Mapping health systems resilience in fragile and conflict-affected settings

The concept of health systems resilience is nowhere more important than in settings marked by conflict or other forms of fragility. Here not only may wider weaknesses in state and community capacities constrain the responsiveness of the health system, but also the demands made of that system may be severe in the face of extreme shocks. This chapter begins with a review of the common shocks and vulnerabilities in fragile and conflict-affected settings. Although the concept of fragility has most frequently applied at the national level (as in the designation of Fragile and Conflict Affected States (FCASs), the relevance of the concept at other scalar levels - specifically regional and local - is noted. The various ways in which fragility impacts health systems functioning are then considered. Conceptualization of resilience, which is particularly pertinent for fragile and conflict-affected settings, is then considered. Common features of such conceptualization are identified as a pro-capacities emphasis, a preventive focus, multi-level analysis and systems orientation. While acknowledging the technical value of the concept of resilience in contexts of fragility, critiques of the term - especially linked to power and inequity - are noted. The chapter then considers the role of system dynamics modelling for understanding mechanisms of health systems resilience in fragile and conflict-affected settings. It outlines the key features of this methodology, and its advantages and constraints. Case studies of examining health systems resilience using this system dynamics modelling approach are then presented. Examples are provided from Yobe State, Nigeria, in the face of the Boko Haram insurgency; in relation to primary care service continuity during the Gaza 50-day war of 2014; and regarding health systems adaptation in the face of climate change in Mozambique. The chapter concludes with a discussion of common findings across contexts. This includes the relevance of the processes of absorption, adaptation and transformation and identification of key strategies and capacities relevant to health system resilience including the presence of collateral pathways, stock retention capacity, trust and decision-making power.