Q&A: Designing a shock-proof health system

How do we ensure resilient health systems and immunisation programmes that can bounce back from future health threats? In this Q&A with Gustavo Correa, Gavi’s Senior Manager for Data systems and Information, and Josh Wunderlich, Gavi programme officer, we explore the ingredients for resiliency.

  • 2 November 2021
  • 8 min read
  • by Priya Joi
Photo by Hush Naidoo Jade Photography on Unsplash
Photo by Hush Naidoo Jade Photography on Unsplash


Q. How would you define a resilient health system and can we use it as a proxy for a resilient immunisation programme? 

Gustavo: There is no global consensus yet on which framework to use, but there are key characteristics of a resilient health system, such as having robust surveillance systems, surge capacity to increase the numbers of health workers in hospitals, adequate communication plans and coordination across sectors such as education and health. Governance is really important and it must be underpinned with independent scientific advice. In a lot of countries, we probably fail substantially because of a lack of trust in government and lack of understanding of science.

“We need to think holistically. In the pandemic, some health systems that had a lot of resources and all the necessary surge capacity still responded badly in this pandemic and had many deaths.”

Josh: Resilience is the ability of the system to withstand shocks. Can we use health system resilience as a proxy for immunisations? Yes, in the sense that vaccines are preventative and it’s important not just to firefight but to prevent disease, as that allows a system to actually respond to unexpected events much better. In terms of what defines resilience, the foundational health system capacity is really important as it correlates, although not perfectly, to the ability to withstand shocks. But as Gustavo said, something that has come out really strongly in the pandemic is having a society that trusts the health system. Ensuring your health system is resilient isn’t something you can do overnight, it takes years of work to build operational capacity, social trust and adaptability to quickly respond to emergencies.

Gustavo: I agree that preventive care is critical as you can save both lives and resources, but at the same time, in some high-income countries, the push towards preventive care through primary health care and the push to have better-performing hospitals led to the underfunding of response capacity, so they had little surge capacity during COVID-19. But even that’s not enough and we need to think holistically. In the pandemic, some health systems that had a lot of resources and all the necessary surge capacity still responded badly in this pandemic and had many deaths. 

Josh: Another key thing is that a resilient system is a learning system that that is capable of adapting to a dynamic situation. So we need to have the right governance structures to allow that to happen, because in some countries, policies are too locked in and even though there are the resources, there is no mechanism for new data to trigger action. 

Q: We saw resilience in action last year as routine immunisation that had fallen at the start of the pandemic bounced back by the end of the year. The African region seemed to have less disruption than south-east Asia or Latin America in April/May 2020 – why was that?

Josh: I think there are a lot of different factors. One is Asia that may be more reliant on outreach services than sub-Saharan Africa and lockdown measures were more stringent across Asia. But a huge component is whether or not you trust that the data was accurate through the year, so it might also be that south-east Asia and Latin America are collecting better data and are better able to pick up on these disruptions than sub-Saharan Africa. 

Gustavo: I would also add that Africa actually has a strong history of outbreak response, and in some countries they do know how to do it. They have all the mechanisms and coordination forums already in place. So even though they may have a shortage of human resources or funding, from a governance perspective, I think they may be better off.

Q. Is one of the reasons that some high-income countries didn’t respond well because they had poor coordination despite having the resources? 

Gustavo: Yes. Having the right stakeholders exchanging information is critical. In a crisis situation, you're going to have bottlenecks everywhere: in human resources, in finance, and public understanding. If we don’t quickly respond and adapt, we are doomed to fail. We will never have the perfect system, but we can be agile enough to react and some degree of independence to take action based on real-time scientific evidence. 

Josh: I fully agree that oftentimes we have separate discussions around global health security and primary health care or universal health care, but those need to be very much integrated to make sure that there's coordination and communication happening. 

Q. Countries have expanded their immunisation programmes over the past few decades. Does this affect their ability to be resilient? 

Gustavo: It probably has had an impact to some extent, but it’s not clear whether it’s a major factor and on which direction. For example, to deliver COVID-19 vaccines, we need the system to quickly adapt to distribute large volumes of a new COVID-19 vaccine, which means the need for increased cold chain capacity. This increased capacity has been recently introduced by recently introduced vaccines. At the same time, new vaccines recently introduced increased the workload of frontline health care workers in systems with a critical lack of human resources for health. 

Josh: Introducing a new vaccine takes a lot of planning and management, so this experience could lead to greater resilience. That said, it is only one component. It’s interesting to think about countries who are well experienced in running vaccine campaigns. Because maybe countries that have lots of experience doing regular measles campaigns might have a better ability to respond in an efficient manner and deliver vaccines to a wider population, but then these countries could also see the inverse as well in the sense that if you are becoming super reliant on campaigns that reach children, then you don't necessarily have a strong routine system.

“The driving factor that really contributed to the hesitancy expanding into low-income countries is the lack of trust in government institutions.”

And in theory, with the introduction of new vaccines, countries should also scale their immunisation capacity to be able to cover that. But that doesn’t always happen, and so rolling out a new vaccine could result in a less resilient system because there isn’t as much breathing room when it comes to cold chain capacity, etc. 

Q. Earlier on, we talked about trust as a key part of a resilient health system, which has been an issue with COVID-19. Has it been a surprise that some people have shown a lack of trust in their health systems and their willingness to get vaccinated?

Gustavo: It's no surprise in high-income countries and we were expecting this to happen progressively in low-income countries too, but it has happened faster than predicted.

Josh: In high-income countries much of this is actually driven by the absence of childhood diseases. For example, we don’t understand just how dangerous measles can be for unvaccinated children. But I think the driving factor that really contributed to the hesitancy expanding into low-income countries is the lack of trust in government institutions. 

We talk about misinformation and conspiracy theories driving hesitancy but what’s missing is a discussion about the much wider problem of government mistrust, where many believe the government is not acting in the best interests of its citizenry and instead have a levy of incentives that actively undermine that.

Gustavo: Yes, inequality and lack of representation is a huge issue. Misinformation is the fire but the mistrust in governments is the firewood and is what allows this misinformation to spread. And mistrust is heavily impacted by the inequality worldwide and how people may feel disenfranchised  with the governments and their elites in many countries. So we need to really push this equity agenda. And this also means decolonising global health. Because unless governance structures change significantly and become more representative, people are likely to feel more neglected and misrepresented. 

It’s a gunpowder barrel and is very dangerous actually. We're already seeing the effects of mistrust on childhood immunisation – COVID-19 is serious, but there are other deadly diseases that are vaccine-preventable like measles, and we run the risk of having terrible outbreaks of those in the future because of hesitancy. 

Q. So does this mean that when we’re talking about resilience in a health system and immunisation programes, it’s not necessarily a big global crisis like COVID-19 that is a shock but it could also be a regional or national crisis where a crisis of trust in the system and in vaccines is leading to outbreaks?

Josh: Yes and this is why it’s so important to have clear and consistent communication, but also a productive dialogue with individual communities as well. Vaccine hesitancy is not homogenous – there are so many different reasons why people are hesitant and it can really differ by community and by country. And we need to make sure that we are actually responding to the needs and context that we're working in.

Gustavo: Communities are really important and some authors would argue a central component. This is a welcoming trend to put communities at the centre, but we should not forget they are only one component in a resilience framework. It’s important to listen to them and design responses with their participation, but we shouldn't lose the epidemiological perspective, the social perspective, the economic perspective, the financial perspective, and so on. That’s why cross-sectoral collaboration is so important.