Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011–15
Publication Date
2020Author
Jackline Odhiambo1 , Caroline Jeffery1 , Richard Lako2 , Baburam Devkota1 and Joseph J Valadez 1
Metadata
Show full item recordAbstract/ Overview
Health systems resilience (HSR) is defined as the ability of a health system to continue providing
normal services in response to a crisis, making it a critical concept for analysis of health systems in
fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and
even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan
to develop a data-driven understanding of resilience. We used 14 maternal, newborn and child health
(MNCH) coverage indicators from household surveys in South Sudan collected at independence
(2011) and following 2 years of protracted conflict (2015), to construct a resilience index (RI) for 9 of
the former 10 states and nationally. We also assessed health system stress using conflict-related
indicators and developed a stress index. We cross tabulated the two indices to assess the relationship
of resilience and stress. For maintaining function for 80% of MNCH indicators, seven state health
systems were resilient, compared with improving function for 50% of the indicators (two states were
resilient). Achieving the health system national target of 50% coverage in half of the MNCH indicators
displayed no resilience. MNCH coverage levels were low, with state averages ranging between 15%
and 44%. Central Equatoria State displayed high resilience and high system stress. Lakes and
Northern Bahr el Ghazal displayed high resilience and low stress. Jonglei and Upper Nile States had
low resilience and high stress. This study is the first to investigate HSR definitions using a resilience
metric and to simultaneously measure health system stress in FCAS. Improving function is the HSR
definition detecting the greatest variation in the RI. HSR and health system stress are not consistently
negatively associated. HSR is highly complex warranting more in-depth analyses in FCAS.