Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa

June 2017
Lucy Gilson, Edwine Barasa, Nonhlanhla Nxumalo, Susan Cleary, Jane Goudge, Sassy Molyneux, Benjamin Tsofa, Uta Lehmann

Resilience has become the new buzz word in international health policy debates as a way of thinking about how health systems cope with siginificant external shocks like the Ebola crisis of 2014-2015.

There is, however, little acknowledgment of the routine 'everyday' challenges that also demand resilience, and there is very little empirical evidence about how to nurture resilience in health systems.

This paper addresses that gap, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach.

What are the new findings?

1. The multiple, routine challenges confronting district health systems include:

  • drug stock-outs
  • funding constraints
  • patient complaints
  • unpredictable staff
  • compliance demands
  • organisational instability linked to decentralisation processes
  • frequently changing, and sometimes unclear, policy imperatives.

2. Stable governance structures and adequate resources are not sufficient by themselves to sustain the everyday resilience of district health systems

3. Everyday resilience requires new forms of leadership that embody respect and empower others, particularly front-line health staff, as well as social networks and relationships across, within and outside the health system.

Recommendations for policy 

  • Governments and donors must pay greater attention to strengthening leadership across systems - the leadership that is offered collectively by multiple actors working at different levels and spaces, and that empowers others and enables learning.
  • New forms of collaboration between researchers and health managers may nurture everyday resilience when researchers become embedded within the social networks surrounding and supporting health systems.


Governance South Africa Kenya Everyday resilience