How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia

Abstract

This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.

Results-based financing as a strategic purchasing intervention: some progress but much further to go in Zimbabwe?

“…The case study is largely retrospective, focusing on the period since 2011, although drawing on insights into the health system in Zimbabwe pre-crisis from earlier studies [15,16]. It is based on KI interviews at national, provincial and district levels, integrated with analysis of documentation (policies and strategies, project documents and manuals, project evaluations and academic articles).…”

Health System Resilience: What Are We Talking About? A Scoping Review Mapping Characteristics and Keywords

“…Its capacity to adapt, absorb and transform when exposed to a shock such as a pandemic, natural disaster, armed conflict or a financial crisis and still retain the same control over its structure and functions was described as everyday resilience, where the context is not a shock but a chronic challenge that occurs every day over a long period of time and that cannot always be predicted. 20,[48][49][50] Financing Effective financial resource allocation and protection of healthcare funding was identified as important for resilience during shocks, long-term changes and normal strains. 8,27,30,40,41 Using diverse and stable financial resources was recognized as minimizing the risk of a response being underfunded.…”

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

“…As our study results suggest, it is important to understand the broader impact of coping since such behaviours can actually bring substantial risks. While short-term coping behaviours to overcome temporary situations may be a sign of resilient health system, the existence of chronic coping behaviours to accommodate prevailing conditions may be an indication that deeper systemic issues exist and need to be addressed 4 28 33. Therefore, when assessing coping, one has to distinguish between temporary versus chronic coping and determine the threshold at which coping has occurred for too long.…”