Can we ReBUILD for Resilience? Learning for health systems in crisis and shock
Kate Hawkins (Pamoja Communications), Thazin La (Burnett Institute Myanmar), Mariele Horncastle (Queen Margaret University), Rouham Yamout (American University of Beirut), Joanna Khalil (American University of Beirut), Karen Miller (LSTM)
“Respect for international humanitarian law is not there anymore,” began Elhadj As Sy, humanitarian and global health leader.
The LSTM Chancellor’s message at the opening of ReBUILD for Resilience’s final meeting explored what health systems research might look like in a new world where the old rules no longer apply and civilians, researchers, and health workers face ongoing and unprecedented danger. He stressed the need for partnerships and communities to care for one another and protect ourselves and health facilities in solidarity.
ReBUILD for Resilience has been conducting research in fragile and shock-prone settings for many years. These fragile states are home to 2.1 billion people and 72% of the world’s extreme poor. In many ways, ReBUILD has acted as a supportive mechanism to help researchers – from Myanmar, Sierra Leone, Lebanon and Nepal – to develop new knowledge in the face of extreme challenges. Their mission was to focus on practical application to build the capacities of health systems to flex in the face of shocks and stresses.
This final meeting was a chance to distil the learning from this large programme, which has worked through pandemics, wars, earthquakes, financial collapse, aid cuts, and geopolitical chaos.
What is health system resilience?
People tend to think of resilience as bouncing back after a disaster, rather than keeping going through the everyday challenge of living in a poly-crisis. For example, in Lebanon, we have worked through an economic crisis, COVID-19, the port explosion and two wars – there has been no normality.
At the meeting we heard that there’s a difference between tolerating a weak system for a long time and building health systems resilience. Adaptation happens in both the formal and informal realm, and yet the informal innovations are not always recognised and built upon in practice. The health systems that have found ways to sustain innovations, and particularly those that have actively involved more actors and communities and have learned from previous experiences were able to act faster to meet local priorities. These are also the systems that have been able to sustain changes for longer, which is why the measurement of changing capacities is so important, particularly at the local level. Sometimes, the local experience has even provided the blueprint for national policy.
“What came across is how dynamic fragility, displacement and crisis are – Rebuild for Resilience has found creative ways to work with and learn from this constant change in fragile contexts” – Katy Davis (LSTM)
Community and the health workforce
The health system begins in the household and community, and very often the labour at this level is unpaid and falls on women and girls. There is a danger that resilience is built on the backs of communities and health workers – what our colleagues in Bangladesh have called the privatisation of resilience. These are often the most vulnerable people in our societies and recognising and mitigating against the propensity for them to be used and exploited by the health system is important. Health workers need support, they are not immune to the shocks and crises, but are often required to keep delivering services. The health system cannot rely on unpaid labour, health worker sacrifice or family support. Health workers require a package of support including fair compensation, recognition, safe conditions, training, psychosocial support and supervision.
Gender and disability
Precarity, feminisation and informalisation of the workforce are all exacerbated by conflict and shock and so understanding how they are managed and supported is key. Much of ReBUILD’s work on the health workforce explicitly took a gendered approach – charting women’s experience of the double burden of domestic responsibilities alongside paid work, their underpayment and lack of recognition. Participatory action research in Lebanon led to the creation of women’s groups among informal refuse women workers – advocating for workers’ rights, providing peer-led childcare and taking part in a film to tell their story to an international audience.
We heard from ReBUILD experts that the work on gender equity and disability inclusion in the consortium showed positive progress; however, these areas could have been better integrated as cross-cutting themes across all consortium activities. Our work on disability in Myanmar was very progressive, but this was not spread equally across the consortium.
Gender and inclusion should not be treated as standalone components, but rather embedded across all areas of work, at least at a basic conceptual and operational level, and properly documented. Overall, there are still gaps in applying gender intersectionality and disability inclusion across our country-level work, beyond specific targeted activities. The session also highlighted the importance of having a clear framework that defines what gender, equity, and justice mean in relation to our work, as these concepts may differ depending on project context, resources, and constraints. This would also help in developing clear indicators to measure progress effectively.
Governance
In fragile and poly-crisis settings, resilient health systems depend on governance that is locally grounded, inclusive and adaptive. ReBUILD’s learning site experience showed that strengthening existing community structures, such as Municipal Health Committees, community health volunteers, and informal health workers, can improve coordination, responsiveness, and sustainability by embedding new practices within established local systems. Continuous mentoring, dialogue, and participatory engagement helped build stakeholder capacity, foster trust, and support evidence-informed planning, while collaborative multi-level approaches strengthened links between communities and institutions. A central lesson is that governance is most effective when it builds on community strengths, prioritizes local ownership, and moves beyond recognizing equity and inclusion to fully integrating them into practice.
Communications and research uptake
Fostering the uptake and use of new knowledge has been central to the ReBUILD approach. But this has not been without challenges. It has been difficult to continuous learning, adaptation, and decision-support processes during uncertainty and shocks. Health systems fragility often creates competing priorities and limited absorptive capacity. Furthermore, timeliness often matters more than perfection in terms of communication in emergencies; the creaky and glacial process of academic publishing often does not meet this need. As a result ReBUILD balanced more traditional research outputs with briefs, blogs, toolkits and other grey literature.
“I was struck by the sheer scale and depth of the ReBUILD for Resilience programme, it was a privilege to be in the same room with so many people who have carried out incredible work in some of the most challenging contexts. I was inspired by the creative outputs shared – from participatory videos with female health workers in Lebanon and Nepal, to colouring books created with people with disabilities in Myanmar. Amidst crises and shocks, creativity emerged alongside resilience, showing how people and systems continue to adapt, respond and imagine new possibilities.” -Shahreen Chowdhury (LSTM)
Concluding words
ReBUILD Director, Joanna Raven, rounds off this blog, reflecting on the many years of work that ReBUILD has contributed to the sector:
“Our collaboration, solidarity, research expertise, and embedded insights have ensured that our research has contributed to developing resilient health systems in fragile settings.”
You can read more on this mini site that houses the ReBUILD final report
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