As global leaders prepare for the G-20 Summit in Hamburg, they are prioritizing efforts to build functioning health systems “as a prerequisite for safeguarding disease outbreaks.” This is vital as the world prepares for the next Ebola-like emergency, but the organizational stress that comes with these shifts in priorities also requires attention if those efforts are going to succeed.
Any attempt to strengthen health systems must take seriously well-recognized stressors such as increasing workloads, changing health needs, resource challenges, and less-often identified but routine challenges. Critical amongst these are the stresses posed by managing people and relationships in the uncertain contexts that are the norm for health systems.
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Introducing new and revised policies is a major part of this chronic stress, even with the best intentions. The constant, and sometimes unconsidered, imposition of new initiatives and ideas on national health systems places great pressure on those working at the front lines of health care delivery and community engagement. Policy changes may include new treatment guidelines and protocols or quality assurance processes, as well as revised human resource and financial management rules, guidance on management structures such as community committees or new planning processes.
New policies are often implemented in a top down manner through the hierarchy of public sector bureaucracy. Often, they are implemented without preparation or adequate information sharing. In addition, new policies frequently come hand in hand with rigid accountability mechanisms — such as those linked to results and performance-based financing or to targets set for health programs, or to finance-linked audit processes that are part and parcel of “good governance” strategies.
These types of accountability mechanisms contribute to creating a “compliance culture" that undermines the managerial flexibility needed to problem-solve and deal with chronic stress or acute challenges. All generally come with yet another new reporting requirement. In fact, the amount of reporting done by frontline health workers in countries such as Kenya and South Africa is simply astounding. As a result, health workers battle to cope with changing demands from managers and communities, whilst remaining poorly supported and resourced.
So, what do global leaders need to do to nurture everyday resilience in the face of chronic stress — and so also strengthen health systems?
First, they need to understand that the "personal" is absolutely integral to a functioning and responsive health system. Without emphasis and acknowledgment of this, efforts to strengthen health systems will be futile. Managing human relations is identified by public health system managers in Kenya and South Africa, including primary care clinics, as a constant challenge in their jobs, and one for which they rarely have adequate training, acknowledgment and resources.
Constant policy change can undermine relationships, and is part of the wider organizational change commonly experienced by health systems. From the radical devolution of public management in Kenya in 2013, to the continuing processes of change experienced in South Africa since 1994, organizational change creates an unstable environment that makes managing other challenges — of people and resources — even more difficult.
Second, and most critically, global leaders must pay attention to how they engage with health systems. They should exercise their power much more cautiously than currently and in ways that empower others to lead and take action. They need to support national and local organizational capacity to problem-solve, motivate, and learn.
The “Thinking and Working Politically” and “Doing Development Differently” networks call wholeheartedly for global leaders to take heed, by refraining from imposing rigid blueprint approaches and paying “far more attention to issues of power, politics and local context.”
Ultimately, strong health systems depend on communities, health workers, managers, researchers and other local stakeholders being empowered to respond to the inevitable, future waves of change we all face. At Health Systems Global, our members represent these multiple groups.
Strengthening everyday resilience demands that we all — governments, donors, researchers, communities, health professionals — work with the resources that health systems already have — their people and relationships. This must be done as we take wider action to confront inequality at all levels. If we do not do that, then efforts to safeguard disease outbreaks will be meaningless.
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About the author
Lucy Gilson
Lucy Gilson holds a joint appointment at the School of Public Health and Family Medicine, University of Cape Town and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine. Her research broadly focusses on how to strengthen health systems to offer better public value, with particular concern for health equity. She also has interests in understanding health system actors’ decision-making, and how trust and power relations shape health system dynamics and complexity. She is a board member of Health Systems Global, and co-research director of RESYST — the Resilience and Responsive Health Systems research consortium — which conducted the research underlying this piece.
