Getting unstuck: reframing health systems strengthening and resilience in fragile and conflict-affected settings

Abstract
The concepts of health systems strengthening and health systems resilience are conceptually different but often used interchangeably in health policy and systems research and practice. Operationalising them can be difficult, but both are particularly relevant in contexts of conflict, violence and institutional fragility. In the current landscape of increasing complexity of humanitarian crises and constrained resources, understanding their meaning can be helpful to reaffirm their significance and value for achieving equitable access to care for the most vulnerable populations.

We propose reframing health systems strengthening and resilience across three key dimensions: actors, levels and time. Donors and multilateral and international organisations need to explicitly recognise and engage a broader range of local health systems actors, including community-based, faith-based and non-state actors, alongside national authorities. Actors should work across levels, from individual and communities to district and national domains, minimising gaps and vulnerabilities. It is also crucial to adopt longer time frames in the conception, design, implementation, monitoring and evaluation of interventions to strengthen health systems and increase their resilience in fragile and conflict-affected settings. This timeframe shift can help mitigate potential unintended long-term consequences of short-term interventions, support sustainability, improve learning capabilities and enhance transformation.

Such a three-pronged shift demands a deeper engagement with the affected communities and local health actors. It entails transferring decision-making power to them rather than exclusively transferring risks. This can ground health systems strengthening and resilience interventions in the contextual reality and needs rather than in externally defined priorities and frameworks.


Summary box
Health systems strengthening and health systems resilience are two distinct concepts that are often conflated, but they both are particularly relevant for fragile and conflict-affected settings.

The relevance of these concepts for achieving equity in access to care for the most vulnerable populations can be increased through shifting the focus to the centrality of people and the communities they are part of across three dimensions: actors, levels and time.

A more inclusive understanding of pluralism and diversity in health systems is critical to identify key actors who can contribute to strengthening health systems and operationalise their resilience, especially in areas where state health actors have no capacity or legitimacy.

At the same time, coordination and convergence of efforts to strengthen health systems and their resilience needs to happen across levels, from individuals to communities, from providers to policy makers.

Finally, and critically, humanitarian aid must move toward a longer time horizon, integrating sustainability and learning into donor investments and international interventions.