Shocks, stress and everyday health system resilience: experiences from the Kenyan coast

Abstract

<jats:title>Abstract</jats:title> <jats:p>Health systems are faced with a wide variety of challenges. As complex adaptive systems, they respond differently and sometimes in unexpected ways to these challenges. We set out to examine the challenges experienced by the health system at a sub-national level in Kenya, a country that has recently undergone rapid devolution, using an ‘everyday resilience’ lens. We focussed on chronic stressors, rather than acute shocks in examining the responses and organizational capacities underpinning those responses, with a view to contributing to the understanding of health system resilience. We drew on learning and experiences gained through working with managers using a learning site approach over the years. We also collected in-depth qualitative data through informal observations, reflective meetings and in-depth interviews with middle-level managers (sub-county and hospital) and peripheral facility managers (n = 29). We analysed the data using a framework approach. Health managers reported a wide range of health system stressors related to resource scarcity, lack of clarity in roles and political interference, reduced autonomy and human resource management. The health managers adopted absorptive, adaptive and transformative strategies but with mixed effects on system functioning. Everyday resilience seemed to emerge from strategies enacted by managers drawing on a varying combination of organizational capacities depending on the stressor and context.</jats:p>

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

“…Second, Area South’s experience confirms other studies' conclusions that response strategies do not linearly evolve from absorption through adaptation to transformation but are deployed at the same time. They may, as in this experience, address different stressors, or be deployed against the same stressor by different actors ( Kagwanja et al, 2020 ) or, as suggested here and by Alameddine et al (2019) , be relevant to different time horizons (with transformative strategies supporting more fundamental, longer-term change). Importantly, however, as previously noted ( Gilson et al, 2017 ), absorption of stress by individuals does not itself demonstrate the collective resilience entailed in EHSR.…”

“…Such persistent, challenging conditions, chronic stress, are an everyday reality of health systems. They include changing patient expectations and demands, staff absenteeism, budgetary constraints, cross-level managerial tensions and the politicization of health system experience ( Felland et al, 2003 ; Gilson et al, 2017 ; Kagwanja et al, 2020 ; ; Lembani et al, 2018 ). Health systems manage these chronic stressors even as they seek to improve.…”

“…However, the foundations for this change lie in earlier rounds of action research supporting new practices of reflection, learning and distributed leadership within one part of the Area's health system ( Cleary et al, 2018 ; Gilson et al, 2017 ). In addition, alongside the positive adjustments observed were some hints of the possible ‘dark side’ of resilience ( Gilson et al, 2017 ; Kagwanja et al, 2020 ; Williams et al, 2017 ). These included the burdens borne by all staff in responding to change, possible opportunity costs in terms of PHC improvements and concerns about the Ideal Clinic program.…”

“…Everyday health system resilience (EHSR) has been proposed as the characteristic of complex, adaptive health systems that allows them to respond to chronic stress in ways that transform how they function ( Barasa et al, 2017 ). Prior explorations of EHSR ( Gilson et al, 2017 ; Kagwanja et al, 2020 ) are among the few empirical analyses of health system resilience (see also Alameddine et al, 2019 ). Their unusual organizational and institutional analysis ( Currie et al, 2012 ; Swanson et al, 2015 ) draws attention to the importance of understanding the health system capacities underpinning EHSR.…”

Vulnerability and agency across treatment-seeking journeys for acutely ill children: how family members navigate complex healthcare before, during and after hospitalisation in a rural Kenyan setting

“…Here we consider, in-depth, the findings from Kilifi, one of Kenya's poorest counties. The county's health system and population face significant structural vulnerabilities, including 68% of the population living below the poverty line [24], a shortage of health workers, regular drug stock-outs and health facility access challenges [25,26]. Most of the population depend on small scale farming, and high levels of gender inequity have also been documented [23,27].…”