A question of resilience

Dr Steve Thomas (PhD) argues why it is important to make health systems resilient in the face of shocks, such as Covid-19

Catastrophic events occurring over the last decade or so have highlighted the need to understand how to govern health systems in the face of shocks. In high-income countries this was triggered by the economic crisis from 2008 and in low and middle income countries by the sudden outbreaks of infectious diseases, such as Ebola, as well as civil conflicts, with catastrophic consequences. Most recently, the emergence and rapid spread of Covid-19 has severely tested almost all health systems around the world.

While the first wave is over for Ireland, the duration of impact of Covid-19 is likely to be long-term. We may be teetering on a second wave and the economy will not recover for some years. In addition, there is the threat of Brexit to provide a more localised shock with implications for our health system and economy. Along with increasing, extreme, climate events, it seems that we may have to get used to shocks to the health system. The concept of health system resilience is important to understand to help us steer our way through the current and future shocks. There is much to learn from international experience of building health system resilience. In this article we will look at what is health system resilience to shocks, what strategies can build resilience and where do we go from here with Ireland.

Health system resilience

Fundamental to the idea of health system resilience is the notion of bouncing back from a shock or perhaps even ideally moving through it to strengthen health system performance. Yet resilience is more than just reacting to an event. Health system resilience can be best understood as the ability to prepare for, manage and learn from shocks. Resilient health systems are those that are able to manage well each stage of the shock cycle (see Figure 1). They must be: Well prepared for different shocks; able to quickly identify when a shock starts and how it is affecting the system; able to absorb the shock and, where necessary, adapt and transform the system to ensure that health system goals are still achieved; and, finally, once the shock has passed they are able to identify the legacy of the shock in relation to health system performance and remedy any negative consequences.

While preparedness is helpful and can mean that systems are quick to respond it does not guarantee a good outcome. Some of the allegedly best-prepared health systems for the Covid-19 pandemic, such as the USA and UK (https://www.ghsindex.org/), were found wanting. At the same time countries that were less well prepared, such as New Zealand and Cost Rica, were able to respond to the problem well with speedy and effective governance, limiting the impact of the shock.

As noted, in today’s global context extreme shocks are becoming more common (extreme weather events, epidemics, mass migration, economic crises). The nature of the required strategic response will be determined by the type and severity of the shock. Intuitively, the more severe the crisis the more resilience is required to deal with it.

Shocks can also be differentiated into those that primarily affect the demand side of the health system (eg, increased need for healthcare following health epidemics) and those that primarily or initially affect the supply side (eg, economic crisis and reduced resources). It is useful to understand the different pathways of each shock. For example, in the case of an epidemic, there will be an increase in demand for care. Nevertheless, the epidemic will also impair the supply side response. There will be a reduction in the ability to cope with all needs as health professionals are themselves impacted by the epidemic; and the need for focussing on the response to the epidemic may crowd out existing healthcare problems, which may create or exacerbate unmet need. In Ireland’s case this translates into even longer waiting lists.

Similarly, economic crises also have both demand and supply side impacts. On the demand side, households may experience reduced income and less ability to pay for healthcare, where they do not have free care, thus reducing their access to needed services. Moreover, adverse economic conditions such as a reduction in income, indebtedness or unemployment in themselves result in poorer population health. At the same time governments may find themselves with fewer resources and less able to supply healthcare when required, even offloading some costs on to households to manage their own budgets or reducing the state-funded basket of care. Ireland had some notable cost-shifting to the old and sick in the austerity era following 2008. Furthermore, austerity may produce demotivation of staff and even emigration further reducing the supply side capacity to meet needs).

Perhaps the biggest challenges is where one shock bleeds into another. With Covid-19 we have the reality of a series of shocks both epidemic and economic. Even as shocks go Covid-19 is extreme, a once in a lifetime occurrence.

Learning and lessons

So what can be done to build health system resilience in such difficult times? A team of researchers from Trinity College Dublin and the World Health Organisation explored this question, publishing its results in June 2020 (https://www.euro.who.int/en/about-us/partners/observatory/publications/policy-briefs-and-summaries/strengthening-health-systems-resilience-key-concepts-and-strategies-2020).

We conducted a rapid review of the literature examining the strategies and metrics used to build or evaluate resilience across all countries and all shocks in the last 10 years. The review utilised 16 peer review articles and nine reports in the grey literature. Thirteen strategies were identified to be deployed at different stages of the shock cycle. These strategies can be categorised according to governance, financing, resource deployment and service delivery, and are highlighted below.

• Governance: (1) Effective and participatory leadership with strong vision and communication; (2) Coordination of activities across government and key stakeholders; (3) Organisational learning culture that is responsive to crises; (4) Effective information systems and flows; and (5) Surveillance enabling timely detection of shocks and their impact.
• Financing: (6) Ensuring sufficient monetary resources in the system and flexibility to reallocate and inject extra funds; (7) Ensuring stability of health system funding through countercyclical health financing mechanisms and reserves; (8) Purchasing flexibility and reallocation of funding to meet changing needs; and (9) Comprehensive health coverage.
• Resources: (10) Appropriate level and distribution of human and physical resources; (11) Ability to increase capacity to cope with a sudden surge in demand; and (12) Motivated and well-supported workforce.
• Service delivery: (13) Alternative and flexible approaches to deliver care.

Next steps for Ireland

Space precludes me from examining and applying all of these strategies in detail, but I will highlight and expand on a few key approaches that I think will be essential to Ireland over the coming period in managing Covid-19, recession and Brexit-related impacts on the health system.

Boosting staff morale
In many ways health system resilience depends on the actions of staff under duress. Well-motivated and supported staff, in terms of effective human resource management and conditions, are more likely to temporarily take on extra burdens to see the system through a transition. Nevertheless, an extended shock tends to undermine motivation without very careful management and support. While health sector staff have responded valiantly to the current challenges, the potential onset of a second wave means that should not be taken for granted. Health workers cannot be expected to put themselves continually on the line without support. Boosting motivation and engagement is complex and multi-faceted, with a whole range of factors that can help, including but certainly not limited to salary increases.

Key factors are the safety and security of staff, alongside better equipment, guaranteed supplies, receptive management, feasible workloads, better training opportunities, appreciation and, of course, remuneration. No one strategy is sufficient, but a combination is helpful. Well-motivated staff who are supported are the key to a resilient response.

Improving access

The additional health burden of Covid-19 and the fear of contracting it have added to the already-present barriers to getting timely care when needed in the Irish health system. There are two key elements to solving this.

Firstly, where possible I would recommend dropping financial barriers and access costs. Many household incomes will suffer over the next year or two, but their health needs will not go away and many with chronic conditions may not be accessing appropriate care. In Lithuania, during their severe economic crisis, fees for accessing care were lowered for the duration of austerity to ensure people get care when needed. Similar strategies may be required for those with chronic conditions or those with a potential cancer diagnosis. One of our own key successes over the austerity era was that the medical card scheme proved durable. Still, many elements of care have a financial barrier for many people and this may not prove helpful where demand for that care has been additionally suppressed by fear of Covid-19 contraction.

Secondly, we need to encourage flexible and innovative provision. One of the most amazing responses to the pandemic was the speedy and effective way that the GP community moved to remote consultations with the Government paying for access for Covid-19 patients. Such rapid innovation continues to be required. The huge waiting lists prior to Covid-19 have been exacerbated. All resources need to be galvanised – telemedecine, phone consultations, contracting with private sector capacity on an industrial scale, home-based care. Using private hospitals to clear the huge waiting list does not solve the causes of long waits for public care but there is little alternative with the problem at hand. While some existing commitment to private patients would need to be honoured, all patients should be on an equal footing for care based on needs.

Finally, effective leadership is obviously important where it is visionary, a step ahead and solidarity building. While this is not new I would recommend that the solidarity building component extends not just to effective communication but also to financing. The measures to cope with this pandemic will cost. I cannot think of a more needy time than this. Historic cases of resilient responses often show health systems drawing on rainy-day funds or utilising counter-cyclical financing of the health system. This is not the time for austerity. Given low interest rates and exceptional need, government borrowing would be very wise to fund the extra capacity required. Furthermore suggestions of leaving older people to die have little sense or cost-effectiveness when your economic and public health response depends on social cohesion and trust.

A key lesson from the resilience case studies is it is never too late. Strategies to boost staff morale, improve access and avoid austerity financing will pay dividends. Even if our health system was unprepared, much can still be achieved to save lives, secure a better functioning health system and protect livelihoods.

Dr Steve Thomas (PhD) is the Edward Kennedy Chair of Health Policy and Management, Trinity College Dublin, and a Health Research Board Research Leader