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

Analysis for health system resilience against the economic crisis: a best-fit framework synthesis

INTRODUCTION

Countries, especially developing countries, are prone to economic crises, which are the consequences of various crises, including pandemics, climate crises, armed conflicts and migration. Therefore, policy-makers need a guiding framework for policy-making against the economic crisis that contributes to health system resilience. This study aimed to provide a holistic framework that guides health system policies before or during an economic crisis.

METHOD

The study utilized the best-fit framework synthesis to enhance and adapt the Resilience Analysis Meta-Framework (RAMF) in the context of an economic crisis. The study analysed and compared the experiences of three high-income countries and three low-middle-income countries with the greatest diversity in terms of their context, shocks that caused the economic crises and their responses to them. The framework was expanded and adjusted on the basis of the adopted policies in the context of the economic crisis.

RESULTS

The adapted RAMF provides a holistic framework which shows the priority and relationships of various policy alternatives in each health system building block. This framework can be used as a guide to analyse any policy solution against the economic crisis by considering its necessary antecedent policies and consequence policies in other health system building blocks.

CONCLUSIONS

Awareness in a health system via adapting appropriate cost control policies and governance structure can contribute to evidence-based cost control in all health system building blocks and need-based financing, drug and medical equipment procurement, human resource planning and service provision.

Managers' Experience of the Response of the Health System to the Covid-19 Pandemic for Inpatient Geriatric Care: Lessons About Organisation and Resilience

BACKGROUND

Effective management of crises is a major challenge for healthcare organisations and their managers. Research suggests that to respond to evolving and unpredictable crises, such as the Covid-19 pandemic, an organisation needs the capability to continually adapt to the changing situation using relevant knowledge. However, there are few empirical studies using an organisational resilience perspective to understand how a health system responds to this type of crisis. This study aimed to describe managers' perspectives on what influenced the response to the Covid-19 pandemic in the Region Stockholm healthcare system for older people.

METHODS

Data collection was conducted through in-depth semi-structured interviews with assistant managers (n = 3) and managers of inpatient geriatric services outside of acute care hospitals (n = 8), managers of three acute care hospitals (n = 3); and the crisis management team for geriatric services (n = 3). Data was analysed using qualitative content analysis.

RESULTS

Crisis management of geriatric care in the Stockholm healthcare system during the Covid-19 pandemic's first 15 months was influenced by a combination of service specific aspects, 'Internal flexible responses', collaborative aspects, 'Coordination within the system', and governance aspects 'Adaptive steering'.

CONCLUSIONS

This study contributes to empirical knowledge about organisational resilience. Managers' responses are facilitated when the governance allow them more flexibility in their internal responses and enable their cross-organisational collaboration. A coordinating function across healthcare services is an important enabler in a crisis when the function has well-established, trustful prior collaborations with the services.

Organizational resilience and primary care nurses' work conditions and well-being: a multilevel empirical study in China

Resilience is crucial for a health system to better prevent and respond to public health threats and provide high-quality services. Despite the growing interest in the concept of resilience in health care, however, there is little empirical evidence of the impact of organizational resilience, especially in primary care settings. As the largest professional group in primary care, primary care nurses are taking more and more responsibilities during their daily practice, which influences both their work conditions and well-being. This study aims to examine the association between organizational resilience and primary care nurses' working conditions and well-being. Using a convenience sampling approach, we recruited 175 primary care nurses from 38 community health centres (CHCs) in four cities in China. Organizational resilience was operationalized as comprising two domains: adaptive capacity and planning capacity, and measured using a 16-item scale. The primary care nurses' working condition indicators comprised variables of psychological safety, organizational commitment, professional commitment, and self-directed learning; well-being indicators included depression and burn-out. Hierarchical linear regression models were built for analysis. We found that the sampled CHCs have a relatively high level of organizational resilience. The organizational resilience was positively associated with the four indicators of working conditions: psychological safety (β = 0.04, P < 0.01), organizational commitment (β = 0.38, P < 0.01), professional commitment (β = 0.39, P < 0.01), and self-directed learning (β = 0.28, P < 0.01). However, organizational resilience was not significantly associated with the two well-being indicators. Furthermore, we found that the adaptive capacity has stronger association compared with planning capacity. Therefore, primary care manager should build resilient organizations, especially the adaptive capacity, in order to enhance primary care nurses' psychological safety, commitment and learning behaviours. Further studies should also be conducted to understand the link between organizational resilience and primary care nurses' well-being.

Building health systems resilience: understanding the social, economic, and cultural impacts of climate change from stakeholders' perspectives in Indonesia

OBJECTIVES

This study explores stakeholders' perspectives on the direct, social, economic, and cultural impacts of climate change on health in Indonesia and identifies possible strategies to enhance health system resilience.

METHODS

This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure comprehensive and transparent reporting. Purposive sampling was used to select 22 stakeholders with relevant expertise, including government officials, representatives from international and professional health organizations, health workers, and community representatives. Semi-structured interviews were conducted, and data were analyzed using directed content analysis. Data saturation was reached when no new themes emerged.

RESULTS

The findings reveal significant challenges to Indonesia's health system due to climate change. Community awareness varies widely, with higher levels in disaster-prone areas. Socially, climate change has fostered community cooperation through collective adaptation efforts but has also led to tensions due to inequitable resource distribution. Economically, rising healthcare costs and financial instability, particularly in rural and disaster-prone regions, place a strain on the system. Culturally, there is a growing emphasis on environmental conservation, promoting eco-friendly practices and the integration of traditional and modern health approaches.

CONCLUSION

Building health system resilience in Indonesia requires addressing the social, economic, and cultural impacts of climate change. Possible strategies include enhancing public health education, strengthening healthcare infrastructure, improving inter-agency coordination, and leveraging technology to support effective responses to climate-related health threats, ultimately promoting national health, social stability, and economic growth.

Resilience of hospitals in an age of disruptions: a systematic literature review on resources and capabilities

Hospitals play a critical role in ensuring continuous and effective healthcare delivery, especially during crises. However, the COVID-19 pandemic exposed vulnerabilities in hospital systems, prompting a need to enhance resilience-the ability to withstand, absorb, respond to, recover from, and learn from disasters. A systematic literature review, grounded in the resource-based view, identified organizational characteristics, in terms of resources and capabilities, and their synergistic effects that bolster hospital resilience. The results demonstrate that digital technologies impact on anticipation and adaptation abilities, organizational capabilities to reorganize roles, tasks, and spaces enhance adaptability, and Inter-organizational collaborations increase the responsiveness of the hospitals. The study provides substantial theoretical and practical contributions. It expands knowledge of hospital resilience in light of recent disruptive events and promotes integration capabilities as determinants for the majority of resilience dimensions. All organisational and inter-organisational collaboration, cooperation, and coordination are deemed crucial for hospital resilience.

Post-COVID health policy responses to healthcare workforce capacities: A comparative analysis of health system resilience in six European countries

A cross countries in Europe, health policy is seeking to adapt to the post-pandemic 'permacrisis', where high demands on the healthcare workforce and shortages continue and combine with climate change, and war. The success of these efforts depends on the capacities of the healthcare workforce. This study aims to compare health policy responses to strengthen the capacities of the healthcare workforce and to explore the underpinning dynamics between health systems, policy actors and health policies. The study draws on a qualitative, comparative analysis of Austria, the Czech Republic, Denmark, Germany, Italy and the Netherlands. The findings suggest that policy responses at the national level focused on hospitals and absorptive capacities, while policy responses at local/regional levels also included general practice and adaptive capacities. There were only few examples of policies directed at transformative capacities. The underling dynamics were shaped by health systems, where individual parts are closely connected, by embeddedness in specific service delivery and areas, and by power dynamics. In conclusion, sub-national health policy responses emerge as key to effective responses to the post-pandemic permacrisis, where health professions are central policy actors. Sub-national health policy responses build on existing power relations, but also have the potential to transcend these power relations.

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.

A resilience view on health system resilience: a scoping review of empirical studies and reviews

BACKGROUND

Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature.

METHODS

We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation.

RESULTS

The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature.

CONCLUSIONS

Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

What made primary health care resilient against COVID-19? A mixed-methods positive deviance study in Nigeria

INTRODUCTION

The SARS-CoV-2 (COVID-19) pandemic overwhelmed some primary health care (PHC) systems, while others adapted and recovered. In Nigeria, large, within-state variations existed in the ability to maintain PHC service volumes. Identifying characteristics of high-performing local government areas (LGAs) can improve understanding of subnational health systems resilience.

METHODS

Employing a sequential explanatory mixed-methods design, we quantitatively identified 'positive deviant' LGAs based on their speed of recovery of outpatient and antenatal care services to prepandemic levels using service volume data from Nigeria's health management information system and matched them to comparators with similar baseline characteristics and slower recoveries. 70 semistructured interviews were conducted with LGA officials, facility officers and community leaders in sampled LGAs to analyse comparisons based on Kruk's resilience framework.

RESULTS

A total of 57 LGAs were identified as positive deviants out of 490 eligible LGAs that experienced a temporary decrease in PHC-level outpatient and antenatal care service volumes. Positive deviants had an average of 8.6% higher outpatient service volume than expected, and comparators had 27.1% lower outpatient volume than expected after the initial disruption to services. Informants in 12 positive deviants described health systems that were more integrated, aware and self-regulating than comparator LGAs. Positive deviants were more likely to employ demand-side adaptations, whereas comparators primarily focused on supply-side adaptations. Barriers included long-standing financing and PHC workforce gaps.

CONCLUSION

Sufficient flexible financing, adequate PHC staffing and local leadership enabled health systems to recover service volumes during COVID-19. Resilient PHC requires simultaneous attention to bottom-up and top-down capabilities connected by strong leadership.

A resilient workforce: patient safety and the workforce response to a cyber-attack on the ICT systems of the national health service in Ireland

BACKGROUND

In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity, and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems, and the risk mitigation measures introduced to safely continue health services. The resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care is explored.

METHODS

To gain an in-depth understanding of staff experiences of the cyber-attack, eight focus groups (n = 36) were conducted. Participants from a diverse range of health services were recruited, including staff from radiology, pathology/laboratories, radiotherapy, maternity, primary care dental services, health and wellbeing, COVID testing, older person's care, and disability services. Thematic Analysis was applied to the data to identify key themes.

RESULTS

The impact of the cyber-attack varied across services depending on the type of care being offered, the reliance on IT systems, and the extent of local IT support. Staff stepped-up to the challenges and quickly developed and implemented innovative solutions, exhibiting great resilience, teamwork and adaptability, with a sharp focus on ensuring patient safety. The cyber-attack resulted in a flattening of the healthcare hierarchy, with shared decision-making at local levels leading to an empowered frontline workforce. However, participants in this study felt the stress placed on staff by the attack was more severe than the cumulative effect of the COVID-19 pandemic.

CONCLUSIONS

Limited contingencies within the health system IT infrastructure - what we call a lack of system resilience - was compensated for by a resilient workforce. Within the context of the prevailing COVID-19 pandemic, this was an enormous burden on a dedicated workforce. The adverse impact of this attack may have long-term and far-reaching consequences for staff wellbeing. Design and investment in a resilient health system must be prioritised.

Flexible delivery of opioid agonist treatment during COVID-19 in Norway: qualitative and quantitative findings from an online survey of provider experiences

BACKGROUND

For patients receiving daily opioid agonist treatment (OAT) for opioid dependence, several countries relaxed treatment guidelines at the beginning of the COVID-19 pandemic. This involved longer take-home intervals for methadone and buprenorphine doses as well as a reduction in supervised dosing and drug screening. To date, little is known about the medium or long-term experience of OAT deregulation. Therefore, we conducted a survey to explore how OAT providers perceived greater flexibility in OAT service delivery at the end of the second year of the pandemic.

METHODS

Nationwide cross-sectional study of twenty-three OAT units in 19 publicly funded hospital trusts in Norway. OAT units were sent a 29-item online questionnaire comprising closed-format and open-ended questions on treatment provider experiences and changes in OAT service delivery during the past 12 months (January to December 2021).

RESULTS

Twenty-three (of whom female: 14; 60.8%) managers or lead physicians of OAT units completed the questionnaire reporting that, in 2021, most OAT units (91.3%, n = 21) still practiced some adjusted approaches as established in the beginning of the pandemic. The most common adaptions were special protocols for COVID-19 cases (95.7%, n = 22), increased use of telephone- (91.3%, n = 21) and video consultations (87.0%, n = 20), and longer take-home intervals for OAT medications (52.2%, n = 12). The use of depot buprenorphine also increased substantially during the pandemic. According to the OAT providers, most patients handled flexible treatment provision well. In individual cases, patients' substance use was identified as key factor necessitating a reintroduction of supervised dosing and drug screening. Collaboration with general practitioners and municipal health and social services was generally perceived as crucial for successful treatment delivery.

CONCLUSIONS

Overall, the Norwegian OAT system proved resilient in the second year of the COVID-19 pandemic, as its healthcare workforce embraced innovation in technology (telemedicine) and drug development (depot buprenorphine). According to our nationally representative sample of OAT providers, most patients were compliant with longer take-home doses of methadone and buprenorphine. Our findings suggest that telemedicine can be useful as adjunct to face-to-face treatment and provide greater flexibility for patients.

Health System Performance and Resilience in Times of Crisis: An Adapted Conceptual Framework

With the COVID-19 pandemic, the notion of health system (HS) performance has been discussed, and the notion of resilience has become increasingly important. Lacking a recognised framework that measures the performance of HSs throughout a crisis, i.e., one that explicitly includes time as a key aspect, we examined the literature about conceptual frameworks for measuring the performance and the resilience of HSs. This review highlighted a significant diversity among 18 distinct HS performance frameworks and 13 distinct HS resilience frameworks. On this basis, we developed a model that integrates the WHO's widely recognised six building block framework in a novel approach derived from the European Observatory on HSs and Policies. The resulting framework adapts the building blocks to the different stages of a crisis, thereby allowing for a comprehensive assessment of an entire health system's performance throughout the crisis's duration, while also considering the key aspect of resilience. For a more pragmatic use of this framework in the future, indicators will be developed as a next step.

The role of local context for managers' strategies when adapting to the COVID-19 pandemic in Norwegian homecare services: a multiple case study

BACKGROUND

The COVID-19 pandemic had a major impact on healthcare systems around the world, and lack of resources, lack of adequate preparedness and infection control equipment have been highlighted as common challenges. Healthcare managers' capacity to adapt to the challenges brought by the COVID-19 pandemic is crucial to ensure safe and high-quality care during a crisis. There is a lack of research on how these adaptations are made at different levels of the homecare services system and how the local context influences the managerial strategies applied in response to a healthcare crisis. This study explores the role of local context for managers' experiences and strategies in homecare services during the COVID-19 pandemic.

METHODS

A qualitative multiple case study in four municipalities with different geographic locations (centralized and decentralized) across Norway. A review of contingency plans was performed, and 21 managers were interviewed individually during the period March to September 2021. All interviews were conducted digitally using a semi-structured interview guide, and data was subjected to inductive thematic analysis.

RESULTS

The analysis revealed variations in managers' strategies related to the size and geographical location of the homecare services. The opportunities to apply different strategies varied among the municipalities. To ensure adequate staffing, managers collaborated, reorganized, and reallocated resources within their local health system. New guidelines, routines and infection control measures were developed and implemented in the absence of adequate preparedness plans and modified according to the local context. Supportive and present leadership in addition to collaboration and coordination across national, regional, and local levels were highlighted as key factors in all municipalities.

CONCLUSION

Managers who designed new and adaptive strategies to respond to the COVID-19 pandemic were central in ensuring high-quality Norwegian homecare services. To ensure transferability, national guidelines and measures must be context-dependent or -sensitive and must accommodate flexibility at all levels in a local healthcare service system.

A synthesis of concepts of resilience to inform operationalization of health systems resilience in recovery from disruptive public health events including COVID-19

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict' Health systems resilience has become a ubiquitous concept as countries respond to and recover from crises such as the COVID-19 pandemic, war and conflict, natural disasters, and economic stressors inter alia. However, the operational scope and definition of health systems resilience to inform health systems recovery and the building back better agenda have not been elaborated in the literature and discourse to date. When widely used terms and their operational definitions appear nebulous or are not consistently used, it can perpetuate misalignment between stakeholders and investments. This can hinder progress in integrated approaches such as strengthening primary health care (PHC) and the essential public health functions (EPHFs) in health and allied sectors as well as hinder progress toward key global objectives such as recovering and sustaining progress toward universal health coverage (UHC), health security, healthier populations, and the Sustainable Development Goals (SDGs). This paper represents a conceptual synthesis based on 45 documents drawn from peer-reviewed papers and gray literature sources and supplemented by unpublished data drawn from the extensive operational experience of the co-authors in the application of health systems resilience at country level. The results present a synthesis of global understanding of the concept of resilience in the context of health systems. We report on different aspects of health systems resilience and conclude by proposing a clear operational definition of health systems resilience that can be readily applied by different stakeholders to inform current global recovery and beyond.

Unfolding alignment - How top management work to align demand and capacity: an ethnographic study of resilience in a Swedish healthcare region

BACKGROUND

Resilient healthcare organizations maintain critical functions and high-quality care under varying conditions. While previous research has focused on the activities of frontline healthcare professionals working at the "sharp end" of care, less attention has been paid to managers at the top management level. More knowledge is needed to fully understand how the managers align demand and capacity at the "blunt end" of care. Therefore, this study aimed to explore how top managers work to align demand and capacity in a healthcare region in Sweden.

METHODS

Observations of management team meetings, interviews, and conversations were conducted with top managers responsible for healthcare in one of Sweden's 21 regions. Data collection used an ethnographic approach. Data were analyzed using qualitative reflexive thematic analysis.

RESULTS

The data showed how alignment work was done through active reflection that built on past experiences and on structures built into the organization at the same time as taking future potential outcomes and consequences into account. In addition to collaborative, preventive, supportive, and contextualizing work, which was conducted in the present, a general approach permeated the organization, which enabled connecting actions, i.e., different forms of alignment work, occurring at different points in time, and connecting different types of knowledge across organizational borders and stakeholders.

CONCLUSION

This study explored how top managers work to align demand and capacity in a healthcare region in Sweden. It was shown how four categories of work; collaborative, preventive, supportive and contextualization work, together with a general approach; focusing on opportunities, building on a stable past and taking a reflective stance, constitute alignment in practice. More; the alignment work was done in the here and now, with both the past and future in mind. The ability to take action to benefit the whole is a possibility and a responsibility for top management. In the region studied, this was done by aligning demands with capacity based on past experiences and focusing on the available opportunities to connect knowledge needed within and across organizational borders.

Living through uncertainty: a qualitative study on leadership and resilience in primary healthcare during COVID-19

BACKGROUND

Resilience is often referred to when assessing the ability of health systems to maintain their functions during unexpected events. Primary healthcare forms the basis for the health system and thus its resilient responses are vital for the outcomes of the whole system. Understanding how primary healthcare organisations are able to build resilience before, during, and after unexpected or sudden shocks, is key to public health preparedness. This study aims to identify how leaders responsible for local health systems interpreted changes in their operational environment during the first year of COVID-19, and to elucidate how these views reflect aspects of resilience in healthcare.

METHODS

The data consist of 14 semi-structured individual interviews with leaders of local health systems in Finland representing primary healthcare. The participants were recruited from four regions. An abductive thematic analysis was used to identify entities from the viewpoints of the purpose, resources, and processes of resilience in the healthcare organisation.

RESULTS

Results were summarised as six themes, which suggest that embracing uncertainty is viewed by the interviewees a basis for primary healthcare functioning. Leading towards adaptability was regarded a distinct leadership task enabling the organisation to modify its functions according to demands of the changing operational environment. Workforce, knowledge and sensemaking, as well as collaboration represented what the leaders viewed as the means for achieving adaptability. The ability to adapt functioned to comprehensively meet the population's service needs built on a holistic approach.

CONCLUSIONS

The results showed how the leaders who participated in this study adapted their work during changes brought on by the pandemic, and what they viewed as critical for maintaining organisational resilience. The leaders considered embracing uncertainty as a principal feature of their work rather than viewing uncertainty as aberrant and something to avoid. These notions, along with what the leaders considered as critical means for building resilience and adaptability should be addressed and elaborated in future research. Research on resilience and leadership should be conducted more in the complex context of primary healthcare, where cumulative stresses are encountered and processed continuously.