical, fieldwork and final analysis. We identified the concept definitions, attributes, antecedents and consequences of health system resilience and constructed an evidence-informed framework on the basis of the findings of this review. We searched PubMed, PsycINFO, CINAHL Complete, EBSCOhost-Academic Search and Premier databases and downloaded identified titles and abstracts on Covidence. We screened 3357 titles and removed duplicate and ineligible records; two reviewers then screened each title, and disagreements were resolved by discussion with the third reviewer. From the 130 eligible manuscripts, we identified the definitions, attributes, antecedents and consequences using a pre-defined data extraction form.

RESULTS

Resilience antecedents are decentralization, available funds, investments and resources, staff environment and motivation, integration and networking and finally, diversification of staff. The attributes are the availability of resources and funds, adaptive capacity, transformative capacity, learning and advocacy and progressive leadership. The consequences of health system resilience are improved health system performance, a balanced governance structure, improved expenditure and financial management of health and maintenance of health services that support universal health coverage (UHC) throughout crises.

CONCLUSION

A resilient health system maintains quality healthcare through times of crisis. During the coronavirus disease 2019 (COVID-19) epidemic, several seemingly robust health systems were strained under the increased demand, and services were disrupted. As such, elements of resilience should be integrated into the functions of a health system to ensure standardized and consistent service quality and delivery. We offer a systematic, evidence-informed method for identifying the attributes of health system resilience, intending to eventually be used to develop a measuring tool to evaluate a country's health system resilience performance.

How Hospitals Overcame Disruptions in the Early Stages of the COVID-19 Pandemic: A Case Study from Tokyo, Japan

The COVID-19 pandemic has caused serious disruptions to health systems across the world. While the pandemic has not ended, it is important to better understand the resilience of health systems by looking at the response to COVID-19 by hospitals and hospital staff. Part of a multi-country study, this study looks at the first and second waves of the pandemic in Japan and examines disruptions experienced by hospitals because of COVID-19 and the processes through which they overcame those disruptions. A holistic multiple case study design was employed, and two public hospitals were selected for the study. A total of 57 interviews were undertaken with purposively selected participants. A thematic approach was used in the analysis. The study found that in the early stages of the pandemic, faced with a previously unknown infectious disease, to facilitate the delivery of care to COVID-19 patients while also providing limited non-COVID-19 health care services, the case study hospitals undertook absorptive, adaptive, and transformative actions in the areas of hospital governance, human resources, nosocomial infection control, space and infrastructure management, and management of supplies. The process of overcoming the disruptions caused by the pandemic was complex, and the solution to one issue often caused other problems. To inform preparations for future health shocks and promote resilience, it is imperative to further investigate both organizational and broader health system factors that build absorptive, adaptive, and transformative capacity in hospitals.

From Threatening Chaos to Temporary Order through a Complex Process of Adaptation: A Grounded Theory Study of the Escalation of Intensive Care during the COVID-19 Pandemic

To ensure high-quality care, operationalize resilience and fill the knowledge gap regarding how to improve the prerequisites for resilient performance, it is necessary to understand how adaptive capacity unfolds in practice. The main aim of this research was to explain the escalation process of intensive care during the first wave of the pandemic from a microlevel perspective, including expressions of resilient performance, intervening conditions at the micro-meso-macrolevels and short- and long-term consequences. A secondary aim was to provide recommendations regarding how to optimize the prerequisites for resilient performance in intensive care. A grounded theory methodology was used. First-person stories from different healthcare professionals (n70) in two Swedish regions were analyzed using the constant comparative method. This resulted in a novel conceptual model (including 6 main categories and 24 subcategories), and 41 recommendations. The conclusion of these findings is that the escalation of intensive care can be conceptualized as a transition from threatening chaos to temporary order through a complex process of adaptation. To prepare for the future, the components of space, stuff, staff, system and science, with associated continuity plans, must be implemented, anchored and communicated to actors at all levels of the system.

Responsive and resilient healthcare? 'Moments of Resilience' in post-hospitalisation services for COVID-19

BACKGROUND

COVID-19 caused disruption to healthcare services globally, resulting in high numbers of hospital admissions and with those discharged often requiring ongoing support. Within the UK, post-discharge services typically developed organically and were shaped over time by local need, funding, and government guidance. Drawing on the Moments of Resilience framework, we explore the development of follow-up services for hospitalised patients by considering the links between resilience at different system levels over time. This study contributes to the resilient healthcare literature by providing empirical evidence of how diverse stakeholders developed and adapted services for patients following hospitalisation with COVID-19 and how action taken at one system level influenced another.

METHODS

Qualitative research comprising comparative case studies based on interviews. Across three purposively selected case studies (two in England, one in Wales) a total of 33 semi-structured interviews were conducted with clinical staff, managers and commissioners who had been involved in developing and/or implementing post-hospitalisation follow-up services. The interviews were audio-recorded and professionally transcribed. Analysis was conducted with the aid of NVivo 12.

RESULTS

Case studies demonstrated three distinct examples of how healthcare organisations developed and adapted their post-discharge care provision for patients, post-hospitalisation with COVID-19. Initially, the moral distress of witnessing the impact of COVID-19 on patients who were being discharged coupled with local demand gave clinical staff the impetus to take action. Clinical staff and managers worked closely to plan and deliver organisations' responses. Funding availability and other contextual factors influenced situated and immediate responses and structural adaptations to the post-hospitalisation services. As the pandemic evolved, NHS England and the Welsh government provided funding and guidance for systemic adaptations to post-COVID assessment clinics. Over time, adaptations made at the situated, structural, and systemic levels influenced the resilience and sustainability of services.

CONCLUSIONS

This paper addresses understudied, yet inherently important, aspects of resilience in healthcare by exploring when and where resilience occurs across the healthcare system and how action taken at one system level influenced another. Comparison across the case studies showed that organisations responded in similar and different ways and on varying timescales to a disruption and national level strategies.

Attributes and Organizational Factors that Enabled Innovation in Health Care Service Delivery during the COVID-19 Pandemic - Case Studies from Brazil, Canada and Japan

Innovation by health service organizations can enable adaptation to and transformation of challenges caused by health shocks. Drawing on results from case studies in Brazil, Canada, and Japan, this study looked at innovations the study hospitals introduced in response to challenges caused by COVID-19 to identify: 1) attributes of the innovations that make them conducive to adoption; and 2) organizational factors that facilitate the creation and implementation of innovative health care approaches during health system shocks. Qualitative information was gathered using key informant interviews, participatory observations at the study hospitals and a review of relevant documentation. A thematic approach was used for analysis, and a cross-country comparison framework was prepared to synthesize findings from the case studies in the three countries. In response to the disruptions caused by COVID-19, the study hospitals undertook innovative changes in services, processes, organizational structures, and operational policy. The driving force behind the innovations was the need and urgency generated by the unprecedented nature of the pandemic. With COVID-19, if an innovation met the perceived needs of hospitals and provided an operational advantage, some level of complexity in the implementation appeared to be acceptable. The study findings suggest that for hospitals to create and implement innovations in response to health shocks, they need to: have adaptive and flexible organizational structures; build and maintain functioning communication systems; have committed leadership; ensure all staff share an understanding of hospital organizational and professional missions; and establish social networks that facilitate the creation and implementation of new ideas.

Realising radical potential: building community power in primary health care through Participatory Action Research

BACKGROUND

While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

METHODS

Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

RESULTS

Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

CONCLUSIONS

Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

Organizational resilience in healthcare: a review and descriptive narrative synthesis of approaches to resilience measurement and assessment in empirical studies

BACKGROUND

The coronavirus pandemic has had a profound impact on organization and delivery of care. The challenges faced by healthcare organizations in dealing with the pandemic have intensified interest in the concept of resilience. While effort has gone into conceptualising resilience, there has been relatively little work on how to evaluate organizational resilience. This paper reports on an extensive review of approaches to resilience measurement and assessment in empirical healthcare studies, and examines their usefulness for researchers, policymakers and healthcare managers.

METHODS

Various databases (MEDLINE, EMBASE, PsycINFO, CINAHL (EBSCO host), Cochrane CENTRAL (Wiley), CDSR, Science Citation Index, and Social Science Citation Index) were searched from January 2000 to September 2021. We included quantitative, qualitative and modelling studies that focused on measuring or qualitatively assessing organizational resilience in a healthcare context. All studies were screened based on titles, abstracts and full text. For each approach, information on the format of measurement or assessment, method of data collection and analysis, and other relevant information were extracted. We classified the approaches to organizational resilience into five thematic areas of contrast: (1) type of shock; (2) stage of resilience; (3) included characteristics or indicators; (4) nature of output; and (5) purpose. The approaches were summarised narratively within these thematic areas.

RESULTS

Thirty-five studies met the inclusion criteria. We identified a lack of consensus on how to evaluate organizational resilience in healthcare, what should be measured or assessed and when, and using what resilience characteristic and indicators. The measurement and assessment approaches varied in scope, format, content and purpose. Approaches varied in terms of whether they were prospective (resilience pre-shock) or retrospective (during or post-shock), and the extent to which they addressed a pre-defined and shock-specific set of characteristics and indicators.

CONCLUSION

A range of approaches with differing characteristics and indicators has been developed to evaluate organizational resilience in healthcare, and may be of value to researchers, policymakers and healthcare managers. The choice of an approach to use in practice should be determined by the type of shock, the purpose of the evaluation, the intended use of results, and the availability of data and resources.

Health systems resilience: is it time to revisit resilience after COVID-19?

The concept of health system resilience has been challenged by the COVID-19 pandemic. Even well-established health systems, considered resilient, collapsed during the pandemic. To revisit the concept of resilience two years and a half after the initial impact of COVID-19, we conducted a qualitative study with 26 international experts in health systems to explore their views on concepts, stages, analytical frameworks, and implementation from a comparative perspective of high- and low-and-middle-income countries (HICs and LMICs). The interview guide was informed by a comprehensive literature review, and all interviewees had practice and academic expertise in some of the largest health systems in the world. Results show that the pandemic did modify experts' views on various aspects of health system resilience, which we summarize and propose as refinements to the current understanding of health systems resilience.

Metrics and indicators used to assess health system resilience in response to shocks to health systems in high income countries-A systematic review

Health system resilience has never been more important than with the COVID-19 pandemic. There is need to identify feasible measures of resilience, potential strategies to build resilience and weaknesses of health systems experiencing shocks. The purpose of this systematic review is to examine how the resilience of health systems has been measured across various health system shocks. Following PRISMA guidelines, with double screening at each stage, the review identified 3175 studies of which 68 studies were finally included for analysis. Almost half (46%) were focused on COVID-19, followed by the economic crises, disasters and previous pandemics. Over 80% of studies included quantitative metrics. The most common WHO health system functions studied were resources and service delivery. In relation to the shock cycle, most studies reported metrics related to the management stage (79%) with the fewest addressing recovery and learning (22%). Common metrics related to staff headcount, staff wellbeing, bed number and type, impact on utilisation and quality, public and private health spending, access and coverage, and information systems. Limited progress has been made with developing standardised qualitative metrics particularly around governance. Quantitative metrics need to be analysed in relation to change and the impact of the shock. The review notes problems with measuring preparedness and the fact that few studies have really assessed the legacy or enduring impact of shocks.

Health systems resilience in practice: a scoping review to identify strategies for building resilience

Background

Research on health systems resilience has focused primarily on the theoretical development of the concept and its dimensions. There is an identified knowledge gap in the research on how to build resilience in health systems in practice and ‘what works’ in different contexts. The aim of this study is to identify practical strategies for building resilient health systems from the empirical research on health systems resilience.

Methods

A scoping review included empirical research on health systems resilience from peer-reviewed literature. The search in the electronic databases PubMed, Web of Science, Global Health was conducted during January to March 2021 for articles published in English between 2013 to February 2021. A total of 1771 articles were screened, and data was extracted from 22 articles. The articles included empirical, applied research on strategies for resilience, that observed or measured resilience during shocks or chronic stress through collection of primary data or analysis of secondary data, or if they were a review study of empirical research. A narrative summary was done by identifying action-oriented strategies, comparing them, and presenting them by main thematic areas.

Results

The results demonstrate examples of strategies used or recommended within nine identified thematic areas; use of community resources, governance and financing, leadership, surveillance, human resources, communication and collaboration, preparedness, organizational capacity and learning and finally health system strengthening.

Conclusions

The findings emphasize the importance of improved governance and financing, empowered middle-level leadership, improved surveillance systems and strengthened human resources. A re-emphasized focus on health systems strengthening with better mainstreaming of health security and international health regulations are demonstrated in the results as a crucial strategy for building resilience. A lack of strategies for recovery and lessons learnt from crises are identified as gaps for resilience in future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08544-8.

Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study

Background

Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. Team leaders are seen as central in coordinating clinical care, but research detailing their contributions in supporting adaptive capacity has been limited. This study aims to explore and describe how leaders enable adaptive capacity in hospital teams.

Methods

This article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation and interviews with leaders, followed by a qualitative content analysis.

Results

Leaders contribute in several ways to enhance their teams’ adaptive capacity. This study identified four key enablers; (1) building sufficient competence in the teams; (2) balancing workload, risk, and staff needs; (3) relational leadership; and (4) emphasising situational understanding and awareness through timely and relevant information.

Conclusion

Team leaders are key actors in everyday healthcare systems and facilitate organisational resilience by supporting adaptive capacity in hospital teams. We have developed a new framework of key leadership enablers that need to be integrated into leadership activities and approaches along with a strong relational and contextual understanding.

What makes health systems resilient? A qualitative analysis of the perspectives of Swiss NGOs

Background

Resilience has become relevant than ever before with the advent of increasing and intensifying shocks on the health system and its amplified effects due to globalization. Using the example of non-state actors based in Switzerland, the aim of this study is to explore how and to what extent NGOs with an interest in global health have dealt with unexpected shocks on the health systems of their partner countries and to reflect on the practical implications of resilience for the multiple actors involved. Consequently, this paper analyses the key attributes of resilience that targeted investments may influence, and the different roles key stakeholders may assume to build resilience.

Methods

This is a descriptive and exploratory qualitative study analysing the perspectives on health system resilience of Swiss-based NGOs through 20 in-depth interviews. Analysis proceeded using a data-driven thematic analysis closely following the framework method. An analytical framework was developed and applied systematically resulting in a complete framework matrix. The results are categorised into the expected role of the governments, the role of the NGOs, and practical future steps for building health system resilience.

Results

The following four key ‘foundations of resilience’ were found to be dominant for unleashing greater resilience attributes regardless of the nature of shocks: ‘realigned relationships,’ ‘foresight,’ ‘motivation,’ and ‘emergency preparedness.’ The attribute to ‘integrate’ was shown to be one of the most crucial characteristics of resilience expected of the national governments from the NGOs, which points to the heightened role of governance. Meanwhile, as a key stakeholder group that is becoming inevitably more powerful in international development cooperation and global health governance, non-state actors namely the NGOs saw themselves in a unique position to facilitate knowledge exchange and to support long-term adaptations of innovative solutions that are increasing in demand. The strongest determinant of resilience in the health system was the degree of investments made for building long-term infrastructures and human resource development which are well-functioning prior to any potential crisis.

Conclusions

Health system resilience is a collective endeavour and a result of many stakeholders’ consistent and targeted investments. These investments open up new opportunities to seek innovative solutions and to keep diverse actors in global health accountable. The experiences and perspectives of Swiss NGOs in this article highlight the vital role NGOs may play in building resilient health systems in their partner countries. Specifically, strong governance, a bi-directional knowledge exchange, and the focus on leveraging science for impact can draw greater potential of resilience in the health systems. Governments and the NGOs have unique points of contribution in this journey towards resilience and bear the responsibility to support governments to prioritise investing in the key ‘foundations of resilience’ in order to activate greater attributes of resilience. Resilience building will not only prepare countries for future shocks but bridge the disparate health and development agenda in order to better address the nexus between humanitarian aid and development cooperation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00848-y.

Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view

Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives - all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.

How to work with intangible software in public health systems: some experiences from India

This commentary focuses on "intangible software", defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this commentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evaluated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in conjunction with structural improvements. Also, such interventions require long-term investments. Based on our experiences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared.

The COVID-19 pandemic and disruptions in a district quality improvement initiative: Experiences from the CLEVER Maternity Care programme

BACKGROUND

 Many health systems were poorly prepared for the coronavirus disease 2019 (COVID-19) pandemic and found it difficult to protect maternity and reproductive health services. The aim of the study was to explore the influence of the COVID-19 pandemic on the ability of maternity healthcare providers to maintain the positive practices introduced by the CLEVER Maternity Care programme and to elicit information on their support needs.

METHODS

 This multimethod study was conducted in midwife-led obstetric units (MOUs) and district hospitals in Tshwane District, South Africa and included a survey questionnaire and qualitative reports and reflections by the CLEVER implementation team. Two five-point Likert-scale items were supplemented by open-ended questions to provide suggestions on improving health systems and supporting healthcare workers.

RESULTS

 Most of the 114 respondents were advanced midwives or registered nurses (86%). Participants from MOUs rated the maintenance of quality care practices significantly higher than those from district hospitals (p = 0.0130). There was a significant difference in perceptions of support from the district management between designations (p = 0.0037), with managers having the most positive perception compared with advanced midwives (p = 0.0018) and registered nurses (p = 0.0115). The interpretation framework had three main themes: working environment and health-system readiness; quality of patient care and service provision; and healthcare workers' response to the pandemic. Health-facility readiness is described as proactive, reactive or lagging.

CONCLUSION

 Lessons learned from this pandemic should be used to build responsive health systems that will enable primary healthcare workers to maintain quality patient care, services and communication.

Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries

BACKGROUND

The health workforce is a key component of any health system and the present crisis offers a unique opportunity to better understand its specific contribution to health system resilience. The literature acknowledges the importance of the health workforce, but there is little systematic knowledge about how the health workforce matters across different countries.

AIMS

We aim to analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January-May/June 2020), and to assess how health systems prerequisites influence these capacities.

MATERIALS AND METHODS

We selected countries according to different types of health systems and pandemic burdens. The analysis is based on short, descriptive country case studies, using written secondary and primary sources and expert information.

RESULTS AND DISCUSSION

Our analysis shows that in our countries, the health workforce drew on a wide range of capacities during the first wave of the pandemic. However, health systems prerequisites seemed to have little influence on the health workforce's specific combinations of capacities.

CONCLUSION

This calls for a reconceptualisation of the institutional perquisites of health system resilience to fully grasp the health workforce contribution. Here, strengthening governance emerges as key to effective health system responses to the COVID-19 crisis, as it integrates health professions as frontline workers and collective actors.

Toward a theory-led meta-framework for implementing health system resilience analysis studies: a systematic review and critical interpretive synthesis

Introduction

The variety of frameworks and models to describe resilience in the health system has led researchers and policymakers to confusion and the inability to its operationalization. Therefore, the purpose of this study was to create a meta-framework using the Critical Interpretive Synthesis method.

Method

For this purpose, studies that provide theories, models, or frameworks for organizational or health system resilience in humanitarian or organizational crises were systematically reviewed. The search strategy was conducted in PubMed, Web of Science, Embase, and Scopus databases. MMAT quality appraisal tool was applied. Data were analysed using MAXQDA 10 and the Meta-ethnography method.

Results

After screening based on eligibility criteria, 43 studies were reviewed. Data analysis led to the identification of five main themes which constitute different framework dimensions. Health system resilience phases, attributes, tools, and strategies besides health system building blocks and goals are various dimensions that provide a systematic framework for health system resilience analysis.

Discussion

This study provides a systemic, comprehensive framework for health system resilience analysis. This meta-framework makes it possible to detect the completeness of resilience phases. It examines the system’s resilience by its achievements in intermediate objectives (resilience system attributes) and health system goals. Finally, it provides policy solutions to achieve health system resilience using tools in the form of absorptive, adaptive, and transformative strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12496-3.

An innovative leadership development initiative to support building everyday resilience in health systems

Effective management and leadership are essential for everyday health system resilience, but actors charged with these roles are often underprepared and undersupported to perform them. Particular challenges have been observed in interpersonal and relational aspects of health managers’ work, including communication skills, emotional competence and supportive oversight. Within the Resilient and Responsive Health Systems (RESYST) consortium in Kenya, we worked with two county health and hospital management teams to adapt a package of leadership development interventions aimed at building these skills. This article provides insights into: (1) the content and co-development of a participatory intervention combining two core elements: a complex health system taught course, and an adapted communications and emotional competence process training; and (2) the findings from a formative evaluation of this intervention which included observations of the training, individual interviews with participating managers and discussions in regular meetings with managers. Following the training, managers reported greater recognition of the importance of health system software (values, belief systems and relationships), and improved self-awareness and team communication. Managers appeared to build valued skills in active listening, giving constructive feedback, ‘stepping back’ from automatic reactions to challenging emotional situations and taking responsibility to communicate with emotional competence. The training also created spaces for managers to share experiences, reflect upon and nurture social competences. We draw on our findings and the literature to propose a theory of change regarding the potential of our leadership development intervention to nurture everyday health system resilience through strengthening cognitive, behavioural and contextual capacities. We recommend further development and evaluation of novel approaches such as those shared in this article to support leadership development and management in complex, hierarchical systems.

Understanding the Factors that Impact Effective Uptake and Integration of Health Programs in South African Primary Health Care Clinics

Introduction : There is an increasingly urgent gap in knowledge regarding the translation of effective HIV prevention and care programming into scaled clinical policy and practice. Challenges limiting the translation of efficacious programming into national policy include both the paucity of proven efficacious programs that are reasonable for clinics to implement and the difficulty in moving a successful program from research trial to scaled programming. This study aims to bridge the divide between science and practice by exploring health care providers’ views on what is needed to integrate of HIV programming into clinic systems. Methods : We conducted 20 in-depth interviews with clinic managers and clinic program implementing staff and 5 key informant interviews with district health managers overseeing programming in the uMgungundlovu District of KwaZulu-Natal Province, South Africa. Qualitative data were analyzed using a template approach. A priori themes were used to construct templates of relevance including current care context for HIV and past predictors of successful implementation. Data were coded and analyzed in accordance with these templates. Results : Heath care providers identified three main factors that impact integration of HIV programming into general clinical care: perceived benefits, resource availability, and clear communication. The perceived benefits of HIV programs hinged on the social validation of the program by early adopters. Wide program availability and improved convenience for providers and patients increased perceived benefit. Limited staffing capacity and a shortage of space were noted as resource constraints. Programs that specifically tackled these constraints through, for example clinic decongestion, were reported as being the most successful. Clear communication with all entities involved in clinic-based programs, some of which include external partners, was noted as central to maximizing program function and provider uptake. Conclusions : Amid the COVID-19 pandemic, new programs are already being developed for implementation at the primary health care level. A better understanding of the factors which both facilitate and prevent programmatic success will improve public health outcomes. Implementation is likely to be most successful when programs capitalize on endorsements from early adopters, tackle resource constraints, and foster greater communication among partners responsible for implementation.

Prioritizing people and rapid learning in times of crisis: A virtual learning initiative to support health workers during the COVID-19 pandemic

The Western Cape province was the early epicentre of the coronavirus disease 2019 pandemic in South Africa and on the African continent. In this short article we report on an initiative set up within the provincial Department of Health early in the pandemic to facilitate collective learning and support for health workers and managers across the health system, emphasising the importance of leadership, systems resilience, nonhierarchical learning and connectedness. These strategies included regular and systematic engagement with organised labour, different ways of gauging and responding to staff morale, and daily ‘huddles’ for raid learning and responsive action. We propose three transformational actions that could deliver health systems that protect staff during good times and in times of system shocks. (a) Continuously invest in building the foundations of system resilience in good times, to draw on in an acute crisis situation. (b) Provide consistent leadership for an explicit commitment to supporting health workers through decisive action across the system. (c) Optimise available resources and partners, act on improvement ideas and obstacles. Build trusting relationships amongst and across actors.

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district

BACKGROUND

As part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system.

METHODS

We conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs.

RESULTS

The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting.

CONCLUSION

District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.