Harder, Better, Faster, Stronger: How are RHS Awardees Building Resilience within Health Systems?
The Resilient Health Systems (RHS) theme of COVIDaction consists of awardees that harness the power of technology to improve health data and service delivery. The commonalities between awardees’ objectives and challenges allowed the COVIDaction team to put together a shared learning agenda that could be used to enhance coaching support across RHS. As the first blog post in the RHS Learning Series, we share what we found when exploring the first question in the RHS learning agenda: How can innovative technologies be sustainably integrated into health systems at scale to improve health system resilience?
One of the buzzwords in health system strengthening initiatives during the COVID-19 pandemic has been resilience. Resilience first came into focus during the Ebola epidemic in West Africa, and the COVID-19 pandemic has only highlighted how important resilience is to consider for strengthening health systems. The COVIDaction Resilient Health System (RHS) theme contributes global work around resilience by supporting tech-enabled, innovative solutions to health system challenges that have emerged from the pandemic to foster health system resilience in response to COVID-19 and beyond.
When the RHS team began our work with the RHS awardees, one of the first things we did was ask them what was holding them back in the short term and what challenges they foresaw with scaling up in the medium to long term. From that feedback, we put together a learning agenda to improve the quality of the coaching support we could provide. One of the first things we noticed was that there were questions around the intersection of innovation and resilience. We suspected that greater engagement with the broader literature on resilience would provide an opportunity to reflect on how each RHS awardee uniquely strengthens resilience-critical components of the health systems they engage with. So we asked the following question: How could resilience frameworks be used to better clarify the role of technology and innovation for building health system resilience?
What is resilience?
First things first — what do we mean by resilience? In RHS, we think of resilience as having two key ingredients. The first is building the capability of health systems to respond to shocks to the health system, like a disease outbreak or a devastating economic recession. The focus here is on what happens during the acute stressor and includes making sure care is provided during crisis and data about the crisis is captured and used in real time. The other ingredient is making the overall system more resilient to withstanding the persistent pressures faced in many low-and middle-income country contexts, such as workforce shortages or supply chain disruptions. The awardees that RHS supports aim to do more than mitigate the impact of COVID; they want to contribute to creating a system that is stronger and more stable in the long term, even once the crisis subsides. By combining the two ingredients of crisis response and sustainable improvements, RHS enables health systems to perform better in good times and bad.
What did we find?
There are many different resilience frameworks out there, but we wanted to focus on what would be most relevant to our work. We asked questions like How would an innovator be able to use this framework? Would it help them better understand the potential impact of their innovation? In the end, we landed on two resilience frameworks we think can add value to the work of health sector innovators.
One of the most popular frameworks from Karl Blanchet et al., which has been used by USAID and others, categorises health system strengthening efforts as enhancing the system’s “capacity” to respond to shocks in one of three possible ways:
- Absorptive capacity enhances the health system’s ability to maintain the “status quo” with regards to service delivery, supply chain, data management, and more. For example, a solution that provides PPE to enable hospital staff to provide the same services to the same standard during the pandemic as it did previously has built the health system’s absorptive capacity.
- Adaptive capacity refers to the health system’s ability to make alterations and improve. These changes go beyond maintaining the status quo and seek to improve the health system in the short and long term. For example, adopting a new technology that monitors drug stock and provides stock-out alerts has built the adaptive capacity of the health system because this change will help to not just maintain but improve service delivery during good times and bad.
- Transformative capacity describes the health system’s flexibility and ability to rethink entire processes for health service delivery and redesign accordingly. These interventions are relatively rare because they involve a severe short-term disruption, but sometimes this change is necessary. For example, the roll-out of health management information systems across many countries in sub-Saharan Africa transformed the health system. By providing this infrastructure for data monitoring and accountability, these changes built the transformative capacity of health systems.
Another framework we thought could be useful for innovators builds on one of the most ubiquitous models out there for visualising health systems. This model, which comes from the World Health Organization, describes health systems as being made up of six big “building blocks”: leadership and governance, information, health workforce, financing, medical products, and service delivery. We liked how My Fridell et al. used that model as a basis of a resilience framework that describes different categories within each building block that can be strengthened to improve resilience. For example, by building diversity and flexibility within the health workforce, that piece of the health system is more equipped to respond to crises when they hit.
What does this mean for innovators?
Frameworks are great, but they only really serve a purpose when they are applied to real work. So that’s what we did. By looking at the way each framework applies to the RHS grantees, we are able to better understand the potential impact they can have.
We started by reviewing the ten-year goal statements developed by each RHS awardee to identify shared objectives and common themes. Across the cohort, innovators aim to integrate their work with the Ministries of Health in the counties they work in to ensure the continuity, management and ownership of patient care. Their combined vision includes well-resourced health care workers who perform end-to-end service delivery in all corners of a country. These innovations generate data for decision-making to promote effective, equitable and resilient health care systems, allowing for the flexibility for appropriate solutions to address chronic illnesses and non-communicable diseases and improve maternal, newborn, and child health.
Next, we used the “capacities of resilience” framework to better understand how our grantees fit into the bigger picture. We found that awardees have adaptive objectives with transformative goals. In other words, through their innovative and novel approaches, the awardees build the health system’s capabilities to change and transform itself to perform better in good times and bad.This was an exciting finding because most resilience work so far has focused on building absorptive and sometimes adaptive capacities, with much less transformative work being done. Basically, these findings show that RHS innovations have the potential for bold and unique impact.
Next, we looked at the health building blocks framework and began to map the objectives of each grantee against the different strategies for building resilience in each “building block”. We were able to see the potential impact of our entire portfolio, as there are innovations addressing each building block of the health system. We also saw that each RHS awardee works across and within multiple building blocks to build resilience. This was a really exciting way to see how innovations have potential to help strengthen systems across these building blocks if they are integrated at scale.
For example, Mango leverages a mobile application platform to improve commodity tracking, reduce stock-outs and enhance timely data essential in managing outbreaks, treatments and health education across several countries in the Sahel region. Fewer stock outs means that access to medical products is improved, in times of crisis and in calm. Conversely, Mango can also reduce over-stocking, which reduces financial waste. The data generated also improves the information available to monitor the health system in the near term, such as better responding to stock outs when they happen, and the long term, such as using the data to plan ahead and prevent future supply chain disruptions. Overall, Mango works across multiple building blocks to strengthen their capacity to absorb shocks and function more effectively in the long term.
Even more narrowly targeted innovations still have impact across more than one building block. Wheels for Life is part of the RHS workstream devoted to improving service delivery during times of crisis and calm, particularly to Kenya’s poorest communities. Their customer relationship management system provides phone-based teleconsultation and, if necessary, transportation to a health facility to pregnant women experiencing a pregnancy-related emergency.Their contributions to the health system’s service delivery building block is undeniable, but they also contribute to other areas. For example, they utilise student doctors to provide teleconsultation support. This builds the resilience of the health workforce both by providing additional training to the next generation of Kenya’s practitioners and also cleverly optimising how the limited health workforce is engaged.
The COVID-19 pandemic has reinforced how essential it is for a health system to be able to withstand and build back from extreme and unpredictable shocks, and how those shocks can often exacerbate underlying chronic vulnerabilities within the health system. Throughout this rapid research cycle, we have been able to reflect on the instrumental role RHS awardees are playing in building back stronger, interconnected, data-driven health systems.
To read more about findings from previous rapid learning cycles conducted by this team, check out these two blog posts: Rapid Research Cycle One and Rapid Research Cycle 2.
