Building Back Better: Development of Health System Resilience in Liberia During and After the Ebola Virus Disease and COVID-19 Outbreaks

Abstract

It is widely accepted that fostering resilience in health systems is a crucial measure to increase preparedness to public health emergencies, preserve the health system’s functions, and protect population health. International organisations and individual global health actors have long endorsed efforts to understand the determinants of health system resilience in hopes of developing operational guidelines. However, much of the scientific work has so far focused on establishing conceptual approaches to frame resilience in health systems, and in measuring resilience as a set of cross-sectional indicators that cursorily assess the system’s aptitudes. Through a descriptive case study, this paper looks at the transformative dimension of health system resilience in Liberia (understood as functional and structural changes to the system’s institutions to improve resilience) to identify drivers and determinants organised under an operational framework and guided by the health system’s main functions. A literature review is used to develop a theory, and primary data collection through key informant interviews and technical document reviews explore evidence to refine the theory and draw conclusions. This study finds that, in operationalising transformative resilience, the Liberian health system fostered institutional evolution in nine areas (leadership and governance, health financing, health workforce, health service delivery, health infrastructure, health information systems, medical products and technologies, community trust and ownership, and interinstitutional collaboration). The study also concludes that policy mechanisms to enable resilience must be embedded into health system planning to successfully undertake transformative change in the system’s institutions and improve their performance during public health emergencies.