Everyday health system resilience: the theory

The everyday health systems resilience framework was initially derived from empirical research undertaken in Kenya and South Africa examining the nature of chronic stress experienced within district health systems, and the locally led responses to such stress. This chapter presents the framework and discusses its core elements by reference to organisational and socio-ecological resilience theory, as well as wider empirical research. Resilience is understood as an emergent process within a complex, adaptive system generated by responding to stress, rather than as an outcome or system goal. Stress responses represent collective actions, developed and implemented by people and teams, and comprise combinations of absorptive, adaptive and/or transformative strategies. Generating, selecting and implementing such collective actions are, moreover, underpinned, or constrained, by the individual-, team- and system-level resources and practices which embody the system’s cognitive, behavioural and contextual capacities. These capacities include resources and practices that might support the inclusion of previously excluded groups, and their experiences, in decision-making, or deepen their exclusion. The capacities may also be transformed through responding to stress in ways that support the system’s responses to future challenges. Applying the framework in analysing empirical experience involves teasing out the strategies and capacities entailed in resilience processes, as well as the resources and practices in which the capacities are embodied. Such analysis offers insights of relevance to: health system strengthening in the face of chronic stress; deepening health system preparedness to respond to acute shocks; and developing systemic approaches to redress power imbalances and promote health system equity.