Images: © UNHCR Sara Hoibak, Flickr (left) & Kellie Ryan IRC (right)
On this page we outline our research questions, hypotheses and associated questions for investigation, methods and expected outcomes. We also introduce both our resilience framework and theory of change.
Our primary research question is, ‘how do we develop resilience capacities to ensure responsive, effective, inclusive, gender-equitable and sustainable health systems in fragile and shock-prone settings?’
Within that there are a number of other questions which we are addressing:
Our approach to resilience is informed by work done by the team on health system resilience (Ager et al. 2015), organisational resilience (Alameddine et al. 2018) and individual resilience (Witter et al. 2017), which empirically modelled the feedback loops through which systems can manage shocks. ReBUILD for Resilience will take this work forward, further examining the capacities which underlie resilience and how these can be built and maintained. At its core, resilience concerns a system’s ability to flex in response to shocks and stresses. However, we recognise that systems perform at different levels, which is why our research will also focus on responsive, effective, inclusive, gender-equitable and sustainable systems. There’s a short essay on the framework’s development here.
Drawing on our resilience framework, we have specified ten preliminary hypotheses on resilience, for discussion, elaboration, testing and refinement in ReBUILD for Resilience.
1. The majority of reactions to stressors or shocks can broadly fit into one the following categories: collapse (i.e. the system is unable to respond and its structure is compromised) or adaptive/maladaptive response (absorptive, adaptive or transformative).
Relating to the above it is also helpful to monitor and explore how policy and practice stakeholders best respond to the communication of research results. For example, does framing research findings around resilience capacities and the core concepts above (absorption, adaptive and transformation) make it easier for policy makers and other health systems actors to understand and act upon research findings? For researchers, does this framing help tease out lessons and/or testing of interventions?
2. In relation to shock response, we typically observe systems deploying absorptive capacities first, with adaptive and transformative responses deployed after longer periods (typically three months or more).
Associated research questions: What level of shock would disrupt the above pattern? Prompting planners to think through different scenarios can assist with emergency preparedness.
3. Despite the pattern observed above, absorption, adaptation and transformation are not linearly dependent and can, and will be, deployed simultaneously in response to diverse shocks. The level to which systems draw on one or multiple approaches is likely dependent on the systems’ previous exposure to shock or stress, as well as underlying organisational culture and history.
4. Absorptive capacity is critically dependent on the availability of human, physical and financial resources and/or the ability to secure these at short notice. Systems that are most agile in the deployment of absorptive response have reflected on the material and financial buffer stock they require to operate in case of shocks (likely as part of emergency and routine service planning), and further have put in place flexible mechanisms for securing these resources (drawing on wider social networks and partnerships) and moving stock between areas.
5. Absorptive response is likely to be sustained by the availability of diverse health professionals, and further by high levels of human resource motivation, support and health workers’ dedication to their role in the short term. However, in the case of prolonged shocks/chronic stressors, motivation is likely to be depleted, leading to attrition and diminished performance (absenteeism, reduced quality of care, etc.), and alternative (adaptive) mechanisms for securing staff wellbeing and motivation are likely to be needed.
6. Adaptive capacity is critically dependent on dedicated leadership structures and distributed control. Systems that have open and inclusive governance structures, within which local leadership and distributed control of resources is both emphasised and nurtured, are likelier to quickly put in place, test and revise adaptive solutions to delivering services in times of shock. Especially for fragile and shock prone settings experiencing inaccessibility to specific areas, the wider social and collaborative networks of district level actors are key to securing service delivery.
7. Of the three approaches outlined, transformation is the most difficult to deploy as it requires systems making strategic and flexible use of multiple and novel pathways and resources, using most of the capacities identified. If deployed successfully, transformation usually sets the ground for future absorptive capacity of systems.
8. Approaches deployed in response to stressors or shocks may at times be maladaptive (meaning that the health system becomes more inequitable or ineffective over time). Where this is the case, we hypothesise that this is due to governance challenges, within the health system and beyond, including institutions, actors, leadership and power structures guided by self-interest and limited accountability to populations, and the absence of prosocial values in core institutions. Fragile settings run higher risks of maladaptive responses, given their social, economic and historic legacies, which can perpetuate their fragile and shock prone condition.
9. For all three approaches (absorptive, adaptive and transformative), active monitoring of socio-political environments, as well as population needs, is essential. Available information systems, as well as social and collaborative networks within the health system and beyond, are critical influences on the effectiveness of monitoring and transmission of information to relevant stakeholders.
The ability of systems to openly reflect on, and learn from, previous responses to shock and stressors, is critical to the deployment of transformative approaches. I.e. systems with inclusive and open governance, which actively monitor the results of their care delivery strategies and have put in place accountability mechanisms between health systems and communities, are likeliest to implement transformative approaches.
10. We further hypothesise that the shape of the social and collaborative network that actors have access to has a direct impact on the comprehensiveness, inclusivity and equity of the resilience approaches enacted.
How will our research improve life for the 1.8 billion people living in fragile contexts? Our theory of change outlines the process.
The diagram shows how inputs and processes will lead to outputs, such as high-quality research, which will in turn contribute to growing awareness, willingness and capacity to use evidence by local, national and international policy stakeholders. This will then contribute to changed policy and practice, leading to stronger and more resilient health systems, and ultimately improve access to and use of effective and equitable health care by people living in fragile and shock-prone settings.
The main approaches to be used, clustered by function, are:
Exploratory and developmental research: problem diagnostics, situation analysis, social network analysis, social connections analysis, life histories, participatory methods such as Photo Voice, feasibility assessment of pilots, policy analysis, expert and community consultation, capacity assessments, appreciative enquiry/positive deviance, political economy analysis, stakeholder mapping, discrete choice experiments
Explanatory: case studies, using mixed methods (often combining observation, interviews, focus groups, document analysis and surveys), prospective studies using quasi-experimental designs, analysis of routine health system data, re-analysis of existing data sets, cross-country comparative analysis, systems dynamic modelling
Evaluative research: impact evaluation, theory-based methods (including realist), contribution analysis, most significant change methods, implementation and process evaluation, participatory action research, outcome mapping, value for money analysis
Methodological and reflective learning: development of conceptual frameworks, improved metrics (eg for resilience and HSS), toolkits for research and engagement, intersectional approaches and analyses, assessment of effectiveness of our research, capacity-strengthening and research uptake strategies
Evidence synthesis: rapid reviews, scoping reviews, participatory reviews, systematic reviews
In all cases, we will start with a review of existing evidence, and research will draw on available data, while also attempting to strengthen these data in future. We will prioritise evidence and learning which can be generated from existing data, such as re-analysis of data sets, building on the wider resources of partners and associates and the flexible funding modalities planned.
As we are concerned with understanding what, why and how interventions (such as policies, guidelines, programmes, technologies or practices) work (or not) in ‘real world’ settings and testing approaches to improve them, we will mainly use implementation and embedded research approaches.
Throughout our work we will remain focused on equity, gender, disability, justice and social inclusion. We will provide on-going training and mentorship to staff and build on our gender and health system work in ReBUILD.
ReBUILD for Resilience will deliver high-quality, practical, multidisciplinary, operationally-relevant and scalable health system research in fragile and shock-prone settings.
As well as academic papers and briefing notes, we will produce a range of high-quality and demand-led outputs such as ‘how to’ guides for local decision makers, client engagement tools, methods toolkits and cross-country analyses. This learning will be disseminated through a comprehensive research uptake strategy.
You will find these outputs in the resources section.
Together these will contribute to strengthening resilience and building stronger systems for health across multiple levels (including at community level) and sectors (public, private, informal and mixes of these).