A Scoping Review of Antimicrobial Nresistance in Sierra Leone
Int J Wellness Policy Manag. 2020 Jan; 9(1): 6–16.
Health System Resilience: What Are Nosotros Talking Almost? A Scoping Review Mapping Characteristics and Keywords
Received 2018 Dec 26; Accepted 2019 Sep 2.
Abstract
Background: Health systems are based on half dozen functions that need to work together at all times to finer deliver safe and quality wellness services. These functions are vulnerable to shocks and changes; if a health system is unable to withstand the pressure from a stupor, information technology may stop to office or plummet. The concept of resilience has been introduced with the goal of strengthening health systems to avoid disruption or collapse. The concept is new within wellness systems research, and no mutual description exists to describe its meaning. The aim of this report is to summarize and characterize the existing descriptions of wellness system resilience to ameliorate understanding of the concept.
Methods and Analysis: A scoping review was undertaken to identify the descriptions and characteristics of wellness system resilience. 4 databases and gray literature were searched using the keywords "health system" and "resilience" for published documents that included descriptions, frameworks or characteristics of wellness system resilience. Additional documents were identified from reference lists. Four good consultations were conducted to gain a broader perspective. Descriptions were analysed past studying the frequency of key terms and were characterized by using the World Health Organization (WHO) wellness system framework. The scoping review identified xi sources with descriptions and 24 sources that presented characteristics of health system resilience. Frequently used terms that were identified in the literature were shock, adapt, maintain, absorb and respond. Change and learning were likewise identified when combining the findings from the descriptions, characteristics and expert consultations. Leadership and governance were recognized as the most important building block for creating health system resilience.
Discussion: No single description of health organization resilience was used consistently. A variation was observed on how resilience is described and to what depth it was explained in the existing literature. The descriptions of wellness system resilience primarily focus on major shocks. Adjustments to long-term changes and the element of learning should be considered for a ameliorate understating of wellness system resilience.
Keywords: Wellness System Resilience, Scoping Review, Shocks, Health System
Background
A wellness arrangement "consists of all organizations, people and actions whose primary intentis to promote, restore or maintain health."1 A World Health Organization (WHO) framework summarizes the functions of a wellness system as 6 interconnected building blocks that are essential to health system functioning.one The building blocks must piece of work together to answer to changing health needs so that the arrangement tin can accomplish the health arrangement goal of improving health.one,2
Recent challenges, such equally shifting burden of illness, antimicrobial resistance, financial crises and an increasing frequency of farthermost weather events, have put pressure on the functions of health systems.3 These challenges range from national or local disruptions to pandemics with substantial global impact, such as the West Africa Ebola outbreak from 2014-2016, which resulted not just in a substantial loss of life but also in astringent impediments to the functioning of the wellness systems in the afflicted countries.4 Similar patterns of a wellness organisation'due south disability to cope accept as well been seen in countries affected by the Zika virus.five,half-dozen Although these diseases mainly affected low- and middle-income countries, other difficulties have affected high-income countries, such as the 2008-2009 financial crunch that forced multiple wellness systems in Europe to reorganize for better efficiency and to brand cutbacks in health budgets.7,8 Farther challenges are slowly emerging worldwide that are causing progressive stress to systems, for instance the connected threat of antibiotic resistance that is predicted to become one of the largest challenges to health systems in the time to come.9
The term resilience has been office of the lexicon of multiple scientific disciplines; psychology, disasters, engineering, and economic science, for instance, all use frameworks of resilience.10-12 One of the commencement disciplinary definitions of resilience came from the field of ecology in 1973, where it was defined by Holling as a system's "ability to absorb modify and disturbance and still maintain the aforementioned relationships betwixt populations or state variables."13 From this definition and definitions from other disciplines, the main concepts of resilience emerged – the capacity of an individual, population or arrangement to blot a stupor, while still retaining the central functions or characteristics of the original country.14,15 Yet, this view of resilience has been critiqued for seeing a organization equally a strictly linear process, with the underlying assumption that the original land of the system is the optimal country, to which a organization should return after beingness shocked into departing from it.16,17 In this scenario, a system tin can only absorb shocks, and remains vulnerable. A more dynamic interpretation of resilience incorporates adaptive and transformative capabilities that permit a system to arrange or change its ain characteristics or actions to soften future shocks while nonetheless retain its basic structure, or even fundamentally change its structure to eliminate risks altogether, if its current country becomes unsustainable.eighteen
While the term has been in use for many years, it was when the negative effects of the Westward Africa Ebola outbreak on local health systems was documented that the term gained popularity as a concept. Health system resilience was swiftly taken up within global wellness as a way to strengthen health systems,4 focusing primarily on acute shocks to the health system, such as the Ebola outbreak and natural disasters.19 This focus has broadened since to include health systems facing chronic stresses that continuously challenge the operation of the organisation or its ability to adapt.20 Still, specific suggestions on how wellness systems tin become resilient to either acute shocks or chronic stress remain insufficiently vague.xi
There is no mutual description of wellness organisation resilience at this stage.19 In lodge to build resilient health systems, a better understanding of what information technology means and should contain is needed.21 Clarifying the meaning of health arrangement resilience could help establish a shared understanding of the concept among researchers and policy-makers.ten The purpose of this study is therefore to summarize and characterize the existing descriptions of wellness arrangement resilience.
Methods
This study combines a scoping review of peer-reviewed and greyness literature with expert consultations.22 A scoping review was chosen due to the broad nature of the concept and to capture the variety in the published information on health systems resilience. Expert consultations were used to supplement the literature and to gain practical perspectives of health systems resilience.22,23
The literature search for peer-reviewed articles was conducted in Jan 2018 and the gray literature search in March 2018. Search strategies for peer-reviewed literature and gray literature were developed. Both used the search keywords of resilience and health systems (Table one). The primary inclusion criteria were documents that were published in English language and described or identified the characteristics of wellness organisation resilience or that presented a health system resilience framework (Table 2).
Tabular array one
Search Terms, by Database
| Source | Blazon of Literature | Search Terms |
| PubMed | Peer-reviewed | (resilien*[tiab] AND health system*[tiab]) |
| Spider web of Science | Peer-reviewed | TS = (resilien* Virtually/3 health system*) |
| Global Health | Peer-reviewed | (health system*) AND (resilien*) |
| IRIS | Gray literature | Resilient OR resilience AND wellness system* title contains resilient OR resilience championship contains health arrangement |
| Gray literature | Health system resilience |
Table ii
Eligibility Criteria for the Review
| Criteria for Inclusion |
| Full text written in English |
| Manufactures, reports, books, stance papers, workshop summaries, briefings, commentaries, or webpages |
| Gives a written clarification of health system resilience |
| Includes a visual representation or discussion of a framework for wellness system resilience |
| Identifies or discusses unlike characteristics, concepts, elements or components of health arrangement resilience |
| Criteria for Exclusion |
| Abstracts, videos, or news articles |
For the peer-reviewed literature, searches were conducted in the PubMed, Spider web of Science, and Global Health databases. The gray literature search followed the methodology of Godin et al24 for a reproducible search. A keyword search was used in the Institutional Repository for Information Sharing (IRIS) database, and a second search was conducted through Google. Organizations that piece of work with health systems or public health were identified from the first 50 hits of a Google search by using the term "health system resilience." The organisation webpages search engines were used to detect relevant documents by using the aforementioned search string. In the absence of a search engine, the website of the organisation was manually searched. After sorting the results by relevance, the first 50 documents from each system were included for screening.
The initial searches produced 811 articles. The first 2 authors independently assessed the documents for inclusion. After screening the titles and abstracts, 112 articles were read in full, and 88 were excluded (Figure i). Additional references were identified from the reference lists of the included articles, and 3 articles were identified during the peer-review process and included in the analysis. In example of a disagreement on the inclusion of a certificate, the document was discussed amid the authors until an understanding was reached. The information were extracted from the included studies and entered into an Excel spreadsheet by the beginning 2 authors. No quality assessment of the manufactures was done, as this is not part of the standard methodology of scoping reviews.22
PRISMA Diagram of the Literature Search. Abridgement: IRIS, Institutional Repository for Information Sharing.
Expert consultations were performed during March and Apr 2018, with experts who were affiliated with an organization, found or governmental bureau that was identified as relevant to health system and policy. The experts were purposively sampled and then that they held a position in the field of health systems and policy and were familiar with the concept of health system resilience. The organizations of the experts were identified through the grayness literature search, and no organization had more than i representative. Experts were contacted by email for recruitment and each one agreed to participate. Experts were asked to describe and identify the characteristics of health system resilience before the interview was conducted. Boosted questions during the interviews used the preliminary findings from the literature review but were not provided to the experts beforehand to avoid potential bias. The consultations were held online, sound recorded, and transcribed by intelligent verbatim.25
The data from the literature search and good consultations were analysed by the get-go 2 authors by mapping the constructs within the descriptions and comparing the occurrence of constructs between the different descriptions.26 Keywords within each description and the resilience characteristics were identified and charted; synonyms were combined into one category and were named for the most frequently used term within this category. Keywords were included in the analysis if they were mentioned in three or more than articles and interviews, in gild to prioritize the words used virtually frequently and to forbid seldomly used words from influencing the results. The characteristics of health system resilience from the dissimilar publications were identified and mapped into one of the WHO's 6 building blocks.one The WHO vi building cake framework was called for its cohesiveness, equally it has been a commonly used framework for health systems resilience research.
Results
The concluding analysis included 24 publications that were published between 2013 and 2018. Iv experts who were affiliated with WHO, the United nations Children'due south Fund (UNICEF), the European Observatory on Health Systems and Policies, and the Swedish Ministry building for Foreign Affairs were consulted.
Eleven of the included articles provided a description of health system resilience (Tabular array 3), 2 articles referenced a description from another paper, 6 articles referred to a description most resilience in general and v articles did non provide a clarification.
Table 3
Health System Resilience Descriptions and Keywords Used in the Included Articles
| Abimbola et al, 2018 | Accommodation with robustness: the case for clarity on the utilise of 'resilience' in wellness systems and global wellness |
| Clarification Resilience implies adaptability in a context of robustness | Context Governance for resilience Keywords used Adapt |
| Ammar et al, 2016 | Health arrangement resilience: Lebanon and the Syrian refugee crisis |
| Description The chapters to blot internal and external shocks and maintain functional health institutions while sustaining achievements | Context Refugee crisis in Lebanon |
| Keywords used Absorb; Stupor*; Maintain | |
| Barasa et al, 2017 | From billowy dorsum, to nurturing emergence: reframing the concept of resilience in health systems strengthening |
| Description Resilience is about (1) everyday resilience, non only response to sudden shocks, (two) health system software, not merely its hardware, and (3) artistic adaptation, and transformation, rather than just bouncing dorsum | Context Everyday resilience |
| Keywords used Response; Shock*; Adapt**; Transform | |
| Barasa et al, 2018 | What is resilience and how tin it be nurtured? A systematic review of empirical literature on organizational resilience |
| Description Refers to organizational resilience, not specific to health systems | Context Organizational resilience |
| Keywords used | |
| Blanchet et al, 2017 | Governance and chapters to manage resilience of health systems: towards a new conceptual framework |
| Description Its chapters to adapt, absorb and transform when exposed to a shock such every bit a pandemic, natural disaster, armed conflict or a financial crisis and even so retain the same command over its construction and functions | Context Governance for resilience |
| Keywords used Suit**; Blot; Transform; Shock; Maintain*** | |
| Blanchet, 2013 | Governance of health systems comment on "A network based theory of health systems and cycles of well-beingness" |
| Description Refers to resilience, not specific to wellness systems | Context Governance for resilience |
| Keywords used | |
| Campbell et al, 2015 | Improving the resilience and workforce of health systems for women's, children's, and adolescents' health |
| Description Its capacity to reply, adapt, and strengthen when exposed to a daze, such as a disease outbreak, natural disaster, or disharmonize | Context Women'south, children'southward and adolescent health |
| Keywords used Respond; Arrange**; Shock* | |
| European Commission, 2014 | Communication from the commission: On effective, accessible and resilient health systems |
| Description Able to adapt effectively to changing environments and tackling significant challenges with limited resources | Context Activity programme for resilience |
| Keywords used Adapt* | |
| Gilson et al, 2017 | Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa |
| Description Refers to resilience, not specific to health systems | Context Everyday resilience |
| Keywords used | |
| Hanefeld et al, 2018 | Towards an understanding of resilience: responding to health systems shocks |
| Description Able to conform its performance to absorb a shock and transform if necessary to recover from disaster | Context Understanding health system resilience |
| Keywords used Adapt**; Absorb; Shock*; Transform | |
| Ho et al, 2016 | Applying the resilient health system framework for universal wellness coverage |
| Description None | Context Digital healthcare resilience |
| Keywords used | |
| International Forum Gastein , 2013 | Resilient and innovative health systems for Europe |
| Clarification None | Context Health system innovations |
| Keywords used | |
| Khan et al, 2017 | A review on the antagonist Ebola: a prophylactic approach |
| Description Refers to resilience, not specific to health systems | Context West Africa Ebola outbreak |
| Keywords used | |
| Kieny et al, 2015 | Across Ebola: a new agenda for resilient health systems |
| Description Can blot the shock of an emergency such as Ebola and simultaneously continue to provide regular wellness services and go out other sectors of the country fully functioning | Context West Africa Ebola outbreak |
| Keywords used Daze*; Absorb | |
| Kruk et al, 2015 | What is a resilient health system? Lessons from Ebola |
| Description The capacity of health actors, institutions, and populations to gear up for and effectively respond to crises, maintain core functions when a crises hits, and informed by lessons learned during the crisis, reorganize if conditions crave it | Context Due west Africa Ebola outbreak |
| Keywords used Respond; Stupor*; Maintain***; Learn; Adapt** | |
| M8 Alliance Kyoto, 2015 | Meeting emerging challenges: toward responsive and resilient wellness systems |
| Description None | Context Emerging challenges for health systems |
| Keywords used | |
| McKenzie et al, 2015 | Edifice a resilient health organization: lessons from Northern Nigeria |
| Description None | Context West Africa Ebola outbreak |
| Keywords used | |
| Mfutso-Bengo et al, 2017 | Proposing the LEGS framework to complement the WHO building blocks for strengthening health systems: ane needs a LEG to run an ethical, resilient arrangement for implementing health rights |
| Description Refers to resilience, not specific to health systems | Context Strengthening health systems |
| Keywords used | |
| Olu , 2017 | Resilient wellness organization as conceptual framework for strengthening public wellness disaster take a chance management: an African viewpoint |
| Clarification Reference to Kruk et al, 2015 | Context Disaster management |
| Keywords used | |
| Oxfam, 2015 | Never again: edifice resilient wellness systems and learning from the Ebola crisis |
| Clarification Reference to Kieny et al, 2015 | Context W Africa Ebola outbreak |
| Keywords used | |
| Ozawa et al, 2016 | Exploring pathways for building trust in vaccination and strengthening health system resilience |
| Description Able to withstand major shocks and disruptions to quickly conform to irresolute circumstances and to maintain a high utilization and need over time | Context Immunization |
| Keywords used Shock*; Arrange**; Withstand; Maintain | |
| RESYST, 2017 | Using intersectionality to amend understand health organisation resilience |
| Description None | Context Everyday resilience |
| Keywords used | |
| Thomas et al, 2013 | The framework for assessing wellness organization resilience in an economical crisis: Ireland every bit a exam case |
| Description Refers to resilience, non specific to health systems | Context Economical resilience |
| Keywords used | |
| WHO, 2015 | Operational framework for building climate resilient health systems |
| Description Can anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stress to provide sustained improvements in population health despite an unstable climate | Context Climate resilient wellness systems |
| Keywords used Shock*; Accommodate**; Maintain***; Respond | |
| Skilful 1 | Organization: UNICEF |
| Description The power to withstand shocks, be they natural or human being-made disturbances | Context Global health |
| Keywords used Stupor*; Learn; Withstand | |
| Expert two | Organisation: Swedish Ministry building of Foreign Diplomacy |
| Description The power to manage and cope with threats, challenges and emergencies while maintaining the normal functions and services of a health organisation; a arrangement can too learn from these experiences and develop and evolve its functionality to become even stronger | Context Global wellness |
| Keywords used Shock*; Maintain***; Larn | |
| Expert iii | Organization: WHO Alliance for Health Policy and Systems Research |
| Description Keywords used to describe resilience | Context Global health |
| Keywords used Shock*; Adapt**; Respond; Larn; Withstand | |
| Expert 4 | Arrangement: European Observatory on Health Systems and Policies |
| Description Keywords used to depict resilience | Context European health policy |
| Keywords used Stupor*; Arrange**; Respond; Learn; Withstand |
9 out of 11 descriptions mentioned shocks, which refer to a crunch or disruption (Tabular array four). 1 source described the meaning of a stupor,19 while the other 8 sources gave examples of what could cause shocks and how they should be addressed.four,21,27-32 Commonly used examples of a shock were pandemics such as Ebola31,33-35 or natural disasters.26,36 Five recurring terms that referred to the capacities or deportment that a organisation could take to be resilient when exposed to a stupor were identified in the descriptions of resilience in the literature, namely, adapt, maintain, absorb, respond and transform. The proficient consultations identified two additional terms, learn and withstand, that were not commonly used in the literature.
Table 4
Explanation of the Key Terms in Relation to Health System Resilience
| Keyword | Times Used | Explanation | |
| Articles | Experts | ||
| Shock | 9 | 4 | A sudden and often surprising consequence that causes an additional brunt to the health system, most often for a short period of fourth dimension. Pandemics such as Ebola or natural disasters caused by climate change were the commonly used examples of a shock. |
| Adapt | 9 | 2 | How a system reacts to meet the changing needs of the population and to continue to evangelize the best possible intendance. To be resilient, a system should adapt both during and after sudden shocks and long-term changes. |
| Maintain | v | 1 | Maintaining the core functions of the health system when managing a stupor. All parts of the health organisation should maintain the same access to and quality of care to be resilient, although resources might be moved towards the response to a shock. |
| Absorb | 4 | 0 | The capacity of a health system to use additional resources when managing a shock and handling challenges in an efficient way. By improve absorbing a stupor, the health system is less affected and more than resilient. |
| Respond | 4 | two | The quick reaction and implementation of constructive strategies to accost a shock before it overwhelms the system. Quickly responding to a shock tin foreclose the shock from persisting or expanding, allowing a organization to more easily combat problems. |
| Learn | 1 | 4 | A wellness system must learn from previous experiences of shocks and changes, both inside its own organisation and other systems, nationally and internationally, to increment resilience. Without the element of learning and evaluating previous experiences, there would be limited improvements in the grooming for similar situations and thus a system would not better its resilience. |
| Transform | iii | 0 | The power of a health arrangement to make a complete change to improve for the future, when exposed to a long-term challenge or a shock. To exist resilient, a wellness system should transform the current status, strategies and behaviours that are no longer feasible. |
| Withstand | 1 | 3 | Used to describe how a system must be sufficiently stiff to cope with a shock and handle the additional strain and normal functions, which links it to the terms answer and maintain. If the arrangement tin can withstand the shock or alter while still providing routine care to the population, the system can be considered resilient. |
In add-on to the keywords used when describing resilience, the publications described health organisation characteristics that can lead to resilience (Figure two). However, several characteristics were not concerned with resilience during a shock but with the periods in between a shock.27,28,32,37-39 This was described as everyday resilience, where the context is not a daze but a chronic challenge that occurs every day over a long period of time and that cannot e'er be predicted.twenty,48-fifty
Characteristics of Health System Resilience Within Each of the WHO 6 Building Blocks. Abbreviation: WHO, World Health Organisation.
Financing
Constructive financial resource allocation and protection of healthcare funding was identified every bit of import for resilience during shocks, long-term changes and normal strains.8,27,xxx,40,41 Using diverse and stable financial resources was recognized as minimizing the risk of a response being underfunded.19,30,40 To be sustainable and able to provide universal health coverage, Hanefeld et al and Kamal-Yanni et al both suggested that a resilient health organization should be nationally funded, preferably through taxes.19,33 Kamal-Yanni et al additionally suggested that the amount of out-of-pocket payments should be reduced to minimize the inequity in the affordability of wellness services and to protect from impoverishment due to healthcare costs.33 In addition, the importance of selling medical products at stable prices during shocks was highlighted.40
Health Workforce
5 articles discussed the need for a workforce with a mix of skills that can arrange to both long-term changes and shocks.19,34,35,xl,42 The competence within the wellness workforce should be sufficiently high to maintain the daily functions of the health organization and nevertheless provide quality care, even when resource may be scarce.19,21,40 The availability of boosted workforce resources was raised every bit a method to ameliorate the speed and effectiveness of the response to a stupor while minimizing the negative bear upon on the system.21,30,31,33,38 Communities were also identified as a resource that should exist involved to improve response by including civil society,36,49,51 and the WHO recommends that customs health workers and other actors within gild should be utilized to assistance raise the sensation in the population near how to manage shocks.35 Both the European Commission and the experts interviewed emphasized that people who work with healthcare need to exist given proper support and incentives at all times.twoscore The experts elaborated that support, including satisfactory financial compensation, is important during stable times to ensure that professionals are motivated to piece of work efficiently and is crucial during shocks when fear may cause wellness workers to get out their stations.
Information
The continuous collection of information to meliorate preparedness and response to both long-term changes and shock was a recurring feature.4,19,27,30,33 V articles discussed the need for good quality surveillance data and so that policies focus on the right areas and make the right decisions to predict changes and shocks that are likely to affect the wellness system.twenty,27,28,40,43 Information was as well mentioned equally fundamental to how quickly a health organisation can adapt to a change.20 The need to analyse previous experiences to guide futurity response was also raised4,19,20,32,42 and could include learning or cooperation with other sectors or countries who have experienced similar shocks in order to guide plans for improved response.nineteen,21,34
Leadership and Governance
The edifice block of leadership and governance was mentioned by 20 sources. Accountability and transparency21,twoscore,43 together with equity43,44 were emphasized as important responsibilities. According to the good consultations, equity was highlighted as an attribute that is often lost during times of a shock. One expert stated that new strategies that are made hastily in the demand for a quick fix often miss equity aspects. Six manufactures stated that a system needs the capacity to predict hereafter challenges to effectively respond and to arrange the organisation when needed.20,21,27,34,forty,45 This capacity should exist built during stable times and not during shocks when the health system is strained and needs to focus on response.4,viii,21,27,32,38 Three articles underscored that new strategies should exist adult based on previous experiences and lessons learned should be efficiently implemented.27,35,45 Multiple manufactures stated that the right actors, both within and outside the wellness sector and at the international level, should be identified to tackle context-specific challenges19,27,35,37,42; the appointment of the right regime and the population was seen as essential to build wellness system resilience, for instance, in the implementation of strategies and the response.19,27,35,37,41,42 Designing institutions to govern for resilience, for example by making health system governance polycentric, was mentioned as a manner to spread the impact of a daze and in that way foster resilience.20,46 Local governance and strong community engagement were highlighted as an investment to conceptualize uncertain shocks.46
Medical Products, Vaccines, and Technologies
The characteristics related to medical products, vaccines and technologies were mentioned in 2 documents and by one skillful.27,33 They mentioned that accessibility to medical products is critical for a health system to function well, even so essential medicines remain unaffordable or inaccessible in lower income countries, according to the WHO.47 The emphasized challenge was that some essential medical products are non bonny to produce due to modest monetary rewards for pharmaceutical companies, and their enquiry and evolution is thus underfunded.27,33 An expert indicated that the incentives for the product of medicines either should exist changed or monetary compensation should be increased to incentivize pharmaceutical companies to produce essential medicines. All 3 sources called for a more than sustainable production of medical products and technological solutions with improved incentives.27,33
Service Delivery
Nine manufactures stated the importance of provision of additional services to the entire population during a stupor while maintaining everyday services.4,8,20,21,33-35,38,46 Focusing on preventive efforts, such as public health interventions, during stable times was identified every bit 1 strategy for a health system to exist well prepared for shocks and changes, although most shocks were seen equally difficult to predict and prevent.4,28,33,43
Discussion
Our study found that in the literature and among health organization experts, health system resilience is described mainly in relation to adaptation, maintenance, assimilation, learning, transformation, withstanding and responding to shocks. The goals and functions of the health system were reflected in the characteristics of resilience,1 and the importance of practiced governance, effective and reliable data systems, and a resilient workforce were emphasized. Although sudden shocks were identified every bit the principal driver of resilience, adjusting to long-term changes in the health system was also stressed as an of import characteristic of resilience that was tied closely to the WHO building cake of leadership and governance.
Out of all the full text articles read during the screening, no single description of resilience was referred to consistently. The virtually common description referenced was the clarification past Kruk et al – "The chapters of wellness actors, institutions, and populations to prepare for and effectively respond to crises; maintain cadre functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it" iv – all the same several authors37,48-51 who refer to Kruk et al did non include the third chemical element of the description on learning. The other descriptions, some of which came subsequently the description past Kruk et al and may accept thus been influenced by it, all lack this component. Although information technology could exist argued that the element of learning is not every bit of import as the other elements, the reverse was observed when analysing the characteristics of wellness system resilience and including the perspectives from the expert consultations. Learning was often discussed within the Data and Leadership and governance building blocks and was mentioned by all experts as an of import chemical element, allowing the health organisation to evolve by learning from previous experiences, thereby increasing the organization's strength and guiding policy-making.
The focus on leadership and governance in both the published literature and by experts is not surprising, given that governance is concerned with how a health organisation and its actors role and perform. Health systems are dynamic systems that are influenced by the context, the values and principles that the organization is built upon, and the variety of interactions among actors and the system.45,52 The capacity and latitude for a wellness system to learn and evolve volition depend to a keen extent on the decisions that formal and informal actors in the wellness arrangement are able or willing to have, in any given context. This was apparent in the recurring theme in the results of cooperation with and dependence on other sectors and actors outside of the health system. Constructive and responsible coordination of operations working towards a mutual goal, within the building blocks and with sectors outside the health system, points to the influence of decision-makers and actors in creating change in the organization.
The remaining 5 building blocks were discussed with similar frequency with a notable exception of the building block of Medical products, vaccines and technologies. Ignoring this building cake in the discussion of health organisation resilience would mean excluding 1 of the key foundations.33 A health system cannot be fully resilient without the availability of essential medicines or without the evolution of new products. A newly developed, non all the same licensed Ebola vaccine was introduced equally an emergency strategy to try and cease the 2018 Ebola outbreak in the Democratic Republic of Congo that is still ongoing, and more than 110 000 people accept and then far been vaccinated.53 This is an analogy of how strengthening the provision of medicines like vaccines may help build resilience in a shocked health organization. Further, the emergence of antibiotic resistance is a claiming that is closely linked to the building block of Medical products, vaccines and technology. It is a slowly emerging disaster that is predicted to become 1 of the largest health challenges if health systems cannot maintain everyday resilience.54 Antibiotic resistance, similar to whatever other claiming, is also an case of where resilience cannot be tackled in isolation but rather must be addressed equally an combination of all the building blocks.
The interactions among the blocks are what brand upward a resilient health system. The linkages among the blocks, including the role of people every bit actors who drive the system forrad, are essential to realize a resilient health system.36 These linkages can be noted in the characteristics that are identified under Service delivery, which were ofttimes not specific to health system resilience but to health system strengthening in full general. Service delivery is the main output of a health organization and is dependent on the functions of the other five building blocks.36 If the other five building blocks do not part, service delivery fails, and resilience has not been reached. Wellness systems are dependent on the interactions among the building blocks to maintain service delivery during everyday challenges and shocks.
It has been argued that the concept of wellness arrangement resilience is limited to context-specific situations, and, therefore, a single description may be problematic.55,56 The diverseness of the challenges and shocks and the degree of vulnerability of health systems make information technology hard to understand and utilise universal characteristics to specific health systems. General guidance for what wellness organisation resilience entails and its general characteristics could help a wellness system to prioritize its actions and strategies within its ain context and reach its own resilience goal, thereby contributing to resilience globally. This requires that the concept of resilience is flexible, to effectively suit to everyday stressors and shocks.55
The adoption of health arrangement resilience as a construct has led to criticism about whether it tin can be applied to complex adaptive systems,57 and concern that information technology is no more than a catchphrase.17,55 At that place has been criticism for seeing resilience every bit a linear process, where health systems are expected to return to an original state, rather than accommodate modify.16 It is worth noting that many of the keywords and descriptions from the literature included in this written report focused on coping and bouncing back from shocks, rather than learning or system transformation. The implication is that at that place is a 'normal' country that health systems can—and should—return to, and disregards existing challenges and deficiencies of the system that could render it to a continually vulnerable land. This tin can be further amplified if prescriptive adaptation strategies are suggested for resilience without taking the context of the wellness systems values, principles, or goals into consideration.58 Notwithstanding the frequent use of the keyword adapt, and the inclusion of the words transform and acquire could signal a growing emphasis on thinking about wellness systems as continuously adapting to shocks and stresses, leading to a richer understanding of how to create resilience within health systems.57
The ambiguity in terminology in the literature and the absence of a mutual understanding of health system resilience is comparable to the criticism around the introduction of the term sustainability in development in the 1990s.21 Sustainability was criticised for beingness a catchphrase59 and lacking consistency in its estimation and clarity, leading to concerns about its political usefulness.60 Yet the shift in the use of the term from an environmental focus to a human focus, coupled with a growing concern nigh the ecology of the planet, brought sustainability to the mainstream,61 and two decades later, sustainability is used in multiple disciplines and is the cardinal epitome of the United Nations Sustainable Evolution Goals of the Calendar 2030.59,62 To further strengthen the concept of health system resilience, experiences from other disciplines could be helpful to ultimately find a mutual style to describe and apply the concept in literature. It remains to be seen if wellness system resilience will be adopted every bit a useful concept that shapes the mode that actors perceive and design wellness systems in the future.
Limitations
Two broad search terms were used to place a greater number of articles during the search. Relevant articles that did not explicitly mention resilience or wellness systems or articles on resilience that were not published in English may have been missed. Our own interpretation and subjectivity of choosing the keywords and characterizing resilience within the WHO vi building block framework may take acquired a limitation of reproducibility. The building block framework was chosen every bit it is a unremarkably used framework, although it places equal emphasis on all edifice blocks and does not take into business relationship the context of the health system. Choosing another framework to employ for the analysis may have shifted the focus towards different dimensions of health systems. In addition, the experts selected for consultation may not be generally representative of wellness system resilience practitioners, and therefore reflect only some of the ideas regarding wellness system resilience.
Determination
Health system resilience is an emerging concept within wellness organisation inquiry, and descriptions of health systems resilience vary in the existing literature. A review of the literature suggests that long-term changes, learning from previous experiences, and everyday resilience are considered important aspects of resilience. Additional case studies of health system successes and failures in diverging contexts may exist a starting point to create a shared understanding of the concept of resilience and to clarify its pregnant.
Acknowledgements
Nosotros give special thanks to the 4 experts who participated in the consultations for their valuable contribution. In addition, we thank Helle Mölsted-Alvesson for her methodological input on the skillful consultations.
Ethical issues
Ideals approval was non sought for the study since the literature search used published data, the skilful consultations collected no personal information and no sensitive topics were discussed. Participation was voluntary. All participants gave oral informed consent to participate in the study and were informed of their right to withdraw at any time during the consultation. No personal data were stored.
Competing interests
Authors declare that they have no competing interests.
Authors' contributions
MF, SE, JvS, and DDS conceptualized and designed the written report. MF and SE nerveless and analyzed the data. MF, SE, JvS, and DDS wrote the manuscript. All authors agreed to the final draft of the manuscript.
Notes
Commendation: Fridell One thousand, Edwin S, von Schreeb J, Saulnier DD. Health organisation resilience: what are we talking well-nigh? A scoping review mapping characteristics and keywords. Int J Health Policy Manag. 2020;9(i):6–16. doi:10.15171/ijhpm.2019.71
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