Revisiting Health Systems Resilience After the Pandemic

The pandemic tested health systems around the world. In this interview, Marco Antonio Catussi Paschoalotto, PhD, affiliated with the University of Minho, shares his recent research into health system resilience, which included a literature review and interviews with health system experts.

What inspired your research into health system resilience?

The COVID-19 pandemic is the most severe global health emergency since the 1918-1919 influenza. It brought unprecedented challenges that tested health systems' capacity to cope and respond to shocks, ultimately revealing that the world was not prepared to respond to such emergencies. This raises the question of whether there is anything new we should look at, 2.5 years after the initial impact of the COVID-19 pandemic, to update knowledge on the health system resilience concept, stages, analytical framework, and implementation mechanisms.

How was your analysis designed, and who participated in the interviews you conducted?

We applied a deductive qualitative approach that comprised 1) a comprehensive literature review on health system resilience; 2) semi-structured interviews with world-renowned health system experts (with an interview guide informed by the literature review); and 3) content analysis of the interviews. The deductive qualitative approach was chosen to link the categories created by the scoping review with the knowledge collected from the experts in the interviews.

We interviewed 26 world-renowned health system experts, with experience in 27 countries across all continents, except Antarctica. The final sample included health systems perspectives from 7 of the 10 most populous countries in the world (China, India, the United States, Brazil, Nigeria, Russia, and Mexico), and some of the leading universities and organizations in health system research.

What are the key findings/concepts from your research? Did any of them surprise you?

First, the resilience concept was improved with the addition of one important element: context dependence. The capacity or ability to respond must engage the community, with an empathetic approach, and be adapted to local contexts. This understanding provides a refinement to the health system resilience definition as seen in the last studies.

Second, decision-making gains a central role in the response to shocks and crises, supported by its management capacity, connected with all the health system resilience stages, and in constant interaction with the health system and the context.

Third, the scoping review and interviews brought advances in the health system resilience dimensions, with a new and adaptable framework. The proposed framework advances the health system resilience analysis with a system model, based on the importance of the decision-makers and management capacity, powered by technology and information, to improve the third-level dimensions performance. Also, the framework shows the importance of communication and participation to connect the health system's performance with the context.

In your opinion, how can your findings inform health system decision-making, either now or in the event of future health crises?

In a comparative vision between high-income countries and lower middle-income countries, the main differences to incorporate resilience in health systems are resources, social protection capacity, logistics and supply chain structure, and information and communication technologies. Governance mechanisms depend on the democracy maturity stage and are more frequently found in high-income countries, while communication and social participation, context, and target dimensions play a similar role in all countries. To properly respond to crises, it is necessary to have all parts of the health system resilience framework work together.

Regarding the implementation of the health system resilience framework, it is necessary to understand people's expectations about what a resilient health care system would be, adapt the discussion to different government levels, and have policy support and a strong narrative. Therefore, organizations and actors must be connected, through an improved information system and flexible regulation, to better respond to a crisis. Having a stable team to manage the initiative and create a benchmarking environment between all the actors should be considered.

Is there anything else you would like to add?

We would like to thank the David Rockefeller Center for Latin American Studies (DRCLAS), Harvard University, for financial support, and São Paulo School of Business Administration, Fundação Getúlio Vargas (EAESP/FGV-SP), for institutional support.

About Dr Paschoalotto

Marco Antonio Catussi Paschoalotto, PhD, is an assistant professor at the University of Minho (Portugal). He was a fellow of the David Rockefeller Center for Latin American Studies at Harvard University; postdoctoral researcher in Public Administration and Government at the São Paulo School of Business Administration of Fundação Getúlio Vargas and in Health Economics NOVA School of Business and Economics (Portugal); and researcher of the PHSSR initiative (Partnership for Health System Sustainability and Resilience – London School Economics and World Economic Forum). 

Dr Paschoalotto earned his PhD and MSc in Organizational Administration at the University of São Paulo (USP – FEA/RP) and his BA in Public Administration at UNESP (Universidade Estadual Paulista “Júlio de Mesquita Filho”), with a study period at the University of Coimbra (Portugal). His research interests include health system resilience, public policy evaluation and subnational/local government performance.