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What is a Shock-Responsive Health System?

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Tom Newton-Lewis, Sophie Witter, Matt Fortnam, Andrew Seal, Peter Hailey, Rithika Nair, and Debbie Hillier


The world is seeing an increased incidence of shocks – whether from natural hazards, epidemics like COVID-19, or conflict. Shocks are often responded to through humanitarian systems that run parallel to national public service delivery systems. This approach misses opportunities to strengthen national systems to manage future shocks, and is increasingly viewed as being unsustainable. Under the Maintaining Essential Services After Natural Disasters (Maintains) programme we are undertaking operational research across six countries (Pakistan, Bangladesh, Ethiopia, Kenya, Uganda, and Sierra Leone) that seeks to understand how national systems can be more responsive to shocks – scaling up to address needs that arise due to the shock, whilst maintaining routine service delivery and avoiding indirect effects from service disruption.

In this working paper, we set out a model of shock-responsiveness in health systems. This builds upon an evidence review (Witter and Russell, 2019) and background paper (Witter, 2019) prepared for Maintains by Professor Sophie Witter, and an initial conceptual model developed by the Centre for Humanitarian Change for their work under Maintains in Kenya and Uganda. The purpose of this model is to standardise the conceptual approach underpinning country and cross-country research under Maintains, and to facilitate comparative learning and synthesis. The model will be iterated based on emergent findings throughout the life of Maintains, as well as other developments in the literature and evidence base. The model has also contributed towards a policy brief prepared for the UK Department for International Development (DFID) on health system resilience in the context of COVID-19 Witter, 2020), as well as a detailed literature review for Maintains on COVID-19’s impact on health services in low- and middle-income countries, recovery measures, and potential reform policies, drawing also on learnings from past disease outbreaks (Nair, 2020).

The concept of shock responsiveness overlaps with the concept of resilience and borrows extensively from the literature on that subject. Resilience is a broader concept – taking into account a system’s ability to manage all kinds of change, not just shocks – as seen in the recent focus on ‘everyday resilience’ (Gilson et al., 2017). Resilience is also a contested term in the literature (Abimbola and Topp, 2018), and has been challenged based on its genesis within the domain of ecology, which models change as mechanistic. Increasingly, health systems are understood as complex, adaptive social systems whose outcomes depend on the decisions and interactions of the people within them (Barasa, Cloete and Gilson, 2017). This has seen a shift away from an emphasis on technical interventions that assume linear, mechanistic change, towards the need to create a conducive environment that supports and influences people to act in ways that create system resilience. We have tried to take into account this thinking in the model we present below. We have also tried to learn from one of the other critiques of the concept of resilience: that it often implicitly focuses on restoring the status quo that existed before a shock, whereas often that status quo is not a desirable state (Topp et al., 2016). Based on this understanding, part of shock responsiveness involves capitalising on the opportunity that shocks present to improve health systems and to make them more effective and better prepared to be responsive to future shocks.

Maintains is actively seeking input and reflection on this model from others working in this space. This note seeks to contribute to the community of practice working on resilient and shock-responsive health systems and health preparedness.