How is resilience operationalized and strengthened in complex crisis settings?: Pathways to health system strengthening at district level in Democratic Republic of the Congo

Abstract

Background Health systems worldwide, particularly in resource-constrained settings, face increasing public health challenges. Health system resilience is widely invoked in response to the convergence of global crises, yet it remains largely a theoretical construct, with little operational guidance for health districts facing protracted crises. Objectives To describe how health districts in Eastern Democratic Republic of the Congo operationalize resilience, to characterise the state of resilience that results, and to identify pathways to strengthen it. Methods Cross-case synthesis of two previously published case studies conducted in South Kivu: a multiple case study of four health districts and a mixed-methods extreme case study of two health districts, using an operational framework linking shocks, contextual conditions and resilience mechanisms. We then applied this framework to the current Ebola outbreak as an illustrative case analysis. Ultimately, this synthesis informed a practical conceptual framework for better-developed resilience, with clear policy directions for strengthening health systems at the operational level amid multiple chronic crises. No new data were collected. Results This study identified a cycle of minimal reductive resilience characterized by districts mobilised scarce resources to sustain basic functions but remained vulnerable to subsequent shocks. Three weaknesses characterized this pattern: a resilience hub with limited capacities, minimum service provision at the expense of quality and equity, and disproportionate costs borne by health workers and communities. The current Ebola response illustrated the gap between accumulated experience and institutionalised preparedness. Moving from minimal reductive to better-developed resilience requires stronger local ownership, non-health sector involvement, sustained resources and systematic learning to improve preparedness, quality and equity. Conclusions Moving beyond minimal reductive resilience requires consolidating locally owned crisis management, involving contextual regulators outside the health sector, and securing systemic enablers (workforce management, infrastructure, negotiated funding) before crises occur.