Hello listeners. I'm Dr. Kim Ozano, and this is Connecting Citizens to Science a podcast, where we talk about the ways that researchers connect with communities to solve challenges together. I'm really excited to bring you a brand new mini series called 'Stories of Resilience Local Lives and Health Systems'. This mini series is brought to you by ReBUILD for Resilience, which is a research consortium that examines health systems resilience in fragile settings that experienced violence, conflict, pandemics, and other shocks. Many people have joined the effort to build resilience in healthcare systems, however it remains a concept that is still quite contested and often difficult to comprehend. So, in this episode, we bring together experts who work in the field of health systems resilience to talk about both the concepts and the language that is used and how this invites participation from communities and other stakeholders. We're also going to be discussing how communities are central to health systems resilience and how we can work with them in a way that suits them and to help us do that. We have a co-host with us today, Professor Sophie Witter, who is a professor of International Health Financing and Health Systems at the Institute for Global Health and Development Division at Queen Margaret University in Edinburgh. She is also a member of the Institute for Global Health and Development Research Centre. Our two guests today are Dr. Sushil Baral, who is the managing director of HERD International, which is a research and development organisation that is dedicated to addressing community needs and emerging health and development issues in Nepal and globally. Our second guest is Dr. Seye Abimbola, who is an associate professor at the university of Sydney and was the previous editor in chief at the BMJ Global Health. Dr. Abimbola's teaching and research has focused on knowledge practices and global health, health systems governance, and the adoption and scale up of innovative health systems. So let's hear from our co-host professor, Sophie Witter. Sophie, welcome to the podcast. And we're really looking forward to this very important conversation. But before we begin, could you talk us through some of the key concepts that we should be thinking about? And why it's important to talk about health systems resilience now more than ever.

Thanks for inviting me onto this exciting discussion. I think the concept of resilience in relation to health systems is something that has really grown in the sort of public debate and academic discussion since the Ebola crisis in West Africa in 2014. Then as we know, both regions and the whole world have been hit by a series of shocks and pandemics, notably COVID, but even now, there's really a sense that we're living in the era of poly crisis. So multiple different stressors and shocks, which really create challenges for providing, um, essential and quality healthcare for populations globally. So we were interested in resilience, which is broadly understood as a capacity to maintain functions and health system functions during shocks and crises. Um, and we try to look at some of the learning from other areas of discipline, other, topics, other literatures that look at kind of complex systems like health systems. Um, but we continue to debate the politics of the term as well, like who is expected to be resilient and what does that mean? And who is bearing the brunt of, of sort of managing these shocks and crises? So in ReBUILD, we're looking at research on how to develop resilience capacities. We're focused on local health systems, which are fragile and shock prone. So again today, I'm really interested to talk about how we can do that. What's the action involved? Because I think a lot of the literature has been around measurement and concepts, but less about how we engage to support resilience, assuming it's a good thing. I'm going to start by just asking Sushil and Seye about how they got involved in this topic. Um, and really what their experiences were in terms of resilience in their local health systems and what can we learn from that. So maybe over to you, first of all, Sushil?

Thank you, Sophie. I was born in village. I'm a village person, where I've seen how the community engaged or disengaged when they were in need of health care services in those communities. I come from a village where many things were not put in place. The many basics were not put in place, including the health system. My motivation working with the community towards understanding the resilience and health system actually started from those villages where I worked as a village health care provider, walked hours and hours long to reach out to the community and provide the basics when they were in need. So that is the main motivation that engaged me in resilience.

That's fascinating. And you've already gone straight into this. One of the big topics in resilience is around knowledge and how that is used and it's whose knowledge and how does it feed back into building that system, which is exactly what you're describing. And you sort of witnessed it from bottom to top there. So yeah, that's fantastic. Seye, how does that relate to your, how you got involved in the resilience discussion?

I worked for about three years at the National Primary Health Care Development Agency in Nigeria, strengthening the primary healthcare system for services. And something that struck me as remarkable was that at the community level in many instances, the community health committees were responsible for picking up the failures of the different levels of government that that were sort of in a sense above them. So in terms of helping to augment the supply of services, helping to, facilitate the demand for services. And in some sense, that was where I started to think about the idea of resilience, that what that level of governance at the community level was doing is, in fact, ensuring that the system was resilient to the failures of the government, the three layered government that sat above them.

I think that that does lead really into this thinking about where does responsibility in a system sit and where does power sit? Because they're often divorced, aren't they? And maybe that's what we're getting to here that often, you know, kind of power shifts upwards in a system, but ultimately responsibility for keeping things going, especially when there's a shock or crisis is often lower down. So perhaps resilience is a bit more about connecting these levels effectively and making sure there's a fair distribution of that power versus the responsibility, because one of the critiques, as you know, and you've been part of that, that writing, Seye, is that, um, you know, resilience puts the burden on local actors to cope and it says you're doing well because you're coping. But actually, is that what we want when we design a resilient system, just to put a lot of that responsibility and that kind of managing shocks challenge at the bottom of the system for people who often have the least power and resources. So any reflections on resilience? Is it a helpful term or are we using it to put too much weight on those local actors?

I'm still not convinced it's a helpful term. In health systems and global health discourse, the question I kept asking myself is, how is this different from strengthening? And when I was thinking about Nigeria, as I described earlier, and I was saying to myself, well, um, a strong health system is a robust health system. In other words, you want there to be power and resources at different levels of governance and ability to function and be connected. And to do that the system needs to be robust in some way. In other words, it needs to have not just what it needs to function today, but what it needs to function in the instance of a shock or stress. And when we say system is resilient, it often will seem to me that what we mean to say is that the system has managed to cope in spite of the odds.

There is quite a similar debate about health system strengthening as well for similar reasons in as much as the term came up a lot in relation to global health institutions initially. And so the question is, is this an external agenda? Is this something that actually resonates locally? So in a way, we can ask the same questions about, I think, about health system strengthening as we can about resilience.

The big question to me, does the resilience mean same thing, a different thing for different people. I think it's, it's very hard to come to a common consensus in any system including health systems. In any country, the health and well being of the people is broadly guided by the politics. Politics, basically defines the policies of system, uh, of the country and how that policies, uh, acted in reality, uh, how those policies are well informed from the evidence, from the power, from the community, from the context that we leave around is, is very, very important to me, uh, when we talk about resilience. I think it requires to be a more, more holistic concept, bringing the whole of the society, whole of the government, whole of the actors together. But it's true that we have seen our actors are guided by their own preferences where the politics come into play. Institutional preferences, all the development partners, they have their own way of defining resilience in their own work plan and agenda.

When we talk about communities and we use language like resilience or strengthening health systems, this is the type of language as academics we use in our daily lives. But Sushil, you know, you were a village health care provider and Seye, you talked about your connection with communities. And we know that language can often create distrust within health systems, or language can facilitate spaces where communities feel confident to participate. Is there something around understanding how to communicate key concepts and using language that is more inclusive for communities?

It's very important. So to me, to answer your question, engaging community by knowing the community better, because these communities are different in different places, you cannot really take a blanket approach of community engagement and communicating our language to them. Rather, I prefer listening their language and building on that.

Yeah, I'm just going to jump in there as well with the reflection because I've one of the things I've thought about is the extent to which resilience and fragility kind of mirror each other. We were doing some work with colleagues on fragility. Ultimately, I think we sort of came down to the view that fragility rests in a kind of disconnect between the system and the communities. That's where a lot of the kind of fragility features come in, which exactly links, I think, to your point, Sushil, about how well we're communicating in a very two way sense.

I think that resilience is the term we use, is how we frame things, is how we try and interpret what we see when we look at systems and how people act within those systems and how they are designed. And it's not how people in the system would necessarily describe or define what it is they're experiencing or going through. And one of the things I care about very deeply is the interpretive lenses we place on systems can in fact marginalise people who function within the systems and how they interpret their own realities. And I'll give an example if you go to many community health committees in Nigeria and sort of ask them what, what is their role and responsibility, one of the things they will tell you is that our role is to fill the gaps left by government action. In fact the paper that I wrote about, committee of committees was titled 'The Government Cannot do it All Alone'. In other words, a lot of their own reflection about their role speaks to how their role has been framed repeatedly. It is about quote unquote self reliance, rather than accountability. They don't necessarily think of their role in terms of making demands, putting pressure, um, and, and functioning in that capacity, but rather what can we do for ourselves? Now that's important. What can we do for ourselves is absolutely important, but so is what should the government be doing that the government isn't doing, right? And I find that one of the things, one of the harms, in my view that the language of resilience can do is to, in fact, further, um, emphasise, um, that self reliance role at the expense, in many cases, I suspect, of that accountability function that the community may, may play.

So, okay, I think that's a good point to move on to, in a sense, where do we go from here? Because what we've shown is that it's very contested and it's debatable how useful it is. At the same time, it is being used because I think it has some intuitive sense that clearly links to challenges that are going on at the moment in the world. But if we think about how do we, build the capacity of communities to both be self protective in some senses, if we use that word rather than self reliance, but also demand accountability, because I'm absolutely on board with you that that's something that in many settings is, is really lacking and it's very problematic.

The way that I'm coming to think about and talk about resilience is, is almost to replace the word with learning. And I find, frankly, that in almost every instance, learning does the job as well, if not better, in fact. And what learning does essentially to put that active agency into resilience. A system that is resilient is one that learns, that can learn from its past and present from its neighbours. And when I think about learning in that way, I'm thinking to myself, how do we then build capacities for learning? And you mentioned connection earlier, but also the ability to say, where are the platforms in each system that allow for that connection to happen and could be in a, in a small community, the marketplace could be the platform. It could be, it could be a village square, so it could be a place where people discuss what the experiences are and able to share ideas and learn and function differently. In other settings, it could be the media, It could be academics like us who actually do move knowledge around as it were. when I think about resilience, I'm thinking learning

Yeah. Thank you. Um, I think that's an excellent point and definitely the learning health system is again, a topic that's risen up the agenda recently and I think rightly so, because it does validate people understanding their own context better than others who are more removed. Um, Sushil, what should we be doing in terms of our engagement? So we're building connectors, is the point that Seye was making, which I think really builds on a lot of the literature around resilience, which is about who has the connections, how do groups work together. Certainly we've seen that a lot in our ReBUILD research, haven't we? What other areas should we be contributing to, to pushing in terms of the agenda?

You can describe the resilience capacity in a number of, um, points and then really understanding where the gaps are. And then working together, with the co-creation component, with the stakeholders, including the community. I bring here the word co-creation in a very meaningful way. You know, abiding the principles of community engagement with the meaningful co-creation with them, having a joint assessment, having a joint planning, and defining this coordination and collaboration structure, uh, put in place, which continuously assist and acted upon linking with the policy and the practices. It is not just a tokenism. It harmonises the power imbalances when the co-creation is acted in local reality considering the local context. So the important point I bring here is the properly defined and agreed coordination and collaboration structure put in place, which often, you know, continuously works in terms of enhancing the resilience capacity.

Thanks very much Sophie for guiding the conversation. I've really enjoyed learning. And I really liked the idea of replacing language like resilience with learning health systems, it's straightforward and language that is more accessible to all involved in building health systems resilience. And once again, the value of co-creation has come out really strongly. So for the final question, I would like to ask all three of you, what is the one piece of advice that you would give to people that are working in different contexts, trying to strengthen or learn from health systems?

It's the million dollar question, isn't it? But I think to me and listening to the conversation really, what's coming out is that the, the key elements are connections, kind of knowledge and resources. And so I think our effort for all of us should be, and this goes from kind of global level down to local, should be on getting these three elements available at the local community and health system levels. Because very often systems are set to kind of move these three elements upwards. Whereas what we've been saying, I think a lot of the conversation is that we need to be empowering local actors, and especially those groups that are most marginalised. But I do also think we need to look at the fair distribution of responsibilities across the system, because I also recognise that some issues need national and international action. They can't all be resolved at the local level, and we don't want to put all the responsibility there, so it's about that balance has to be right.

One of the dangers of playing the devil's advocate is that sometimes, sometimes you become the devil yourself. And in this regard, I often push back when people say fragmentation is such a bad thing. It's a term used pejoratively and for me, a centralised unified system, is a system that is not particularly resilient to shocks. Um, and so I'm always looking for where the lines of decentralisation are and how to make sure that we don't remove them simply because we want things to be simple and streamlined and straightforward. Sometimes those are valuable. Um, often we do that at the risk of a potential future shock or stress really breaking, breaking apart the system. So one key advice is to not be too quick to remove fragmentation, quote, unquote. And second is to be alive to the possibility of facilitating learning connections anywhere in the system..

Amen. Sushil.

I would say we should prioritise the learning aspects of the health system, feature that in policy, and more strongly listen to the community. The system has to create space, ample space and opportunities to bring the community into the mainstream and, and hearing them is very, very vital towards the local system resiliency. There's a message to global health actors, uh, in order to really have a coordination mechanism, better coordination mechanism at the global level to this identified priorities and collective mechanism to pull the resources towards the resilient healthcare system, uh, with the evidence informed policy.

Some excellent pieces of advice there and lots to think about. So thank you for our guests, for joining us and taking part in this conversation, we've really appreciated your being part of Connecting Citizens to Science and thank you to our listeners as always for joining us and listening to this episode. Please do rate share, and follow and all of the different platforms. Also listeners, if you have any comments and opinions or would like to be on Connecting Citizens to Science or have an episode or mini-series that you would like us to host, please get in touch with us at the Stop, Collaborate and Listen Agency. We would really love to hear from you. For now enjoy the rest of your day until next time. Bye from Connecting Citizens to Science.