Fragile states and the development of resilient health systems through the lens of human capital

Since the end of the 2014 West Africa Ebola epidemic there has been a call for countries to recognise the role frameworks of resilience can play in health system development, particularly in low resourced settings. This thesis will use the findings from five papers in two related studies to examine and critique frameworks of resilience in relation to the health system in Sierra Leone. Study one addressed the quality of pre-registration education for maternal and child health aides and study two examined the impact of the Ebola epidemic on maternal and newborn care.

Findings from the included papers are utilised to explore how theories of human and social capital may be utilised to examine concepts of resilience in relation to the health system in sierra Leone. The framing of resilience among health care workers and pre-registration tutors; the current capacities and characteristics of health care workers and their relationship to the human capital requirements of resilience frameworks will also be explored.

Findings from this thesis demonstrate that discussion on human capital for developing resilient systems is largely missing from the resilience agenda. Elements of everyday resilience may be evident amongst health care workers and tutors, but this has not led to system adaption and transformation. In a fragile state such as Sierra Leone there is a danger that focusing on resilience alone will mask the investments that are needed in human capital and the political and social changes needed to improve health care. In the context of Sierra Leone concepts of resilience need to be reframed to acknowledge the cultural context, and recognise the underlying fragility of the state and lack of agency amongst the majority of the health care work force. Investment in human capital should therefore be included as a pre-condition in resilience frameworks which can then be built upon to bring about universal health coverage and system resilience.