Shift 4: From fragility to resilience

Pandemics like COVID-19—as well as other shocks, including conflict or natural disaster—can devastate health systems and reverse years of hard-won health, development, and economic progress. “Health security” refers to the activities required to minimize the danger and impact of health shocks. Neither health security nor UHC can be achieved without building resilient health systems (UHC 2030 and SHFA 2020); WHO has reminded countries that the best foundation for resilient systems is PHC (WHO 2020a).

What is meant by resilience in PHC?

There is as yet no universally agreed definition of health system resilience. This report follows the influential definition proposed by Kruk et al. (2015) and widely adopted by the community of organizations working to advance UHC:

62 Health system resilience can be defined as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it. Health systems are resilient if they protect human life and produce good health outcomes for all during a crisis and in its aftermath.

Kruk etal.’s model characterizes resilient systems in terms of five fundamental attributes. Resilient health systems are (1) aware, (2) diverse, (3) self-regulating, (4) integrated, and (5) adaptable (Kruk et al. 2015).

Resilience is closely related to another concept widely discussed in the current health systems literature: preparedness (IWG 2017). Linguistically and practically, “preparedness” emphasizes pre-crisis actions to anticipate health emergencies, while “resilience” as defined by Kruk encompasses preparation, response, and post-crisis recovery. In this sense, preparedness can be considered as a stage of the continuous cyclical process to improve health system resilience (Rajan et al. 2021).

The overall definition of health system resilience and its conception as a cyclical process also apply to PHC. A PHC system is resilient if + It is well prepared for health emergencies.

+ It effectively responds to health emergences and maintains access to high-quality routine PHC services, as well as to public-health services during an emergency.

+ It recovers promptly once the health emergency is over by making the necessary adjustments, revising emergency action plans accordingly, and resuming its core functions.

A distinctive feature of a resilient PHC system is that, for each stage of the continuous cyclical process described, it maintains and reinforces three interconnected core functions: service delivery, surveillance, and communications (box 3.6).

Service delivery refers to the capacity of PHC to deliver both routine and emergency-related health services. Emergency-related PHC services have included, in the case of the COVID-19 pandemic, basic treatment and follow-up care for patients with mild symptoms, provision or facilitation of laboratory tests, triage, referral to hospitals, and mental health services. Routine PHC services typically include reproductive, maternal, newborn, and child health (RMNCH) services; infectious disease services (for example addressing HIV, tuberculosis, and sexually transmitted infections); and noncommunicable disease services. In many countries, COVID-19 forced overstretched health systems to suspend many PHC-level routine services in order to manage the waves of acutely ill coronavirus patients. The result, especially but not only in LMICs, has been large numbers of excess deaths caused not by the virus itself but by its effects on overall health service provision (box 3.7).

Surveillance mainly relates to the collection and reporting of high-quality and timely data on the disease burden and on the services delivered to the population. Especially for emergencies related to an infectious outbreak, passive surveillance—data collection and reporting activities—is usually accompanied by active surveillance—testing, contact tracing, and isolation management activities.

Communications refers to PHC’s capacity to conduct an ongoing dialogue with the community to promote trust, healthy behaviors, and actions for

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