Poverty is the main driver of poor health. In 2020, extreme poverty rose for the first time in 20 years, thanks to COVID-19. The economic burden of the pandemic has placed severe strain on people living in low- to middle-income countries (LMICs) where social and financial support systems are limited. Factor in vaccine inequity and the existing disease burden, and many LMICs—especially those affected by conflict—will be feeling the weight of the pandemic for years to come.

So, what now? How do we defend hard-won development gains and better prepare for the next health system shock? Here are three key factors.

All Hands on Deck

Resilient health systems absorb shocks; they provide consistent, basic, healthcare services despite conflicts or epidemics. Resilience does not necessarily mean uninterrupted service—it means being prepared and responsive to the challenges a health system is facing. Our experience in the coronavirus pandemic shows that meeting these challenges increasingly means innovating—for example, developing the ability of a health facility to absorb additional patient loads, creating mobile diagnostic services, identifying alternate suppliers, and bringing in others to absorb the health services demand.

Other sectors and services can also help. Health ministries need to engage with businesses, sanitation teams, educators, animal health and biodiversity specialists, and local governments to maintain continuity and ensure surge capacity. Development and aid actors can support these efforts by coordinating across humanitarian and development spheres to respond to the most urgent needs and use the health workforce most effectively.

The TDDA team quickly responded to the need for COVID-19 testing in Chad and other countries. Photo: FCDO TDDA.

For example, the U.K. Foreign, Commonwealth & Development Office (FCDO)-funded Tackling Deadly Diseases in Africa (TDDA) project was able to absorb pandemic response needs in Cameroon and Chad by working with local governments to adapt early response mechanisms, improve laboratories’ capacities to diagnose COVID-19, roll out free testing, and develop guidelines for detecting and managing sick travelers at border entry points.

Build Adaptive Capacity

Responsiveness and resilience go hand in hand. Developing our health systems’ ability to adapt quickly is crucial, and online and digital tools are an essential part of that capability. Mobile and pop-up health services, for example, can provide both temporary solutions to health challenges and real advantages in reaching at-risk populations. For example, USAID Jalin in Indonesia was charged with developing a national protocol for local governments and health service providers to continue maternal and neonatal health services despite the pandemic; during these times of limited face-to-face interactions, Jalin transitioned to online mobile services for counseling on pregnancy, antenatal care, and symptoms of high-risk pregnancy.

Providing mobile counseling services to a pregnant woman in Cileles Village. Photo: Oscar Siagian for USAID Jalin.

But responsive adaptation to emerging challenges goes beyond technology. Engaging users in shaping service improvements is critical. The USAID Honduras Local Governance Activity, for example, worked with 89 municipalities to set up citizen-transparency committees that do social audits. Based on the citizen inputs that emerged through these audits, the municipalities were able to develop a range of solutions for health centers that are improving stock management, thereby reducing shortages and wastage; improving contraceptive availability for adolescents; and enhancing routine equipment maintenance to ensure vaccine cold storage.

Adaptive processes and potential solutions are all around us. We need to identify, expand, and scale them to address challenges such as primary health care screening, continuity of care for chronic diseases, and maternal, child, and adolescent health.

Change at the Foundation

Finally, resilient health systems need to transform. Static, legacy systems, including some passed down from the colonial era, will have to be modernized if they are not working for people in LMICs. Structural inequalities and old stereotypes must end. We have seen positive signs of an appetite for fundamental change, such as the rise of the Africa Centre for Disease Control, the appointment of Dr. Chikwe Ihekweazu as head of the new World Health Organization Hub for Pandemic and Epidemic Intelligence, and a call for equity in vaccine manufacturing—taken up by several African countries in an effort to transform global vaccine supply chains.

Facilities in Northern Nigeria have been upgraded to withstand future health emergencies. Photo: USAID Nigeria.

Fundamentally, health ministries and service providers need to ensure their approach makes sense within their context. For example, historically many African hospitals were designed based on European infrastructure guidelines, meaning they may not have the required ventilation, access points, or other critical features appropriate to the African environment. On the FCDO’s Reviving Routine Immunization in Northern Nigeria project, DAI constructed a model health facility incorporating user-centered design principles. As a result, Nigeria introduced a yearly inventory update of newly rehabilitated buildings and utilities and consulted with communities prior to rebuilding. Future health facility rehabilitation and construction benefitted from the documentation and sharing of context-appropriate design innovations.

Resilience is not a new concept to healthcare systems in LMICs. Local healthcare systems are very familiar with critical supply shortages, limited workforce pools, and disease outbreaks. A lot of the answers are already within countries themselves—and local partnerships. We just need to help uncover and scale solutions. If we can support health systems to be empowered and resourced to pivot when needed—then we have contributed to the capability of the health system to absorb, adapt, and move toward health resilience.