Background Resilience is often referred to when assessing the ability of health systems to maintain their functions during unexpected events. Primary healthcare forms the basis for the health system and thus its resilient responses are vital for the outcomes of the whole system. Understanding how primary healthcare organisations are able to build resilience before, during, and after unexpected or sudden shocks, is key to public health preparedness. This study aims to identify how leaders responsible for local health systems interpreted changes in their operational environment during the first year of COVID-19, and to elucidate how these views reflect aspects of resilience in healthcare. Methods The data consist of 14 semi-structured individual interviews with leaders of local health systems in Finland representing primary healthcare. The participants were recruited from four regions. An abductive thematic analysis was used to identify entities from the viewpoints of the purpose, resources, and processes of resilience in the healthcare organisation. Results Results were summarised as six themes, which suggest that embracing uncertainty is viewed by the interviewees a basis for primary healthcare functioning. Leading towards adaptability was regarded a distinct leadership task enabling the organisation to modify its functions according to demands of the changing operational environment. Workforce, knowledge and sensemaking, as well as collaboration represented what the leaders viewed as the means for achieving adaptability. The ability to adapt functioned to comprehensively meet the population’s service needs built on a holistic approach. Conclusions The results showed how the leaders who participated in this study adapted their work during changes brought on by the pandemic, and what they viewed as critical for maintaining organisational resilience. The leaders considered embracing uncertainty as a principal feature of their work rather than viewing uncertainty as aberrant and something to avoid. These notions, along with what the leaders considered as critical means for building resilience and adaptability should be addressed and elaborated in future research. Research on resilience and leadership should be conducted more in the complex context of primary healthcare, where cumulative stresses are encountered and processed continuously.
The pressure of COVID-19 on health system functioning has made policies to strengthen health system resilience a major theme of research. Accordingly, crises like COVID-19 can be seen as windows of opportunity for health system reforms to enhance health system resilience. In Finland, COVID-19 arrived on the eve of a major health system reform. In 2023 running health and social services will be transferred from 309 municipalities to 22 counties. While the reform was framed before the pandemic, we explore how lessons from COVID-19 matter for the future reform. Our results come from interviews of 53 top managers and civil servants in the year one of COVID-19, representing municipalities, municipal healthcare authorities and state agencies. The results offer a lookout to how national and local healthcare leaders view pandemic responses in connection to the future reform. Finland fared well in the pandemic compared to many countries e.g. in terms of excess deaths. However, our results reveal a tension between major issues in managing COVID-19 and implementing the reform. While the data suggest that dealing with a prolonged crisis proved challenging due to lack of trust, communication, and transparency between national and subnational actors in the health system, the dominant lessons learned and needs for reform among the interviewees build upon obvious fixes, such as ensuring supply of PPEs and ICU beds for the next pandemic. While being important in preparedness, these can build a legacy not tackling the root causes of lacking resilience and can be inconsistent with reform goals. The pandemic provides an opportunity to analyse the reformed system from a new viewpoint and may reveal weaknesses not considered in reform planning. Reforms can impact health system resilience in positive and negative ways. While different shocks may open new avenues for system transformation, they can also create path dependencies weakening the systems’ ability to prepare for unknown threats.
PurposeThe purpose of this study was to elucidate facilitators and barriers to health system resilience and resilient responses at local and regional levels during the first year of the COVID-19 pandemic in Finland.Design/methodology/approachThe authors utilized a qualitative research approach and conducted semi-structured interviews (n = 32) with study participants representing five different regions in Finland. Study participants were recruited using purposive and snowball sampling. All study participants had been in management and civil servant positions during the first year of the pandemic, representing municipalities, municipalities' social and healthcare services, hospital districts and regional state administrative agencies. All interviews were completed remotely from April to December 2021 and the recordings transcribed verbatim. The authors coded the transcripts in ATLAS.ti 9.1 using directed content analysis.FindingsThe findings highlighted a wide range of localized responses to the pandemic in Finland. Facilitators to health system resilience included active networks of cooperation, crisis anticipation, transitioning into crisis leadership mode, learning how to incorporate new modes of operation, as well as relying on the competencies and motivation of health workforce. The authors found several barriers to health system resilience, including fragmented organization and management particularly in settings where integrated health care systems were not in place, insufficient preparedness to a prolonged crisis, lack of reliable information regarding COVID-19, not having plans in place for crisis communication, pandemic fatigue, and outflux of health workforce to other positions with better compensation and working conditions.Originality/valueFactors affecting health system resilience are often studied at the aggregate level of a nation. This study offers insights into what resilient responses look like from the perspective of local and regional actors in a decentralized health system. The results highlight that local capacities and context matter greatly for resilience. The authors call for more nuanced analyses on health systems and health system resilience at the sub-national level.
Background Crisis management Managing crises often requires diverging from predetermined plans. In this paper, we investigate how public health authorities in Finland acted, what kind of roles they adopted and how the expected roles and actions appeared in relation to the legislative framework and preparedness plans during the COVID-19 pandemic. Based on inter-country comparisons, Finland has managed COVID-19 pandemic relatively well. The study provides qualitative insights on pandemic governance in a decentralized multi-stakeholder public health system. Methods Semi-structured interviews (n = 53) with key public health actors at central, regional and local levels were conducted during March 2021-February 2022. The data was analysed with thematic analysis. Results The predetermined roles and duties for pandemic management were not unequivocal in practice and appeared unrealistic considering the resources of the public health system. Responsibility was divided between several actors, but lack of interaction enhanced emerging tensions between them. Local and regional actors experienced national steering intervening in operational decisions. At central level distrust towards the capabilities of local and regional actors was expressed. The pandemic was framed and managed as a health crisis despite of its wider societal effects. This challenged local and regional decision-making, where wider societal impacts had to be considered. Conclusions Public health authorities in Finland interpreted their roles and responsibilities in pandemic governance in various ways: some actors adopted more active agency than others and the roles were not always in line with the existing regulative framework. Key messages • Interpretation of the roles outlined in preparedness plans are context dependent and may lead to conflicts between different actors. • In a system with multiple actors at multiple levels, building trust and improving interaction are important for coordinated action.
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