Building healthsystem resilience inan uncertain world
An Economist Impact report

Supported byBuilding health system resilience in an uncertain world

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Contents

3

About this report		

4

Introduction

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Chapter 1: The value of resilient health systems

10 Chapter 2: Building resilient systems – the challenges
13 Chapter 3: The way forward
25 Conclusion© Economist Impact 2022

Building health system resilience in an uncertain world3

About this report“Building health system resilience in an uncertain world” is a report written
by Economist Impact and supported by UNOPS, the UN agency with acore mandate for infrastructure, project management and procurement.
This paper explores key strategies for strengthening health systems in lowand middle-income countries, including the role of governance, financing,procurement and infrastructure in building resilience, and draws on a series
of in-depth interviews.
Economist Impact wishes to thank the following experts, who kindly
agreed to participate in the interview programme for this report (orderedalphabetically by surname):• Dr Shyam Bishen, head of health and healthcare, World Economic
Forum• Dr Somsak Chunharas, president of the Thai National HealthFoundation and former deputy minister of public health for Thailand• Francesca Colombo, head of health division, OECD
• Professor Lucy Gilson, professor of health policy and systems, London
School of Hygiene & Tropical Medicine/University of the Western Cape
• Janeen Madan Keller, senior policy analyst and assistant director of
global health, Center for Global Development• Stefan Nachuk, senior advisor, health systems, Bill & Melinda Gates
Foundation© Economist Impact 2022

Building health system resilience in an uncertain world

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Introduction

A multitude of shocks—including the covid-19
pandemic, ongoing conflicts around the world,
climate change and economic instability—have
severely challenged global health systems inrecent years.
Although it is likely that the most acute impactsof the pandemic are behind us, further shocks
are inevitable and turbulence is mounting.
Emerging risks include new infectious disease
outbreaks (as illustrated by the recent surge inmonkeypox cases) and supply-chain disruption,
as well as slower-burn stressors such as ageing
societies and increasing incidence of noncommunicable diseases (NCDs). In particular,
the climate crisis constitutes a severe threat to
global health, given the increasing frequencyof extreme weather events such as floods,
heatwaves and droughts.
Developing the resilience of health systems
will ensure that they are able to withstand thepressures of acute shocks and longer-term,
chronic threats. This is particularly importantin low- and middle-income countries (LMICs),
which are typically less well equipped to financeand resource health systems’ responses tosurges in demand. The last few years have1

demonstrated the significance of health system
resilience, particularly in LMICs. There is now awindow of opportunity to consider what actions
can be taken to strengthen health system
resilience.
This report draws on interviews conductedwith a number of experts to examine the valueof building resilient health systems (Chapter1), the challenges in building resilience within
LMICs (Chapter 2), and what strategies,
including improvements in procurement
processes and health infrastructure spending,can be adopted to foster resilience (Chapter 3).
Key findings include:• Strong co-ordination at the supra-national levelis particularly important when countering global
threats to public health, such as infectious
disease outbreaks and climate change.
• Value-based healthcare (VBHC), whereby
providers are paid for patient outcomes
rather than the services they supply, canensure that healthcare financing is used
more effectively and incentivise activities andinvestments that are beneficial for day-to-day
operations and the emergency preparednessof health systems.1

https://impact.economist.com/perspectives/sites/default/files/EIU_Medtronic_Findings-and-Methodology_1.pdf© Economist Impact 2022

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Building health system resilience in an uncertain world• Digital technologies can help to improveaccess to healthcare services and reduce
costs for patients. However, they must be
considered a complement—rather than asubstitute—to investments in other areas of ahealth system.
• Increased transparency in procurement
processes plays an important role in enabling
health systems to purchase and maintainadequate stocks of medical supplies, thus
fostering health systems resilience.

• Dispersed and mobile networks of basic
healthcare facilities can ensure greater
healthcare coverage, particularly forunderserved populations. Furthermore,
the design and location of such physicalinfrastructure will play an increasingly
important role in determining resilienceagainst climate change-related threats.

What is health system resilience?
The covid-19 pandemic has drawn the attention of policymakers, healthcare providers and thegeneral public to the importance of health system resilience. However, there is little consensus on
how to define it. Academics disagree as to whether the term should only apply to the resilience of
health systems against acute shocks (such as pandemics or natural disasters) or whether it should
also account for resilience against chronic stresses (such as antibiotic resistance or an ageing
population). This report adopts an expansive definition of resilience, covering a wide variety of
threats and challenges that health systems may face. This approach, which was corroborated
by our interviews with experts in the field, is modelled on that set out by Hollnagel et al (2013),
who define resilience as “the ability of the healthcare system (a clinic, a ward, a hospital, acountry) to adjust its functioning prior to, during or following events (changes, disturbances andopportunities), and thereby sustain required operations under both expected and unexpectedconditions.”2
For this report, our interpretation of resilience captures the capacity of health systems to (i)prepare for and effectively respond to crises (including both acute shocks and chronic stresses);(ii) maintain provision of essential healthcare services during periods of crisis; (iii) demonstrate
flexibility, such that health systems adapt with agility to changing population needs, pressures andcontexts; (iv) learn from experience, with the result that health systems are able to improve their
responses to challenges over time.

2

Hollnagel, E. et al. (2013). Resilient health care. Ashgate Studies in Resilience Engineering. Surrey, UK: Ashgate Publishing.
© Economist Impact 2022

Building health system resilience in an uncertain world6

Chapter 1:
The value of resilient
health systems
Health systems will always face diverse and unpredictable challenges.
Building resilience will help countries circumvent future costs, while also
generating broader health and social benefits in times of stability.

The costs of under-investment
The covid-19 pandemic has tragicallydemonstrated the costs that can result
from a lack of health system preparedness.
Shortages in essential medical supplies suchas personal protective equipment (PPE) werea major problem in many countries. In someinstances, lack of PPE meant that medical staff
and other front-line workers were forced tocontinue working without adequate protection,
increasing their likelihood of exposure andonward transmission of the virus.3 Furthermore,
health systems were unprepared to respond to
shortages in the medical workforce, which arose
as a result of the twin pressures of increased
demand and higher absenteeism due to sickor quarantining medical professionals. These
shortages exacerbated issues of overcrowding
in emergency departments. Finally, lockdown
measures resulted in the delay or cancellation ofroutine health services, including vaccinations
and elective surgeries. Crucially, the effectsof health service disruptions and lockdown

measures were more pronounced among themost vulnerable groups, thus widening preexisting health and socio-economic disparities.
Health systems’ under-preparedness forthe pandemic also had damaging impacts
on the broader economy and society. Illness
and worker absenteeism, which arose asa result of the poorly controlled spread of
the virus, resulted in productivity losses
and lower tax revenues for governments.
Overall, the pandemic instigated a worldwide
economic contraction, leading to a dropin real GDP of 2.2% in 2020 in emergingmarket and developing economies.4 The
protracted economic downturn threatens to
set back decades of progress in healthcare
and poverty reduction made within LMICs
and hampers progress towards achieving the
UN Sustainable Development Goals (SDGs).
For instance, extreme poverty, defined as
the proportion of people living on less than
US$1.90 a day, rose by roughly 3% in West
Africa in 2020.5

https://www.bbc.com/news/newsbeat-52440641
https://blogs.imf.org/2021/04/06/managing-divergent-recoveries/
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https://news.un.org/en/story/2022/01/1110192
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4© Economist Impact 2022

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Building health system resilience in an uncertain world

The pandemic’s impact on government budgets
is likely to have long-lasting repercussions foraccess to healthcare, particularly in LMICs.
Many governments were forced to spend large
sums of money on their pandemic response
programmes, in spite of their tax revenues
being significantly reduced. This has led to theaccumulation of high volumes of government
debt. Servicing this debt in the future mayforce governments to constrain public budgets,
including expenditure on health.6 This isparticularly true of LMICs, whose governments
face tighter funding constraints than theirwealthier counterparts. LMICs’ government
budgets have also been threatened by recent
macroeconomic disturbances, owing to the factthat their economies have typically been more
exposed to pandemic-related disruptions to
trade, travel and foreign direct investment.7
The argument for investing in strengthening
health systems is not limited to mitigating thecosts incurred by future pandemics. A multitudeof other threats will challenge the functioning

6
7of health systems in the future, and proactive
investment in building resilience today is
crucial to early action and thus minimising theimpact of these threats. Shyam Bishen, head ofhealth and healthcare at the World Economic
Forum, notes that a range of threats are likely
to impact health system resilience in LMICs,
including the spread of infectious diseases,
increasing incidence of cardiovascular diseases,
worsening mental health and increasing
frequency of extreme weather events arisingfrom global warming.

“Unless health systems
are made to be strong,sustainable and resilient,
we will face serious
challenges in future.”
Dr Shyam Bishen, World Economic Forum

World Health Organisation. (2020). Global spending on health: Weathering the storm. https://www.who.int/publications/i/item/9789240017788
World Health Organisation. (2020). Global spending on health: Weathering the storm. https://www.who.int/publications/i/item/9789240017788© Economist Impact 2022

Building health system resilience in an uncertain world

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The resilience dividend
By definition, building the resilience of healthsystems should improve a country’s capacity to
prepare for and respond to a crisis. However,some have argued that improvements inresilience should also yield everyday benefits
to population health.8 Margaret Kruk, aprofessor of health systems at Harvard
University, calls this double benefit to healthsystem performance, in times of both crisisand stability, “the resilience dividend”. Thisis because the building blocks of a resilientsystem—whether a skilled healthcare workforce,strong data tracking capabilities or a high levelof public trust in health institutions—also
support the equitable and effective delivery ofhealth services on a day-to-day level.9

A resilient health system can help to mitigate
the costs imposed by acute and chronic threats
on health, social and economic outcomes.
Crucially, however, the resilience dividendmeans that building resilience also helps todrive improvements in health outcomes more
broadly. Furthermore, the value of healthsystem resilience can also be understood
through its contribution to achieving the SDGs
(see insert: “Building health system resilience:a key pillar of the Sustainable Development
Goals”). These benefits are particularly salientin the case of LMICs, where limited government
budgets mean that the value of investments inresilience must be made especially clear.

“Investments that you are making
today to improve the performanceof your health system—that
is, addressing things like basic
infectious disease problems or
maternal child health— will havethe added benefit of helping you
prepare for an unexpected event.”
Stefan Nachuk, Bill and Melinda Gates Foundation

8
9

Kruk, M. et al. (2015). What is a resilient health system? Lessons from Ebola. Lancet 385(9980): 1910-2
https://www.theglobalfund.org/en/resilient-sustainable-systems-for-health/© Economist Impact 2022

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Building health system resilience in an uncertain world“If a system is resilient it can better
cope in a crisis—but it can also use
those characteristics to do manyother things in a positive way.
Resilience is beneficial for healthin general.”
Dr Somsak Chunharas, president of the Thai National
Health Foundation and former deputy minister ofpublic health for Thailand

Building health system resilience: a key pillar of the Sustainable Development
Goals
Health system resilience is highly interlinked with the UN Sustainable Development Goals (SDGs).
In particular, it has the potential to make a valuable contribution to the following:
SDG 2: Zero Hunger—End hunger, achieve food security and improved nutrition, andpromote sustainable agriculture.
Threats to global nutrition are set to increase as climate change exacerbates the frequency of
extreme weather events, including heatwaves, floods and droughts. Building the resilience of
health systems—such as by extending the reach of emergency care across remote rural areas—will
also help to mitigate the impacts of acute food shortages and malnutrition.
SDG 3: Good Health and Wellbeing—Ensure healthy lives and promote wellbeing for all at
all ages.
Ensuring the health and wellbeing of the general public is contingent on health systems’ capacity
to effectively respond to threats and challenges, whether acute or chronic. Furthermore,
initiatives aimed at building resilience, such as expanding access to healthcare services in remote,underserved areas, will concurrently accelerate progress towards universal healthcare coverage.
SDG 5: Gender Equality—Achieve gender equality and empower all women and girls.
Gender disparities in access to healthcare constitute a major barrier to fostering resilience inmany LMICs; a study in Central Malawi found that women were less likely than men to receive
financial aid for healthcare (68.8% versus 88.8%) and more likely to underuse critical healthcare
services (37.2% versus 22.4%).10 As such, initiatives aimed at building health system resilience cansimultaneously bring about improved health outcomes for women.
It is estimated that an additional 18m health workers are needed in LMICs by 2030 in order toachieve the SDGs.11 Thus, boosting the participation of women in the healthcare system can play a
critical role in enhancing capacity within the healthcare workforce and fostering resilience.

10
11

Azad, A.D. et al. (2020). The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi. Arch Public Health 78: 119
Ayaz et al. (2021). Participation of women in the health workforce in the fragile and conflict-affected countries: a scoping review. Hum Resour Health.19 (94): 1-14.
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Building health system resilience in an uncertain world

Chapter 2:
Building resilient systems –the challenges
Despite strong incentives to shore up health system resilience, significant
challenges—health system fragmentation, limited domestic resourcing,
constrained manufacturing capacity and poor procurement practices— remain
stubborn barriers to resilience.

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13

There are strong incentives for all countries tobuild resilience in their health systems. However,a number of barriers hinder progress towards
building resilience in LMICs. Remedying these
deficiencies is crucial to ensuring that healthsystems can effectively respond to futurechallenges and threats.

government ministries (such as the Ministry ofFragmentation of health systems—including
incoherence in policy and financing—is aparticular barrier to resilience in LMICs.
Fragmentation occurs when many different
health “sub-systems” co-exist, with eachproviding care for different parts of a country’s
population. Fragmentation is problematic, as it
results in gaps in the provision of health services,with certain segments of the population—often
the poorest—being left without coverage.12
This significantly reduces the capacity ofhealth systems to mitigate systemic shocks.
For example, fragmentation has hindered
the Yemeni health system from effectively
responding to the ongoing humanitarian crisisin the country.13 In particular, the fragmentationof healthcare provision between different

responsibility for public health matters—such as

Defence, which provides health services to thearmy) has jeopardised the ability of the Ministryof Public Health and Population to implement
nationwide public health programmes that might
alleviate the crisis. Furthermore, a lack of cooperation between different entities with sharedwater or sanitation—has constrained institutional
capacity to contain outbreaks of infectious
diseases, such as cholera.
Inadequate or non-existent surveillance andearly-warning systems also present an obstacle
to the development of health system resiliencein all countries, particularly LMICs. Multi sectoral,transparent and agile surveillance and response
systems play a critical role in ensuring thatdisease outbreaks are identified early and theirspread is rapidly investigated and minimised.
Where deficiencies exist within these systems,
the length, spread and severity of outbreaks
is increased. The importance of surveillance,
response and early-warning systems was

Goss, P.E. et al. (2013). Planning cancer control in Latin America and the Caribbean. Lancet Oncol. 14(5): 391-436
Dureab, F. et al. (2021). Forms of Health System Fragmentation During Conflict: The Case of Yemen. Front Public Health 12(9)© Economist Impact 2022

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Figure 1: Percentage of people who received at least one dose of covid-19 vaccine
Total number of people who received at least one vaccine dose, divided by the total population of the country
European Union

United Kingdom

India

United States

Ghana
United Kingdom
United States
European Union
India

80%
70%
60%
50%
40%

Ghana

30%
20%
10%
0%
01-Oct-20

01-Jan-21

01-Apr-21

01-Jul-21

01-Oct-21

01-Jan-22

01-Apr-22

01-Jul-22

01-Oct-22

Source: Our World In Data. These estimates are based on the total population for each country.

evidenced during the Ebola outbreak in West
Africa, which began in December 2013, wasfirst detected in March 2014 - and was declareda Public Health Emergency of International
Concern in August 2014. Weak surveillancesystems contributed towards difficulties incontaining the outbreak, facilitating its spread
across the region.14
A lack of progress towards universal healthcoverage is a longstanding challenge to healthsystem resilience in LMICs. Although there are
numerous causes of low healthcare coveragein LMICs, a particularly salient issue is chronic
underinvestment in healthcare infrastructure,such as hospitals and clinics. Underinvestment
in such physical facilities leaves significant
portions of the population—particularly inpoorer, rural areas—lacking access to essential
healthcare services, including consultations andimmunisations. These gaps in care consequently
threaten the collective health security of the
population—for example, by facilitating the
emergence of infectious disease outbreaks.

A robust and effective health system is reliant
on adequate supplies of medicines, medical
devices, personal protective equipment andother products. Unfortunately, constrained
government budgets and limited domestic
manufacturing capacity mean that LMICs
often struggle to maintain adequate stocks of
medical supplies, presenting a major challenge
to the resilience of their health systems. Thisis particularly evident when LMICs are forced
to compete with higher-income countries for
scarce supplies, as was demonstrated during the
global contest for covid-19 vaccines.
The impacts of disparities in local manufacturing
capacities have underscored the challenges that
result from dependency on importing essential
supplies. For example, while India—a country
with a strong vaccine manufacturing industry—
had given at least one covid-19 vaccine to 35%
of its population by August 31st 2021, just 4.9%of Africans had received a vaccine by the samedate.15 Such inequities in vaccination rates risk
prolonging the pandemic in countries without

https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html
https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&time=2021-08-31&facet=none&pickerSort=desc&pickerMetric=population&hideControls=true&Metric=People+vaccinated+%28by+dose%29&Interval=Cumulative&Relative+to+Population=true&Color+by+test+positivity=false&country=Africa~IND

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15© Economist Impact 2022

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Building health system resilience in an uncertain world

free access to vaccines or vaccine manufacturing
capacity, exacerbating the damage done tohealth, social and economic outcomes. Dr
Chunharas, president of the Thai National HealthFoundation and former deputy minister of publichealth for Thailand, reiterates the importanceof having adequate medical supplies noting thatdeveloping countries—such as Thailand—”haveto make sure that essential supplies can be
manufactured … regionally … if not nationally”.

processes in LMICs mean that some of thepoorest countries pay the highest prices globally.
Purchasers in LMICs pay as much as 20 to 30
times more for basic generic medicines, relative
to international minimum prices.16 High prices
restrict access to medical supplies, thus acting asa key barrier to building health system resilience.
One 2017 study found that patients in Nigeria
are required to purchase medicines at 2 to 64
times international reference prices.17

Access to medicines, medical devices andequipment is largely influenced by the efficiency
of procurement. Ineffective procurement

Deficiencies in the healthcare workforce
constitute another key barrier to healthsystem resilience in LMICs. Staff shortages andinsufficient investment in employee wellbeing
lead to burnout and reduced productivity
and result in the healthcare workforce being
overstretched. This inhibits health systems frombeing able to absorb rapid spikes in demand,as may arise during shocks like an infectious
disease outbreak, extreme weather event or
military conflict. Expanding on this point, Stefan
Nachuk, senior advisor, health systems at theBill & Melinda Gates Foundation, notes theissue of widespread staff absenteeism—thefailure of remunerated health professionals towork as contracted—in many LMICs. This leads
to significant wastage of health expenditureand limits health systems’ capacity to deliver
positive health outcomes. Mr Nachuk attributes
absenteeism to systemic issues, including
poorly provisioned facilities and low pay by thegovernment, which incentivise physicians to seek
unofficial employment in private hospitals. While
this is a particular problem in India, where theaverage absenteeism rate for doctors and other
healthcare providers is around 40%, absenteeism
is a problem in a diverse array of LMICs, including
Peru, Indonesia and Uganda.18,19

https://cgdev.org/better-health-procurement
https://www.afro.who.int/sites/default/files/2017-06/nigeria_medicine_prices.pdf
18
Panagariya, Arvind. India: The Crisis in Rural Health Care. Brookings Institution, 28 July 2016, www.brookings.edu/opinions/india-the-crisis-in-rural-health-care/.
19
Chaudhury, N. et al. (2006). Missing in action: teacher and health worker absence in developing countries. J Econ Perspect. 20(1): 91–116.
16
17© Economist Impact 2022

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Chapter 3:
The way forward
A package of policies focused on health system governance, financing, resources,
infrastructure and delivery will be needed to foster resilience in LMICs.
Given the complex barriers that exist to building
health system resilience, a set of strategies isurgently needed to pave the way forward for
LMICs. To this end, we present a number ofpolicies designed to catalyse progress. While theseby no means constitute a comprehensive list, theyaccount for the most salient strategies to emerge
from our literature review and interviews withexperts. The strategies that we have identified forenhancing resilience are mapped onto five key
health system functions: governance, financing,resources, infrastructure and delivery.

will differ between countries of different income
levels, necessitating the development of LMICspecific policies.
In order to articulate what resilient governancelooks like, Stefan Nachuk suggests thatgovernance should be considered in two
parts: good management and good politics.
Good management refers to a health system’sability to execute defined plans. Good politics,
on the other hand, refers to the ability of ahealth system to build “some sense of nationalawareness and solidarity,” he says; it is contingent

Governance
Resilience is dependent on health systems’capacity to react with agility to emerging
challenges at the local level.
Health system governance—the steering andrule-making function of a health system—isessential to ensuring that health systems deliveron national health policy objectives, including
those that emerge during a crisis. “If we haveproper governance, then everything else is linked
to that,” says Dr Bishen. “You can do other things
well if you have strong governance and goodfinancing.” Importantly, resilient governance islikely to be highly context-dependent, varying
with factors like the overarching politicalsystem in a country and the level of economic
development. As such, governance strategies

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upon public unity and “a high degree of trust in
public institutions.”
A key component of good management ishealth systems’ ability to mobilise and coordinate critical stakeholders, particularly
amid a crisis. Given the complexity of a healthsystem’s response to a systemic shock, coordination and alignment of activities between
governments and key stakeholders—including
healthcare providers, the private sector, NGOs,international organisations and communities—iskey. To facilitate effective inter-stakeholder
co-operation, high-performing health systems
during the covid-19 pandemic implemented
comprehensive information sharing and coordination arrangements between stakeholders
early on.20 Singapore, for example, initiated near-

Legido-Quigley H et al. (2020). Are high-performing health systems resilient against the covid-19 epidemic? Lancet, 395(10227):848–850.
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Building health system resilience in an uncertain world

14“Both of those factors—the politics andthe ability to deliver on some relatively
simple things, but on a massive
scale, in a very consistent manner,
really differentiate the winners fromthe losers.”
Stefan Nachuk, Bill & Melinda Gates Foundation

daily meetings between Regional Health Systemmanagers, hospital leaders and the Ministryof Health. Similarly, South Africa developed
cross-functional mechanisms for rapid decisionmaking, including surveillance “huddles” thatbrought outbreak response teams together
with the epidemiology and surveillance teamand provincial communication offices to share
information across districts.21
Co-ordination and stakeholder mobilisation is
not only important within countries—it is also
vital at the international level. Global healthpartnerships have significant potential toconvene and rapidly accelerate global solutions
to systemic threats. As demonstrated by thestark regional disparities that emerged in accessto covid-19 vaccines, empowering partnerships
such as Gavi, the Vaccine Alliance (and co-leaderof the COVAX initiative to expand covid-19
vaccine access) is crucial to increasing equitable
access to global public goods.
The determinants of health reach far beyond thehealthcare sector. “Health systems are nested inbroader social systems [and] ill health is nested
in broader social ills,” says Lucy Gilson, professorof health policy and systems at London School ofHygiene & Tropical Medicine and the Universityof the Western Cape. “[To build resilience] weneed more than healthcare—we need to createa system that offers resilience to society at large.”

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Tackling these broader social determinants ofhealth, which range from access to adequate
sanitation to the price of energy, requires theparticipation of a diversity of sectors acrossgovernment and society more broadly. As such,
resilience is also contingent on the extent towhich health systems have embedded intersectoral collaboration into their governance.
Good management also includes a healthsystem’s capacity to adapt to novel contexts. Thisrequires health systems to respond to challenges
by tailoring solutions to the population’s needs,
rather than implementing policies haphazardly.
In Dr Chunharas’ experience of the Thai healthservice, this was contingent on two main factors:
allowing sub-units of the health system to operate
independently of the centre and ensuring a highdegree of community participation in the healthsystem. In Thailand, community participation
is fostered through a vast network of village
health communicators and volunteers (see box,
“Thailand’s universal healthcare model”). This
network of local participants in the health system
has in turn enabled peripheral subunits of thehealth system to respond actively and flexibly to
localised challenges. This approach has enhanced
Thailand’s ability “to better cope with changing
demand” and “mobilise people quickly”, says
Dr Chunharas. “It is community participation[that] has been the force that has kept the system
dynamic.”

https://www.hst.org.za/publications/South%20African%20Health%20Reviews/Chapter16_SAHR21_04022022_OD.pdf© Economist Impact 2022

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Building health system resilience in an uncertain world

Thailand’s universal healthcare model
Thailand’s initial response to the onset of the covid-19 pandemic in 2020 was widely lauded as a
success story, including by the World Health Organisation (WHO).22 A widely recognised strengthof Thailand’s health system that may have contributed to the nation’s resilience during the
pandemic is its universal healthcare model.
The foundations of this model were laid in 1979, when the Thai government committed tohealthcare for all, with a focus on primary healthcare. To increase the reach of the health system inrural areas, the Ministry of Public Health introduced two categories of health actors—village healthcommunicators and village health volunteers—respectively tasked with communication and healthservice provision. The development and training of a cadre of over 1m such volunteers—mostly
women—has helped to make the Thai health system more dynamic, responsive and resilient.23
In 2002 the government became one of the first in a middle-income country to adopt universal
healthcare, entitling almost all of the population to healthcare access (‘stateless’ people andindividuals without documentation were not covered24), with significant benefits to public healthand society. For example, in the subsequent decade the correlation between poverty and infantmortality disappeared, and evidence also suggests that the scheme reduced the likelihood of
employees reporting as too sick to work.25,26 Perhaps most importantly, by extending healthcare
access across the population and encouraging community participation in healthcare provision,
Thailand’s health system has become better able to adapt to the evolving needs of the population,
fostering greater resilience against future challenges.

“Whatever made the universal
healthcare system adapt andevolve, is what made the Thai
health system better able to copewith covid-19.”
Dr Somsak Chunharas, president of the Thai
National Health Foundation and former deputy
minister of public health for Thailand

https://news.un.org/en/story/2020/08/1069191
Rajatanavin, Chunharas, Sawasdivorn, Jongudomsuk & Thammatacharee (2019). Resilient health system and UHC.
24
Suphanchaimat, R. et al. (2016). Health insurance for people with citizenship problems in Thailand: a case study of policy implementation. Health Policy and Planning 31(2):229–238
25
Gruber, J. et al. (2014). The Great Equalizer: Health Care Access and Infant Mortality in Thailand. Am Econ J Appl Econ. 1;6(1): 91-107
26
Wagstaff, A. and Manachotphong, W. (2012). The Health Effects of Universal Health Care: Evidence from Thailand. World Bank Policy Research Working Paper No. 6119,
Available at SSRN: https://ssrn.com/abstract=2103016
22
23© Economist Impact 2022

Building health system resilience in an uncertain world16“We need to recognise that health systems
are shaped by politics. In crisis moments,
politics is a particularly strong influence.”
Professor Lucy Gilson, London School of Hygiene & Tropical
Medicine/University of the Western Cape

The impact of good politics on fostering resilient
health systems should not be understated.
“Probably the biggest difference that we’veseen during the covid-19 period is the abilityof national governments to actually motivate
populations and change behaviour,” says Mr
Nachuk. “And interestingly some of the best
examples in the world are not OECD countries.”
Mr Nachuk points to the fact that “manyEuropean and North American countries reallystruggled with this during the pandemic”, whileothers—such as Vietnam—have managed to“mobilise and be disciplined around issues thatare seen as national crises.” According to the IMF,
Vietnam’s success in this regard was attributable
to the use of effective, transparent messaging.
This was done using a co-ordinated, multimedia
approach—including mass media, public posters
and campaigns by grassroots organisations—that fostered public trust and encouraged
adherence to containment measures.27 Vietnam’s
communications strategy should serve as an
example of how to galvanise public support for
public health measures during a crisis.

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Financing
Effective financing—and anti-corruption
measures such as transparent
e-procurement systems—can help to reduce
wastage of public resources and increase
government savings, enabling healthsystems to maintain adequate stocks of
medical supplies.
Effective investment and financing is key tobuilding health system resilience—“You cantell how resilient a health system is by looking
at [ its] financing,” says Dr Bishen. The efficient
allocation of funds is particularly crucialin LMICs, where government budgets are
significantly more constrained than in wealthiercountries. And while the scale of financing isimportant, the size of a country’s funds are far
from the only important factor. “The size [offunds] does not matter as much as the system’sability to evolve,” says Dr Chunharas. In essence,a health financing system that is very rigid will
exhibit poor resilience, regardless of the volume
of funds channelled into it.

https://www.imf.org/en/News/Articles/2020/06/29/na062920-vietnams-success-in-containing-covid19-offers-roadmap-for-other-developing-countries© Economist Impact 2022

Building health system resilience in an uncertain world

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Value-based healthcare is one strategy that may
help to integrate resilience into health systemfinancing. In a value-based system, providers arepaid for patient outcomes, rather than by theactivities or services they supply. Such models
may incentivise activities and investments thatare beneficial for both day-to-day operations
and improving health systems’ emergency
preparedness. They may also ensure that funds
are used more effectively. “Value-based healthcare
should be an integral part of your investment
as you develop your healthcare system,” says
Dr Bishen. Value-based schemes are currently
still nascent in LMICs. However, there is growinginterest in the potential of value-based healthcare
to resolve longstanding challenges to healthsystem performance. USAID, for instance, hasinvested US$8m in a three-year pilot project
applying value-based care to address the
tuberculosis epidemic in India.28
It is important to acknowledge the potential
for corruption to infiltrate health systemprocurement, especially during times of crisis.
Many countries have implemented policies
to enhance transparency and integrity inprocurement, to mitigate the risk of corruption.
Ukraine achieved a breakthrough in this regard
in 2016, when it transitioned to transparent,
competitive public procurement of medicines
through ProZorro, a digital e-procurement
platform. As well as combating corruption,
ProZorro has helped to increase competition
for government tenders, reduce spending oncontracting processes and ensure that suppliers
are treated fairly. This has helped the government
to make substantial savings—over 18% of
Ukraine’s planned healthcare budget was savedin the year following Prozorro’s introduction.29
The savings facilitated by increased transparency
help health systems to purchase and maintainadequate stocks of medical supplies. This
subsequently strengthens the resilience of healthsystems during spikes in demand.

“Transparency in monitoring andaccountability of procurement
processes is critical so thatdecisions being made can be tracked
accordingly.”
Professor Lucy Gilson, London School of Hygiene &Tropical Medicine/University of the Western Cape28
29

https://www.leapfrogtovalue.org/case-study
https://en.interfax.com.ua/news/economic/343760.html© Economist Impact 2022

Building health system resilience in an uncertain world

18

Improvements in public financial management
may also facilitate increased health system
resilience, particularly in LMICs. Effective publicfinancial management enables countries toact quickly in a crisis. Yet poor public financial
management is a “massive and unknown problem”
in LMICs, says Mr Nachuk. Highly centralised
countries like Bangladesh, for example, “have been
struggling to move cash down to the facility level
for things like vaccines”—despite having the funds
available. This is in part due to the existence of“powerful incentives not to make mistakes and not
to be accused of corruption, but [few] incentives todisperse [funds], even if that would do something
better.” Flexible public financial management has
had demonstrable benefits in the context of thecovid-19 pandemic: countries with health budgets
that release funds according to programmaticenvelopes linked to policy objectives, rather
than detailed line items, have tended to be able
to redirect funds to emergency responses more
quickly.30 For example, provinces in South Africa
were empowered to reallocate up to 1 billion
South African Rand for covid-19 expenditure,enabling a more agile pandemic response.31

Resources
Creating surge capacity by mobilising andrecruiting additional healthcare workers or
volunteers can allow countries to effectively
respond to changing demands in timesof crisis.
The ability to accommodate sudden surges indemand is integral to health system resilience.
This was evidenced during the height of thecovid-19 pandemic, when even high-income
nations struggled to maintain adequate suppliesof essential medical equipment—such as
ventilators—leading to poorer health outcomesfor hospitalised patients.32 Health systems must
integrate resilience into supplies of resources,
including medicines, medical equipment and thehealthcare workforce.
High-quality human resources—in essence,a well-staffed, well-trained and motivatedhealthcare workforce—are essential tomaintaining health system performance underpressure. How health systems “train, recruit,reward and deploy their workforce says a
lot about health system resilience,” says Dr
Bishen. Similarly, Dr Chunharas emphasises theimportance of the “quality of human resourcesin the [Thai] system”—including doctors,
community health providers and village healthvolunteers—in fostering health system resiliencein Thailand. In particular, Dr Chunharas highlights
the role played by “healthcare workers in the
periphery”, who are integral to maintaining trustand good relationships between healthcare
institutions and the public.
Staff shortages are a major challenge forthe human resources of a health system. For
example, in 2019 Ghana had just 1.7 physiciansper 10,000 people, far lower than high-income
countries like Ireland (34.9) or Israel (36.3).33
These shortages impose severe limitations on
how effectively a health system can function
on a day-to-day manner, as well as in a crisis.
There are multiple ways in which LMIC healthsystems have sought to tackle this problem.
One strategy is to employ a higher proportionof nurses (who are generally cheaper to employ
and more readily available than more specialised
staff) to mitigate shortfalls in the number ofhttps://p4h.world/en/blog-lessons-for-managing-public-finances-from-COVID-19-response
ibid.
32
https://www.reuters.com/article/uk-health-coronavirus-ventilators-exclus-idUKKBN2153GU
33
Global Health Workforce Statistics, World Health Organization, Geneva. https://www.who.int/data/gho/data/themes/topics/health-workforce
30
31© Economist Impact 2022

Building health system resilience in an uncertain world

19

Figure 2: Physicians per 10,000 people in selected countries, 2020
Ghana

ThailandAlbania

IrelandIsraelGhana

1.7
Thailand

9.5
Albania18.75
Ireland34.9
Israel

36.26
0

5

10

15

20

25

30

35

40

Source: WHO Global Health workforce statistics database.

doctors. For example, Mr Nachuk points to theThai health system’s “low-cost, relatively highquality approach to providing reasonable care”,
which relies upon a large cohort of “well-trained,
low-cost technical nurses”. These nurses are
particularly important in rural areas, which face
the greatest challenges in employing sufficientnumbers of trained physicians.
To address workforce shortages during thecovid-19 pandemic, a number of countries
devised innovative approaches to enhance
the capacity of the healthcare workforce. For
example, in Bosnia and Herzegovina, medical
students who were not yet in their final yearof study were called upon to assist with the
pandemic effort and a campaign was launchedto persuade retired medical professionals
to return to work.34 By formalising plans forsuch arrangements in times of stability, healthsystems suffering from shortages in staff canbetter prepare for the next crisis.
As discussed in the previous chapter, highprevalence of workforce absenteeism is asignificant threat to health system resiliencein many LMICs. To address this issue, novel
approaches such as community-based
supervision have been suggested as a way tomake the working environment more attractive

34

for the healthcare workforce. Community-based
supervision involves tasking the local community
with monitoring the activities of health workers,
as well as identifying areas where health workers
may need more support. Health systems should“experiment with a range of things,” says Mr
Nachuk, “including recruitment from local
communities, using hard and soft incentives(including allowing some degree of dual practice)and trying to create some incentives for better
performance within the system.”Market inefficiencies are a significant barrier
to resilience in the procurement of medical
supplies in LMICs. “Medicines markets in [LMICs]
are really quite broken,” says Janeen Keller,
senior policy analyst and assistant director of
global health at the Center for Global Health
Development. “There is very little competitionin these markets, which essentially drives
up prices for purchasers.” One strategy that
Ms Keller highlights as a remedy is reformof outdated regulations, quality-control
processes and antiquated systems that inhibit
purchasers from acquiring medical products
at the optimum price. When these processes
are overly burdensome, they act as a barrier toentry for manufacturers of medical products(particularly generics), resulting in lower
competition and higher product prices.

https://apps.who.int/iris/bitstream/handle/10665/336296/Eurohealth-26-2-51-57-eng.pdf© Economist Impact 2022

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Building health system resilience in an uncertain world

everyday health services. This point is especiallypertinent in LMICs, where resource shortages
are generally more pronounced. Evidence
from the covid-19 pandemic suggests that theindirect effects of a health system’s responseto an infectious disease outbreak can be just as
damaging—or even worse—than the direct tollof the disease itself. For example, in 2020 theMeasles and Rubella Initiative reported that morethan 117m children would miss out on measles
vaccinations as a result of coronavirus-induced
cancellations of routine vaccination campaigns,
posing an enormous threat to future publichealth.37 Decision-makers must carefully consider
In order to streamline such processes, Ms Keller
notes the benefits of participation in the WHO’s
Collaborative Registration Procedure (CRP).35
The CRP empowers regulatory authorities toapprove medical products by relying on theassessments of stringent regulatory authorities
in other jurisdictions, rather than having toundertake these assessments themselves. This
reduces the time taken for products to receive
approval (by an average of 40% according to theWHO’s evaluation of the CRP pilot programme),
and thereby facilitates the emergence of greater
competition in the market.36 Taken together,such reforms are key to developing vibrant,
competitive markets for medical supplies thatare better able to weather disruptions to global
supply chains.
While devising strategies to maintain adequate
supplies of resources during a crisis is important,
it is also crucial that governments think carefully
about how such resources are allocated. In
particular, it is key that opportunity costs areaccounted for when making decisions onwhether to divert scarce resources away fromthe consequences of diverting resources awayfrom key priority areas for health in LMICs—
including HIV/AIDS, tuberculosis and malaria—
when devising strategies for how to allocate
resources during a crisis.

Physical Infrastructure
The distribution, location and design ofphysical healthcare facilities will play anincreasingly important role in determining
health system resilience, given the risingfrequency of climate change-related natural
disasters.
Adequate infrastructure is critical to supportinga health system’s response to shocks andchronic threats. In particular, integrating
resilience into physical infrastructure—for
example by ensuring that facilities are protectedagainst climate change—will play an increasingly
important role.
Physical facilities—from local community
clinics to large district hospitals—are where themajority of healthcare services are provided. As

https://www.who.int/news/item/15-02-2022-who-collaborative-registration-procedure-using-stringent-regulatory-authorities-medicine-evaluation-reliance-in-action
Vaz, A. et al. (2022). WHO collaborative registration procedure using stringent regulatory authorities’ medicine evaluation: reliance in action? Expert Review of ClinicalPharmacology 15(1): 11-1737https://www.thenewhumanitarian.org/news/2020/04/14/coronavirus-measles-vaccination
35
36© Economist Impact 2022

Building health system resilience in an uncertain world

21

such, their distribution, location and design
are integral to the ability of a health system tocope in a crisis. Ensuring widespread access tobasic healthcare through a dispersed networkof basic health facilities is vital. “The key
thing is not large, fancy hospitals, [because]
what you really are trying to do [ in a crisis]
is mitigate and lower caseloads,” says Mr
Nachuk. “For that you require a large numberof facilities relatively close to the population.”
In line with this philosophy, in May 2022 theIndonesian minister of health, Budi Gunadi
Sadikin, proposed establishing 300,000 healthposts across the country—equivalent to
one health post for every 900 Indonesians.38
These will seek to boost Indonesia’s child
immunisation drive—a critical factor tosafeguarding the country’s health systemagainst future infectious disease outbreaks.

Effective surveillance infrastructure plays anessential role in supporting health system
resilience by enabling the timely detection andcontrol of potential high-risk events. Colombia’s
Public Health Emergency Operations Centre—the first of its kind in South America—hasreceived international recognition for its rolein controlling the spread of measles among thethousands of Venezuelan refugees who arrived
in Colombia in 2018.39
Looking to the future, there is an increasingneed to integrate surveillance infrastructurewith information systems from other sectors.40
For example, given the increasing role that
extreme weather events such as droughts andfloods will play in influencing population health,health surveillance infrastructure could benefit
by incorporating data from weather forecasting
systems.

“In countries like Bangladesh, location matters… You are going to want to build infrastructure
in such a manner where you have high ceilingsand ventilation, given heat stresses—because
you aren’t going to have air conditioning inthese places— and you are going to want tobuild on high ground, because flooding will
become a bigger issue in the future.”Stefan Nachuk, Bill & Melinda Gates Foundation

https://indonesiaseharusnya-bali.com/govt-reactivates-300000-health-services-posts-to-improve-healthcare-services-for-mothers-children/
https://www.cdc.gov/globalhealth/healthprotection/fieldupdates/spring-2019/Colombia-nphi-preparedness.html
40
Hanefeld J et al. (2018). Towards an understanding of resilience: Responding to health systems shocks. Health Policy and Planning, 33(3):355–367.
38
39© Economist Impact 2022

Building health system resilience in an uncertain world

22

Finally, in the context of defending against
future outbreaks of infectious disease, testing
infrastructure plays a critical role in supporting
resilience. In particular, effective testing
infrastructure is contingent on the existence ofa comprehensive network of national labs thatare prepared to test high volumes of samples
at a rapid rate. “Labs were part of the unsung
hero of this pandemic,” says Mr Nachuk—successful countries have been those that “hadbasic, good lab facilities where they can … turnaround really, really fast tests.” For a countryof its income group and level of development,
Senegal stands out as a success story in thisregard, having managed to rapidly set up fieldlabs in each region of the country with capacity
to process tests within 48 hours or less.41

DeliveryInvestment in preventive care—such as
vaccination campaigns—can reduce pressureson healthcare systems and substantially
improve health outcomes. Community healthworkers play an important role in delivering
preventive care in many LMICs.
In times of crisis, health systems may needto adopt alternative methods of healthcare
provision, as was evidenced by the covid-19
pandemic. The capacity to adopt and scaleup flexible approaches for delivering care is
therefore critical to determining how healthsystems cope with unexpected shocks.
Many countries implemented innovative
methods of service delivery during the covid-19
pandemic, including the use of telemedicine
and virtual care. Telemedicine can help toreduce the spread of infectious diseases bylimiting in-person contact between patientsand healthcare providers. It also has thepotential to increase the efficiency of healthservice delivery by enabling doctors to carryout more appointments per day, at a lower cost
per appointment.42 Furthermore, telemedicine
may help to broaden access to healthcare byallowing specialised physicians to reach ruralcommunities (see insert: “Unlocking innovationin healthcare”).
These impacts alleviate pressure on
overburdened health systems during spikes indemand, thereby boosting resilience in timesof crisis. For example, widespread uptake oftelemedicine in Lebanon during the pandemic
was accompanied by a positive shift inphysicians’ perceptions of telehealth, indicating
greater confidence in its potential.43 However, it
is important to consider contextual factors thathinder the realisation of telemedicine’s potential
in other LMICs, including limited supporting
infrastructure (such as reliable internet
connections). While telemedicine holds thepotential to improve access to healthcare andbolster resilience in LMICs, the uptake of digitaltechnology should not supplant investment intraditional components of the health system,
including the healthcare workforce and physicalinfrastructure. “[Information technology] can bea massive enabler, but it cannot be a substitute,”
says Mr Nachuk.
Health systems can also build resilience outside
the context of a crisis. By emphasising thedelivery of preventive care during times ofstability, health systems can proactively tackle
emerging challenges before they threaten

https://www.vox.com/22397842/senegal-covid-19-pandemic-playbook
Mahmoud, K. et al. (2022). Telemedicine in Low- and Middle-Income Countries During the covid-19 Pandemic: A Scoping Review. Front Public Health. 22(10): 914423.
43Helou, S. et al. (2020). The effect of the covid-19 pandemic on physicians’ use and perception of telehealth: the case of Lebanon. Int J Environ Res Public Health. 17:4866.
41
42© Economist Impact 2022

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Building health system resilience in an uncertain world

to overwhelm the system. “Investment inpreventative care [is] important,” because it
results in “less pressure on hospital care,” says
Dr Bishen. “It is extremely important that you[not only] look at the response to something,but you [also] build preventative care, so thatyou are proactive.” This is particularly important,given the increasing burden of NCDs in LMICs.

Unlocking innovation in healthcare
Health systems’ adoption of digital technologies has undergone a marked acceleration since theonset of the pandemic. A number of African countries have embraced the potential of digital
innovation to enhance the effectiveness and resilience of health systems in the face of systemic
threats.
Nigeria’s Surveillance Outbreak Response Management and Analysis System (SORMAS) is an opensource, digital early-warning and disease-management system, first developed during the Ebola
outbreak.44 Available via desktop, tablet and mobile-phone applications, SORMAS allows individual
healthcare workers and surveillance officers to upload data on suspected cases of infectious
disease. By connecting informants on the ground with epidemiologists, health officials andpolicymakers in real time, SORMAS allows for rapid and targeted responses to potential infectious
outbreaks.
Although SORMAS was initially designed to track the incidence of Ebola, its modular designmeans that it is able to adapt to novel infectious diseases quickly. In fact, a covid-19 module hadalready been incorporated in February 2020, before Nigeria had registered its first confirmed caseof the virus. Although there has not yet been a formal evaluation of SORMAS’ role in supporting
Nigeria’s covid-19 response, stakeholders in Nigeria have praised its utility in rapidly identifyingcase clusters, facilitating contact tracing and reducing reliance on paper-based forms.45 In fact, theperceived impacts of SORMAS in fostering resilience have led to its rollout in a variety of other
LMICs, including Ghana and Fiji, as well as high-income countries such as France and Germany.
Given the scale of the challenges faced by many African countries, the scope for private-sector
involvement in fostering innovative solutions is considerable. In 2016 Zipline, an American logistics
company, began supplying rural communities in Rwanda with lifesaving medicines via remotely
operated drones.46 By 2019 the service had expanded nationwide, delivering 75% of the nation’s
supply of blood outside of the capital, Kigali.47
Following the onset of the covid-19 pandemic, Zipline has expanded its operations to Ghana,establishing four distribution centres with the capacity to serve 12m people. By enabling
healthcare workers to place orders for medical supplies via app, with delivery within 30 minutes,
Zipline’s drone network has enabled rapid local responses to shortages in medicines, vaccinesand equipment. Zipline succeeded in distributing over 1m doses of vaccines in Ghana in 2020,
demonstrating the potential for drones to foster resilience and strengthen public health acrossother LMICs.48

https://www.exemplars.health/emerging-topics/epidemic-preparedness-and-response/digital-health-tools/sormas-nigeria
Ibid.
46
https://borgenproject.org/tag/zipline-in-ghana/47
https://www3.weforum.org/docs/WEF_Medicine_from_the_Sky_2021.pdf
48
ibid.
44
45

© Economist Impact 2022

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Building health system resilience in an uncertain world

Rwanda has recognised the value of preventive
care in building long-term health system
resilience, as demonstrated through its drive
to eliminate human papillomavirus (HPV), a
virus that can cause cervical cancer (currently
the most common cancer among Rwandan
women). The country has implemented an
HPV vaccination programme that has achieved
broader coverage than in wealthy counterparts

like the UK.49 Thanks to the efforts of a networkof community health workers who havespearheaded the vaccination campaign, Rwanda
has now established itself as a frontrunner inthe race to eliminate the disease. Community
health workers play a vital role in delivering
preventive care in LMICs and are a key asset tohealth systems, given their community-rooted
credibility and understanding.

“[Community health workers] have ahuge role to play…[LMICs] have moreof a structure of these community
health workers that can work closelywith GPs and populations and havethat trust. That trust is fundamental,
specifically in the context ofa pandemic.”
Francesca Colombo, OECD49

https://www.theguardian.com/global-development/2022/aug/18/how-rwanda-could-become-one-of-the-first-countries-to-wipe-out-cervical-cancer-acc© Economist Impact 2022

Building health system resilience in an uncertain world

25

Conclusion

It is clear that all countries need to ensure that their health systems are better prepared to deal with
future shocks and challenges. A recurring theme in our interviews with experts was the warning thatthe covid-19 pandemic will not be the last challenge to threaten the resilience of health systems. Fromclimate change to economic shocks, the challenges that health systems are due to face are multifacetedand complex and thereby warrant careful consideration in today’s evolving context.
There are many lessons that countries can draw on from previous crises that can be used to inform
strategies for building resilience. As the examples in our report demonstrate, a health system’s capacity
to effectively adapt to changing population needs and contexts will play an important role in improving
health outcomes and preparing for future challenges. Digital technology can also play an important rolein increasing healthcare access and reducing costs to patients, when complemented with the necessary
workforce and infrastructure.
The role of effective governance in building a resilient health system cannot be understated.
Looking ahead, governments will need to carefully consider how to strike a balance between investing
and allocating resources towards crisis preparedness and response, while simultaneously accounting forthe resources needed to maintain the delivery of day-to-day essential health services.

© Economist Impact 2022

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Building health system resilience in an uncertain world

While every effort has been taken to verify the accuracy of thisinformation, Economist Impact cannot accept any responsibility
or liability for reliance by any person on this report or any of theinformation, opinions or conclusions set out in this report.
The findings and views expressed in the report do not necessarilyreflect the views of UNOPS.

© Economist Impact 2022

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